In an intensive push to fill acute workforce shortages, the US Department of Veterans Affairs (VA) is holding a “national onboarding surge event” the week of November 14. The goal is to get people who have already said yes to a job in the VA on that job more quickly. Every VA facility has been asked to submit a list of the highest-priority candidates, regardless of the position.

One of the most pressing reasons for getting more workers into the pipeline faster is that more and more veterans are entering VA care. As of October 1, tens of thousands of veterans will be eligible for VA health care, thanks to the Sergeant First Class Heath Robinson Honoring our Promise to Address Comprehensive Toxics Act of 2022 (PACT Act), passed in August, which expanded benefits for post-9/11 service members with illnesses due to toxic exposures.

Another reason is the need to fill the gaps left by attrition. In an October 19 press briefing, VA Undersecretary for Health Shereef Elnahal said the agency needs to hire about 52,000 employees per year just to keep up with the rate of health care professionals (HCPs) leaving the agency. At a September breakfast meeting with the Defense Writers Group, VA Secretary Denis McDonough said July 2022 marked the first month this year that the VA hired more nurses than it lost to retirement. He said the VA needs to hire 45,000 nurses over the next 3 years to keep up with attrition and growing demand for veteran care.

“We have to do a better job on hiring,” McDonough said. Streamlining the process is a major goal. Hiring rules loosened during the pandemic have since tightened back up. He pointed out that in many cases, the VA takes 90 to 100 days to onboard candidates and called the long-drawn-out process “being dragged through a bureaucratic morass.” During that time, he said, “They’re not being paid, they’re filling out paperwork… That’s disastrous.” In his press briefing, Elnahal said “we lose folks after we’ve made the selection” because the process is so long.

Moreover, the agency has a critical shortage not only of HCPs but the human resources professionals needed to fast-track the hirees’ progress. McDonough called it a “supply chain issue.” “We have the lowest ratio of human resource professionals per employee in the federal government by a long shot.” Partly, he said, because “a lot of our people end up hired away to other federal agencies.”

McDonough said the VA is also interested in transitioning more active-duty service members with in-demand skills, certifications, and talent into the VA workforce. “Cross-walking active duty into VA service much more aggressively,” he said, is another way to “grow that supply of ready, deployable, trained personnel.” The PACT Act gives the VA new incentives to entice workers, such as expanded recruitment, retention bonuses, and student loan repayment. The VA already provides training to about 1500 nurse and nurse residency programs across the VA, McDonough said but has plans for expanding to 5 times its current scope. He also addressed the question of a looming physician shortage: “Roughly 7 in 10 doctors in the United States will have had some portion of their training in a VA facility. We have to maintain that training function going forward.” The VA trains doctors, he added, “better than anybody else.”

The onboarding event will serve as a “national signal that we take this priority very seriously,” Elnahal said. “This will be not only a chance to have a step function improvement in the number of folks on board, which is an urgent priority, but to also set the groundwork for the more longitudinal work that we will need to do to improve the hiring process.”

Bulking up the workforce, he said, is “still far and away among our first priorities. Because if we don’t get our hospitals and facility staffed, it’s going to be a really hard effort to make process on the other priorities.”

In an intensive push to fill acute workforce shortages, the US Department of Veterans Affairs (VA) is holding a “national onboarding surge event” the week of November 14. The goal is to get people who have already said yes to a job in the VA on that job more quickly. Every VA facility has been asked to submit a list of the highest-priority candidates, regardless of the position.

One of the most pressing reasons for getting more workers into the pipeline faster is that more and more veterans are entering VA care. As of October 1, tens of thousands of veterans will be eligible for VA health care, thanks to the Sergeant First Class Heath Robinson Honoring our Promise to Address Comprehensive Toxics Act of 2022 (PACT Act), passed in August, which expanded benefits for post-9/11 service members with illnesses due to toxic exposures.

Another reason is the need to fill the gaps left by attrition. In an October 19 press briefing, VA Undersecretary for Health Shereef Elnahal said the agency needs to hire about 52,000 employees per year just to keep up with the rate of health care professionals (HCPs) leaving the agency. At a September breakfast meeting with the Defense Writers Group, VA Secretary Denis McDonough said July 2022 marked the first month this year that the VA hired more nurses than it lost to retirement. He said the VA needs to hire 45,000 nurses over the next 3 years to keep up with attrition and growing demand for veteran care.

“We have to do a better job on hiring,” McDonough said. Streamlining the process is a major goal. Hiring rules loosened during the pandemic have since tightened back up. He pointed out that in many cases, the VA takes 90 to 100 days to onboard candidates and called the long-drawn-out process “being dragged through a bureaucratic morass.” During that time, he said, “They’re not being paid, they’re filling out paperwork… That’s disastrous.” In his press briefing, Elnahal said “we lose folks after we’ve made the selection” because the process is so long.

Moreover, the agency has a critical shortage not only of HCPs but the human resources professionals needed to fast-track the hirees’ progress. McDonough called it a “supply chain issue.” “We have the lowest ratio of human resource professionals per employee in the federal government by a long shot.” Partly, he said, because “a lot of our people end up hired away to other federal agencies.”

McDonough said the VA is also interested in transitioning more active-duty service members with in-demand skills, certifications, and talent into the VA workforce. “Cross-walking active duty into VA service much more aggressively,” he said, is another way to “grow that supply of ready, deployable, trained personnel.” The PACT Act gives the VA new incentives to entice workers, such as expanded recruitment, retention bonuses, and student loan repayment. The VA already provides training to about 1500 nurse and nurse residency programs across the VA, McDonough said but has plans for expanding to 5 times its current scope. He also addressed the question of a looming physician shortage: “Roughly 7 in 10 doctors in the United States will have had some portion of their training in a VA facility. We have to maintain that training function going forward.” The VA trains doctors, he added, “better than anybody else.”

The onboarding event will serve as a “national signal that we take this priority very seriously,” Elnahal said. “This will be not only a chance to have a step function improvement in the number of folks on board, which is an urgent priority, but to also set the groundwork for the more longitudinal work that we will need to do to improve the hiring process.”

Bulking up the workforce, he said, is “still far and away among our first priorities. Because if we don’t get our hospitals and facility staffed, it’s going to be a really hard effort to make process on the other priorities.”

In an intensive push to fill acute workforce shortages, the US Department of Veterans Affairs (VA) is holding a “national onboarding surge event” the week of November 14. The goal is to get people who have already said yes to a job in the VA on that job more quickly. Every VA facility has been asked to submit a list of the highest-priority candidates, regardless of the position.

One of the most pressing reasons for getting more workers into the pipeline faster is that more and more veterans are entering VA care. As of October 1, tens of thousands of veterans will be eligible for VA health care, thanks to the Sergeant First Class Heath Robinson Honoring our Promise to Address Comprehensive Toxics Act of 2022 (PACT Act), passed in August, which expanded benefits for post-9/11 service members with illnesses due to toxic exposures.

Another reason is the need to fill the gaps left by attrition. In an October 19 press briefing, VA Undersecretary for Health Shereef Elnahal said the agency needs to hire about 52,000 employees per year just to keep up with the rate of health care professionals (HCPs) leaving the agency. At a September breakfast meeting with the Defense Writers Group, VA Secretary Denis McDonough said July 2022 marked the first month this year that the VA hired more nurses than it lost to retirement. He said the VA needs to hire 45,000 nurses over the next 3 years to keep up with attrition and growing demand for veteran care.

“We have to do a better job on hiring,” McDonough said. Streamlining the process is a major goal. Hiring rules loosened during the pandemic have since tightened back up. He pointed out that in many cases, the VA takes 90 to 100 days to onboard candidates and called the long-drawn-out process “being dragged through a bureaucratic morass.” During that time, he said, “They’re not being paid, they’re filling out paperwork… That’s disastrous.” In his press briefing, Elnahal said “we lose folks after we’ve made the selection” because the process is so long.

Moreover, the agency has a critical shortage not only of HCPs but the human resources professionals needed to fast-track the hirees’ progress. McDonough called it a “supply chain issue.” “We have the lowest ratio of human resource professionals per employee in the federal government by a long shot.” Partly, he said, because “a lot of our people end up hired away to other federal agencies.”

McDonough said the VA is also interested in transitioning more active-duty service members with in-demand skills, certifications, and talent into the VA workforce. “Cross-walking active duty into VA service much more aggressively,” he said, is another way to “grow that supply of ready, deployable, trained personnel.” The PACT Act gives the VA new incentives to entice workers, such as expanded recruitment, retention bonuses, and student loan repayment. The VA already provides training to about 1500 nurse and nurse residency programs across the VA, McDonough said but has plans for expanding to 5 times its current scope. He also addressed the question of a looming physician shortage: “Roughly 7 in 10 doctors in the United States will have had some portion of their training in a VA facility. We have to maintain that training function going forward.” The VA trains doctors, he added, “better than anybody else.”

The onboarding event will serve as a “national signal that we take this priority very seriously,” Elnahal said. “This will be not only a chance to have a step function improvement in the number of folks on board, which is an urgent priority, but to also set the groundwork for the more longitudinal work that we will need to do to improve the hiring process.”

Bulking up the workforce, he said, is “still far and away among our first priorities. Because if we don’t get our hospitals and facility staffed, it’s going to be a really hard effort to make process on the other priorities.”

The field of “reproductive rheumatology” has received growing attention in recent years as we learn more about how autoimmune rheumatic diseases and their treatment affect women of reproductive age. In 2020, the American College of Rheumatology published a comprehensive guideline that includes recommendations and supporting evidence for managing issues related to reproductive health in patients with rheumatic diseases and has since launched an ongoing Reproductive Health Initiative, with the goal of translating established guidelines into practice through various education and awareness campaigns. One area addressed by the guideline that comes up commonly in practice but receives less attention and research is the use of assisted reproductive technology (ART) in patients with rheumatic diseases.

Literature is conflicting regarding whether patients with autoimmune rheumatic diseases are inherently at increased risk for infertility, defined as failure to achieve a clinical pregnancy after 12 months or more of regular unprotected intercourse, or subfertility, defined as a delay in conception. Regardless, several factors indirectly contribute to a disproportionate risk for infertility or subfertility in this patient population, including active inflammatory disease, reduced ovarian reserve, and medications.

Patients with subfertility or infertility who desire pregnancy may pursue ovulation induction with timed intercourse or intrauterine insemination, in vitro fertilization (IVF)/intracytoplasmic sperm injection with either embryo transfer, or gestational surrogacy. Those who require treatment with cyclophosphamide or who plan to defer pregnancy for whatever reason can opt for oocyte cryopreservation (colloquially known as “egg freezing”). For IVF and oocyte cryopreservation, controlled ovarian stimulation is typically the first step (except in unstimulated, or “natural cycle,” IVF).

Various protocols are used for ovarian stimulation and ovulation induction, the nuances of which are beyond the scope of this article. In general, ovarian stimulation involves gonadotropin therapy (follicle-stimulating hormone and/or human menopausal gonadotropin) administered via scheduled subcutaneous injections to stimulate follicular growth, as well as gonadotropin-releasing hormone (GnRH) agonists or antagonists to suppress luteinizing hormone, preventing ovulation. Adjunctive oral therapy (clomiphene citrate or letrozole, an aromatase inhibitor) may be used as well. The patient has frequent lab monitoring of hormone levels and transvaginal ultrasounds to measure follicle number and size and, when the timing is right, receives an “ovulation trigger” – either human chorionic gonadotropin or GnRH agonist, depending on the protocol. At this point, transvaginal ultrasound–guided egg retrieval is done under sedation. Recovered oocytes are then either frozen for later use or fertilized in the lab for embryo transfer. Lastly, exogenous hormones are often used: estrogen to support frozen embryo transfers and progesterone for so-called luteal phase support.

ART is not contraindicated in patients with autoimmune rheumatic diseases, but there may be additional factors to consider, particularly for those with systemic lupus erythematosus (SLE), antiphospholipid syndrome (APS), and antiphospholipid antibodies (aPL) without clinical APS.

Ovarian stimulation elevates estrogen levels to varying degrees depending on the patient and the medications used. In all cases, though, peak levels are significantly lower than levels reached during pregnancy. It is well established that elevated estrogen – whether from hormone therapies or pregnancy – significantly increases thrombotic risk, even in healthy people. High-risk patients should receive low-molecular-weight heparin – a prophylactic dose for patients with either positive aPL without clinical APS (including those with SLE) or with obstetric APS, and a therapeutic dose for those with thrombotic APS – during ART procedures.

In patients with SLE, another concern is that increased estrogen will cause disease flare. One case series published in 2017 reported 37 patients with SLE and/or APS who underwent 97 IVF cycles, of which 8% were complicated by flare or thrombotic events. Notably, half of these complications occurred in patients who stopped prescribed therapies (immunomodulatory therapy in two patients with SLE, anticoagulation in two patients with APS) after failure to conceive. In a separate study from 2000 including 19 patients with SLE, APS, or high-titer aPL who underwent 68 IVF cycles, 19% of cycles in patients with SLE were complicated by flare, and no thrombotic events occurred in the cohort. The authors concluded that ovulation induction does not exacerbate SLE or APS. In these studies, the overall pregnancy rates were felt to be consistent with those achieved by the general population through IVF. Although obstetric complications, such as preeclampsia and preterm delivery, were reported in about half of the pregnancies described, these are known to occur more frequently in those with SLE and APS, especially when active disease or other risk factors are present. There are no large-scale, controlled studies evaluating ART outcomes in patients with autoimmune rheumatic diseases to date.

Finally, ovarian hyperstimulation syndrome (OHSS) is an increasingly rare but severe complication of ovarian stimulation. OHSS is characterized by capillary leak, fluid overload, and cytokine release syndrome and can lead to thromboembolic events. Comorbidities like hypertension and renal failure, which can go along with autoimmune rheumatic diseases, are risk factors for OHSS. The use of human chorionic gonadotropin to trigger ovulation is also associated with an increased risk for OHSS, so a GnRH agonist trigger may be preferable.

The ACR guideline recommends that individuals with any of these underlying conditions undergo ART only in expert centers. The ovarian stimulation protocol needs to be tailored to the individual patient to minimize risk and optimize outcomes. The overall goal when managing patients with autoimmune rheumatic diseases during ART is to establish and maintain disease control with pregnancy-compatible medications (when pregnancy is the goal). With adequate planning, appropriate treatment, and collaboration between obstetricians and rheumatologists, individuals with autoimmune rheumatic diseases can safely pursue ART and go on to have successful pregnancies.

Dr. Siegel is a 2022-2023 UCB Women’s Health rheumatology fellow in the rheumatology reproductive health program of the Barbara Volcker Center for Women and Rheumatic Diseases at Hospital for Special Surgery/Weill Cornell Medicine, New York. Her clinical and research focus is on reproductive health issues in individuals with rheumatic disease. Dr. Chan is an assistant professor at Weill Cornell Medical College and an attending physician at Hospital for Special Surgery and Memorial Sloan Kettering Cancer Center in New York. Before moving to New York City, she spent 7 years in private practice in Rhode Island and was a columnist for a monthly rheumatology publication, writing about the challenges of starting life as a full-fledged rheumatologist in a private practice. Follow Dr Chan on Twitter. Dr. Siegel and Dr. Chan disclosed no relevant financial relationships.

A version of this article – an editorial collaboration between Medscape and the Hospital for Special Surgery – first appeared on Medscape.com.

The field of “reproductive rheumatology” has received growing attention in recent years as we learn more about how autoimmune rheumatic diseases and their treatment affect women of reproductive age. In 2020, the American College of Rheumatology published a comprehensive guideline that includes recommendations and supporting evidence for managing issues related to reproductive health in patients with rheumatic diseases and has since launched an ongoing Reproductive Health Initiative, with the goal of translating established guidelines into practice through various education and awareness campaigns. One area addressed by the guideline that comes up commonly in practice but receives less attention and research is the use of assisted reproductive technology (ART) in patients with rheumatic diseases.

Literature is conflicting regarding whether patients with autoimmune rheumatic diseases are inherently at increased risk for infertility, defined as failure to achieve a clinical pregnancy after 12 months or more of regular unprotected intercourse, or subfertility, defined as a delay in conception. Regardless, several factors indirectly contribute to a disproportionate risk for infertility or subfertility in this patient population, including active inflammatory disease, reduced ovarian reserve, and medications.

Patients with subfertility or infertility who desire pregnancy may pursue ovulation induction with timed intercourse or intrauterine insemination, in vitro fertilization (IVF)/intracytoplasmic sperm injection with either embryo transfer, or gestational surrogacy. Those who require treatment with cyclophosphamide or who plan to defer pregnancy for whatever reason can opt for oocyte cryopreservation (colloquially known as “egg freezing”). For IVF and oocyte cryopreservation, controlled ovarian stimulation is typically the first step (except in unstimulated, or “natural cycle,” IVF).

Various protocols are used for ovarian stimulation and ovulation induction, the nuances of which are beyond the scope of this article. In general, ovarian stimulation involves gonadotropin therapy (follicle-stimulating hormone and/or human menopausal gonadotropin) administered via scheduled subcutaneous injections to stimulate follicular growth, as well as gonadotropin-releasing hormone (GnRH) agonists or antagonists to suppress luteinizing hormone, preventing ovulation. Adjunctive oral therapy (clomiphene citrate or letrozole, an aromatase inhibitor) may be used as well. The patient has frequent lab monitoring of hormone levels and transvaginal ultrasounds to measure follicle number and size and, when the timing is right, receives an “ovulation trigger” – either human chorionic gonadotropin or GnRH agonist, depending on the protocol. At this point, transvaginal ultrasound–guided egg retrieval is done under sedation. Recovered oocytes are then either frozen for later use or fertilized in the lab for embryo transfer. Lastly, exogenous hormones are often used: estrogen to support frozen embryo transfers and progesterone for so-called luteal phase support.

ART is not contraindicated in patients with autoimmune rheumatic diseases, but there may be additional factors to consider, particularly for those with systemic lupus erythematosus (SLE), antiphospholipid syndrome (APS), and antiphospholipid antibodies (aPL) without clinical APS.

Ovarian stimulation elevates estrogen levels to varying degrees depending on the patient and the medications used. In all cases, though, peak levels are significantly lower than levels reached during pregnancy. It is well established that elevated estrogen – whether from hormone therapies or pregnancy – significantly increases thrombotic risk, even in healthy people. High-risk patients should receive low-molecular-weight heparin – a prophylactic dose for patients with either positive aPL without clinical APS (including those with SLE) or with obstetric APS, and a therapeutic dose for those with thrombotic APS – during ART procedures.

In patients with SLE, another concern is that increased estrogen will cause disease flare. One case series published in 2017 reported 37 patients with SLE and/or APS who underwent 97 IVF cycles, of which 8% were complicated by flare or thrombotic events. Notably, half of these complications occurred in patients who stopped prescribed therapies (immunomodulatory therapy in two patients with SLE, anticoagulation in two patients with APS) after failure to conceive. In a separate study from 2000 including 19 patients with SLE, APS, or high-titer aPL who underwent 68 IVF cycles, 19% of cycles in patients with SLE were complicated by flare, and no thrombotic events occurred in the cohort. The authors concluded that ovulation induction does not exacerbate SLE or APS. In these studies, the overall pregnancy rates were felt to be consistent with those achieved by the general population through IVF. Although obstetric complications, such as preeclampsia and preterm delivery, were reported in about half of the pregnancies described, these are known to occur more frequently in those with SLE and APS, especially when active disease or other risk factors are present. There are no large-scale, controlled studies evaluating ART outcomes in patients with autoimmune rheumatic diseases to date.

Finally, ovarian hyperstimulation syndrome (OHSS) is an increasingly rare but severe complication of ovarian stimulation. OHSS is characterized by capillary leak, fluid overload, and cytokine release syndrome and can lead to thromboembolic events. Comorbidities like hypertension and renal failure, which can go along with autoimmune rheumatic diseases, are risk factors for OHSS. The use of human chorionic gonadotropin to trigger ovulation is also associated with an increased risk for OHSS, so a GnRH agonist trigger may be preferable.

The ACR guideline recommends that individuals with any of these underlying conditions undergo ART only in expert centers. The ovarian stimulation protocol needs to be tailored to the individual patient to minimize risk and optimize outcomes. The overall goal when managing patients with autoimmune rheumatic diseases during ART is to establish and maintain disease control with pregnancy-compatible medications (when pregnancy is the goal). With adequate planning, appropriate treatment, and collaboration between obstetricians and rheumatologists, individuals with autoimmune rheumatic diseases can safely pursue ART and go on to have successful pregnancies.

Dr. Siegel is a 2022-2023 UCB Women’s Health rheumatology fellow in the rheumatology reproductive health program of the Barbara Volcker Center for Women and Rheumatic Diseases at Hospital for Special Surgery/Weill Cornell Medicine, New York. Her clinical and research focus is on reproductive health issues in individuals with rheumatic disease. Dr. Chan is an assistant professor at Weill Cornell Medical College and an attending physician at Hospital for Special Surgery and Memorial Sloan Kettering Cancer Center in New York. Before moving to New York City, she spent 7 years in private practice in Rhode Island and was a columnist for a monthly rheumatology publication, writing about the challenges of starting life as a full-fledged rheumatologist in a private practice. Follow Dr Chan on Twitter. Dr. Siegel and Dr. Chan disclosed no relevant financial relationships.

A version of this article – an editorial collaboration between Medscape and the Hospital for Special Surgery – first appeared on Medscape.com.

The field of “reproductive rheumatology” has received growing attention in recent years as we learn more about how autoimmune rheumatic diseases and their treatment affect women of reproductive age. In 2020, the American College of Rheumatology published a comprehensive guideline that includes recommendations and supporting evidence for managing issues related to reproductive health in patients with rheumatic diseases and has since launched an ongoing Reproductive Health Initiative, with the goal of translating established guidelines into practice through various education and awareness campaigns. One area addressed by the guideline that comes up commonly in practice but receives less attention and research is the use of assisted reproductive technology (ART) in patients with rheumatic diseases.

Literature is conflicting regarding whether patients with autoimmune rheumatic diseases are inherently at increased risk for infertility, defined as failure to achieve a clinical pregnancy after 12 months or more of regular unprotected intercourse, or subfertility, defined as a delay in conception. Regardless, several factors indirectly contribute to a disproportionate risk for infertility or subfertility in this patient population, including active inflammatory disease, reduced ovarian reserve, and medications.

Patients with subfertility or infertility who desire pregnancy may pursue ovulation induction with timed intercourse or intrauterine insemination, in vitro fertilization (IVF)/intracytoplasmic sperm injection with either embryo transfer, or gestational surrogacy. Those who require treatment with cyclophosphamide or who plan to defer pregnancy for whatever reason can opt for oocyte cryopreservation (colloquially known as “egg freezing”). For IVF and oocyte cryopreservation, controlled ovarian stimulation is typically the first step (except in unstimulated, or “natural cycle,” IVF).

Various protocols are used for ovarian stimulation and ovulation induction, the nuances of which are beyond the scope of this article. In general, ovarian stimulation involves gonadotropin therapy (follicle-stimulating hormone and/or human menopausal gonadotropin) administered via scheduled subcutaneous injections to stimulate follicular growth, as well as gonadotropin-releasing hormone (GnRH) agonists or antagonists to suppress luteinizing hormone, preventing ovulation. Adjunctive oral therapy (clomiphene citrate or letrozole, an aromatase inhibitor) may be used as well. The patient has frequent lab monitoring of hormone levels and transvaginal ultrasounds to measure follicle number and size and, when the timing is right, receives an “ovulation trigger” – either human chorionic gonadotropin or GnRH agonist, depending on the protocol. At this point, transvaginal ultrasound–guided egg retrieval is done under sedation. Recovered oocytes are then either frozen for later use or fertilized in the lab for embryo transfer. Lastly, exogenous hormones are often used: estrogen to support frozen embryo transfers and progesterone for so-called luteal phase support.

ART is not contraindicated in patients with autoimmune rheumatic diseases, but there may be additional factors to consider, particularly for those with systemic lupus erythematosus (SLE), antiphospholipid syndrome (APS), and antiphospholipid antibodies (aPL) without clinical APS.

Ovarian stimulation elevates estrogen levels to varying degrees depending on the patient and the medications used. In all cases, though, peak levels are significantly lower than levels reached during pregnancy. It is well established that elevated estrogen – whether from hormone therapies or pregnancy – significantly increases thrombotic risk, even in healthy people. High-risk patients should receive low-molecular-weight heparin – a prophylactic dose for patients with either positive aPL without clinical APS (including those with SLE) or with obstetric APS, and a therapeutic dose for those with thrombotic APS – during ART procedures.

In patients with SLE, another concern is that increased estrogen will cause disease flare. One case series published in 2017 reported 37 patients with SLE and/or APS who underwent 97 IVF cycles, of which 8% were complicated by flare or thrombotic events. Notably, half of these complications occurred in patients who stopped prescribed therapies (immunomodulatory therapy in two patients with SLE, anticoagulation in two patients with APS) after failure to conceive. In a separate study from 2000 including 19 patients with SLE, APS, or high-titer aPL who underwent 68 IVF cycles, 19% of cycles in patients with SLE were complicated by flare, and no thrombotic events occurred in the cohort. The authors concluded that ovulation induction does not exacerbate SLE or APS. In these studies, the overall pregnancy rates were felt to be consistent with those achieved by the general population through IVF. Although obstetric complications, such as preeclampsia and preterm delivery, were reported in about half of the pregnancies described, these are known to occur more frequently in those with SLE and APS, especially when active disease or other risk factors are present. There are no large-scale, controlled studies evaluating ART outcomes in patients with autoimmune rheumatic diseases to date.

Finally, ovarian hyperstimulation syndrome (OHSS) is an increasingly rare but severe complication of ovarian stimulation. OHSS is characterized by capillary leak, fluid overload, and cytokine release syndrome and can lead to thromboembolic events. Comorbidities like hypertension and renal failure, which can go along with autoimmune rheumatic diseases, are risk factors for OHSS. The use of human chorionic gonadotropin to trigger ovulation is also associated with an increased risk for OHSS, so a GnRH agonist trigger may be preferable.

The ACR guideline recommends that individuals with any of these underlying conditions undergo ART only in expert centers. The ovarian stimulation protocol needs to be tailored to the individual patient to minimize risk and optimize outcomes. The overall goal when managing patients with autoimmune rheumatic diseases during ART is to establish and maintain disease control with pregnancy-compatible medications (when pregnancy is the goal). With adequate planning, appropriate treatment, and collaboration between obstetricians and rheumatologists, individuals with autoimmune rheumatic diseases can safely pursue ART and go on to have successful pregnancies.

Dr. Siegel is a 2022-2023 UCB Women’s Health rheumatology fellow in the rheumatology reproductive health program of the Barbara Volcker Center for Women and Rheumatic Diseases at Hospital for Special Surgery/Weill Cornell Medicine, New York. Her clinical and research focus is on reproductive health issues in individuals with rheumatic disease. Dr. Chan is an assistant professor at Weill Cornell Medical College and an attending physician at Hospital for Special Surgery and Memorial Sloan Kettering Cancer Center in New York. Before moving to New York City, she spent 7 years in private practice in Rhode Island and was a columnist for a monthly rheumatology publication, writing about the challenges of starting life as a full-fledged rheumatologist in a private practice. Follow Dr Chan on Twitter. Dr. Siegel and Dr. Chan disclosed no relevant financial relationships.

A version of this article – an editorial collaboration between Medscape and the Hospital for Special Surgery – first appeared on Medscape.com.

A commonly prescribed direct oral anticoagulant (DOAC) has the lowest risk of bleeding, say researchers. Used to prevent strokes in those with atrial fibrillation (AFib), DOACs have recently become more common than warfarin, the previous standard treatment, as they do not require as much follow-up monitoring – which was “particularly valuable” during the COVID-19 pandemic – and have “less risk” of side effects, highlighted the authors of a new study, published in Annals of Internal Medicine.

However, the authors explained that, although current guidelines recommend using DOACs over warfarin in patients with AFib, “head-to-head trial data do not exist to guide the choice of DOAC.” So, they set out to try and fill this evidence gap by doing a large-scale comparison between all DOACs – apixaban, dabigatran, edoxaban, and rivaroxaban – in routine clinical practice.

Wallis Lau, PhD, University College London, and co–lead author, said: “Direct oral anticoagulants have been prescribed with increasing frequency worldwide in recent years, but evidence comparing them directly has been limited.”
 

One drug stood out

For the multinational population-based cohort study the researchers compared the efficacy and risk of side effects for the four most common DOACs. They reviewed data – from five standardized electronic health care databases that covered 221 million people in the United Kingdom, France, Germany, and the United States – of 527,226 patients who had been newly diagnosed with AFib between 2010 and 2019, and who had received a new DOAC prescription. The study included 281,320 apixaban users, 61,008 dabigatran users, 12,722 edoxaban users, and 172,176 rivaroxaban users.

Database-specific hazard ratios of ischemic stroke or systemic embolism, intracranial hemorrhage, gastrointestinal bleeding, and all-cause mortality between DOACs were estimated using a Cox regression model stratified by propensity score and pooled using a random-effects model.

In total, 9,530 ischemic stroke or systemic embolism events, 841 intercranial hemorrhage events, 8,319 gastrointestinal bleeding events, and 1,476 deaths were identified over the study follow-up. The researchers found that all four drugs were comparable on outcomes for ischemic stroke, intercranial hemorrhage, and all-cause mortality.

However, they identified a difference in the risk of gastrointestinal bleeding, which they highlighted “is one of the most common and concerning side effects of DOACs.”

“Apixaban stood out as having lower risk of gastrointestinal bleeding,” said the authors, with a 19%-28% lower risk when compared directly with each of the other three DOACs. Specifically, apixaban use was associated with lower risk for gastrointestinal bleeding than use of dabigatran (HR, 0.81; 95% confidence interval, 0.70-0.94), edoxaban (HR, 0.77; 95% CI, 0.66-0.91), or rivaroxaban (HR, 0.72; 95% CI, 0.66-0.79).

The researchers also highlighted that their findings held true when looking at data only from those aged over 80, and those with chronic kidney disease, two groups that are “often underrepresented” in clinical trials.
 

Apixaban may be preferable

The researchers concluded that, among patients with AFib, apixaban use was associated with lower risk for gastrointestinal bleeding and similar rates of ischemic stroke or systemic embolism, intracranial hemorrhage and all-cause mortality, compared with dabigatran, edoxaban, and rivaroxaban.

“Our results indicate that apixaban may be preferable to other blood thinners because of the lower rate of gastrointestinal bleeding and similar rates of stroke, a finding that we hope will be supported by randomized controlled trials,” said Dr. Lau.

However, he emphasized that, “as with all medications, potential risks and benefits can differ between people, so considering the full spectrum of outcomes and side effects will still be necessary for each individual patient.”

The authors all declared no conflicting interests.

A version of this article first appeared on Medscape UK.

A commonly prescribed direct oral anticoagulant (DOAC) has the lowest risk of bleeding, say researchers. Used to prevent strokes in those with atrial fibrillation (AFib), DOACs have recently become more common than warfarin, the previous standard treatment, as they do not require as much follow-up monitoring – which was “particularly valuable” during the COVID-19 pandemic – and have “less risk” of side effects, highlighted the authors of a new study, published in Annals of Internal Medicine.

However, the authors explained that, although current guidelines recommend using DOACs over warfarin in patients with AFib, “head-to-head trial data do not exist to guide the choice of DOAC.” So, they set out to try and fill this evidence gap by doing a large-scale comparison between all DOACs – apixaban, dabigatran, edoxaban, and rivaroxaban – in routine clinical practice.

Wallis Lau, PhD, University College London, and co–lead author, said: “Direct oral anticoagulants have been prescribed with increasing frequency worldwide in recent years, but evidence comparing them directly has been limited.”
 

One drug stood out

For the multinational population-based cohort study the researchers compared the efficacy and risk of side effects for the four most common DOACs. They reviewed data – from five standardized electronic health care databases that covered 221 million people in the United Kingdom, France, Germany, and the United States – of 527,226 patients who had been newly diagnosed with AFib between 2010 and 2019, and who had received a new DOAC prescription. The study included 281,320 apixaban users, 61,008 dabigatran users, 12,722 edoxaban users, and 172,176 rivaroxaban users.

Database-specific hazard ratios of ischemic stroke or systemic embolism, intracranial hemorrhage, gastrointestinal bleeding, and all-cause mortality between DOACs were estimated using a Cox regression model stratified by propensity score and pooled using a random-effects model.

In total, 9,530 ischemic stroke or systemic embolism events, 841 intercranial hemorrhage events, 8,319 gastrointestinal bleeding events, and 1,476 deaths were identified over the study follow-up. The researchers found that all four drugs were comparable on outcomes for ischemic stroke, intercranial hemorrhage, and all-cause mortality.

However, they identified a difference in the risk of gastrointestinal bleeding, which they highlighted “is one of the most common and concerning side effects of DOACs.”

“Apixaban stood out as having lower risk of gastrointestinal bleeding,” said the authors, with a 19%-28% lower risk when compared directly with each of the other three DOACs. Specifically, apixaban use was associated with lower risk for gastrointestinal bleeding than use of dabigatran (HR, 0.81; 95% confidence interval, 0.70-0.94), edoxaban (HR, 0.77; 95% CI, 0.66-0.91), or rivaroxaban (HR, 0.72; 95% CI, 0.66-0.79).

The researchers also highlighted that their findings held true when looking at data only from those aged over 80, and those with chronic kidney disease, two groups that are “often underrepresented” in clinical trials.
 

Apixaban may be preferable

The researchers concluded that, among patients with AFib, apixaban use was associated with lower risk for gastrointestinal bleeding and similar rates of ischemic stroke or systemic embolism, intracranial hemorrhage and all-cause mortality, compared with dabigatran, edoxaban, and rivaroxaban.

“Our results indicate that apixaban may be preferable to other blood thinners because of the lower rate of gastrointestinal bleeding and similar rates of stroke, a finding that we hope will be supported by randomized controlled trials,” said Dr. Lau.

However, he emphasized that, “as with all medications, potential risks and benefits can differ between people, so considering the full spectrum of outcomes and side effects will still be necessary for each individual patient.”

The authors all declared no conflicting interests.

A version of this article first appeared on Medscape UK.

A commonly prescribed direct oral anticoagulant (DOAC) has the lowest risk of bleeding, say researchers. Used to prevent strokes in those with atrial fibrillation (AFib), DOACs have recently become more common than warfarin, the previous standard treatment, as they do not require as much follow-up monitoring – which was “particularly valuable” during the COVID-19 pandemic – and have “less risk” of side effects, highlighted the authors of a new study, published in Annals of Internal Medicine.

However, the authors explained that, although current guidelines recommend using DOACs over warfarin in patients with AFib, “head-to-head trial data do not exist to guide the choice of DOAC.” So, they set out to try and fill this evidence gap by doing a large-scale comparison between all DOACs – apixaban, dabigatran, edoxaban, and rivaroxaban – in routine clinical practice.

Wallis Lau, PhD, University College London, and co–lead author, said: “Direct oral anticoagulants have been prescribed with increasing frequency worldwide in recent years, but evidence comparing them directly has been limited.”
 

One drug stood out

For the multinational population-based cohort study the researchers compared the efficacy and risk of side effects for the four most common DOACs. They reviewed data – from five standardized electronic health care databases that covered 221 million people in the United Kingdom, France, Germany, and the United States – of 527,226 patients who had been newly diagnosed with AFib between 2010 and 2019, and who had received a new DOAC prescription. The study included 281,320 apixaban users, 61,008 dabigatran users, 12,722 edoxaban users, and 172,176 rivaroxaban users.

Database-specific hazard ratios of ischemic stroke or systemic embolism, intracranial hemorrhage, gastrointestinal bleeding, and all-cause mortality between DOACs were estimated using a Cox regression model stratified by propensity score and pooled using a random-effects model.

In total, 9,530 ischemic stroke or systemic embolism events, 841 intercranial hemorrhage events, 8,319 gastrointestinal bleeding events, and 1,476 deaths were identified over the study follow-up. The researchers found that all four drugs were comparable on outcomes for ischemic stroke, intercranial hemorrhage, and all-cause mortality.

However, they identified a difference in the risk of gastrointestinal bleeding, which they highlighted “is one of the most common and concerning side effects of DOACs.”

“Apixaban stood out as having lower risk of gastrointestinal bleeding,” said the authors, with a 19%-28% lower risk when compared directly with each of the other three DOACs. Specifically, apixaban use was associated with lower risk for gastrointestinal bleeding than use of dabigatran (HR, 0.81; 95% confidence interval, 0.70-0.94), edoxaban (HR, 0.77; 95% CI, 0.66-0.91), or rivaroxaban (HR, 0.72; 95% CI, 0.66-0.79).

The researchers also highlighted that their findings held true when looking at data only from those aged over 80, and those with chronic kidney disease, two groups that are “often underrepresented” in clinical trials.
 

Apixaban may be preferable

The researchers concluded that, among patients with AFib, apixaban use was associated with lower risk for gastrointestinal bleeding and similar rates of ischemic stroke or systemic embolism, intracranial hemorrhage and all-cause mortality, compared with dabigatran, edoxaban, and rivaroxaban.

“Our results indicate that apixaban may be preferable to other blood thinners because of the lower rate of gastrointestinal bleeding and similar rates of stroke, a finding that we hope will be supported by randomized controlled trials,” said Dr. Lau.

However, he emphasized that, “as with all medications, potential risks and benefits can differ between people, so considering the full spectrum of outcomes and side effects will still be necessary for each individual patient.”

The authors all declared no conflicting interests.

A version of this article first appeared on Medscape UK.

For those affected, recurrent urinary tract infections (UTIs) are sometimes stressful. However, even an informative discussion about risk factors and the imparting of behavioral recommendations can be very helpful for many women. Antibiotic prophylaxis should only be considered once all nonantibiotic therapy options have been exhausted.

One in seven women suffers at least once a year from cystitis. Around a third of those women develop a further urinary tract infection 6-12 months after the first infection. A urinary tract infection is classified as recurrent if two symptomatic episodes have occurred within the last 6 months or if three episodes have occurred within the last 12 months.

There are many different approaches to reducing the recurrence rate of urinary tract infections, Daniel Klussmann and Florian Wagenlehner, MD, of the department and outpatient clinic for urology at the University of Giessen (Germany) wrote in DMW Klinischer Fortschritt. Aside from general information and advice, nonantibiotic therapy options are particularly important for recurrence reduction, with the aim of preventing the development of resistance and the corresponding adverse effects of antibiotics.
 

Fluids and D-mannose

An individual consultation discussion is the most important nonantibiotic strategy. Studies have shown that this strategy alone can lower the frequency of recurrent UTIs. According to the authors, special education programs on the causes and behavioral measures are especially helpful. Included in these programs is the recommendation to drink a sufficient, but not excessive, amount of fluids: approximately 1.5 liters per day. In one randomized study, this level of consumption halved UTI frequency. However, drinking an excessive amount of fluids should also be avoided, otherwise the antimicrobial peptides present in the urine become overly diluted.

The regular consumption of fruit juice, especially of that from berries, is also beneficial, according to the authors. However, study results on long-term prevention using cranberry products are inconsistent, and they are not recommended in the updated guideline. Like cranberries, D-mannose also inhibits the fimbriae of the Escherichia coli bacteria and therefore the bacteria’s ability to bind to the bladder epithelium. The authors cite a study in which, following the intake of 2 g of D-mannose dissolved in a glass of water every day, the rate of urinary tract infections dropped significantly, compared with consumption of placebo.

Additional recommendations in the S3 guideline include various phytotherapeutic products such as bearberry leaves, nasturtium herb, or horseradish root, although studies on the comparability of phytotherapeutic agents are very difficult to execute, the authors conceded.

It is already known that there is a positive correlation (by a factor of 60) between the recurrence rate of UTIs and the frequency of sexual intercourse. Even with contraceptive methods (such as vaginal suppositories, diaphragms or condoms coated with spermicide, and intrauterine devices), the risk of urinary tract infections increases by a factor of 2-14. Sexual abstinence, even if temporary, can be a remedy. Evidence for the recommendation to urinate immediately after coitus is contradictory in the literature, however. Excessive intimate hygiene clearly damages the local protective environment.
 

Estrogen substitution beneficial

For postmenopausal women, there is also the option of local estriol substitution (0.5 mg/day) as another nonantibiotic method of prophylaxis. This treatment serves as therapy for vaginal atrophy and reduces both vaginal colonization with uropathogens and the vaginal pH level. The authors cite Scandinavian studies that detected no increase in the risk of breast cancer from the local application of estriol.

Furthermore, the current guidelines recommend oral immunostimulation with bacterial cell wall components from uropathogenic strains of E. coli (OM-89, Uro-Vaxom). The authors reported on two meta-studies in which the average recurrence rate was reduced by 39%, compared with placebo. In addition, the treatment time for breakthrough infections decreased significantly, and prevention with OM-89 could even be started during acute therapy. Also recommended is parenteral immunostimulation with inactivated pathogens (StroVac). Acupuncture as cutaneous immunostimulation has also displayed a positive protective effect.

Only when nonantibiotic therapy fails and the patient is under a high amount of psychological strain should antibiotic prophylaxis be initiated, according to the authors. A period of 3-6 months should be the target here. When choosing an antibiotic and before starting therapy, the corresponding pathogen should be confirmed through a urine culture, and resistance testing should be performed. On the other hand, single-use, postcoital antibiotic prevention could be an alternative, particularly for women in whom a correlation between recurrent UTIs and sexual intercourse has been suspected, the authors wrote.

This article was translated from Univadis Germany. A version appeared on Medscape.com.

For those affected, recurrent urinary tract infections (UTIs) are sometimes stressful. However, even an informative discussion about risk factors and the imparting of behavioral recommendations can be very helpful for many women. Antibiotic prophylaxis should only be considered once all nonantibiotic therapy options have been exhausted.

One in seven women suffers at least once a year from cystitis. Around a third of those women develop a further urinary tract infection 6-12 months after the first infection. A urinary tract infection is classified as recurrent if two symptomatic episodes have occurred within the last 6 months or if three episodes have occurred within the last 12 months.

There are many different approaches to reducing the recurrence rate of urinary tract infections, Daniel Klussmann and Florian Wagenlehner, MD, of the department and outpatient clinic for urology at the University of Giessen (Germany) wrote in DMW Klinischer Fortschritt. Aside from general information and advice, nonantibiotic therapy options are particularly important for recurrence reduction, with the aim of preventing the development of resistance and the corresponding adverse effects of antibiotics.
 

Fluids and D-mannose

An individual consultation discussion is the most important nonantibiotic strategy. Studies have shown that this strategy alone can lower the frequency of recurrent UTIs. According to the authors, special education programs on the causes and behavioral measures are especially helpful. Included in these programs is the recommendation to drink a sufficient, but not excessive, amount of fluids: approximately 1.5 liters per day. In one randomized study, this level of consumption halved UTI frequency. However, drinking an excessive amount of fluids should also be avoided, otherwise the antimicrobial peptides present in the urine become overly diluted.

The regular consumption of fruit juice, especially of that from berries, is also beneficial, according to the authors. However, study results on long-term prevention using cranberry products are inconsistent, and they are not recommended in the updated guideline. Like cranberries, D-mannose also inhibits the fimbriae of the Escherichia coli bacteria and therefore the bacteria’s ability to bind to the bladder epithelium. The authors cite a study in which, following the intake of 2 g of D-mannose dissolved in a glass of water every day, the rate of urinary tract infections dropped significantly, compared with consumption of placebo.

Additional recommendations in the S3 guideline include various phytotherapeutic products such as bearberry leaves, nasturtium herb, or horseradish root, although studies on the comparability of phytotherapeutic agents are very difficult to execute, the authors conceded.

It is already known that there is a positive correlation (by a factor of 60) between the recurrence rate of UTIs and the frequency of sexual intercourse. Even with contraceptive methods (such as vaginal suppositories, diaphragms or condoms coated with spermicide, and intrauterine devices), the risk of urinary tract infections increases by a factor of 2-14. Sexual abstinence, even if temporary, can be a remedy. Evidence for the recommendation to urinate immediately after coitus is contradictory in the literature, however. Excessive intimate hygiene clearly damages the local protective environment.
 

Estrogen substitution beneficial

For postmenopausal women, there is also the option of local estriol substitution (0.5 mg/day) as another nonantibiotic method of prophylaxis. This treatment serves as therapy for vaginal atrophy and reduces both vaginal colonization with uropathogens and the vaginal pH level. The authors cite Scandinavian studies that detected no increase in the risk of breast cancer from the local application of estriol.

Furthermore, the current guidelines recommend oral immunostimulation with bacterial cell wall components from uropathogenic strains of E. coli (OM-89, Uro-Vaxom). The authors reported on two meta-studies in which the average recurrence rate was reduced by 39%, compared with placebo. In addition, the treatment time for breakthrough infections decreased significantly, and prevention with OM-89 could even be started during acute therapy. Also recommended is parenteral immunostimulation with inactivated pathogens (StroVac). Acupuncture as cutaneous immunostimulation has also displayed a positive protective effect.

Only when nonantibiotic therapy fails and the patient is under a high amount of psychological strain should antibiotic prophylaxis be initiated, according to the authors. A period of 3-6 months should be the target here. When choosing an antibiotic and before starting therapy, the corresponding pathogen should be confirmed through a urine culture, and resistance testing should be performed. On the other hand, single-use, postcoital antibiotic prevention could be an alternative, particularly for women in whom a correlation between recurrent UTIs and sexual intercourse has been suspected, the authors wrote.

This article was translated from Univadis Germany. A version appeared on Medscape.com.

For those affected, recurrent urinary tract infections (UTIs) are sometimes stressful. However, even an informative discussion about risk factors and the imparting of behavioral recommendations can be very helpful for many women. Antibiotic prophylaxis should only be considered once all nonantibiotic therapy options have been exhausted.

One in seven women suffers at least once a year from cystitis. Around a third of those women develop a further urinary tract infection 6-12 months after the first infection. A urinary tract infection is classified as recurrent if two symptomatic episodes have occurred within the last 6 months or if three episodes have occurred within the last 12 months.

There are many different approaches to reducing the recurrence rate of urinary tract infections, Daniel Klussmann and Florian Wagenlehner, MD, of the department and outpatient clinic for urology at the University of Giessen (Germany) wrote in DMW Klinischer Fortschritt. Aside from general information and advice, nonantibiotic therapy options are particularly important for recurrence reduction, with the aim of preventing the development of resistance and the corresponding adverse effects of antibiotics.
 

Fluids and D-mannose

An individual consultation discussion is the most important nonantibiotic strategy. Studies have shown that this strategy alone can lower the frequency of recurrent UTIs. According to the authors, special education programs on the causes and behavioral measures are especially helpful. Included in these programs is the recommendation to drink a sufficient, but not excessive, amount of fluids: approximately 1.5 liters per day. In one randomized study, this level of consumption halved UTI frequency. However, drinking an excessive amount of fluids should also be avoided, otherwise the antimicrobial peptides present in the urine become overly diluted.

The regular consumption of fruit juice, especially of that from berries, is also beneficial, according to the authors. However, study results on long-term prevention using cranberry products are inconsistent, and they are not recommended in the updated guideline. Like cranberries, D-mannose also inhibits the fimbriae of the Escherichia coli bacteria and therefore the bacteria’s ability to bind to the bladder epithelium. The authors cite a study in which, following the intake of 2 g of D-mannose dissolved in a glass of water every day, the rate of urinary tract infections dropped significantly, compared with consumption of placebo.

Additional recommendations in the S3 guideline include various phytotherapeutic products such as bearberry leaves, nasturtium herb, or horseradish root, although studies on the comparability of phytotherapeutic agents are very difficult to execute, the authors conceded.

It is already known that there is a positive correlation (by a factor of 60) between the recurrence rate of UTIs and the frequency of sexual intercourse. Even with contraceptive methods (such as vaginal suppositories, diaphragms or condoms coated with spermicide, and intrauterine devices), the risk of urinary tract infections increases by a factor of 2-14. Sexual abstinence, even if temporary, can be a remedy. Evidence for the recommendation to urinate immediately after coitus is contradictory in the literature, however. Excessive intimate hygiene clearly damages the local protective environment.
 

Estrogen substitution beneficial

For postmenopausal women, there is also the option of local estriol substitution (0.5 mg/day) as another nonantibiotic method of prophylaxis. This treatment serves as therapy for vaginal atrophy and reduces both vaginal colonization with uropathogens and the vaginal pH level. The authors cite Scandinavian studies that detected no increase in the risk of breast cancer from the local application of estriol.

Furthermore, the current guidelines recommend oral immunostimulation with bacterial cell wall components from uropathogenic strains of E. coli (OM-89, Uro-Vaxom). The authors reported on two meta-studies in which the average recurrence rate was reduced by 39%, compared with placebo. In addition, the treatment time for breakthrough infections decreased significantly, and prevention with OM-89 could even be started during acute therapy. Also recommended is parenteral immunostimulation with inactivated pathogens (StroVac). Acupuncture as cutaneous immunostimulation has also displayed a positive protective effect.

Only when nonantibiotic therapy fails and the patient is under a high amount of psychological strain should antibiotic prophylaxis be initiated, according to the authors. A period of 3-6 months should be the target here. When choosing an antibiotic and before starting therapy, the corresponding pathogen should be confirmed through a urine culture, and resistance testing should be performed. On the other hand, single-use, postcoital antibiotic prevention could be an alternative, particularly for women in whom a correlation between recurrent UTIs and sexual intercourse has been suspected, the authors wrote.

This article was translated from Univadis Germany. A version appeared on Medscape.com.

For devout Muslims, praying multiple times a day is a lifelong observance and a core aspect of their faith. But osteoarthritis of the knee (KOA) can make kneeling and prostration challenging. To address this problem in an aging U.S. Muslim population, a multicenter team developed literature-based guidelines published online in Arthritis & Rheumatology.

In an interview, corresponding author Mahfujul Z. Haque, a medical student at Michigan State University, Grand Rapids, discussed the guide, which he assembled with Marina N. Magrey, MD, the Ronald Moskowitz Professor of Rheumatology at Case Western Reserve University, Cleveland, and orthopedic surgeon Karl C. Roberts, MD, president of West Michigan Orthopaedics in Grand Rapids, among others.

Could you detail the clinical and cultural context for these recommendations?

Mr. Haque: Muslims currently make up 1.1% of the U.S. population, or 3.45 million people. This guidance provides advice to Muslim patients with KOA in a culturally sensitive manner that can supplement standard care. Prayer, or Salah, is a religious obligation typically performed in 17-48 daily repetitions of squatting, floor sitting, full-knee flexion, and kneeling. For patients with KOA, prayer can be painful, and a few studies have found a link between these repeated movements and KOA progression.

Carlina Teteris/Moment/Getty Images

Yet recommending stopping or limiting prayer is insensitive, so our group did a thorough literature search to identify easily implemented and culturally appropriate ways to ease praying.

Is there a traditional preference for praying on a hard surface?

Mr. Haque: Prayer can be performed on any surface that is clean and free from impurities. Cushioned and carpeted surfaces are permissible if the surface is somewhat firm and supportive for when worshippers prostrate themselves and put their faces on the ground. For example, compacted snow that wouldn’t allow the face to sink into it is permissible, but snow that is soft and would allow the face to sink in is not.

Have an increasing number of older patients raised the issue of knee pain during prayers?

Mr. Haque: We found no research on this in the literature. Anecdotally, however, two of our authors lead prayer in large Muslim communities in Detroit, and people often share with them that they feel discomfort during prayer and ask if there is anything they can do to limit this.

It is important to dispel the common myth that after total knee replacement one cannot kneel. About 20% of patients have some anterior knee discomfort after total knee arthroplasty, which can be exacerbated by kneeling, but kneeling causes no harm and can be done safely.

Could you outline the main recommendations?

Mr. Haque: These fall under three main categories: prayer surface, mechanics, and lifestyle modifications. The surface recommendations essentially advise using prayer rugs that provide cushioning or using cushioned kneepads.

The mechanics recommendations involve bracing with the palms down, standing up using the hands and knees, and guiding prayer motions with the hands. Chairs may be used as well.

Lifestyle recommendations outline home-exercise programs tailored to KOA and suggest the use of ice and compression during acute exacerbations.

Could these recommendations benefit other arthritic joints such as the wrists?

Mr. Haque: Anecdotally, our authors do not hear about pain in joints except for the knee and spine. To a limited extent, some of these recommendations may help patients with spinal arthritis as well.

What do you see as the greatest obstacle to implementation?

Mr. Haque: These recommendations, although permissible in the Muslim faith, are not part of traditional ritual and thus patients may simply forget to implement them. We advise physicians to ask patients which recommendations they are most likely to follow and to monitor how these have worked for them.

What is your best overall advice for broaching this issue with patients?

Mr. Haque: Holistic, functional, and culturally sensitive recommendations will be highly appreciated. Physicians are therefore encouraged to share this guidance with Muslim patients while using terms such as Salah, pronounced saa-laah, and Sajdah, pronounced sajduh and meaning prostration, and engage in a healthy dialogue.

These guidelines received no funding. The authors disclosed no competing interests relevant to their recommendations, but Dr. Magrey reported consulting and research relationships with private-sector companies outside of this work.

For devout Muslims, praying multiple times a day is a lifelong observance and a core aspect of their faith. But osteoarthritis of the knee (KOA) can make kneeling and prostration challenging. To address this problem in an aging U.S. Muslim population, a multicenter team developed literature-based guidelines published online in Arthritis & Rheumatology.

In an interview, corresponding author Mahfujul Z. Haque, a medical student at Michigan State University, Grand Rapids, discussed the guide, which he assembled with Marina N. Magrey, MD, the Ronald Moskowitz Professor of Rheumatology at Case Western Reserve University, Cleveland, and orthopedic surgeon Karl C. Roberts, MD, president of West Michigan Orthopaedics in Grand Rapids, among others.

Could you detail the clinical and cultural context for these recommendations?

Mr. Haque: Muslims currently make up 1.1% of the U.S. population, or 3.45 million people. This guidance provides advice to Muslim patients with KOA in a culturally sensitive manner that can supplement standard care. Prayer, or Salah, is a religious obligation typically performed in 17-48 daily repetitions of squatting, floor sitting, full-knee flexion, and kneeling. For patients with KOA, prayer can be painful, and a few studies have found a link between these repeated movements and KOA progression.

Carlina Teteris/Moment/Getty Images

Yet recommending stopping or limiting prayer is insensitive, so our group did a thorough literature search to identify easily implemented and culturally appropriate ways to ease praying.

Is there a traditional preference for praying on a hard surface?

Mr. Haque: Prayer can be performed on any surface that is clean and free from impurities. Cushioned and carpeted surfaces are permissible if the surface is somewhat firm and supportive for when worshippers prostrate themselves and put their faces on the ground. For example, compacted snow that wouldn’t allow the face to sink into it is permissible, but snow that is soft and would allow the face to sink in is not.

Have an increasing number of older patients raised the issue of knee pain during prayers?

Mr. Haque: We found no research on this in the literature. Anecdotally, however, two of our authors lead prayer in large Muslim communities in Detroit, and people often share with them that they feel discomfort during prayer and ask if there is anything they can do to limit this.

It is important to dispel the common myth that after total knee replacement one cannot kneel. About 20% of patients have some anterior knee discomfort after total knee arthroplasty, which can be exacerbated by kneeling, but kneeling causes no harm and can be done safely.

Could you outline the main recommendations?

Mr. Haque: These fall under three main categories: prayer surface, mechanics, and lifestyle modifications. The surface recommendations essentially advise using prayer rugs that provide cushioning or using cushioned kneepads.

The mechanics recommendations involve bracing with the palms down, standing up using the hands and knees, and guiding prayer motions with the hands. Chairs may be used as well.

Lifestyle recommendations outline home-exercise programs tailored to KOA and suggest the use of ice and compression during acute exacerbations.

Could these recommendations benefit other arthritic joints such as the wrists?

Mr. Haque: Anecdotally, our authors do not hear about pain in joints except for the knee and spine. To a limited extent, some of these recommendations may help patients with spinal arthritis as well.

What do you see as the greatest obstacle to implementation?

Mr. Haque: These recommendations, although permissible in the Muslim faith, are not part of traditional ritual and thus patients may simply forget to implement them. We advise physicians to ask patients which recommendations they are most likely to follow and to monitor how these have worked for them.

What is your best overall advice for broaching this issue with patients?

Mr. Haque: Holistic, functional, and culturally sensitive recommendations will be highly appreciated. Physicians are therefore encouraged to share this guidance with Muslim patients while using terms such as Salah, pronounced saa-laah, and Sajdah, pronounced sajduh and meaning prostration, and engage in a healthy dialogue.

These guidelines received no funding. The authors disclosed no competing interests relevant to their recommendations, but Dr. Magrey reported consulting and research relationships with private-sector companies outside of this work.

For devout Muslims, praying multiple times a day is a lifelong observance and a core aspect of their faith. But osteoarthritis of the knee (KOA) can make kneeling and prostration challenging. To address this problem in an aging U.S. Muslim population, a multicenter team developed literature-based guidelines published online in Arthritis & Rheumatology.

In an interview, corresponding author Mahfujul Z. Haque, a medical student at Michigan State University, Grand Rapids, discussed the guide, which he assembled with Marina N. Magrey, MD, the Ronald Moskowitz Professor of Rheumatology at Case Western Reserve University, Cleveland, and orthopedic surgeon Karl C. Roberts, MD, president of West Michigan Orthopaedics in Grand Rapids, among others.

Could you detail the clinical and cultural context for these recommendations?

Mr. Haque: Muslims currently make up 1.1% of the U.S. population, or 3.45 million people. This guidance provides advice to Muslim patients with KOA in a culturally sensitive manner that can supplement standard care. Prayer, or Salah, is a religious obligation typically performed in 17-48 daily repetitions of squatting, floor sitting, full-knee flexion, and kneeling. For patients with KOA, prayer can be painful, and a few studies have found a link between these repeated movements and KOA progression.

Carlina Teteris/Moment/Getty Images

Yet recommending stopping or limiting prayer is insensitive, so our group did a thorough literature search to identify easily implemented and culturally appropriate ways to ease praying.

Is there a traditional preference for praying on a hard surface?

Mr. Haque: Prayer can be performed on any surface that is clean and free from impurities. Cushioned and carpeted surfaces are permissible if the surface is somewhat firm and supportive for when worshippers prostrate themselves and put their faces on the ground. For example, compacted snow that wouldn’t allow the face to sink into it is permissible, but snow that is soft and would allow the face to sink in is not.

Have an increasing number of older patients raised the issue of knee pain during prayers?

Mr. Haque: We found no research on this in the literature. Anecdotally, however, two of our authors lead prayer in large Muslim communities in Detroit, and people often share with them that they feel discomfort during prayer and ask if there is anything they can do to limit this.

It is important to dispel the common myth that after total knee replacement one cannot kneel. About 20% of patients have some anterior knee discomfort after total knee arthroplasty, which can be exacerbated by kneeling, but kneeling causes no harm and can be done safely.

Could you outline the main recommendations?

Mr. Haque: These fall under three main categories: prayer surface, mechanics, and lifestyle modifications. The surface recommendations essentially advise using prayer rugs that provide cushioning or using cushioned kneepads.

The mechanics recommendations involve bracing with the palms down, standing up using the hands and knees, and guiding prayer motions with the hands. Chairs may be used as well.

Lifestyle recommendations outline home-exercise programs tailored to KOA and suggest the use of ice and compression during acute exacerbations.

Could these recommendations benefit other arthritic joints such as the wrists?

Mr. Haque: Anecdotally, our authors do not hear about pain in joints except for the knee and spine. To a limited extent, some of these recommendations may help patients with spinal arthritis as well.

What do you see as the greatest obstacle to implementation?

Mr. Haque: These recommendations, although permissible in the Muslim faith, are not part of traditional ritual and thus patients may simply forget to implement them. We advise physicians to ask patients which recommendations they are most likely to follow and to monitor how these have worked for them.

What is your best overall advice for broaching this issue with patients?

Mr. Haque: Holistic, functional, and culturally sensitive recommendations will be highly appreciated. Physicians are therefore encouraged to share this guidance with Muslim patients while using terms such as Salah, pronounced saa-laah, and Sajdah, pronounced sajduh and meaning prostration, and engage in a healthy dialogue.

These guidelines received no funding. The authors disclosed no competing interests relevant to their recommendations, but Dr. Magrey reported consulting and research relationships with private-sector companies outside of this work.

Patients with the systemic sclerosis subtype of pulmonary arterial hypertension showed a distinctive bioactive metabolic profile associated with more severe disease than other subgroups, based on data from approximately 1,500 individuals.

The overall prognosis and therapeutic response for patients with pulmonary arterial hypertension associated with systemic sclerosis (SSc-PAH) tends to be worse than for patients with other types of PAH, such as idiopathic pulmonary arterial hypertension (IPAH), but the impact of different metabolite profiles among subtypes of disease has not been explored, wrote Mona Alotaibi, MD, of the University of California, San Diego, and colleagues.

“Recently, metabolic dysregulation has been proposed as a key mechanism by which IPAH and SSc-PAH differ and could control such disparities,” they noted. Clarifying the molecular mechanisms of SSc-PAH could inform management and treatment, they added.

In a study published in the journal Chest, the researchers sought to identify a bioactive lipid signature unique to SSc-PAH. They identified 400 patients with SSc-PAH and 1,082 with IPAH. An additional 100 patients with scleroderma but no PH and 44 patients with scleroderma who had PH were included for external validation. The mean ages of the patients with IPAH and SSc-PAH in the discovery and validation cohorts ranged from approximately 51 to 65 years; more than 75% of patients across the groups were women.

The researchers tested more than 700 bioactive lipid metabolites using liquid chromatography/mass spectrometry. They found five metabolites that distinguished SSc-PAH and IPAH that were significantly associated with markers of disease severity: 17-beta estradiol, novel Eic, nervonic acid, fatty acid esters of hydroxy fatty acids, and prostaglandin F2 alpha (PGF 2 alpha).

The biomarkers were increased in SSc-PAH patients compared to patients with SSC alone, which suggests that the biomarkers are related to PAH and not to scleroderma alone, the researchers noted.

In particular, nervonic acid was associated with worse functional capacity, in SSc-PAH patients, as were higher levels of 17-beta estradiol and prostaglandin F2 alpha. Also, 17-beta estradiol was associated with lower cardiac impairment (CI) and stroke volume index (SVI) in SSc-PAH patients, but higher SVI in IPAH patients. PGF 2 alpha was associated with lower CI and SVI and higher pulmonary vascular resistance in SSc-PAH and IPAH combined.

The study findings were limited by several factors including the inability to adjust for all potential confounders between IPAH and SSc-PAH, and the fact that a clear causal relationship could not be determined, the researchers noted. Inadequate statistical power to analyze SSc-PAH data was another limitation, and studies with detailed scleroderma phenotypes are needed to validate the results, they said.

However, the current study provides insight on the metabolic differences in SSc-PAH and the potential impact on disease pathology that may inform diagnosis, prognosis, and treatment strategies for SSc-PAH patients, they concluded.

The study was supported by the National Institutes of Health. Several individual investigators received support from organizations including the American Heart Association and the Chest Foundation, and from companies including Livanova, Equillium, Corvus, Bayer, and Actelion, but the authors had no relevant financial conflicts to disclose.

Patients with the systemic sclerosis subtype of pulmonary arterial hypertension showed a distinctive bioactive metabolic profile associated with more severe disease than other subgroups, based on data from approximately 1,500 individuals.

The overall prognosis and therapeutic response for patients with pulmonary arterial hypertension associated with systemic sclerosis (SSc-PAH) tends to be worse than for patients with other types of PAH, such as idiopathic pulmonary arterial hypertension (IPAH), but the impact of different metabolite profiles among subtypes of disease has not been explored, wrote Mona Alotaibi, MD, of the University of California, San Diego, and colleagues.

“Recently, metabolic dysregulation has been proposed as a key mechanism by which IPAH and SSc-PAH differ and could control such disparities,” they noted. Clarifying the molecular mechanisms of SSc-PAH could inform management and treatment, they added.

In a study published in the journal Chest, the researchers sought to identify a bioactive lipid signature unique to SSc-PAH. They identified 400 patients with SSc-PAH and 1,082 with IPAH. An additional 100 patients with scleroderma but no PH and 44 patients with scleroderma who had PH were included for external validation. The mean ages of the patients with IPAH and SSc-PAH in the discovery and validation cohorts ranged from approximately 51 to 65 years; more than 75% of patients across the groups were women.

The researchers tested more than 700 bioactive lipid metabolites using liquid chromatography/mass spectrometry. They found five metabolites that distinguished SSc-PAH and IPAH that were significantly associated with markers of disease severity: 17-beta estradiol, novel Eic, nervonic acid, fatty acid esters of hydroxy fatty acids, and prostaglandin F2 alpha (PGF 2 alpha).

The biomarkers were increased in SSc-PAH patients compared to patients with SSC alone, which suggests that the biomarkers are related to PAH and not to scleroderma alone, the researchers noted.

In particular, nervonic acid was associated with worse functional capacity, in SSc-PAH patients, as were higher levels of 17-beta estradiol and prostaglandin F2 alpha. Also, 17-beta estradiol was associated with lower cardiac impairment (CI) and stroke volume index (SVI) in SSc-PAH patients, but higher SVI in IPAH patients. PGF 2 alpha was associated with lower CI and SVI and higher pulmonary vascular resistance in SSc-PAH and IPAH combined.

The study findings were limited by several factors including the inability to adjust for all potential confounders between IPAH and SSc-PAH, and the fact that a clear causal relationship could not be determined, the researchers noted. Inadequate statistical power to analyze SSc-PAH data was another limitation, and studies with detailed scleroderma phenotypes are needed to validate the results, they said.

However, the current study provides insight on the metabolic differences in SSc-PAH and the potential impact on disease pathology that may inform diagnosis, prognosis, and treatment strategies for SSc-PAH patients, they concluded.

The study was supported by the National Institutes of Health. Several individual investigators received support from organizations including the American Heart Association and the Chest Foundation, and from companies including Livanova, Equillium, Corvus, Bayer, and Actelion, but the authors had no relevant financial conflicts to disclose.

Patients with the systemic sclerosis subtype of pulmonary arterial hypertension showed a distinctive bioactive metabolic profile associated with more severe disease than other subgroups, based on data from approximately 1,500 individuals.

The overall prognosis and therapeutic response for patients with pulmonary arterial hypertension associated with systemic sclerosis (SSc-PAH) tends to be worse than for patients with other types of PAH, such as idiopathic pulmonary arterial hypertension (IPAH), but the impact of different metabolite profiles among subtypes of disease has not been explored, wrote Mona Alotaibi, MD, of the University of California, San Diego, and colleagues.

“Recently, metabolic dysregulation has been proposed as a key mechanism by which IPAH and SSc-PAH differ and could control such disparities,” they noted. Clarifying the molecular mechanisms of SSc-PAH could inform management and treatment, they added.

In a study published in the journal Chest, the researchers sought to identify a bioactive lipid signature unique to SSc-PAH. They identified 400 patients with SSc-PAH and 1,082 with IPAH. An additional 100 patients with scleroderma but no PH and 44 patients with scleroderma who had PH were included for external validation. The mean ages of the patients with IPAH and SSc-PAH in the discovery and validation cohorts ranged from approximately 51 to 65 years; more than 75% of patients across the groups were women.

The researchers tested more than 700 bioactive lipid metabolites using liquid chromatography/mass spectrometry. They found five metabolites that distinguished SSc-PAH and IPAH that were significantly associated with markers of disease severity: 17-beta estradiol, novel Eic, nervonic acid, fatty acid esters of hydroxy fatty acids, and prostaglandin F2 alpha (PGF 2 alpha).

The biomarkers were increased in SSc-PAH patients compared to patients with SSC alone, which suggests that the biomarkers are related to PAH and not to scleroderma alone, the researchers noted.

In particular, nervonic acid was associated with worse functional capacity, in SSc-PAH patients, as were higher levels of 17-beta estradiol and prostaglandin F2 alpha. Also, 17-beta estradiol was associated with lower cardiac impairment (CI) and stroke volume index (SVI) in SSc-PAH patients, but higher SVI in IPAH patients. PGF 2 alpha was associated with lower CI and SVI and higher pulmonary vascular resistance in SSc-PAH and IPAH combined.

The study findings were limited by several factors including the inability to adjust for all potential confounders between IPAH and SSc-PAH, and the fact that a clear causal relationship could not be determined, the researchers noted. Inadequate statistical power to analyze SSc-PAH data was another limitation, and studies with detailed scleroderma phenotypes are needed to validate the results, they said.

However, the current study provides insight on the metabolic differences in SSc-PAH and the potential impact on disease pathology that may inform diagnosis, prognosis, and treatment strategies for SSc-PAH patients, they concluded.

The study was supported by the National Institutes of Health. Several individual investigators received support from organizations including the American Heart Association and the Chest Foundation, and from companies including Livanova, Equillium, Corvus, Bayer, and Actelion, but the authors had no relevant financial conflicts to disclose.

Dementia and mild cognitive impairment (MCI) disproportionately affect Black and Hispanic individuals, as well as people with less education, based on new U.S. data from The Health and Retirement Study (HRS).

These inequities likely stem from structural racism and income inequality, necessitating a multifaceted response at an institutional level, according to lead author Jennifer J. Manly, PhD, a professor of neuropsychology in neurology at the Gertrude H. Sergievsky Center and the Taub Institute for Research in Aging and Alzheimer’s Disease at Columbia University, New York.
 

A more representative dataset

Between 2001 and 2003, a subset of HRS participants underwent extensive neuropsychological assessment in the Aging, Demographics, and Memory Study (ADAMS), providing data which have since been cited by hundreds of published studies, the investigators wrote in JAMA Neurology. Those data, however, failed to accurately represent the U.S. population at the time, and have not been updated since.

“The ADAMS substudy was small, and the limited inclusion of Black, Hispanic, and American Indian or Alaska Native participants contributed to lack of precision of estimates among minoritized racial and ethnic groups that have been shown to experience a higher burden of cognitive impairment and dementia,” Dr. Manly and colleagues wrote.

The present analysis used a more representative dataset from HRS participants who were 65 years or older in 2016. From June 2016 to October 2017, 3,496 of these individuals underwent comprehensive neuropsychological test battery and informant interview, with dementia and MCI classified based on standard diagnostic criteria.

In total, 393 people were classified with dementia (10%), while 804 had MCI (22%), both of which approximate estimates reported by previous studies, according to the investigators. In further alignment with past research, age was a clear risk factor; each 5-year increment added 17% and 95% increased risk of MCI and dementia, respectively.

Compared with college-educated participants, individuals who did not graduate from high school had a 60% increased risk for both dementia (odds ratio, 1.6; 95% confidence interval, 1.1-2.3) and MCI (OR, 1.6; 95% CI, 1.2-2.2). Other educational strata were not associated with significant differences in risk.

Compared with White participants, Black individuals had an 80% increased risk of dementia (OR, 1.8; 95% CI, 1.2-2.7), but no increased risk of MCI. Conversely, non-White Hispanic individuals had a 40% increased risk of MCI (OR, 1.4; 95% CI, 1.0-2.0), but no increased risk of dementia, compared with White participants.

“Older adults racialized as Black and Hispanic are more likely to develop cognitive impairment and dementia because of historical and current structural racism and income inequality that restrict access to brain-health benefits and increase exposure to harm,” Dr. Manly said in a written comment.

These inequities deserve a comprehensive response, she added.

“Actions and policies that decrease discriminatory and aggressive policing policies, invest in schools that serve children that are racialized as Black and Hispanic, repair housing and economic inequalities, and provide equitable access to mental and physical health, can help to narrow disparities in later life cognitive impairment,” Dr. Manly said. “Two other areas of focus for policy makers are the shortage in the workforce of dementia care specialists, and paid family leave for caregiving.”
 

Acknowledging the needs of the historically underrepresented

Lealani Mae Acosta, MD, MPH, associate professor of neurology at Vanderbilt University Medical Center, Nashville, Tenn., applauded the investigators for their “conscious effort to expand representation of historically underrepresented minorities.”

The findings themselves support what has been previously reported, Dr. Acosta said in an interview, including the disproportionate burden of cognitive disorders among people of color and those with less education.

Clinicians need to recognize that certain patient groups face increased risks of cognitive disorders, and should be screened accordingly, Dr. Acosta said, noting that all aging patients should undergo such screening. The push for screening should also occur on a community level, along with efforts to build trust between at-risk populations and health care providers.

While Dr. Acosta reiterated the importance of these new data from Black and Hispanic individuals, she noted that gaps in representation remain, and methods of characterizing populations deserve refinement.

“I’m a little bit biased because I’m an Asian physician,” Dr. Acosta said. “As much as I’m glad that they’re highlighting these different disparities, there weren’t enough [participants in] specific subgroups like American Indian or Alaska Native, Asian, Native Hawaiian or Pacific Islander, to be able to identify specific trends within [those groups] that are, again, historically underrepresented patient populations.”

Grouping all people of Asian descent may also be an oversimplification, she added, as differences may exist between individuals originating from different countries.

“We always have to be careful about lumping certain groups together in analyses,” Dr. Acosta said. “That’s just another reminder to us – as clinicians, as researchers – that we need to do better by our patients by expanding research opportunities, and really studying these historically underrepresented populations.”

The study was supported by the National Institute on Aging. The investigators disclosed additional relationships with the Alzheimer’s Association and the National Institutes of Health. Dr. Acosta reported no relevant competing interests.

Dementia and mild cognitive impairment (MCI) disproportionately affect Black and Hispanic individuals, as well as people with less education, based on new U.S. data from The Health and Retirement Study (HRS).

These inequities likely stem from structural racism and income inequality, necessitating a multifaceted response at an institutional level, according to lead author Jennifer J. Manly, PhD, a professor of neuropsychology in neurology at the Gertrude H. Sergievsky Center and the Taub Institute for Research in Aging and Alzheimer’s Disease at Columbia University, New York.
 

A more representative dataset

Between 2001 and 2003, a subset of HRS participants underwent extensive neuropsychological assessment in the Aging, Demographics, and Memory Study (ADAMS), providing data which have since been cited by hundreds of published studies, the investigators wrote in JAMA Neurology. Those data, however, failed to accurately represent the U.S. population at the time, and have not been updated since.

“The ADAMS substudy was small, and the limited inclusion of Black, Hispanic, and American Indian or Alaska Native participants contributed to lack of precision of estimates among minoritized racial and ethnic groups that have been shown to experience a higher burden of cognitive impairment and dementia,” Dr. Manly and colleagues wrote.

The present analysis used a more representative dataset from HRS participants who were 65 years or older in 2016. From June 2016 to October 2017, 3,496 of these individuals underwent comprehensive neuropsychological test battery and informant interview, with dementia and MCI classified based on standard diagnostic criteria.

In total, 393 people were classified with dementia (10%), while 804 had MCI (22%), both of which approximate estimates reported by previous studies, according to the investigators. In further alignment with past research, age was a clear risk factor; each 5-year increment added 17% and 95% increased risk of MCI and dementia, respectively.

Compared with college-educated participants, individuals who did not graduate from high school had a 60% increased risk for both dementia (odds ratio, 1.6; 95% confidence interval, 1.1-2.3) and MCI (OR, 1.6; 95% CI, 1.2-2.2). Other educational strata were not associated with significant differences in risk.

Compared with White participants, Black individuals had an 80% increased risk of dementia (OR, 1.8; 95% CI, 1.2-2.7), but no increased risk of MCI. Conversely, non-White Hispanic individuals had a 40% increased risk of MCI (OR, 1.4; 95% CI, 1.0-2.0), but no increased risk of dementia, compared with White participants.

“Older adults racialized as Black and Hispanic are more likely to develop cognitive impairment and dementia because of historical and current structural racism and income inequality that restrict access to brain-health benefits and increase exposure to harm,” Dr. Manly said in a written comment.

These inequities deserve a comprehensive response, she added.

“Actions and policies that decrease discriminatory and aggressive policing policies, invest in schools that serve children that are racialized as Black and Hispanic, repair housing and economic inequalities, and provide equitable access to mental and physical health, can help to narrow disparities in later life cognitive impairment,” Dr. Manly said. “Two other areas of focus for policy makers are the shortage in the workforce of dementia care specialists, and paid family leave for caregiving.”
 

Acknowledging the needs of the historically underrepresented

Lealani Mae Acosta, MD, MPH, associate professor of neurology at Vanderbilt University Medical Center, Nashville, Tenn., applauded the investigators for their “conscious effort to expand representation of historically underrepresented minorities.”

The findings themselves support what has been previously reported, Dr. Acosta said in an interview, including the disproportionate burden of cognitive disorders among people of color and those with less education.

Clinicians need to recognize that certain patient groups face increased risks of cognitive disorders, and should be screened accordingly, Dr. Acosta said, noting that all aging patients should undergo such screening. The push for screening should also occur on a community level, along with efforts to build trust between at-risk populations and health care providers.

While Dr. Acosta reiterated the importance of these new data from Black and Hispanic individuals, she noted that gaps in representation remain, and methods of characterizing populations deserve refinement.

“I’m a little bit biased because I’m an Asian physician,” Dr. Acosta said. “As much as I’m glad that they’re highlighting these different disparities, there weren’t enough [participants in] specific subgroups like American Indian or Alaska Native, Asian, Native Hawaiian or Pacific Islander, to be able to identify specific trends within [those groups] that are, again, historically underrepresented patient populations.”

Grouping all people of Asian descent may also be an oversimplification, she added, as differences may exist between individuals originating from different countries.

“We always have to be careful about lumping certain groups together in analyses,” Dr. Acosta said. “That’s just another reminder to us – as clinicians, as researchers – that we need to do better by our patients by expanding research opportunities, and really studying these historically underrepresented populations.”

The study was supported by the National Institute on Aging. The investigators disclosed additional relationships with the Alzheimer’s Association and the National Institutes of Health. Dr. Acosta reported no relevant competing interests.

Dementia and mild cognitive impairment (MCI) disproportionately affect Black and Hispanic individuals, as well as people with less education, based on new U.S. data from The Health and Retirement Study (HRS).

These inequities likely stem from structural racism and income inequality, necessitating a multifaceted response at an institutional level, according to lead author Jennifer J. Manly, PhD, a professor of neuropsychology in neurology at the Gertrude H. Sergievsky Center and the Taub Institute for Research in Aging and Alzheimer’s Disease at Columbia University, New York.
 

A more representative dataset

Between 2001 and 2003, a subset of HRS participants underwent extensive neuropsychological assessment in the Aging, Demographics, and Memory Study (ADAMS), providing data which have since been cited by hundreds of published studies, the investigators wrote in JAMA Neurology. Those data, however, failed to accurately represent the U.S. population at the time, and have not been updated since.

“The ADAMS substudy was small, and the limited inclusion of Black, Hispanic, and American Indian or Alaska Native participants contributed to lack of precision of estimates among minoritized racial and ethnic groups that have been shown to experience a higher burden of cognitive impairment and dementia,” Dr. Manly and colleagues wrote.

The present analysis used a more representative dataset from HRS participants who were 65 years or older in 2016. From June 2016 to October 2017, 3,496 of these individuals underwent comprehensive neuropsychological test battery and informant interview, with dementia and MCI classified based on standard diagnostic criteria.

In total, 393 people were classified with dementia (10%), while 804 had MCI (22%), both of which approximate estimates reported by previous studies, according to the investigators. In further alignment with past research, age was a clear risk factor; each 5-year increment added 17% and 95% increased risk of MCI and dementia, respectively.

Compared with college-educated participants, individuals who did not graduate from high school had a 60% increased risk for both dementia (odds ratio, 1.6; 95% confidence interval, 1.1-2.3) and MCI (OR, 1.6; 95% CI, 1.2-2.2). Other educational strata were not associated with significant differences in risk.

Compared with White participants, Black individuals had an 80% increased risk of dementia (OR, 1.8; 95% CI, 1.2-2.7), but no increased risk of MCI. Conversely, non-White Hispanic individuals had a 40% increased risk of MCI (OR, 1.4; 95% CI, 1.0-2.0), but no increased risk of dementia, compared with White participants.

“Older adults racialized as Black and Hispanic are more likely to develop cognitive impairment and dementia because of historical and current structural racism and income inequality that restrict access to brain-health benefits and increase exposure to harm,” Dr. Manly said in a written comment.

These inequities deserve a comprehensive response, she added.

“Actions and policies that decrease discriminatory and aggressive policing policies, invest in schools that serve children that are racialized as Black and Hispanic, repair housing and economic inequalities, and provide equitable access to mental and physical health, can help to narrow disparities in later life cognitive impairment,” Dr. Manly said. “Two other areas of focus for policy makers are the shortage in the workforce of dementia care specialists, and paid family leave for caregiving.”
 

Acknowledging the needs of the historically underrepresented

Lealani Mae Acosta, MD, MPH, associate professor of neurology at Vanderbilt University Medical Center, Nashville, Tenn., applauded the investigators for their “conscious effort to expand representation of historically underrepresented minorities.”

The findings themselves support what has been previously reported, Dr. Acosta said in an interview, including the disproportionate burden of cognitive disorders among people of color and those with less education.

Clinicians need to recognize that certain patient groups face increased risks of cognitive disorders, and should be screened accordingly, Dr. Acosta said, noting that all aging patients should undergo such screening. The push for screening should also occur on a community level, along with efforts to build trust between at-risk populations and health care providers.

While Dr. Acosta reiterated the importance of these new data from Black and Hispanic individuals, she noted that gaps in representation remain, and methods of characterizing populations deserve refinement.

“I’m a little bit biased because I’m an Asian physician,” Dr. Acosta said. “As much as I’m glad that they’re highlighting these different disparities, there weren’t enough [participants in] specific subgroups like American Indian or Alaska Native, Asian, Native Hawaiian or Pacific Islander, to be able to identify specific trends within [those groups] that are, again, historically underrepresented patient populations.”

Grouping all people of Asian descent may also be an oversimplification, she added, as differences may exist between individuals originating from different countries.

“We always have to be careful about lumping certain groups together in analyses,” Dr. Acosta said. “That’s just another reminder to us – as clinicians, as researchers – that we need to do better by our patients by expanding research opportunities, and really studying these historically underrepresented populations.”

The study was supported by the National Institute on Aging. The investigators disclosed additional relationships with the Alzheimer’s Association and the National Institutes of Health. Dr. Acosta reported no relevant competing interests.

VIENNA – The production of estrogen in the thalamus appears to be curtailed by just one dose of nicotine, equivalent to that in a cigarette, reveals a whole brain analysis of healthy women in the first study of its kind.

The findings were presented at the 35th European College of Neuropsychopharmacology (ECNP) Congress.

The researchers performed both MRI and positron emission tomography (PET) scans in 10 healthy women using a tracer that binds to aromatase, also known as estrogen synthase.

They found that, following an intranasal spray delivering 1 mg of nicotine, there was a significant reduction in estrogen synthase in both the right and left thalamus.

“For the first time, we can see that nicotine works to shut down the estrogen production mechanism in the brains of women,” said lead researcher Erika Comasco, PhD, department of neuroscience, Uppsala University, Sweden, in a release.

“We were surprised to see that this effect could be seen even with a single dose of nicotine, equivalent to just one cigarette, showing how powerful the effects of smoking are on a woman’s brain.”

Emphasizing the preliminary nature of the study and the need for a larger sample, she added: “We’re still not sure what the behavioral or cognitive outcomes are, only that nicotine acts on this area of the brain.

“However, we note that the affected brain system is a target for addictive drugs, such as nicotine.”

Previous research has revealed that women are less successful at quitting smoking than men, and appear to be more resistant to nicotine replacement therapy, and experience more relapses.

There is evidence to suggest that there is a complex interaction between sex and steroid hormones and the reward effect of nicotine, modulated by the dopaminergic system.

Moreover, women who smoke enter menopause earlier than nonsmokers, and have lower plasma estrogen levels, Dr. Camasco told this news organization.

Dr. Comasco explained that “besides its role in reproductive function and sexual behavior, estrogen has an impact on the brain wherever there are receptors, which is basically regions that are related to emotional regulation, cognitive function, and so on.”

Estrogen, she continued, has two main mechanisms of action, via dopaminergic and serotonergic signaling. However, levels of the hormone cannot be measured directly in the brain.

The researchers therefore turned to estrogen synthase, which regulates the synthesis of estrogen, and is highly expressed in the limbic system, a brain region associated with addiction.

Moreover, estrogen synthase levels can be measured in vivo, and previous animal studies have indicated that nicotine inhibits estrogen synthase.

To investigate its impact in humans, the researchers performed structural MRI and two ¹¹C-cetrozole PET scans in 10 healthy women.

The assessments were performed before and after the nasal administration of 1 mg of nicotine, the dose contained in one cigarette, via two sprays of a nasal spray each containing 0.5 mg of nicotine.

A whole brain analysis was then used to determine changes in nondisplaceable binding potential of ¹¹C-cetrozole to estrogen synthase between the two scans to indicate the availability of the enzyme at the two time points.

The results showed that, at baseline, high availability of estrogen synthase was observed in the thalamus, hypothalamus, and amygdala, with the highest levels in the right and left thalamus.

However, nicotine exposure was associated with a significant reduction in estrogen binding bilaterally in the thalamus when averaged across the participants (P < .01).

Region-of-interest analysis using within-individual voxel-wise comparison confirmed reduced estrogen synthase levels in both the right and left thalamus (P < .05), as well as in the subthalamic area.

Next, Dr. Comasco would like to test the impact of nicotine on estrogen synthase in men.

While men have lower levels of estrogen then women, “the reaction will take place anyway,” she said, although the “impact would be different.”

She would also like to look at the behavioral effects of reductions in estrogen synthase, and look at the effect of nicotine from a functional point of view.

Wim van den Brink, MD, PhD, professor of psychiatry and addiction at the Academic Medical Center, University of Amsterdam, commented that this is an “important first finding.”

“Smoking has many adverse effects in men and in women, but this particular effect of nicotine on the reduction of estrogen production in women was not known before,” he added in the release.

However, he underlined that tobacco addition is a “complex disorder” and it is “unlikely that this specific effect of nicotine on the thalamus explains all the observed differences in the development, treatment, and outcomes between male and female smokers.”

“It is still a long way from a nicotine-induced reduction in estrogen production to a reduced risk of nicotine addiction and negative effects of treatment and relapse in female cigarette smokers, but this work merits further investigation,” Dr. van den Brink said.

The study was funded by the Science for Life Laboratory/Uppsala University.

No relevant financial relationships were declared.

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

VIENNA – The production of estrogen in the thalamus appears to be curtailed by just one dose of nicotine, equivalent to that in a cigarette, reveals a whole brain analysis of healthy women in the first study of its kind.

The findings were presented at the 35th European College of Neuropsychopharmacology (ECNP) Congress.

The researchers performed both MRI and positron emission tomography (PET) scans in 10 healthy women using a tracer that binds to aromatase, also known as estrogen synthase.

They found that, following an intranasal spray delivering 1 mg of nicotine, there was a significant reduction in estrogen synthase in both the right and left thalamus.

“For the first time, we can see that nicotine works to shut down the estrogen production mechanism in the brains of women,” said lead researcher Erika Comasco, PhD, department of neuroscience, Uppsala University, Sweden, in a release.

“We were surprised to see that this effect could be seen even with a single dose of nicotine, equivalent to just one cigarette, showing how powerful the effects of smoking are on a woman’s brain.”

Emphasizing the preliminary nature of the study and the need for a larger sample, she added: “We’re still not sure what the behavioral or cognitive outcomes are, only that nicotine acts on this area of the brain.

“However, we note that the affected brain system is a target for addictive drugs, such as nicotine.”

Previous research has revealed that women are less successful at quitting smoking than men, and appear to be more resistant to nicotine replacement therapy, and experience more relapses.

There is evidence to suggest that there is a complex interaction between sex and steroid hormones and the reward effect of nicotine, modulated by the dopaminergic system.

Moreover, women who smoke enter menopause earlier than nonsmokers, and have lower plasma estrogen levels, Dr. Camasco told this news organization.

Dr. Comasco explained that “besides its role in reproductive function and sexual behavior, estrogen has an impact on the brain wherever there are receptors, which is basically regions that are related to emotional regulation, cognitive function, and so on.”

Estrogen, she continued, has two main mechanisms of action, via dopaminergic and serotonergic signaling. However, levels of the hormone cannot be measured directly in the brain.

The researchers therefore turned to estrogen synthase, which regulates the synthesis of estrogen, and is highly expressed in the limbic system, a brain region associated with addiction.

Moreover, estrogen synthase levels can be measured in vivo, and previous animal studies have indicated that nicotine inhibits estrogen synthase.

To investigate its impact in humans, the researchers performed structural MRI and two ¹¹C-cetrozole PET scans in 10 healthy women.

The assessments were performed before and after the nasal administration of 1 mg of nicotine, the dose contained in one cigarette, via two sprays of a nasal spray each containing 0.5 mg of nicotine.

A whole brain analysis was then used to determine changes in nondisplaceable binding potential of ¹¹C-cetrozole to estrogen synthase between the two scans to indicate the availability of the enzyme at the two time points.

The results showed that, at baseline, high availability of estrogen synthase was observed in the thalamus, hypothalamus, and amygdala, with the highest levels in the right and left thalamus.

However, nicotine exposure was associated with a significant reduction in estrogen binding bilaterally in the thalamus when averaged across the participants (P < .01).

Region-of-interest analysis using within-individual voxel-wise comparison confirmed reduced estrogen synthase levels in both the right and left thalamus (P < .05), as well as in the subthalamic area.

Next, Dr. Comasco would like to test the impact of nicotine on estrogen synthase in men.

While men have lower levels of estrogen then women, “the reaction will take place anyway,” she said, although the “impact would be different.”

She would also like to look at the behavioral effects of reductions in estrogen synthase, and look at the effect of nicotine from a functional point of view.

Wim van den Brink, MD, PhD, professor of psychiatry and addiction at the Academic Medical Center, University of Amsterdam, commented that this is an “important first finding.”

“Smoking has many adverse effects in men and in women, but this particular effect of nicotine on the reduction of estrogen production in women was not known before,” he added in the release.

However, he underlined that tobacco addition is a “complex disorder” and it is “unlikely that this specific effect of nicotine on the thalamus explains all the observed differences in the development, treatment, and outcomes between male and female smokers.”

“It is still a long way from a nicotine-induced reduction in estrogen production to a reduced risk of nicotine addiction and negative effects of treatment and relapse in female cigarette smokers, but this work merits further investigation,” Dr. van den Brink said.

The study was funded by the Science for Life Laboratory/Uppsala University.

No relevant financial relationships were declared.

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

VIENNA – The production of estrogen in the thalamus appears to be curtailed by just one dose of nicotine, equivalent to that in a cigarette, reveals a whole brain analysis of healthy women in the first study of its kind.

The findings were presented at the 35th European College of Neuropsychopharmacology (ECNP) Congress.

The researchers performed both MRI and positron emission tomography (PET) scans in 10 healthy women using a tracer that binds to aromatase, also known as estrogen synthase.

They found that, following an intranasal spray delivering 1 mg of nicotine, there was a significant reduction in estrogen synthase in both the right and left thalamus.

“For the first time, we can see that nicotine works to shut down the estrogen production mechanism in the brains of women,” said lead researcher Erika Comasco, PhD, department of neuroscience, Uppsala University, Sweden, in a release.

“We were surprised to see that this effect could be seen even with a single dose of nicotine, equivalent to just one cigarette, showing how powerful the effects of smoking are on a woman’s brain.”

Emphasizing the preliminary nature of the study and the need for a larger sample, she added: “We’re still not sure what the behavioral or cognitive outcomes are, only that nicotine acts on this area of the brain.

“However, we note that the affected brain system is a target for addictive drugs, such as nicotine.”

Previous research has revealed that women are less successful at quitting smoking than men, and appear to be more resistant to nicotine replacement therapy, and experience more relapses.

There is evidence to suggest that there is a complex interaction between sex and steroid hormones and the reward effect of nicotine, modulated by the dopaminergic system.

Moreover, women who smoke enter menopause earlier than nonsmokers, and have lower plasma estrogen levels, Dr. Camasco told this news organization.

Dr. Comasco explained that “besides its role in reproductive function and sexual behavior, estrogen has an impact on the brain wherever there are receptors, which is basically regions that are related to emotional regulation, cognitive function, and so on.”

Estrogen, she continued, has two main mechanisms of action, via dopaminergic and serotonergic signaling. However, levels of the hormone cannot be measured directly in the brain.

The researchers therefore turned to estrogen synthase, which regulates the synthesis of estrogen, and is highly expressed in the limbic system, a brain region associated with addiction.

Moreover, estrogen synthase levels can be measured in vivo, and previous animal studies have indicated that nicotine inhibits estrogen synthase.

To investigate its impact in humans, the researchers performed structural MRI and two ¹¹C-cetrozole PET scans in 10 healthy women.

The assessments were performed before and after the nasal administration of 1 mg of nicotine, the dose contained in one cigarette, via two sprays of a nasal spray each containing 0.5 mg of nicotine.

A whole brain analysis was then used to determine changes in nondisplaceable binding potential of ¹¹C-cetrozole to estrogen synthase between the two scans to indicate the availability of the enzyme at the two time points.

The results showed that, at baseline, high availability of estrogen synthase was observed in the thalamus, hypothalamus, and amygdala, with the highest levels in the right and left thalamus.

However, nicotine exposure was associated with a significant reduction in estrogen binding bilaterally in the thalamus when averaged across the participants (P < .01).

Region-of-interest analysis using within-individual voxel-wise comparison confirmed reduced estrogen synthase levels in both the right and left thalamus (P < .05), as well as in the subthalamic area.

Next, Dr. Comasco would like to test the impact of nicotine on estrogen synthase in men.

While men have lower levels of estrogen then women, “the reaction will take place anyway,” she said, although the “impact would be different.”

She would also like to look at the behavioral effects of reductions in estrogen synthase, and look at the effect of nicotine from a functional point of view.

Wim van den Brink, MD, PhD, professor of psychiatry and addiction at the Academic Medical Center, University of Amsterdam, commented that this is an “important first finding.”

“Smoking has many adverse effects in men and in women, but this particular effect of nicotine on the reduction of estrogen production in women was not known before,” he added in the release.

However, he underlined that tobacco addition is a “complex disorder” and it is “unlikely that this specific effect of nicotine on the thalamus explains all the observed differences in the development, treatment, and outcomes between male and female smokers.”

“It is still a long way from a nicotine-induced reduction in estrogen production to a reduced risk of nicotine addiction and negative effects of treatment and relapse in female cigarette smokers, but this work merits further investigation,” Dr. van den Brink said.

The study was funded by the Science for Life Laboratory/Uppsala University.

No relevant financial relationships were declared.

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

Visits to emergency departments following sexual assault increased 15-fold from 2006 through 2019, as determined from a national database of visits to hospitals in the United States.

Data from the Federal Bureau of Investigation show an increase in reported rapes and sexual assaults (SAs) since 2006, and studies of victims show an increased risk of conditions such as suicidal ideation, PTSD, depression, substance use, and chronic conditions, write Emily L. Vogt of the University of Michigan, Ann Arbor, and colleagues.

However, trends and disparities in ED use by adults seeking care following SA have not been explored, they said.

For a study that was published in JAMA Network Open, researchers reviewed data from the Nationwide Emergency Department Sample (NEDS), a large, nationally representative database managed by the Agency for Healthcare Research and Quality. The dataset consisted of 120 million to 143 million weighted ED visits reported annually from 2006 through 2016. The study population included adults aged 18-65 years who had made an ED visit that was recorded in the NEDS and that was coded as an SA. SA was defined using ICD-9 codes until the fourth quarter of 2015, at which time ICD-10 codes came into use.

Overall, the number of SA-related ED visits increased by 1,533.0% during the study period, from 3,607 in 2006 to 55,296 in 2019. The average annual percentage change was 23.0% (P < .001). The greatest increase occurred from 2015 to 2016, when annual visits increased from 17,709 to 47,732. This increase likely reflected the updated ICD-10 codes, in which there are categories for suspected adult rape, confirmed adult rape, and adult forced sexual exploitation, the researchers note.

Patients presenting to the ED after an SA were mainly women (91.5%). Individuals aged 18-25 years accounted for nearly half of the presentations. Individuals in the lowest and second-lowest income quartiles also were overrepresented.

Despite the increased presentation to EDs, admission rates for SA decreased, from 12.6% to 4.3%, the researchers note. Patients who were older and were insured through Medicaid were more likely to be admitted than persons of other demographic groups.

The researchers also found that increases in ED presentations outpaced increases in SA reports to law enforcement. They compared the ED trends with FBI-reported rapes/SAs from 2015 to 2019 and found increases of 7% and 22% during the times of ICD-9 and ICD-10 codes, respectively. However, in 2019, the number of SA survivors who sought ED care remained below the number who reported to law enforcement (55,296 vs. 139,815, as determined on the basis of revised SA definitions).

“Although the association between increased coding specificity and documentation of SA is still unclear, ICD-10 likely contributed to increased ED documentation of SA,” but the data show steady increases that are independent of the coding change, the researchers write.

The study findings were limited by several factors, including the potential for multiple representations of patients, coding errors associated with the NEDS database, and the reliance on voluntary reports in the NEDS and FBI datasets, the researchers note. The results were strengthened by the large, diverse sample size and by the inclusion of hospital admissions and crime data for comparison, they say.

“As few as 21% of survivors seek medical care after SA, meaning that the survivors captured in this study represent a fraction of total SA-related care need,” the researchers write. “Our finding that most SA ED visits are by young, female, and low-income survivors can inform policy changes to better support these individuals,” which could include the development of outpatient and longitudinal care settings to better serve these populations, they conclude.

Better understanding not only of the trends underlying SA reporting but also of the demographics of survivors who seek treatment and evaluation after SA is vital, said Robert Glatter, MD, in an interview.

“Being able to better understand how social and societal movements affect a patient’s comfort in reporting an SA is vital in tracking the numbers of people who seek care in the ED,” said Dr. Glatter, an emergency medicine physician at Lenox Hill Hospital at Northwell Health, New York, and also of Hofstra University, Hempstead, N.Y.

Dr. Glatter said he was not surprised by the significant increase in sexual assault presentations, especially in light of increased awareness and the influence of the #MeToo movement and other social justice movements over the past decade.

“While I believe that victims of sexual violence may now feel more empowered to report an assault, the volume of SA that go unreported remains a serious public health issue and concern” in the United States and globally, he emphasized.

A key message from the current study is that there is a need for investment in “compassionate and comprehensive care for all survivors of SA,” Dr. Glatter said. “This includes recognition of the extensive mental health consequences of SA that can lead to not only depression, PTSD, and anxiety but also to suicidal ideation and suicide. The longer-term medical effects become life altering, permeating families and future generations,” he emphasized.

“As a society, we must also place a strong emphasis on caring for all SA survivors, but particularly those who come from economically or socially disadvantaged backgrounds who are uninsured or underinsured,” Dr. Glatter said. Issues of race, gender identity, and sexual identity among SA survivors also must be taken into consideration, he added.

“We need to better understand how our health care system can provide more nuanced follow-up care and reporting for survivors in outpatient settings. … Making access easier, while ensuring confidentiality, will allow more survivors of SA to seek treatment and care,” he said. “We also need to understand how using forensic nurses in this capacity, and beyond the ED, can better serve minority and racially diverse communities” and to increase the recruitment and training of such specialized nurses to care for SA victims, Dr. Glatter noted.

The study was supported by internal funding from the University of Michigan and the department of obstetrics and gynecology. Corresponding author Erica C. Marsh, MD, has received personal fees from Myovant Sciences and Pfizer unrelated to the current study. Dr. Glatter has disclosed no relevant financial relationships.

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

Visits to emergency departments following sexual assault increased 15-fold from 2006 through 2019, as determined from a national database of visits to hospitals in the United States.

Data from the Federal Bureau of Investigation show an increase in reported rapes and sexual assaults (SAs) since 2006, and studies of victims show an increased risk of conditions such as suicidal ideation, PTSD, depression, substance use, and chronic conditions, write Emily L. Vogt of the University of Michigan, Ann Arbor, and colleagues.

However, trends and disparities in ED use by adults seeking care following SA have not been explored, they said.

For a study that was published in JAMA Network Open, researchers reviewed data from the Nationwide Emergency Department Sample (NEDS), a large, nationally representative database managed by the Agency for Healthcare Research and Quality. The dataset consisted of 120 million to 143 million weighted ED visits reported annually from 2006 through 2016. The study population included adults aged 18-65 years who had made an ED visit that was recorded in the NEDS and that was coded as an SA. SA was defined using ICD-9 codes until the fourth quarter of 2015, at which time ICD-10 codes came into use.

Overall, the number of SA-related ED visits increased by 1,533.0% during the study period, from 3,607 in 2006 to 55,296 in 2019. The average annual percentage change was 23.0% (P < .001). The greatest increase occurred from 2015 to 2016, when annual visits increased from 17,709 to 47,732. This increase likely reflected the updated ICD-10 codes, in which there are categories for suspected adult rape, confirmed adult rape, and adult forced sexual exploitation, the researchers note.

Patients presenting to the ED after an SA were mainly women (91.5%). Individuals aged 18-25 years accounted for nearly half of the presentations. Individuals in the lowest and second-lowest income quartiles also were overrepresented.

Despite the increased presentation to EDs, admission rates for SA decreased, from 12.6% to 4.3%, the researchers note. Patients who were older and were insured through Medicaid were more likely to be admitted than persons of other demographic groups.

The researchers also found that increases in ED presentations outpaced increases in SA reports to law enforcement. They compared the ED trends with FBI-reported rapes/SAs from 2015 to 2019 and found increases of 7% and 22% during the times of ICD-9 and ICD-10 codes, respectively. However, in 2019, the number of SA survivors who sought ED care remained below the number who reported to law enforcement (55,296 vs. 139,815, as determined on the basis of revised SA definitions).

“Although the association between increased coding specificity and documentation of SA is still unclear, ICD-10 likely contributed to increased ED documentation of SA,” but the data show steady increases that are independent of the coding change, the researchers write.

The study findings were limited by several factors, including the potential for multiple representations of patients, coding errors associated with the NEDS database, and the reliance on voluntary reports in the NEDS and FBI datasets, the researchers note. The results were strengthened by the large, diverse sample size and by the inclusion of hospital admissions and crime data for comparison, they say.

“As few as 21% of survivors seek medical care after SA, meaning that the survivors captured in this study represent a fraction of total SA-related care need,” the researchers write. “Our finding that most SA ED visits are by young, female, and low-income survivors can inform policy changes to better support these individuals,” which could include the development of outpatient and longitudinal care settings to better serve these populations, they conclude.

Better understanding not only of the trends underlying SA reporting but also of the demographics of survivors who seek treatment and evaluation after SA is vital, said Robert Glatter, MD, in an interview.

“Being able to better understand how social and societal movements affect a patient’s comfort in reporting an SA is vital in tracking the numbers of people who seek care in the ED,” said Dr. Glatter, an emergency medicine physician at Lenox Hill Hospital at Northwell Health, New York, and also of Hofstra University, Hempstead, N.Y.

Dr. Glatter said he was not surprised by the significant increase in sexual assault presentations, especially in light of increased awareness and the influence of the #MeToo movement and other social justice movements over the past decade.

“While I believe that victims of sexual violence may now feel more empowered to report an assault, the volume of SA that go unreported remains a serious public health issue and concern” in the United States and globally, he emphasized.

A key message from the current study is that there is a need for investment in “compassionate and comprehensive care for all survivors of SA,” Dr. Glatter said. “This includes recognition of the extensive mental health consequences of SA that can lead to not only depression, PTSD, and anxiety but also to suicidal ideation and suicide. The longer-term medical effects become life altering, permeating families and future generations,” he emphasized.

“As a society, we must also place a strong emphasis on caring for all SA survivors, but particularly those who come from economically or socially disadvantaged backgrounds who are uninsured or underinsured,” Dr. Glatter said. Issues of race, gender identity, and sexual identity among SA survivors also must be taken into consideration, he added.

“We need to better understand how our health care system can provide more nuanced follow-up care and reporting for survivors in outpatient settings. … Making access easier, while ensuring confidentiality, will allow more survivors of SA to seek treatment and care,” he said. “We also need to understand how using forensic nurses in this capacity, and beyond the ED, can better serve minority and racially diverse communities” and to increase the recruitment and training of such specialized nurses to care for SA victims, Dr. Glatter noted.

The study was supported by internal funding from the University of Michigan and the department of obstetrics and gynecology. Corresponding author Erica C. Marsh, MD, has received personal fees from Myovant Sciences and Pfizer unrelated to the current study. Dr. Glatter has disclosed no relevant financial relationships.

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

Visits to emergency departments following sexual assault increased 15-fold from 2006 through 2019, as determined from a national database of visits to hospitals in the United States.

Data from the Federal Bureau of Investigation show an increase in reported rapes and sexual assaults (SAs) since 2006, and studies of victims show an increased risk of conditions such as suicidal ideation, PTSD, depression, substance use, and chronic conditions, write Emily L. Vogt of the University of Michigan, Ann Arbor, and colleagues.

However, trends and disparities in ED use by adults seeking care following SA have not been explored, they said.

For a study that was published in JAMA Network Open, researchers reviewed data from the Nationwide Emergency Department Sample (NEDS), a large, nationally representative database managed by the Agency for Healthcare Research and Quality. The dataset consisted of 120 million to 143 million weighted ED visits reported annually from 2006 through 2016. The study population included adults aged 18-65 years who had made an ED visit that was recorded in the NEDS and that was coded as an SA. SA was defined using ICD-9 codes until the fourth quarter of 2015, at which time ICD-10 codes came into use.

Overall, the number of SA-related ED visits increased by 1,533.0% during the study period, from 3,607 in 2006 to 55,296 in 2019. The average annual percentage change was 23.0% (P < .001). The greatest increase occurred from 2015 to 2016, when annual visits increased from 17,709 to 47,732. This increase likely reflected the updated ICD-10 codes, in which there are categories for suspected adult rape, confirmed adult rape, and adult forced sexual exploitation, the researchers note.

Patients presenting to the ED after an SA were mainly women (91.5%). Individuals aged 18-25 years accounted for nearly half of the presentations. Individuals in the lowest and second-lowest income quartiles also were overrepresented.

Despite the increased presentation to EDs, admission rates for SA decreased, from 12.6% to 4.3%, the researchers note. Patients who were older and were insured through Medicaid were more likely to be admitted than persons of other demographic groups.

The researchers also found that increases in ED presentations outpaced increases in SA reports to law enforcement. They compared the ED trends with FBI-reported rapes/SAs from 2015 to 2019 and found increases of 7% and 22% during the times of ICD-9 and ICD-10 codes, respectively. However, in 2019, the number of SA survivors who sought ED care remained below the number who reported to law enforcement (55,296 vs. 139,815, as determined on the basis of revised SA definitions).

“Although the association between increased coding specificity and documentation of SA is still unclear, ICD-10 likely contributed to increased ED documentation of SA,” but the data show steady increases that are independent of the coding change, the researchers write.

The study findings were limited by several factors, including the potential for multiple representations of patients, coding errors associated with the NEDS database, and the reliance on voluntary reports in the NEDS and FBI datasets, the researchers note. The results were strengthened by the large, diverse sample size and by the inclusion of hospital admissions and crime data for comparison, they say.

“As few as 21% of survivors seek medical care after SA, meaning that the survivors captured in this study represent a fraction of total SA-related care need,” the researchers write. “Our finding that most SA ED visits are by young, female, and low-income survivors can inform policy changes to better support these individuals,” which could include the development of outpatient and longitudinal care settings to better serve these populations, they conclude.

Better understanding not only of the trends underlying SA reporting but also of the demographics of survivors who seek treatment and evaluation after SA is vital, said Robert Glatter, MD, in an interview.

“Being able to better understand how social and societal movements affect a patient’s comfort in reporting an SA is vital in tracking the numbers of people who seek care in the ED,” said Dr. Glatter, an emergency medicine physician at Lenox Hill Hospital at Northwell Health, New York, and also of Hofstra University, Hempstead, N.Y.

Dr. Glatter said he was not surprised by the significant increase in sexual assault presentations, especially in light of increased awareness and the influence of the #MeToo movement and other social justice movements over the past decade.

“While I believe that victims of sexual violence may now feel more empowered to report an assault, the volume of SA that go unreported remains a serious public health issue and concern” in the United States and globally, he emphasized.

A key message from the current study is that there is a need for investment in “compassionate and comprehensive care for all survivors of SA,” Dr. Glatter said. “This includes recognition of the extensive mental health consequences of SA that can lead to not only depression, PTSD, and anxiety but also to suicidal ideation and suicide. The longer-term medical effects become life altering, permeating families and future generations,” he emphasized.

“As a society, we must also place a strong emphasis on caring for all SA survivors, but particularly those who come from economically or socially disadvantaged backgrounds who are uninsured or underinsured,” Dr. Glatter said. Issues of race, gender identity, and sexual identity among SA survivors also must be taken into consideration, he added.

“We need to better understand how our health care system can provide more nuanced follow-up care and reporting for survivors in outpatient settings. … Making access easier, while ensuring confidentiality, will allow more survivors of SA to seek treatment and care,” he said. “We also need to understand how using forensic nurses in this capacity, and beyond the ED, can better serve minority and racially diverse communities” and to increase the recruitment and training of such specialized nurses to care for SA victims, Dr. Glatter noted.

The study was supported by internal funding from the University of Michigan and the department of obstetrics and gynecology. Corresponding author Erica C. Marsh, MD, has received personal fees from Myovant Sciences and Pfizer unrelated to the current study. Dr. Glatter has disclosed no relevant financial relationships.

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

ObesityWeek 2022 is the largest international conference on obesity, with over 100 sessions, and coincides with the 40th anniversary of the Obesity Society. Being held Nov. 1-4, it is a hybrid meeting that participants can attend onsite in sunny San Diego or virtually.
 

“The meeting offers a wide perspective, from basic science, all the way to public policy on studies of treatment and prevention of obesity,” program planning chair for ObesityWeek, Kelly C. Allison, PhD, said in an interview.

Rodrigo Cuel/Thinkstock

The Presidential Plenary session on Nov. 1 will kick off the meeting with “a series of 10-minute rapid talks on cutting-edge topics in the field,” noted Dr. Allison, who is also director, Center for Weight and Eating Disorders, Hospital of the University of Pennsylvania, and professor of psychiatry, University of Pennsylvania, both in Philadelphia.

Among others, Ania M. Jastreboff, MD, PhD, will speak about “New developments in anti-obesity pharmacotherapy,” and Theodore K. Kyle, RPh, MBA, will discuss “Reducing barriers to treatment: Insurance coverage.”

“We’re seeing some pretty effective antiobesity medication, but still they are not being covered by many insurances,” said Dr. Allison. Some clinicians might be hesitant to prescribe antiobesity medications, remembering older drugs that were pulled from the market for health concerns, and some patients may also have concerns, she speculated. There is a need for greater education about the current antiobesity drugs.

In his presidential address, Dan Bessesen, MD, professor of medicine at the University of Colorado at Denver, Aurora, will discuss “Regulation of body weight and adaptive responses to weight loss.”

Pediatric obesity is a major focus of this year›s conference too, Allison noted.

At 8 a.m on Nov. 3, The Obesity Society, the World Obesity Federation, the European Association for the Study of Obesity, and Obesity Canada will present a joint symposium, “International innovations in pediatric obesity,” with speakers from Canada, Australia, and Ireland discussing ongoing paradigm shifts in the prevention and treatment of pediatric obesity.

Two hours later, at a joint symposium by the American Academy of Pediatrics/The Obesity Society, attendees will get a behind-the-scenes look at the making of the new AAP Obesity Clinical Practice Guideline for children and adolescents with obesity.

The conference tracks reflect the broad scope of this event: Track 1: Metabolism and Integrative Physiology; Track 2: Neuroscience; Track 3: Interventional and Clinical Studies; Track 4: Population Health; Track 5: Clinical/Professional Practice; Track 6: Policy/Public Health, and a subtrack: Eradicating Treatment Barriers.

Dr. Allison highlighted the following oral presentations and posters about antiobesity drugs:

• “Once-weekly subcutaneous semaglutide 2.4 mg in adolescents with overweight or obesity,” with an extended Q&A session, Nov. 2.
• “Clinical outcomes with medication use in tertiary pediatric weight management program,” by Enayet and colleagues. Poster 030.
• “The metabolically healthy obese paradigm and liver fat content in the Fels longitudinal study,” by Garza and colleagues Oral 055, Nov. 2.
• “Phase 3 clinical trial of metformin for treatment of COVID-19 in adults with overweight and obesity,” by Bramante and colleagues. Oral 067, Nov. 3. This trial was published in the  (N Engl J Med. 2022;387:599-610). 
• “Glucagon/GLP-1 receptor dual agonist BI 456906 reduces bodyweight in patients with type 2 diabetes,” by Rosenstock and colleagues. Oral-063, Nov. 3. 
• “A randomized controlled trial of naltrexone and bupropion and behavior therapy for binge-eating disorder,” by Grilo and colleagues. Oral 066, Nov. 3.

And on Nov. 4, researchers will present four oral abstracts about the dual glucose-dependent insulinotropic polypeptide and glucagonlike peptide–1 (GLP-1) receptor agonist tirzepatide (Mounjaro), which is approved for type 2 diabetes and now has fast track designation for weight loss from the Food and Drug Administration. Oral abstracts 109, 110, 111, and 112 cover weight loss with tirzepatide across different age groups, body mass indexes, and comorbidities, as well as quality of life.

Dr. Allison also highlighted the following presentations that cover other diverse topics:

• Family-based treatment: “Pilot study to inform a randomized controlled trial of HeLP: Obesity prevention & treatment for the entire Hispanic family,” by Haemer and colleagues. Oral 029. November 2.
• Bariatric surgery: “Long-term outcomes of laparoscopic sleeve gastrectomy from 2010-2016: A nationwide cohort study,” Oral 014. Nov. 2.
• Prevention/public health: “Impact of positive and negative front-of-package food labels in a randomized experiment,” by Grummon and colleagues. Oral 068. Nov. 3.
• Time-restricted eating: “Effects of 8-hour time restricted eating for weight loss over 12 months,” by Gabel and colleagues. Oral 102. Nov. 4.
• Patient management: “Identifying interprofessional drivers of practice gaps in the management of patients with obesity,” by Robinson and colleagues. Poster 055.

On Nov. 4, researchers will present five winning papers that will be published in the December issue of the Obesity journal about GLP-1 agonists versus bariatric surgery; monoacylglycerol O-acyltransferase 1 in mice; a behavioral weight-loss intervention; the Canberra Obesity Management Service; and macronutrient (im)balance in an obesogenic environment.

“I’m always excited to hear some talks that are outside of my comfort area to understand the mechanisms of obesity better,” concluded Dr. Allison.

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

ObesityWeek 2022 is the largest international conference on obesity, with over 100 sessions, and coincides with the 40th anniversary of the Obesity Society. Being held Nov. 1-4, it is a hybrid meeting that participants can attend onsite in sunny San Diego or virtually.
 

“The meeting offers a wide perspective, from basic science, all the way to public policy on studies of treatment and prevention of obesity,” program planning chair for ObesityWeek, Kelly C. Allison, PhD, said in an interview.

Rodrigo Cuel/Thinkstock

The Presidential Plenary session on Nov. 1 will kick off the meeting with “a series of 10-minute rapid talks on cutting-edge topics in the field,” noted Dr. Allison, who is also director, Center for Weight and Eating Disorders, Hospital of the University of Pennsylvania, and professor of psychiatry, University of Pennsylvania, both in Philadelphia.

Among others, Ania M. Jastreboff, MD, PhD, will speak about “New developments in anti-obesity pharmacotherapy,” and Theodore K. Kyle, RPh, MBA, will discuss “Reducing barriers to treatment: Insurance coverage.”

“We’re seeing some pretty effective antiobesity medication, but still they are not being covered by many insurances,” said Dr. Allison. Some clinicians might be hesitant to prescribe antiobesity medications, remembering older drugs that were pulled from the market for health concerns, and some patients may also have concerns, she speculated. There is a need for greater education about the current antiobesity drugs.

In his presidential address, Dan Bessesen, MD, professor of medicine at the University of Colorado at Denver, Aurora, will discuss “Regulation of body weight and adaptive responses to weight loss.”

Pediatric obesity is a major focus of this year›s conference too, Allison noted.

At 8 a.m on Nov. 3, The Obesity Society, the World Obesity Federation, the European Association for the Study of Obesity, and Obesity Canada will present a joint symposium, “International innovations in pediatric obesity,” with speakers from Canada, Australia, and Ireland discussing ongoing paradigm shifts in the prevention and treatment of pediatric obesity.

Two hours later, at a joint symposium by the American Academy of Pediatrics/The Obesity Society, attendees will get a behind-the-scenes look at the making of the new AAP Obesity Clinical Practice Guideline for children and adolescents with obesity.

The conference tracks reflect the broad scope of this event: Track 1: Metabolism and Integrative Physiology; Track 2: Neuroscience; Track 3: Interventional and Clinical Studies; Track 4: Population Health; Track 5: Clinical/Professional Practice; Track 6: Policy/Public Health, and a subtrack: Eradicating Treatment Barriers.

Dr. Allison highlighted the following oral presentations and posters about antiobesity drugs:

• “Once-weekly subcutaneous semaglutide 2.4 mg in adolescents with overweight or obesity,” with an extended Q&A session, Nov. 2.
• “Clinical outcomes with medication use in tertiary pediatric weight management program,” by Enayet and colleagues. Poster 030.
• “The metabolically healthy obese paradigm and liver fat content in the Fels longitudinal study,” by Garza and colleagues Oral 055, Nov. 2.
• “Phase 3 clinical trial of metformin for treatment of COVID-19 in adults with overweight and obesity,” by Bramante and colleagues. Oral 067, Nov. 3. This trial was published in the  (N Engl J Med. 2022;387:599-610). 
• “Glucagon/GLP-1 receptor dual agonist BI 456906 reduces bodyweight in patients with type 2 diabetes,” by Rosenstock and colleagues. Oral-063, Nov. 3. 
• “A randomized controlled trial of naltrexone and bupropion and behavior therapy for binge-eating disorder,” by Grilo and colleagues. Oral 066, Nov. 3.

And on Nov. 4, researchers will present four oral abstracts about the dual glucose-dependent insulinotropic polypeptide and glucagonlike peptide–1 (GLP-1) receptor agonist tirzepatide (Mounjaro), which is approved for type 2 diabetes and now has fast track designation for weight loss from the Food and Drug Administration. Oral abstracts 109, 110, 111, and 112 cover weight loss with tirzepatide across different age groups, body mass indexes, and comorbidities, as well as quality of life.

Dr. Allison also highlighted the following presentations that cover other diverse topics:

• Family-based treatment: “Pilot study to inform a randomized controlled trial of HeLP: Obesity prevention & treatment for the entire Hispanic family,” by Haemer and colleagues. Oral 029. November 2.
• Bariatric surgery: “Long-term outcomes of laparoscopic sleeve gastrectomy from 2010-2016: A nationwide cohort study,” Oral 014. Nov. 2.
• Prevention/public health: “Impact of positive and negative front-of-package food labels in a randomized experiment,” by Grummon and colleagues. Oral 068. Nov. 3.
• Time-restricted eating: “Effects of 8-hour time restricted eating for weight loss over 12 months,” by Gabel and colleagues. Oral 102. Nov. 4.
• Patient management: “Identifying interprofessional drivers of practice gaps in the management of patients with obesity,” by Robinson and colleagues. Poster 055.

On Nov. 4, researchers will present five winning papers that will be published in the December issue of the Obesity journal about GLP-1 agonists versus bariatric surgery; monoacylglycerol O-acyltransferase 1 in mice; a behavioral weight-loss intervention; the Canberra Obesity Management Service; and macronutrient (im)balance in an obesogenic environment.

“I’m always excited to hear some talks that are outside of my comfort area to understand the mechanisms of obesity better,” concluded Dr. Allison.

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

ObesityWeek 2022 is the largest international conference on obesity, with over 100 sessions, and coincides with the 40th anniversary of the Obesity Society. Being held Nov. 1-4, it is a hybrid meeting that participants can attend onsite in sunny San Diego or virtually.
 

“The meeting offers a wide perspective, from basic science, all the way to public policy on studies of treatment and prevention of obesity,” program planning chair for ObesityWeek, Kelly C. Allison, PhD, said in an interview.

Rodrigo Cuel/Thinkstock

The Presidential Plenary session on Nov. 1 will kick off the meeting with “a series of 10-minute rapid talks on cutting-edge topics in the field,” noted Dr. Allison, who is also director, Center for Weight and Eating Disorders, Hospital of the University of Pennsylvania, and professor of psychiatry, University of Pennsylvania, both in Philadelphia.

Among others, Ania M. Jastreboff, MD, PhD, will speak about “New developments in anti-obesity pharmacotherapy,” and Theodore K. Kyle, RPh, MBA, will discuss “Reducing barriers to treatment: Insurance coverage.”

“We’re seeing some pretty effective antiobesity medication, but still they are not being covered by many insurances,” said Dr. Allison. Some clinicians might be hesitant to prescribe antiobesity medications, remembering older drugs that were pulled from the market for health concerns, and some patients may also have concerns, she speculated. There is a need for greater education about the current antiobesity drugs.

In his presidential address, Dan Bessesen, MD, professor of medicine at the University of Colorado at Denver, Aurora, will discuss “Regulation of body weight and adaptive responses to weight loss.”

Pediatric obesity is a major focus of this year›s conference too, Allison noted.

At 8 a.m on Nov. 3, The Obesity Society, the World Obesity Federation, the European Association for the Study of Obesity, and Obesity Canada will present a joint symposium, “International innovations in pediatric obesity,” with speakers from Canada, Australia, and Ireland discussing ongoing paradigm shifts in the prevention and treatment of pediatric obesity.

Two hours later, at a joint symposium by the American Academy of Pediatrics/The Obesity Society, attendees will get a behind-the-scenes look at the making of the new AAP Obesity Clinical Practice Guideline for children and adolescents with obesity.

The conference tracks reflect the broad scope of this event: Track 1: Metabolism and Integrative Physiology; Track 2: Neuroscience; Track 3: Interventional and Clinical Studies; Track 4: Population Health; Track 5: Clinical/Professional Practice; Track 6: Policy/Public Health, and a subtrack: Eradicating Treatment Barriers.

Dr. Allison highlighted the following oral presentations and posters about antiobesity drugs:

• “Once-weekly subcutaneous semaglutide 2.4 mg in adolescents with overweight or obesity,” with an extended Q&A session, Nov. 2.
• “Clinical outcomes with medication use in tertiary pediatric weight management program,” by Enayet and colleagues. Poster 030.
• “The metabolically healthy obese paradigm and liver fat content in the Fels longitudinal study,” by Garza and colleagues Oral 055, Nov. 2.
• “Phase 3 clinical trial of metformin for treatment of COVID-19 in adults with overweight and obesity,” by Bramante and colleagues. Oral 067, Nov. 3. This trial was published in the  (N Engl J Med. 2022;387:599-610). 
• “Glucagon/GLP-1 receptor dual agonist BI 456906 reduces bodyweight in patients with type 2 diabetes,” by Rosenstock and colleagues. Oral-063, Nov. 3. 
• “A randomized controlled trial of naltrexone and bupropion and behavior therapy for binge-eating disorder,” by Grilo and colleagues. Oral 066, Nov. 3.

And on Nov. 4, researchers will present four oral abstracts about the dual glucose-dependent insulinotropic polypeptide and glucagonlike peptide–1 (GLP-1) receptor agonist tirzepatide (Mounjaro), which is approved for type 2 diabetes and now has fast track designation for weight loss from the Food and Drug Administration. Oral abstracts 109, 110, 111, and 112 cover weight loss with tirzepatide across different age groups, body mass indexes, and comorbidities, as well as quality of life.

Dr. Allison also highlighted the following presentations that cover other diverse topics:

• Family-based treatment: “Pilot study to inform a randomized controlled trial of HeLP: Obesity prevention & treatment for the entire Hispanic family,” by Haemer and colleagues. Oral 029. November 2.
• Bariatric surgery: “Long-term outcomes of laparoscopic sleeve gastrectomy from 2010-2016: A nationwide cohort study,” Oral 014. Nov. 2.
• Prevention/public health: “Impact of positive and negative front-of-package food labels in a randomized experiment,” by Grummon and colleagues. Oral 068. Nov. 3.
• Time-restricted eating: “Effects of 8-hour time restricted eating for weight loss over 12 months,” by Gabel and colleagues. Oral 102. Nov. 4.
• Patient management: “Identifying interprofessional drivers of practice gaps in the management of patients with obesity,” by Robinson and colleagues. Poster 055.

On Nov. 4, researchers will present five winning papers that will be published in the December issue of the Obesity journal about GLP-1 agonists versus bariatric surgery; monoacylglycerol O-acyltransferase 1 in mice; a behavioral weight-loss intervention; the Canberra Obesity Management Service; and macronutrient (im)balance in an obesogenic environment.

“I’m always excited to hear some talks that are outside of my comfort area to understand the mechanisms of obesity better,” concluded Dr. Allison.

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