In the November 2021 issue of Pediatric News are two stories that on the surface present viewpoints that couldn’t be more divergent. On page 1 under the headline “Gender dysphoria” you will read about a position statement by the Royal Australian and New Zealand College of Psychiatrists (RANZCP) in which they strongly recommend a mental health evaluation for any child or adolescent with gender dysphoria “before any firm decisions are made on whether to prescribe hormonal treatments to transition, or perform surgeries.”

On page 6 is another story titled “Gender-affirming care ‘can save lives’ new research shows” that reports on a research study in which transgender and binary young people who received a year of gender-affirming care experienced less depression and fewer suicidal thoughts. Dr. David J. Inwards-Breland, chief of adolescent and young adult medicine at Rady Children’s Hospital in San Diego and one of the authors of the study is quoted as saying “The younger we can provide gender-affirming care, the less likely [our patients are] to have depression and then negative outcomes.” One can’t avoid the impression that he is in favor of moving ahead without delay in prescribing gender-affirming care.

Where does the new recommendation by the RANZCP fit in with this sense of urgency? Does requiring a mental health evaluation constitute a delay in the institution of gender-affirming care that could increase the risk of negative mental health outcomes for gender dysphoric patients?

In one of the final paragraphs in the Pediatric News article one learns that Dr. Inwards-Breland would agree with the folks of RANZCP. He acknowledges that his study relied on screening and not diagnostic testing and says that “future studies should look at a mental health evaluation and diagnosis by a mental health provider.”

When we drill into the details there are two issues that demand clarification. First, what kind of time course are we talking about for a mental health evaluation? Are we talking weeks, or months, hopefully not years? This of course depends on the availability of mental health services for the specific patient and the depth of the evaluation required. How long a delay is acceptable?

Second, will the evaluation be performed by a provider free of bias? Can it be performed without creating the impression that the patient needs to see a mental health provider because there is something wrong with being trans and we can fix it? One would hope these evaluations would be performed in the spirit of wanting to learn more about the patient with the goal of making the process go more smoothly.

Listening to neighborhood discussions around the fire pit I find that the RANZCP plea for a broader and deeper look at each gender-dysphoric child strikes a chord with the general population. More and more people are realizing that gender-dysphoria happens and that for too long it was closeted with unfortunate consequences. However, there is a feeling, in fact one in which I share, that the rapid rise in its prevalence contains an element of social contagion. And, some irreversible decisions are being made without sufficient consideration. This may or not be a valid concern but it seems to me a thorough and sensitively done mental health evaluation might minimize the collateral damage from some gender-affirming care and at least help those patients for whom it is prescribed transition more smoothly.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].

In the November 2021 issue of Pediatric News are two stories that on the surface present viewpoints that couldn’t be more divergent. On page 1 under the headline “Gender dysphoria” you will read about a position statement by the Royal Australian and New Zealand College of Psychiatrists (RANZCP) in which they strongly recommend a mental health evaluation for any child or adolescent with gender dysphoria “before any firm decisions are made on whether to prescribe hormonal treatments to transition, or perform surgeries.”

On page 6 is another story titled “Gender-affirming care ‘can save lives’ new research shows” that reports on a research study in which transgender and binary young people who received a year of gender-affirming care experienced less depression and fewer suicidal thoughts. Dr. David J. Inwards-Breland, chief of adolescent and young adult medicine at Rady Children’s Hospital in San Diego and one of the authors of the study is quoted as saying “The younger we can provide gender-affirming care, the less likely [our patients are] to have depression and then negative outcomes.” One can’t avoid the impression that he is in favor of moving ahead without delay in prescribing gender-affirming care.

Where does the new recommendation by the RANZCP fit in with this sense of urgency? Does requiring a mental health evaluation constitute a delay in the institution of gender-affirming care that could increase the risk of negative mental health outcomes for gender dysphoric patients?

In one of the final paragraphs in the Pediatric News article one learns that Dr. Inwards-Breland would agree with the folks of RANZCP. He acknowledges that his study relied on screening and not diagnostic testing and says that “future studies should look at a mental health evaluation and diagnosis by a mental health provider.”

When we drill into the details there are two issues that demand clarification. First, what kind of time course are we talking about for a mental health evaluation? Are we talking weeks, or months, hopefully not years? This of course depends on the availability of mental health services for the specific patient and the depth of the evaluation required. How long a delay is acceptable?

Second, will the evaluation be performed by a provider free of bias? Can it be performed without creating the impression that the patient needs to see a mental health provider because there is something wrong with being trans and we can fix it? One would hope these evaluations would be performed in the spirit of wanting to learn more about the patient with the goal of making the process go more smoothly.

Listening to neighborhood discussions around the fire pit I find that the RANZCP plea for a broader and deeper look at each gender-dysphoric child strikes a chord with the general population. More and more people are realizing that gender-dysphoria happens and that for too long it was closeted with unfortunate consequences. However, there is a feeling, in fact one in which I share, that the rapid rise in its prevalence contains an element of social contagion. And, some irreversible decisions are being made without sufficient consideration. This may or not be a valid concern but it seems to me a thorough and sensitively done mental health evaluation might minimize the collateral damage from some gender-affirming care and at least help those patients for whom it is prescribed transition more smoothly.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].

In the November 2021 issue of Pediatric News are two stories that on the surface present viewpoints that couldn’t be more divergent. On page 1 under the headline “Gender dysphoria” you will read about a position statement by the Royal Australian and New Zealand College of Psychiatrists (RANZCP) in which they strongly recommend a mental health evaluation for any child or adolescent with gender dysphoria “before any firm decisions are made on whether to prescribe hormonal treatments to transition, or perform surgeries.”

On page 6 is another story titled “Gender-affirming care ‘can save lives’ new research shows” that reports on a research study in which transgender and binary young people who received a year of gender-affirming care experienced less depression and fewer suicidal thoughts. Dr. David J. Inwards-Breland, chief of adolescent and young adult medicine at Rady Children’s Hospital in San Diego and one of the authors of the study is quoted as saying “The younger we can provide gender-affirming care, the less likely [our patients are] to have depression and then negative outcomes.” One can’t avoid the impression that he is in favor of moving ahead without delay in prescribing gender-affirming care.

Where does the new recommendation by the RANZCP fit in with this sense of urgency? Does requiring a mental health evaluation constitute a delay in the institution of gender-affirming care that could increase the risk of negative mental health outcomes for gender dysphoric patients?

In one of the final paragraphs in the Pediatric News article one learns that Dr. Inwards-Breland would agree with the folks of RANZCP. He acknowledges that his study relied on screening and not diagnostic testing and says that “future studies should look at a mental health evaluation and diagnosis by a mental health provider.”

When we drill into the details there are two issues that demand clarification. First, what kind of time course are we talking about for a mental health evaluation? Are we talking weeks, or months, hopefully not years? This of course depends on the availability of mental health services for the specific patient and the depth of the evaluation required. How long a delay is acceptable?

Second, will the evaluation be performed by a provider free of bias? Can it be performed without creating the impression that the patient needs to see a mental health provider because there is something wrong with being trans and we can fix it? One would hope these evaluations would be performed in the spirit of wanting to learn more about the patient with the goal of making the process go more smoothly.

Listening to neighborhood discussions around the fire pit I find that the RANZCP plea for a broader and deeper look at each gender-dysphoric child strikes a chord with the general population. More and more people are realizing that gender-dysphoria happens and that for too long it was closeted with unfortunate consequences. However, there is a feeling, in fact one in which I share, that the rapid rise in its prevalence contains an element of social contagion. And, some irreversible decisions are being made without sufficient consideration. This may or not be a valid concern but it seems to me a thorough and sensitively done mental health evaluation might minimize the collateral damage from some gender-affirming care and at least help those patients for whom it is prescribed transition more smoothly.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].

An artificial intelligence (AI) system called “ENDOANGEL” was effective for real-time monitoring of endoscopic “blind spots” and improved detection of early gastric cancer (EGC) during esophagogastroduodenoscopy (EGD), according to research published recently.

Science Photo Library/SCIEPRO/Brand X Pictures

While EGD is widely used to examine lesions found in the upper gastrointestinal tract, there is considerable variability among endoscopists regarding performance, resulting in a substantial miss rate for EGC. But in a study published in the journal Endoscopy, researchers suggest a more objective assessment of lesions with AI technology could improve detection rates in real time, thus improving the chances of establishing an early diagnosis and initiating prompt treatment of gastric cancer.

The researchers updated a developed AI system called WISENSE, which previously demonstrated an ability to monitor gastric areas overlooked during EGD (termed “blind spots”). The investigators integrated a trained real-time EGC detection model into the WISENSE system and changed the name of the updated system to ENDOANGEL.

Researchers from the Renmin Hospital of Wuhan (China) University used deep convolutional neural networks and deep reinforcement learning to develop the ENDOANGEL. A total of 1,050 patients from five hospitals in China who were undergoing EGD were randomized to either an ENDOANGEL-assisted protocol (n = 498) or a control group (n = 504) that did not use the ENDOANGEL system. Examination consisted of white-light imaging observation, magnifying image-enhanced endoscopy observation, and biopsy of suspicious lesions.

The investigators compared the groups in terms of the number of blind spots after the intervention. They assessed the performance of the AI-based ENDOANGEL system in its ability to predict EGC in a real-world clinical setting.

Patients assigned to ENDOANGEL had a significantly fewer mean number of blind spots compared with patients assigned to control (5.38 vs. 9.82, respectively; P < .001). Despite this advantage, patients in the ENDOANGEL group had significantly longer inspection time (5.40 minutes vs. 4.38 minutes; P < .001).

There were 819 lesions reported by endoscopists in the ENDOANGEL group, which included 196 gastric lesions with pathological results. According to the investigators, the ENDOANGEL system correctly predicted all three EGCs, including one mucosal carcinoma and two high grade neoplasias, as well as two advanced gastric cancers. The per-lesion accuracy was 84.7 %, while the sensitivity and specificity rates for detecting gastric cancer were 100% and 84.3%, respectively.

The authors noted limitations of the analysis itself and those stemming from the short follow-up, as well as possible bias introduced by unblinded statisticians. Further research is warranted, they wrote.

“In conclusion, ENDOANGEL, a system for improving endoscopy quality based on deep learning, achieved real-time monitoring of endoscopic blind spots, timing, and EGC detection during EGD,” according to the authors. “ENDOANGEL greatly improved the quality of EGD in this multicenter study, and showed potential for detecting EGC in real clinical settings.”
 

Spotting the blind spots

An AI-based system such as ENDOANGEL could overcome some of the natural weaknesses to standard diagnostic testing, thereby improving rates of EGC testing, David Hoffman, MD, a gastroenterology oncologist and medical director of Cedars-Sinai Cancer Beverly Hills, said in an interview. “I think that there are ethical questions that we’re going to have to grapple with respect to accessibility and data mining and what that really means,” said Dr. Hoffman, who wasn’t involved in the study. “But I think that in the optimistic view, using AI with machine learning and deep learning has tremendous potential for public health and for cancer medicine in particular.”

Dr. Hoffman added that beyond early detection of cancer, AI systems may hold additional benefits, particularly in regard to assisting decisions for personalized medicine and assisting in real-time surgical interventions. “Using AI with machine learning and deep learning has tremendous potential and I think it sort of is a natural offshoot into what we’re seeing in ... algorithmic approaches to use of big data, so it’s sort of a natural evolution in terms of medical applications,” he explained.

Anuj Patel, MD, a medical oncology specialist at the Dana-Farber Cancer Institute, Boston, who wasn’t involved in the new research, explained that any strategy that helps detect gastric cancer at earlier stages could have a visible global impact. “We have a lower incidence of gastric cancer in the United States, but the training of and clinical volume of early gastric cancers seen by different providers can vary,” Dr. Patel said in an interview. “AI systems could provide a second layer of evaluation during procedures where an endoscopist might otherwise miss the subtle features associated with some early gastric cancers.”

While the findings from the ENDOANGEL study appear promising, Dr. Patel noted that the most important long-term question is whether this reduction of endoscopic blind spots as a result of implementing the system will translate to meaningful improvements in patient outcomes. “More broadly, I think that we will need to see how well these techniques can be applied across different populations,” he added. “Because AI models such as these need to be trained, it will be important to see if they need to be retrained when used in countries where gastric cancer might present differently or with distinctive endoscopic equipment and techniques.”

The study authors, as well as Dr. Patel and Dr. Hoffman, had no conflicts of interest to disclose.

An artificial intelligence (AI) system called “ENDOANGEL” was effective for real-time monitoring of endoscopic “blind spots” and improved detection of early gastric cancer (EGC) during esophagogastroduodenoscopy (EGD), according to research published recently.

Science Photo Library/SCIEPRO/Brand X Pictures

While EGD is widely used to examine lesions found in the upper gastrointestinal tract, there is considerable variability among endoscopists regarding performance, resulting in a substantial miss rate for EGC. But in a study published in the journal Endoscopy, researchers suggest a more objective assessment of lesions with AI technology could improve detection rates in real time, thus improving the chances of establishing an early diagnosis and initiating prompt treatment of gastric cancer.

The researchers updated a developed AI system called WISENSE, which previously demonstrated an ability to monitor gastric areas overlooked during EGD (termed “blind spots”). The investigators integrated a trained real-time EGC detection model into the WISENSE system and changed the name of the updated system to ENDOANGEL.

Researchers from the Renmin Hospital of Wuhan (China) University used deep convolutional neural networks and deep reinforcement learning to develop the ENDOANGEL. A total of 1,050 patients from five hospitals in China who were undergoing EGD were randomized to either an ENDOANGEL-assisted protocol (n = 498) or a control group (n = 504) that did not use the ENDOANGEL system. Examination consisted of white-light imaging observation, magnifying image-enhanced endoscopy observation, and biopsy of suspicious lesions.

The investigators compared the groups in terms of the number of blind spots after the intervention. They assessed the performance of the AI-based ENDOANGEL system in its ability to predict EGC in a real-world clinical setting.

Patients assigned to ENDOANGEL had a significantly fewer mean number of blind spots compared with patients assigned to control (5.38 vs. 9.82, respectively; P < .001). Despite this advantage, patients in the ENDOANGEL group had significantly longer inspection time (5.40 minutes vs. 4.38 minutes; P < .001).

There were 819 lesions reported by endoscopists in the ENDOANGEL group, which included 196 gastric lesions with pathological results. According to the investigators, the ENDOANGEL system correctly predicted all three EGCs, including one mucosal carcinoma and two high grade neoplasias, as well as two advanced gastric cancers. The per-lesion accuracy was 84.7 %, while the sensitivity and specificity rates for detecting gastric cancer were 100% and 84.3%, respectively.

The authors noted limitations of the analysis itself and those stemming from the short follow-up, as well as possible bias introduced by unblinded statisticians. Further research is warranted, they wrote.

“In conclusion, ENDOANGEL, a system for improving endoscopy quality based on deep learning, achieved real-time monitoring of endoscopic blind spots, timing, and EGC detection during EGD,” according to the authors. “ENDOANGEL greatly improved the quality of EGD in this multicenter study, and showed potential for detecting EGC in real clinical settings.”
 

Spotting the blind spots

An AI-based system such as ENDOANGEL could overcome some of the natural weaknesses to standard diagnostic testing, thereby improving rates of EGC testing, David Hoffman, MD, a gastroenterology oncologist and medical director of Cedars-Sinai Cancer Beverly Hills, said in an interview. “I think that there are ethical questions that we’re going to have to grapple with respect to accessibility and data mining and what that really means,” said Dr. Hoffman, who wasn’t involved in the study. “But I think that in the optimistic view, using AI with machine learning and deep learning has tremendous potential for public health and for cancer medicine in particular.”

Dr. Hoffman added that beyond early detection of cancer, AI systems may hold additional benefits, particularly in regard to assisting decisions for personalized medicine and assisting in real-time surgical interventions. “Using AI with machine learning and deep learning has tremendous potential and I think it sort of is a natural offshoot into what we’re seeing in ... algorithmic approaches to use of big data, so it’s sort of a natural evolution in terms of medical applications,” he explained.

Anuj Patel, MD, a medical oncology specialist at the Dana-Farber Cancer Institute, Boston, who wasn’t involved in the new research, explained that any strategy that helps detect gastric cancer at earlier stages could have a visible global impact. “We have a lower incidence of gastric cancer in the United States, but the training of and clinical volume of early gastric cancers seen by different providers can vary,” Dr. Patel said in an interview. “AI systems could provide a second layer of evaluation during procedures where an endoscopist might otherwise miss the subtle features associated with some early gastric cancers.”

While the findings from the ENDOANGEL study appear promising, Dr. Patel noted that the most important long-term question is whether this reduction of endoscopic blind spots as a result of implementing the system will translate to meaningful improvements in patient outcomes. “More broadly, I think that we will need to see how well these techniques can be applied across different populations,” he added. “Because AI models such as these need to be trained, it will be important to see if they need to be retrained when used in countries where gastric cancer might present differently or with distinctive endoscopic equipment and techniques.”

The study authors, as well as Dr. Patel and Dr. Hoffman, had no conflicts of interest to disclose.

An artificial intelligence (AI) system called “ENDOANGEL” was effective for real-time monitoring of endoscopic “blind spots” and improved detection of early gastric cancer (EGC) during esophagogastroduodenoscopy (EGD), according to research published recently.

Science Photo Library/SCIEPRO/Brand X Pictures

While EGD is widely used to examine lesions found in the upper gastrointestinal tract, there is considerable variability among endoscopists regarding performance, resulting in a substantial miss rate for EGC. But in a study published in the journal Endoscopy, researchers suggest a more objective assessment of lesions with AI technology could improve detection rates in real time, thus improving the chances of establishing an early diagnosis and initiating prompt treatment of gastric cancer.

The researchers updated a developed AI system called WISENSE, which previously demonstrated an ability to monitor gastric areas overlooked during EGD (termed “blind spots”). The investigators integrated a trained real-time EGC detection model into the WISENSE system and changed the name of the updated system to ENDOANGEL.

Researchers from the Renmin Hospital of Wuhan (China) University used deep convolutional neural networks and deep reinforcement learning to develop the ENDOANGEL. A total of 1,050 patients from five hospitals in China who were undergoing EGD were randomized to either an ENDOANGEL-assisted protocol (n = 498) or a control group (n = 504) that did not use the ENDOANGEL system. Examination consisted of white-light imaging observation, magnifying image-enhanced endoscopy observation, and biopsy of suspicious lesions.

The investigators compared the groups in terms of the number of blind spots after the intervention. They assessed the performance of the AI-based ENDOANGEL system in its ability to predict EGC in a real-world clinical setting.

Patients assigned to ENDOANGEL had a significantly fewer mean number of blind spots compared with patients assigned to control (5.38 vs. 9.82, respectively; P < .001). Despite this advantage, patients in the ENDOANGEL group had significantly longer inspection time (5.40 minutes vs. 4.38 minutes; P < .001).

There were 819 lesions reported by endoscopists in the ENDOANGEL group, which included 196 gastric lesions with pathological results. According to the investigators, the ENDOANGEL system correctly predicted all three EGCs, including one mucosal carcinoma and two high grade neoplasias, as well as two advanced gastric cancers. The per-lesion accuracy was 84.7 %, while the sensitivity and specificity rates for detecting gastric cancer were 100% and 84.3%, respectively.

The authors noted limitations of the analysis itself and those stemming from the short follow-up, as well as possible bias introduced by unblinded statisticians. Further research is warranted, they wrote.

“In conclusion, ENDOANGEL, a system for improving endoscopy quality based on deep learning, achieved real-time monitoring of endoscopic blind spots, timing, and EGC detection during EGD,” according to the authors. “ENDOANGEL greatly improved the quality of EGD in this multicenter study, and showed potential for detecting EGC in real clinical settings.”
 

Spotting the blind spots

An AI-based system such as ENDOANGEL could overcome some of the natural weaknesses to standard diagnostic testing, thereby improving rates of EGC testing, David Hoffman, MD, a gastroenterology oncologist and medical director of Cedars-Sinai Cancer Beverly Hills, said in an interview. “I think that there are ethical questions that we’re going to have to grapple with respect to accessibility and data mining and what that really means,” said Dr. Hoffman, who wasn’t involved in the study. “But I think that in the optimistic view, using AI with machine learning and deep learning has tremendous potential for public health and for cancer medicine in particular.”

Dr. Hoffman added that beyond early detection of cancer, AI systems may hold additional benefits, particularly in regard to assisting decisions for personalized medicine and assisting in real-time surgical interventions. “Using AI with machine learning and deep learning has tremendous potential and I think it sort of is a natural offshoot into what we’re seeing in ... algorithmic approaches to use of big data, so it’s sort of a natural evolution in terms of medical applications,” he explained.

Anuj Patel, MD, a medical oncology specialist at the Dana-Farber Cancer Institute, Boston, who wasn’t involved in the new research, explained that any strategy that helps detect gastric cancer at earlier stages could have a visible global impact. “We have a lower incidence of gastric cancer in the United States, but the training of and clinical volume of early gastric cancers seen by different providers can vary,” Dr. Patel said in an interview. “AI systems could provide a second layer of evaluation during procedures where an endoscopist might otherwise miss the subtle features associated with some early gastric cancers.”

While the findings from the ENDOANGEL study appear promising, Dr. Patel noted that the most important long-term question is whether this reduction of endoscopic blind spots as a result of implementing the system will translate to meaningful improvements in patient outcomes. “More broadly, I think that we will need to see how well these techniques can be applied across different populations,” he added. “Because AI models such as these need to be trained, it will be important to see if they need to be retrained when used in countries where gastric cancer might present differently or with distinctive endoscopic equipment and techniques.”

The study authors, as well as Dr. Patel and Dr. Hoffman, had no conflicts of interest to disclose.

Key clinical point: Circulating biomarkers for inflammation, abnormal extracellular matrix remodeling, congestion, and myocardial injury were associated with alterations in cardiac structure and function that affected prognosis in patients with rheumatoid arthritis (RA).

Major finding: Left ventricular mass index (LVMi), left atrial volume index (LAVi), and diastolic function (E/e′) were associated with biomarkers of inflammation (tumor necrosis factor receptor superfamily member 11a, bone morphogenetic protein 9, and pentraxin-related protein 3), extracellular matrix remodeling (placental growth factor), congestion (N-terminal probrain natriuretic peptide and adrenomedullin), and myocardial injury (troponin; all P < .05). Higher LVMi (adjusted hazard ratio [aHR] 1.03; P < .001) and E/e¢ (aHR 1.06; P = .042) were associated with poor prognosis.

Study details: This study included 355 adult patients with RA from the RA Porto cohort.

Disclosures: No information on funding was provided. The authors declared no conflict of interests.

Source: Kobayashi M et al. Front Cardiovasc Med. 2021;8:754784 (Nov 18). Doi: 10.3389/fcvm.2021.754784.

Key clinical point: Circulating biomarkers for inflammation, abnormal extracellular matrix remodeling, congestion, and myocardial injury were associated with alterations in cardiac structure and function that affected prognosis in patients with rheumatoid arthritis (RA).

Major finding: Left ventricular mass index (LVMi), left atrial volume index (LAVi), and diastolic function (E/e′) were associated with biomarkers of inflammation (tumor necrosis factor receptor superfamily member 11a, bone morphogenetic protein 9, and pentraxin-related protein 3), extracellular matrix remodeling (placental growth factor), congestion (N-terminal probrain natriuretic peptide and adrenomedullin), and myocardial injury (troponin; all P < .05). Higher LVMi (adjusted hazard ratio [aHR] 1.03; P < .001) and E/e¢ (aHR 1.06; P = .042) were associated with poor prognosis.

Study details: This study included 355 adult patients with RA from the RA Porto cohort.

Disclosures: No information on funding was provided. The authors declared no conflict of interests.

Source: Kobayashi M et al. Front Cardiovasc Med. 2021;8:754784 (Nov 18). Doi: 10.3389/fcvm.2021.754784.

Key clinical point: Circulating biomarkers for inflammation, abnormal extracellular matrix remodeling, congestion, and myocardial injury were associated with alterations in cardiac structure and function that affected prognosis in patients with rheumatoid arthritis (RA).

Major finding: Left ventricular mass index (LVMi), left atrial volume index (LAVi), and diastolic function (E/e′) were associated with biomarkers of inflammation (tumor necrosis factor receptor superfamily member 11a, bone morphogenetic protein 9, and pentraxin-related protein 3), extracellular matrix remodeling (placental growth factor), congestion (N-terminal probrain natriuretic peptide and adrenomedullin), and myocardial injury (troponin; all P < .05). Higher LVMi (adjusted hazard ratio [aHR] 1.03; P < .001) and E/e¢ (aHR 1.06; P = .042) were associated with poor prognosis.

Study details: This study included 355 adult patients with RA from the RA Porto cohort.

Disclosures: No information on funding was provided. The authors declared no conflict of interests.

Source: Kobayashi M et al. Front Cardiovasc Med. 2021;8:754784 (Nov 18). Doi: 10.3389/fcvm.2021.754784.

Key clinical point: Herpes zoster (HZ) events occur in tofacitinib-treated patients with rheumatoid arthritis (RA), but most of them are nonserious, mild, or moderate with HZ events resolving in most patients.

Major finding: Overall, 11.1% and 8.0% of patients with RA experienced at least 1 or recurring HZ events, respectively. Most events were nonserious, mild, or moderate in severity, with the majority of the first (97.6%) and second (96.8%) HZ events resolved in most patients. Tofacitinib treatment remained unchanged in 47.3% of patients with the first HZ event and was temporarily or permanently discontinued in 42.8% and 9.1% of patients, respectively.

Study details: The data come from a post hoc analysis of pooled data from 21 RA and 3 psoriatic arthritis (PsA) clinical studies involving 7,061 and 783 tofacitinib-treated patients with RA and PsA, respectively.

Disclosures: These studies were sponsored by Pfizer Inc. T Hirose, J L Rivas, and K Kwok reported being employees and shareholders of Pfizer Inc. Other authors reported receiving grant/research support and speaker/consultancy fees from various companies including Pfizer.

Source: Winthrop KL et al. Rheumatol Ther. 2021 (Dec 6). Doi: 10.1007/s40744-021-00390-0.

Key clinical point: Herpes zoster (HZ) events occur in tofacitinib-treated patients with rheumatoid arthritis (RA), but most of them are nonserious, mild, or moderate with HZ events resolving in most patients.

Major finding: Overall, 11.1% and 8.0% of patients with RA experienced at least 1 or recurring HZ events, respectively. Most events were nonserious, mild, or moderate in severity, with the majority of the first (97.6%) and second (96.8%) HZ events resolved in most patients. Tofacitinib treatment remained unchanged in 47.3% of patients with the first HZ event and was temporarily or permanently discontinued in 42.8% and 9.1% of patients, respectively.

Study details: The data come from a post hoc analysis of pooled data from 21 RA and 3 psoriatic arthritis (PsA) clinical studies involving 7,061 and 783 tofacitinib-treated patients with RA and PsA, respectively.

Disclosures: These studies were sponsored by Pfizer Inc. T Hirose, J L Rivas, and K Kwok reported being employees and shareholders of Pfizer Inc. Other authors reported receiving grant/research support and speaker/consultancy fees from various companies including Pfizer.

Source: Winthrop KL et al. Rheumatol Ther. 2021 (Dec 6). Doi: 10.1007/s40744-021-00390-0.

Key clinical point: Herpes zoster (HZ) events occur in tofacitinib-treated patients with rheumatoid arthritis (RA), but most of them are nonserious, mild, or moderate with HZ events resolving in most patients.

Major finding: Overall, 11.1% and 8.0% of patients with RA experienced at least 1 or recurring HZ events, respectively. Most events were nonserious, mild, or moderate in severity, with the majority of the first (97.6%) and second (96.8%) HZ events resolved in most patients. Tofacitinib treatment remained unchanged in 47.3% of patients with the first HZ event and was temporarily or permanently discontinued in 42.8% and 9.1% of patients, respectively.

Study details: The data come from a post hoc analysis of pooled data from 21 RA and 3 psoriatic arthritis (PsA) clinical studies involving 7,061 and 783 tofacitinib-treated patients with RA and PsA, respectively.

Disclosures: These studies were sponsored by Pfizer Inc. T Hirose, J L Rivas, and K Kwok reported being employees and shareholders of Pfizer Inc. Other authors reported receiving grant/research support and speaker/consultancy fees from various companies including Pfizer.

Source: Winthrop KL et al. Rheumatol Ther. 2021 (Dec 6). Doi: 10.1007/s40744-021-00390-0.

Key clinical point: Consumption of flaxseed for 12 weeks improved disease activity and reduced pain, morning stiffness, and disease feeling in patients with rheumatoid arthritis (RA).

Major finding: Disease Activity Score 28-joints-erythrocyte sedimentation rate improved significantly in patients receiving flaxseed plus regular diet (RF; P = .001), but not in patients receiving flaxseed plus anti-inflammatory diet (AIF; P = .057) and roasted wheat plus regular diet (RW; P = .110). Significant reductions in pain severity (P ≤ .001), morning stiffness (P < .05), and disease feeling (P < .01) were observed in the AIF and RF groups.

Study details: This randomized controlled trial included 120 patients with RA who were randomly assigned to 12-week intervention with AIF, RF, or RW diet groups.

Disclosures: This study was funded by the Shiraz University of Medical Sciences, Shiraz, Iran. No disclosures were reported.

Source: Ghaseminasab-Parizi M et al. Eur J Nutr. 2021 (Nov 27). Doi: 10.1007/s00394-021-02707-9.

Key clinical point: Consumption of flaxseed for 12 weeks improved disease activity and reduced pain, morning stiffness, and disease feeling in patients with rheumatoid arthritis (RA).

Major finding: Disease Activity Score 28-joints-erythrocyte sedimentation rate improved significantly in patients receiving flaxseed plus regular diet (RF; P = .001), but not in patients receiving flaxseed plus anti-inflammatory diet (AIF; P = .057) and roasted wheat plus regular diet (RW; P = .110). Significant reductions in pain severity (P ≤ .001), morning stiffness (P < .05), and disease feeling (P < .01) were observed in the AIF and RF groups.

Study details: This randomized controlled trial included 120 patients with RA who were randomly assigned to 12-week intervention with AIF, RF, or RW diet groups.

Disclosures: This study was funded by the Shiraz University of Medical Sciences, Shiraz, Iran. No disclosures were reported.

Source: Ghaseminasab-Parizi M et al. Eur J Nutr. 2021 (Nov 27). Doi: 10.1007/s00394-021-02707-9.

Key clinical point: Consumption of flaxseed for 12 weeks improved disease activity and reduced pain, morning stiffness, and disease feeling in patients with rheumatoid arthritis (RA).

Major finding: Disease Activity Score 28-joints-erythrocyte sedimentation rate improved significantly in patients receiving flaxseed plus regular diet (RF; P = .001), but not in patients receiving flaxseed plus anti-inflammatory diet (AIF; P = .057) and roasted wheat plus regular diet (RW; P = .110). Significant reductions in pain severity (P ≤ .001), morning stiffness (P < .05), and disease feeling (P < .01) were observed in the AIF and RF groups.

Study details: This randomized controlled trial included 120 patients with RA who were randomly assigned to 12-week intervention with AIF, RF, or RW diet groups.

Disclosures: This study was funded by the Shiraz University of Medical Sciences, Shiraz, Iran. No disclosures were reported.

Source: Ghaseminasab-Parizi M et al. Eur J Nutr. 2021 (Nov 27). Doi: 10.1007/s00394-021-02707-9.

Key clinical point: Patients with rheumatoid arthritis (RA) do not exhibit an elevated risk for acute or 1-year postoperative surgical site infection following total knee arthroplasty (TKA) compared with patients with osteoarthritis.

Major finding: The risk for surgical site infection at 90 days (adjusted odds ratio [aOR] 0.81; P = .598) and 1 year (aOR 0.463; P = .26) post-TKA was not significantly different between patients with RA and osteoarthritis.

Study details: This retrospective cohort study included patients with RA (n = 1,126) and osteoarthritis (n = 63,215) who underwent primary TKA.

Disclosures: No external funding was received for this study. The authors declared no conflict of interests.

Source: Chung HK et al. Sci Rep. 2021;11:22704 (Nov 22). Doi: 10.1038/s41598-021-02153-x.

Key clinical point: Patients with rheumatoid arthritis (RA) do not exhibit an elevated risk for acute or 1-year postoperative surgical site infection following total knee arthroplasty (TKA) compared with patients with osteoarthritis.

Major finding: The risk for surgical site infection at 90 days (adjusted odds ratio [aOR] 0.81; P = .598) and 1 year (aOR 0.463; P = .26) post-TKA was not significantly different between patients with RA and osteoarthritis.

Study details: This retrospective cohort study included patients with RA (n = 1,126) and osteoarthritis (n = 63,215) who underwent primary TKA.

Disclosures: No external funding was received for this study. The authors declared no conflict of interests.

Source: Chung HK et al. Sci Rep. 2021;11:22704 (Nov 22). Doi: 10.1038/s41598-021-02153-x.

Key clinical point: Patients with rheumatoid arthritis (RA) do not exhibit an elevated risk for acute or 1-year postoperative surgical site infection following total knee arthroplasty (TKA) compared with patients with osteoarthritis.

Major finding: The risk for surgical site infection at 90 days (adjusted odds ratio [aOR] 0.81; P = .598) and 1 year (aOR 0.463; P = .26) post-TKA was not significantly different between patients with RA and osteoarthritis.

Study details: This retrospective cohort study included patients with RA (n = 1,126) and osteoarthritis (n = 63,215) who underwent primary TKA.

Disclosures: No external funding was received for this study. The authors declared no conflict of interests.

Source: Chung HK et al. Sci Rep. 2021;11:22704 (Nov 22). Doi: 10.1038/s41598-021-02153-x.

Key clinical point: Positive correlations between circulating inflammatory cytokines and coinhibitory checkpoint molecules modulated by anticitrullinated peptide antibodies (ACPA) or joint damage stage existed in patients with rheumatoid arthritis (RA).

Major finding: Serum levels of interleukin-6 (IL-6) and tumor necrosis factor-a (TNF-α) were positively associated with RA disease activity and galectin-9, independent of ACPA titers (all P < .05) and with soluble T-cell immunoglobulin and mucin-domain containing-3 in patients with ACPA <200 U/mL (P < .05). Galectin-9 was positively correlated with IL-6 (P = .005) only in patients without advanced joint damage and with TNF-a (P = .001) and IL-6 (P = .02) in patients with advanced joint damage.

Study details: This retrospective analysis included 132 patients with RA.

Disclosures: The work was funded by the Japan Grant-in-Aid for Scientific Research. K Migita received grants from Chugai, Pfizer, and AbbVie. Other authors declared no conflict of interests.

Source: Matsumoto H et al. PLoS One. 2021;16(11):e0260254 (Nov 18). Doi: 10.1371/journal.pone.0260254.

Key clinical point: Positive correlations between circulating inflammatory cytokines and coinhibitory checkpoint molecules modulated by anticitrullinated peptide antibodies (ACPA) or joint damage stage existed in patients with rheumatoid arthritis (RA).

Major finding: Serum levels of interleukin-6 (IL-6) and tumor necrosis factor-a (TNF-α) were positively associated with RA disease activity and galectin-9, independent of ACPA titers (all P < .05) and with soluble T-cell immunoglobulin and mucin-domain containing-3 in patients with ACPA <200 U/mL (P < .05). Galectin-9 was positively correlated with IL-6 (P = .005) only in patients without advanced joint damage and with TNF-a (P = .001) and IL-6 (P = .02) in patients with advanced joint damage.

Study details: This retrospective analysis included 132 patients with RA.

Disclosures: The work was funded by the Japan Grant-in-Aid for Scientific Research. K Migita received grants from Chugai, Pfizer, and AbbVie. Other authors declared no conflict of interests.

Source: Matsumoto H et al. PLoS One. 2021;16(11):e0260254 (Nov 18). Doi: 10.1371/journal.pone.0260254.

Key clinical point: Positive correlations between circulating inflammatory cytokines and coinhibitory checkpoint molecules modulated by anticitrullinated peptide antibodies (ACPA) or joint damage stage existed in patients with rheumatoid arthritis (RA).

Major finding: Serum levels of interleukin-6 (IL-6) and tumor necrosis factor-a (TNF-α) were positively associated with RA disease activity and galectin-9, independent of ACPA titers (all P < .05) and with soluble T-cell immunoglobulin and mucin-domain containing-3 in patients with ACPA <200 U/mL (P < .05). Galectin-9 was positively correlated with IL-6 (P = .005) only in patients without advanced joint damage and with TNF-a (P = .001) and IL-6 (P = .02) in patients with advanced joint damage.

Study details: This retrospective analysis included 132 patients with RA.

Disclosures: The work was funded by the Japan Grant-in-Aid for Scientific Research. K Migita received grants from Chugai, Pfizer, and AbbVie. Other authors declared no conflict of interests.

Source: Matsumoto H et al. PLoS One. 2021;16(11):e0260254 (Nov 18). Doi: 10.1371/journal.pone.0260254.

Key clinical point: Complete treatment adherence has still not been achieved in rheumatoid arthritis (RA), and factors like having patient-physician agreement on the treatment and the type of treatment prescribed are significant predictors of adherence.

Major finding: The 6-month prevalence of adherence was 59.1% (95% CI 48.1%-71.8%), with treatment agreement between patient and physician (odds ratio [OR] 4.29; P = .01) and information adaptation (OR 1.54; P = .015) being significant predictors of adherence. Treatment adherence was higher with second-line conventional synthetic disease-modifying rheumatic drug (csDMARD; OR 4.72; P = .005) and biological DMARDs/targeted synthetic DMARDs (OR 3.50; P = .029) vs. first-line csDMARDs.

Study details: This was a 6-month observational longitudinal prospective cohort study involving 180 patients with RA.

Disclosures: The ADHIERA trial was supported by a grant from Roche España to the Spanish Foundation of Rheumatology. A Balsa reported receiving speaker fees from various sources including Roche. Two other authors did not receive fees or personal grants from any laboratory, although their institute works by contract for laboratories for various sources.

Source: Balsa A et al. Ann Rheum Dis. 2021 (Nov 29). Doi: 10.1136/annrheumdis-2021-221163.

Key clinical point: Complete treatment adherence has still not been achieved in rheumatoid arthritis (RA), and factors like having patient-physician agreement on the treatment and the type of treatment prescribed are significant predictors of adherence.

Major finding: The 6-month prevalence of adherence was 59.1% (95% CI 48.1%-71.8%), with treatment agreement between patient and physician (odds ratio [OR] 4.29; P = .01) and information adaptation (OR 1.54; P = .015) being significant predictors of adherence. Treatment adherence was higher with second-line conventional synthetic disease-modifying rheumatic drug (csDMARD; OR 4.72; P = .005) and biological DMARDs/targeted synthetic DMARDs (OR 3.50; P = .029) vs. first-line csDMARDs.

Study details: This was a 6-month observational longitudinal prospective cohort study involving 180 patients with RA.

Disclosures: The ADHIERA trial was supported by a grant from Roche España to the Spanish Foundation of Rheumatology. A Balsa reported receiving speaker fees from various sources including Roche. Two other authors did not receive fees or personal grants from any laboratory, although their institute works by contract for laboratories for various sources.

Source: Balsa A et al. Ann Rheum Dis. 2021 (Nov 29). Doi: 10.1136/annrheumdis-2021-221163.

Key clinical point: Complete treatment adherence has still not been achieved in rheumatoid arthritis (RA), and factors like having patient-physician agreement on the treatment and the type of treatment prescribed are significant predictors of adherence.

Major finding: The 6-month prevalence of adherence was 59.1% (95% CI 48.1%-71.8%), with treatment agreement between patient and physician (odds ratio [OR] 4.29; P = .01) and information adaptation (OR 1.54; P = .015) being significant predictors of adherence. Treatment adherence was higher with second-line conventional synthetic disease-modifying rheumatic drug (csDMARD; OR 4.72; P = .005) and biological DMARDs/targeted synthetic DMARDs (OR 3.50; P = .029) vs. first-line csDMARDs.

Study details: This was a 6-month observational longitudinal prospective cohort study involving 180 patients with RA.

Disclosures: The ADHIERA trial was supported by a grant from Roche España to the Spanish Foundation of Rheumatology. A Balsa reported receiving speaker fees from various sources including Roche. Two other authors did not receive fees or personal grants from any laboratory, although their institute works by contract for laboratories for various sources.

Source: Balsa A et al. Ann Rheum Dis. 2021 (Nov 29). Doi: 10.1136/annrheumdis-2021-221163.

Key clinical point: Compared with the general population, the risk for COVID-19 was significantly higher in patients with rheumatoid arthritis (RA) but not in those with osteoarthritis, supporting recommendations for booster vaccines and priority access to anti-SARS-CoV-2 monoclonal antibody treatment for patients with RA.

Major finding: Compared with the general population, the risk for suspected/confirmed COVID-19 was significantly higher in patients with RA (hazard ratio [HR] 1.19; 95% CI 1.04-1.36) but not in patients with osteoarthritis (HR 1.00; 95% CI 0.93-1.07).

Study details: This was a cohort analysis that compared the risk for COVID-19 among 17,268 patients with RA and 1,616,600 participants from the general population.

Disclosures: This work was supported by the National Natural Science Foundation of China, the Project Program of National Clinical Research Center for Geriatric Disorders (Xiangya Hospital), and others. No conflict of interests was reported.

Source: Wang Y et al. Arthritis Care Res (Hoboken). 2021 (Dec 7). Doi: 10.1002/acr.24831.

Key clinical point: Compared with the general population, the risk for COVID-19 was significantly higher in patients with rheumatoid arthritis (RA) but not in those with osteoarthritis, supporting recommendations for booster vaccines and priority access to anti-SARS-CoV-2 monoclonal antibody treatment for patients with RA.

Major finding: Compared with the general population, the risk for suspected/confirmed COVID-19 was significantly higher in patients with RA (hazard ratio [HR] 1.19; 95% CI 1.04-1.36) but not in patients with osteoarthritis (HR 1.00; 95% CI 0.93-1.07).

Study details: This was a cohort analysis that compared the risk for COVID-19 among 17,268 patients with RA and 1,616,600 participants from the general population.

Disclosures: This work was supported by the National Natural Science Foundation of China, the Project Program of National Clinical Research Center for Geriatric Disorders (Xiangya Hospital), and others. No conflict of interests was reported.

Source: Wang Y et al. Arthritis Care Res (Hoboken). 2021 (Dec 7). Doi: 10.1002/acr.24831.

Key clinical point: Compared with the general population, the risk for COVID-19 was significantly higher in patients with rheumatoid arthritis (RA) but not in those with osteoarthritis, supporting recommendations for booster vaccines and priority access to anti-SARS-CoV-2 monoclonal antibody treatment for patients with RA.

Major finding: Compared with the general population, the risk for suspected/confirmed COVID-19 was significantly higher in patients with RA (hazard ratio [HR] 1.19; 95% CI 1.04-1.36) but not in patients with osteoarthritis (HR 1.00; 95% CI 0.93-1.07).

Study details: This was a cohort analysis that compared the risk for COVID-19 among 17,268 patients with RA and 1,616,600 participants from the general population.

Disclosures: This work was supported by the National Natural Science Foundation of China, the Project Program of National Clinical Research Center for Geriatric Disorders (Xiangya Hospital), and others. No conflict of interests was reported.

Source: Wang Y et al. Arthritis Care Res (Hoboken). 2021 (Dec 7). Doi: 10.1002/acr.24831.

Key clinical point: The risk for preterm birth (PTB) and small for gestational age (SGA) is almost 2-fold higher in pregnant women with vs. without rheumatoid arthritis (RA), with high maternal RA disease activity during pregnancy being a significant risk factor.

Major finding: The risk for PTB (adjusted odds ratio [aOR] 1.92; 95% CI 1.56-2.35) and SGA (aOR 1.93; 95% CI 1.45-2.57) was significantly higher in RA pregnancies vs. control pregnancies, with the risk even higher with maternal Disease Activity Score in 28 joints-C-reactive protein of >4.1 vs. <3.2 during pregnancy (PTB: aOR 3.38; 95% CI 1.52-7.55; SGA: aOR 3.90; 95% CI 1.46-10.4).

Study details: This was a prospective cohort study of 1,739 RA-pregnancies matched with 17,390 control-pregnancies.

Disclosures: This study was supported by NordForsk and others. Some of the authors declared receiving consultancy fees, research grants, and serving on the steering committee for various sources.

Source: Hellgren K et al. Rheumatology (Oxford). 2021;keab894 (Dec 3). Doi:  10.1093/rheumatology/keab894.

Key clinical point: The risk for preterm birth (PTB) and small for gestational age (SGA) is almost 2-fold higher in pregnant women with vs. without rheumatoid arthritis (RA), with high maternal RA disease activity during pregnancy being a significant risk factor.

Major finding: The risk for PTB (adjusted odds ratio [aOR] 1.92; 95% CI 1.56-2.35) and SGA (aOR 1.93; 95% CI 1.45-2.57) was significantly higher in RA pregnancies vs. control pregnancies, with the risk even higher with maternal Disease Activity Score in 28 joints-C-reactive protein of >4.1 vs. <3.2 during pregnancy (PTB: aOR 3.38; 95% CI 1.52-7.55; SGA: aOR 3.90; 95% CI 1.46-10.4).

Study details: This was a prospective cohort study of 1,739 RA-pregnancies matched with 17,390 control-pregnancies.

Disclosures: This study was supported by NordForsk and others. Some of the authors declared receiving consultancy fees, research grants, and serving on the steering committee for various sources.

Source: Hellgren K et al. Rheumatology (Oxford). 2021;keab894 (Dec 3). Doi:  10.1093/rheumatology/keab894.

Key clinical point: The risk for preterm birth (PTB) and small for gestational age (SGA) is almost 2-fold higher in pregnant women with vs. without rheumatoid arthritis (RA), with high maternal RA disease activity during pregnancy being a significant risk factor.

Major finding: The risk for PTB (adjusted odds ratio [aOR] 1.92; 95% CI 1.56-2.35) and SGA (aOR 1.93; 95% CI 1.45-2.57) was significantly higher in RA pregnancies vs. control pregnancies, with the risk even higher with maternal Disease Activity Score in 28 joints-C-reactive protein of >4.1 vs. <3.2 during pregnancy (PTB: aOR 3.38; 95% CI 1.52-7.55; SGA: aOR 3.90; 95% CI 1.46-10.4).

Study details: This was a prospective cohort study of 1,739 RA-pregnancies matched with 17,390 control-pregnancies.

Disclosures: This study was supported by NordForsk and others. Some of the authors declared receiving consultancy fees, research grants, and serving on the steering committee for various sources.

Source: Hellgren K et al. Rheumatology (Oxford). 2021;keab894 (Dec 3). Doi:  10.1093/rheumatology/keab894.