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Few poorly prepped colonoscopies repeated within 1 year
Approximately one-third of colonoscopies with inadequate bowel preparation were repeated within 1 year despite current guidelines, according to data from a new study of more than 260,000 procedures.
Previous studies have shown that poor bowel prep, which occurs in approximately 25% of colonoscopies, can lead to lesion miss rates of as much as 42%-48%, Audrey H. Calderwood, MD, an associate professor of medicine at Dartmouth-Hitchcock Medical Center, Lebanon, N.H., and colleagues wrote. However, factors affecting recommendations for repeat colonoscopies following poor bowel prep have not been examined.
In the study, published in Gastrointestinal Endoscopy, the researchers conducted a cross-sectional retrospective analysis of 260,314 colonoscopies reported to the GI Quality Improvement Consortium (GIQuIC) from 2011 to 2018. The review included adults aged 50-75 years in whom bowel preparation was deemed inadequate. The GIQuIC database defines adequate bowel preparation as “sufficient to accurately detect polyps greater than 5 mm in size,” the researchers noted. The procedures in this study were performed at 672 sites by 4,001 endoscopists, and the primary outcome was a recommendation for a repeat colonoscopy within 1 year.
In 31.9% of the procedures, the recommended follow-up interval for repeat colonoscopy was within 1 year, and there were no significant differences according to indication for the procedures (32.3% of screening and 31.2% of surveillance). Of these, 54.9% of patients received a follow-up interval of 1 year and 24.7% a follow-up interval within 3 months. Only 2.4% were advised they required no follow-up procedure.
The researchers found that patients with more severe disease had a higher likelihood of receiving a recommendation for follow-up colonoscopy within 1 year – 84% with adenocarcinoma, 51.8% with advanced lesions, and 23.2% with one to two small adenomas.
In the multivariate analysis, there were specific patient factors significantly associated with 1-year follow-up recommendations. The researchers found patients aged 70-75 years were less likely than younger patients (adjusted odds ratio, 0.96; 95% confidence interval, 0.93-0.98) to receive a 1-year follow-up recommendation; men were more likely than women (aOR, 1.04; 95% CI, 1.02-1.06) to receive a 1-year follow-up recommendation; and patients with adenocarcinoma findings more likely to receive a 1-year follow-up recommendation compared to those with no adenocarcinoma (aOR, 10.43; 95% CI, 7.77-13.98). In addition, they found patients residing in the Northeast and those whose procedure was performed by an endoscopist with an adenoma detection rate of at least25% were more likely to receive recommendations for a repeat colonoscopy within 1 year.
“The recommendation for repeat screening or surveillance colonoscopy within 1 year when the index colonoscopy has an inadequate bowel preparation is currently a quality measure in gastroenterology,” the researchers noted. “Although our study period started in 2011, when we looked at the time period of 2014 to 2018, which is after publication of guidelines of when to repeat colonoscopy after inadequate bowel preparation, there were still low rates of guideline-concordant recommendations.”
These overall low rates, which are consistent with other studies, may be due uncertainty on the part of the endoscopist in determining inadequate bowel prep based on evolving guidelines, the researchers noted. However, the higher frequency of recommendations for repeat procedures within 1 year for patients with advanced disease suggests that endoscopists are taking pathology into account.
The study findings were limited by several factors, including the lack of standardized assessment of bowel prep quality, variation in descriptions of bowel cleanliness, and lack of information on the primary factor in follow-up recommendations. However, the results were strengthened by the large sample size, the inclusion of multiple sites and providers, and the low volume of timely repeat procedures, which has clinical implications in terms of missed lesions, “including potential interval CRC [colorectal cancer],” the researchers said.
Get the word out on describing preps and planning follow-ups
The current study is important because it highlights that, even when endoscopists have a reasonable understanding on how to set follow-up intervals for polyp follow-up, what to do with a patient who comes in poorly prepped is more of a problem, Kim L. Isaacs, MD, of the University of North Carolina at Chapel Hill, said in an interview.
Dr Isaacs said she was not surprised by the study findings. “There are all gradations of inadequate preps that limit visualization in different ways, and there are many ways of recording this on procedure reports. The findings in the current study emphasize several points. The first is that the recommendation of following up an inadequate or poor prep in a year needs to be widely disseminated. The second is that there needs to be more education on standardization on how preps are described. In some poor preps, much of the colon can be seen, and clinicians can identify polyps 5-6 mm, so a 1-year follow-up may not be needed.” This type of research is challenging if the data are not standardized, she added.
Dr. Isaacs agreed with the authors’ description of repeat colonoscopies after poor bowel prep as a quality improvement area given the variability in following current recommendations, which leads into next steps for research.
“Understanding reasons for the recommendations that endoscopists made for follow-up would be the next step in this type of research,” Dr Isaacs noted. “After that, studies on the impact of an educational intervention, followed by repeating the initial assessment.”
The study received no outside funding. The researchers had no financial conflicts to disclose; however, lead author Dr. Calderwood disclosed support from the National Cancer Institute, the Dartmouth-Hitchcock Cancer Research Fellows Program, the Dartmouth-Hitchcock Norris Cotton Cancer Center, and the Dartmouth Clinical and Translational Science Institute. Dr Isaacs had no financial conflicts to disclose but has previously served on the editorial board of GI & Hepatology News.
Approximately one-third of colonoscopies with inadequate bowel preparation were repeated within 1 year despite current guidelines, according to data from a new study of more than 260,000 procedures.
Previous studies have shown that poor bowel prep, which occurs in approximately 25% of colonoscopies, can lead to lesion miss rates of as much as 42%-48%, Audrey H. Calderwood, MD, an associate professor of medicine at Dartmouth-Hitchcock Medical Center, Lebanon, N.H., and colleagues wrote. However, factors affecting recommendations for repeat colonoscopies following poor bowel prep have not been examined.
In the study, published in Gastrointestinal Endoscopy, the researchers conducted a cross-sectional retrospective analysis of 260,314 colonoscopies reported to the GI Quality Improvement Consortium (GIQuIC) from 2011 to 2018. The review included adults aged 50-75 years in whom bowel preparation was deemed inadequate. The GIQuIC database defines adequate bowel preparation as “sufficient to accurately detect polyps greater than 5 mm in size,” the researchers noted. The procedures in this study were performed at 672 sites by 4,001 endoscopists, and the primary outcome was a recommendation for a repeat colonoscopy within 1 year.
In 31.9% of the procedures, the recommended follow-up interval for repeat colonoscopy was within 1 year, and there were no significant differences according to indication for the procedures (32.3% of screening and 31.2% of surveillance). Of these, 54.9% of patients received a follow-up interval of 1 year and 24.7% a follow-up interval within 3 months. Only 2.4% were advised they required no follow-up procedure.
The researchers found that patients with more severe disease had a higher likelihood of receiving a recommendation for follow-up colonoscopy within 1 year – 84% with adenocarcinoma, 51.8% with advanced lesions, and 23.2% with one to two small adenomas.
In the multivariate analysis, there were specific patient factors significantly associated with 1-year follow-up recommendations. The researchers found patients aged 70-75 years were less likely than younger patients (adjusted odds ratio, 0.96; 95% confidence interval, 0.93-0.98) to receive a 1-year follow-up recommendation; men were more likely than women (aOR, 1.04; 95% CI, 1.02-1.06) to receive a 1-year follow-up recommendation; and patients with adenocarcinoma findings more likely to receive a 1-year follow-up recommendation compared to those with no adenocarcinoma (aOR, 10.43; 95% CI, 7.77-13.98). In addition, they found patients residing in the Northeast and those whose procedure was performed by an endoscopist with an adenoma detection rate of at least25% were more likely to receive recommendations for a repeat colonoscopy within 1 year.
“The recommendation for repeat screening or surveillance colonoscopy within 1 year when the index colonoscopy has an inadequate bowel preparation is currently a quality measure in gastroenterology,” the researchers noted. “Although our study period started in 2011, when we looked at the time period of 2014 to 2018, which is after publication of guidelines of when to repeat colonoscopy after inadequate bowel preparation, there were still low rates of guideline-concordant recommendations.”
These overall low rates, which are consistent with other studies, may be due uncertainty on the part of the endoscopist in determining inadequate bowel prep based on evolving guidelines, the researchers noted. However, the higher frequency of recommendations for repeat procedures within 1 year for patients with advanced disease suggests that endoscopists are taking pathology into account.
The study findings were limited by several factors, including the lack of standardized assessment of bowel prep quality, variation in descriptions of bowel cleanliness, and lack of information on the primary factor in follow-up recommendations. However, the results were strengthened by the large sample size, the inclusion of multiple sites and providers, and the low volume of timely repeat procedures, which has clinical implications in terms of missed lesions, “including potential interval CRC [colorectal cancer],” the researchers said.
Get the word out on describing preps and planning follow-ups
The current study is important because it highlights that, even when endoscopists have a reasonable understanding on how to set follow-up intervals for polyp follow-up, what to do with a patient who comes in poorly prepped is more of a problem, Kim L. Isaacs, MD, of the University of North Carolina at Chapel Hill, said in an interview.
Dr Isaacs said she was not surprised by the study findings. “There are all gradations of inadequate preps that limit visualization in different ways, and there are many ways of recording this on procedure reports. The findings in the current study emphasize several points. The first is that the recommendation of following up an inadequate or poor prep in a year needs to be widely disseminated. The second is that there needs to be more education on standardization on how preps are described. In some poor preps, much of the colon can be seen, and clinicians can identify polyps 5-6 mm, so a 1-year follow-up may not be needed.” This type of research is challenging if the data are not standardized, she added.
Dr. Isaacs agreed with the authors’ description of repeat colonoscopies after poor bowel prep as a quality improvement area given the variability in following current recommendations, which leads into next steps for research.
“Understanding reasons for the recommendations that endoscopists made for follow-up would be the next step in this type of research,” Dr Isaacs noted. “After that, studies on the impact of an educational intervention, followed by repeating the initial assessment.”
The study received no outside funding. The researchers had no financial conflicts to disclose; however, lead author Dr. Calderwood disclosed support from the National Cancer Institute, the Dartmouth-Hitchcock Cancer Research Fellows Program, the Dartmouth-Hitchcock Norris Cotton Cancer Center, and the Dartmouth Clinical and Translational Science Institute. Dr Isaacs had no financial conflicts to disclose but has previously served on the editorial board of GI & Hepatology News.
Approximately one-third of colonoscopies with inadequate bowel preparation were repeated within 1 year despite current guidelines, according to data from a new study of more than 260,000 procedures.
Previous studies have shown that poor bowel prep, which occurs in approximately 25% of colonoscopies, can lead to lesion miss rates of as much as 42%-48%, Audrey H. Calderwood, MD, an associate professor of medicine at Dartmouth-Hitchcock Medical Center, Lebanon, N.H., and colleagues wrote. However, factors affecting recommendations for repeat colonoscopies following poor bowel prep have not been examined.
In the study, published in Gastrointestinal Endoscopy, the researchers conducted a cross-sectional retrospective analysis of 260,314 colonoscopies reported to the GI Quality Improvement Consortium (GIQuIC) from 2011 to 2018. The review included adults aged 50-75 years in whom bowel preparation was deemed inadequate. The GIQuIC database defines adequate bowel preparation as “sufficient to accurately detect polyps greater than 5 mm in size,” the researchers noted. The procedures in this study were performed at 672 sites by 4,001 endoscopists, and the primary outcome was a recommendation for a repeat colonoscopy within 1 year.
In 31.9% of the procedures, the recommended follow-up interval for repeat colonoscopy was within 1 year, and there were no significant differences according to indication for the procedures (32.3% of screening and 31.2% of surveillance). Of these, 54.9% of patients received a follow-up interval of 1 year and 24.7% a follow-up interval within 3 months. Only 2.4% were advised they required no follow-up procedure.
The researchers found that patients with more severe disease had a higher likelihood of receiving a recommendation for follow-up colonoscopy within 1 year – 84% with adenocarcinoma, 51.8% with advanced lesions, and 23.2% with one to two small adenomas.
In the multivariate analysis, there were specific patient factors significantly associated with 1-year follow-up recommendations. The researchers found patients aged 70-75 years were less likely than younger patients (adjusted odds ratio, 0.96; 95% confidence interval, 0.93-0.98) to receive a 1-year follow-up recommendation; men were more likely than women (aOR, 1.04; 95% CI, 1.02-1.06) to receive a 1-year follow-up recommendation; and patients with adenocarcinoma findings more likely to receive a 1-year follow-up recommendation compared to those with no adenocarcinoma (aOR, 10.43; 95% CI, 7.77-13.98). In addition, they found patients residing in the Northeast and those whose procedure was performed by an endoscopist with an adenoma detection rate of at least25% were more likely to receive recommendations for a repeat colonoscopy within 1 year.
“The recommendation for repeat screening or surveillance colonoscopy within 1 year when the index colonoscopy has an inadequate bowel preparation is currently a quality measure in gastroenterology,” the researchers noted. “Although our study period started in 2011, when we looked at the time period of 2014 to 2018, which is after publication of guidelines of when to repeat colonoscopy after inadequate bowel preparation, there were still low rates of guideline-concordant recommendations.”
These overall low rates, which are consistent with other studies, may be due uncertainty on the part of the endoscopist in determining inadequate bowel prep based on evolving guidelines, the researchers noted. However, the higher frequency of recommendations for repeat procedures within 1 year for patients with advanced disease suggests that endoscopists are taking pathology into account.
The study findings were limited by several factors, including the lack of standardized assessment of bowel prep quality, variation in descriptions of bowel cleanliness, and lack of information on the primary factor in follow-up recommendations. However, the results were strengthened by the large sample size, the inclusion of multiple sites and providers, and the low volume of timely repeat procedures, which has clinical implications in terms of missed lesions, “including potential interval CRC [colorectal cancer],” the researchers said.
Get the word out on describing preps and planning follow-ups
The current study is important because it highlights that, even when endoscopists have a reasonable understanding on how to set follow-up intervals for polyp follow-up, what to do with a patient who comes in poorly prepped is more of a problem, Kim L. Isaacs, MD, of the University of North Carolina at Chapel Hill, said in an interview.
Dr Isaacs said she was not surprised by the study findings. “There are all gradations of inadequate preps that limit visualization in different ways, and there are many ways of recording this on procedure reports. The findings in the current study emphasize several points. The first is that the recommendation of following up an inadequate or poor prep in a year needs to be widely disseminated. The second is that there needs to be more education on standardization on how preps are described. In some poor preps, much of the colon can be seen, and clinicians can identify polyps 5-6 mm, so a 1-year follow-up may not be needed.” This type of research is challenging if the data are not standardized, she added.
Dr. Isaacs agreed with the authors’ description of repeat colonoscopies after poor bowel prep as a quality improvement area given the variability in following current recommendations, which leads into next steps for research.
“Understanding reasons for the recommendations that endoscopists made for follow-up would be the next step in this type of research,” Dr Isaacs noted. “After that, studies on the impact of an educational intervention, followed by repeating the initial assessment.”
The study received no outside funding. The researchers had no financial conflicts to disclose; however, lead author Dr. Calderwood disclosed support from the National Cancer Institute, the Dartmouth-Hitchcock Cancer Research Fellows Program, the Dartmouth-Hitchcock Norris Cotton Cancer Center, and the Dartmouth Clinical and Translational Science Institute. Dr Isaacs had no financial conflicts to disclose but has previously served on the editorial board of GI & Hepatology News.
FROM GASTROINTESTINAL ENDOSCOPY
Aspirin lowered preeclampsia risk in real-world lupus study
Women with systemic lupus erythematous (SLE) who are at risk for preeclampsia may benefit from timely treatment with low-dose aspirin and perhaps hydroxychloroquine, according to German researchers.
In a prospective, real-world study of 190 pregnancies in 148 women (average age, 30 years), the use of low-dose aspirin starting around the 16th week of gestation was associated with a lower risk for preeclampsia than was no aspirin use (adjusted odds ratio [aOR], 0.21; P < .05).
The use of hydroxychloroquine starting in the first trimester had a “moderating effect,” said Isabell Haase, MD, a senior clinician scientist in the department of rheumatology at Hiller-Research Unit, Düsseldorf, Germany. Although this was not a statistically significant effect (aOR, 0.47; P = .21), the association strengthened if only high-risk pregnancies were considered (aOR, 0.28; P = .075).
“I think this once more shows us that counseling and risk assessment in our lupus patients is very important to find out those with the highest risk and treat them as good as possible,” Dr. Haase said at an international congress on systemic lupus erythematosus.
Preeclampsia and lupus
“Women with SLE face a high risk of preeclampsia because of their autoimmune disease,” Dr. Haase explained. “This [risk] can be further increased if a woman carries additional risk factors, like hypertension or lupus nephritis.”
Low-dose aspirin is known to protect against the development of preeclampsia in women without autoimmune disease if started before the 16th gestational week of pregnancy, Dr. Haase added. That is why it’s recommended by both the American College of Rheumatology and the European Alliance of Associations for Rheumatology.
“For hydroxychloroquine, we only have some small studies and its mechanism of action that lead us to the idea that it could also have a beneficial effect on preeclampsia in lupus patients,” she said.
Study design and results
The aim of the study was to see in a real-world cohort whether there was any beneficial effect of either aspirin or hydroxychloroquine regarding the development of preeclampsia.
The researchers used prospectively collected data from pregnancies seen at an outpatient pregnancy clinic during 1995-2019. They used multiple logistic regression to determine whether there was any effect of four treatments on the development of preeclampsia: aspirin (n = 39 patients) or hydroxychloroquine (n = 39) alone, in combination (n = 43), or neither drug (n = 69).
Overall, 56% of the women had significant risk factors for preeclampsia, including a prior history, multifetal gestation, chronic hypertension, lupus nephritis, or antiphospholipid antibodies (aPL). A further 28% had moderate risk factors, including not having had children, a body mass index >30 kg/m2, and being older than 35 years.
The overall rate of preeclampsia in the study population was 13.2%, “which is in line with other studies in lupus pregnancies,” Dr. Haase said. Rates in each of the four treatment groups were 15.4% with aspirin alone, 7.7% with hydroxychloroquine alone, 14% with both drugs, and 14.5% with neither.
The odds of developing preeclampsia were lower with both aspirin and hydroxychloroquine. Factors that raised the odds were high disease activity in the first trimester (aOR, 4.55), a BMI of >30 kg/m2 (aOR, 6.14), having high-risk aPL or antiphospholipid syndrome (aOR, 8.02), and a history of preeclampsia (aOR, 9.78).
Only high disease activity in the first trimester and BMI >30 kg/m2 remained independent predictors of preeclampsia when the researchers considered only high-risk pregnancies (aOR, 7.74 for high disease activity in first trimester and 10.04 for a high BMI).
The results are “really impressive,” said Angela Tincani, MD, senior consultant at the Rheumatology and Clinical Immunology Unit of ASST–Spedali Civili di Brescia, in Italy.
Dr. Tincani observed that the study had covered a “large number of years” (1995-2020).
“I think that our attitude in looking after lupus patients [changed] during this time,” she said.
“As an example, I think that we probably use less corticosteroids now than in the 90s,” she said.
When asked whether changes in practices have influenced the findings, she acknowledged, “You can see that the prescription of the different medications has changed a lot. We also thought that we have to take into account the years as a confounder, but we haven’t statistically analyzed that, but it’s definitely something that we are going to do next.”
The study received no outside funding. Dr. Haase has received travel fees from AbbVie, Celgene, Chugai, Janssen-Cilag, Eli Lilly, and Medac. Dr. Tincani has disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
Women with systemic lupus erythematous (SLE) who are at risk for preeclampsia may benefit from timely treatment with low-dose aspirin and perhaps hydroxychloroquine, according to German researchers.
In a prospective, real-world study of 190 pregnancies in 148 women (average age, 30 years), the use of low-dose aspirin starting around the 16th week of gestation was associated with a lower risk for preeclampsia than was no aspirin use (adjusted odds ratio [aOR], 0.21; P < .05).
The use of hydroxychloroquine starting in the first trimester had a “moderating effect,” said Isabell Haase, MD, a senior clinician scientist in the department of rheumatology at Hiller-Research Unit, Düsseldorf, Germany. Although this was not a statistically significant effect (aOR, 0.47; P = .21), the association strengthened if only high-risk pregnancies were considered (aOR, 0.28; P = .075).
“I think this once more shows us that counseling and risk assessment in our lupus patients is very important to find out those with the highest risk and treat them as good as possible,” Dr. Haase said at an international congress on systemic lupus erythematosus.
Preeclampsia and lupus
“Women with SLE face a high risk of preeclampsia because of their autoimmune disease,” Dr. Haase explained. “This [risk] can be further increased if a woman carries additional risk factors, like hypertension or lupus nephritis.”
Low-dose aspirin is known to protect against the development of preeclampsia in women without autoimmune disease if started before the 16th gestational week of pregnancy, Dr. Haase added. That is why it’s recommended by both the American College of Rheumatology and the European Alliance of Associations for Rheumatology.
“For hydroxychloroquine, we only have some small studies and its mechanism of action that lead us to the idea that it could also have a beneficial effect on preeclampsia in lupus patients,” she said.
Study design and results
The aim of the study was to see in a real-world cohort whether there was any beneficial effect of either aspirin or hydroxychloroquine regarding the development of preeclampsia.
The researchers used prospectively collected data from pregnancies seen at an outpatient pregnancy clinic during 1995-2019. They used multiple logistic regression to determine whether there was any effect of four treatments on the development of preeclampsia: aspirin (n = 39 patients) or hydroxychloroquine (n = 39) alone, in combination (n = 43), or neither drug (n = 69).
Overall, 56% of the women had significant risk factors for preeclampsia, including a prior history, multifetal gestation, chronic hypertension, lupus nephritis, or antiphospholipid antibodies (aPL). A further 28% had moderate risk factors, including not having had children, a body mass index >30 kg/m2, and being older than 35 years.
The overall rate of preeclampsia in the study population was 13.2%, “which is in line with other studies in lupus pregnancies,” Dr. Haase said. Rates in each of the four treatment groups were 15.4% with aspirin alone, 7.7% with hydroxychloroquine alone, 14% with both drugs, and 14.5% with neither.
The odds of developing preeclampsia were lower with both aspirin and hydroxychloroquine. Factors that raised the odds were high disease activity in the first trimester (aOR, 4.55), a BMI of >30 kg/m2 (aOR, 6.14), having high-risk aPL or antiphospholipid syndrome (aOR, 8.02), and a history of preeclampsia (aOR, 9.78).
Only high disease activity in the first trimester and BMI >30 kg/m2 remained independent predictors of preeclampsia when the researchers considered only high-risk pregnancies (aOR, 7.74 for high disease activity in first trimester and 10.04 for a high BMI).
The results are “really impressive,” said Angela Tincani, MD, senior consultant at the Rheumatology and Clinical Immunology Unit of ASST–Spedali Civili di Brescia, in Italy.
Dr. Tincani observed that the study had covered a “large number of years” (1995-2020).
“I think that our attitude in looking after lupus patients [changed] during this time,” she said.
“As an example, I think that we probably use less corticosteroids now than in the 90s,” she said.
When asked whether changes in practices have influenced the findings, she acknowledged, “You can see that the prescription of the different medications has changed a lot. We also thought that we have to take into account the years as a confounder, but we haven’t statistically analyzed that, but it’s definitely something that we are going to do next.”
The study received no outside funding. Dr. Haase has received travel fees from AbbVie, Celgene, Chugai, Janssen-Cilag, Eli Lilly, and Medac. Dr. Tincani has disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
Women with systemic lupus erythematous (SLE) who are at risk for preeclampsia may benefit from timely treatment with low-dose aspirin and perhaps hydroxychloroquine, according to German researchers.
In a prospective, real-world study of 190 pregnancies in 148 women (average age, 30 years), the use of low-dose aspirin starting around the 16th week of gestation was associated with a lower risk for preeclampsia than was no aspirin use (adjusted odds ratio [aOR], 0.21; P < .05).
The use of hydroxychloroquine starting in the first trimester had a “moderating effect,” said Isabell Haase, MD, a senior clinician scientist in the department of rheumatology at Hiller-Research Unit, Düsseldorf, Germany. Although this was not a statistically significant effect (aOR, 0.47; P = .21), the association strengthened if only high-risk pregnancies were considered (aOR, 0.28; P = .075).
“I think this once more shows us that counseling and risk assessment in our lupus patients is very important to find out those with the highest risk and treat them as good as possible,” Dr. Haase said at an international congress on systemic lupus erythematosus.
Preeclampsia and lupus
“Women with SLE face a high risk of preeclampsia because of their autoimmune disease,” Dr. Haase explained. “This [risk] can be further increased if a woman carries additional risk factors, like hypertension or lupus nephritis.”
Low-dose aspirin is known to protect against the development of preeclampsia in women without autoimmune disease if started before the 16th gestational week of pregnancy, Dr. Haase added. That is why it’s recommended by both the American College of Rheumatology and the European Alliance of Associations for Rheumatology.
“For hydroxychloroquine, we only have some small studies and its mechanism of action that lead us to the idea that it could also have a beneficial effect on preeclampsia in lupus patients,” she said.
Study design and results
The aim of the study was to see in a real-world cohort whether there was any beneficial effect of either aspirin or hydroxychloroquine regarding the development of preeclampsia.
The researchers used prospectively collected data from pregnancies seen at an outpatient pregnancy clinic during 1995-2019. They used multiple logistic regression to determine whether there was any effect of four treatments on the development of preeclampsia: aspirin (n = 39 patients) or hydroxychloroquine (n = 39) alone, in combination (n = 43), or neither drug (n = 69).
Overall, 56% of the women had significant risk factors for preeclampsia, including a prior history, multifetal gestation, chronic hypertension, lupus nephritis, or antiphospholipid antibodies (aPL). A further 28% had moderate risk factors, including not having had children, a body mass index >30 kg/m2, and being older than 35 years.
The overall rate of preeclampsia in the study population was 13.2%, “which is in line with other studies in lupus pregnancies,” Dr. Haase said. Rates in each of the four treatment groups were 15.4% with aspirin alone, 7.7% with hydroxychloroquine alone, 14% with both drugs, and 14.5% with neither.
The odds of developing preeclampsia were lower with both aspirin and hydroxychloroquine. Factors that raised the odds were high disease activity in the first trimester (aOR, 4.55), a BMI of >30 kg/m2 (aOR, 6.14), having high-risk aPL or antiphospholipid syndrome (aOR, 8.02), and a history of preeclampsia (aOR, 9.78).
Only high disease activity in the first trimester and BMI >30 kg/m2 remained independent predictors of preeclampsia when the researchers considered only high-risk pregnancies (aOR, 7.74 for high disease activity in first trimester and 10.04 for a high BMI).
The results are “really impressive,” said Angela Tincani, MD, senior consultant at the Rheumatology and Clinical Immunology Unit of ASST–Spedali Civili di Brescia, in Italy.
Dr. Tincani observed that the study had covered a “large number of years” (1995-2020).
“I think that our attitude in looking after lupus patients [changed] during this time,” she said.
“As an example, I think that we probably use less corticosteroids now than in the 90s,” she said.
When asked whether changes in practices have influenced the findings, she acknowledged, “You can see that the prescription of the different medications has changed a lot. We also thought that we have to take into account the years as a confounder, but we haven’t statistically analyzed that, but it’s definitely something that we are going to do next.”
The study received no outside funding. Dr. Haase has received travel fees from AbbVie, Celgene, Chugai, Janssen-Cilag, Eli Lilly, and Medac. Dr. Tincani has disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
FROM LUPUS 2021
Why toilet paper is the unofficial symbol of anxiety during COVID
How did toilet paper become the unofficial symbol of anxiety during the pandemic? Empty store shelves are a stark reminder of how COVID-19 has taken a toll on people.
At the beginning of the pandemic, stay-at-home orders drove people to buy large amounts of household goods, especially toilet paper. Demand grew to unforeseen heights in March 2020, with $1.45 billion in toilet paper sales in the 4-week period ending March 29, up 112% from the year before, according to IRI, a Chicago-based market research firm.
As the Delta variant drove a COVID-19 resurgence this summer, market research suggests that almost one in two Americans started stockpiling toilet paper again over fears that supply would run out. The higher demand causes ripples through the retail chain, and a growing number of stores are again facing challenges in stocking toilet paper.
Yet there is plenty for everyone if people don’t stockpile too much, according to paper industry market analyst Ronalds Gonzalez, PhD, an associate professor of conversion economics and sustainability at North Carolina State University, Raleigh.
“As long as people buy what they actually need and don’t get into a panic, there won’t be any issue with the supply of hygienic tissue,” he says, adding that “too much” would equate to stockpiling 6-8 months’ worth of toilet paper, as some people did early in the pandemic.
But retailers are worried that history will repeat itself. In late September 2021, warehouse retail giant Costco told Wall Street analysts that it decided to limit customer purchases of essential items like toilet paper and water. Another retailer, Sam’s Club, began limiting customer purchases of supplies like toilet paper at the end of July.
“We are wired to run with the herd,” says Bradley Klontz, PsyD, an associate professor of practice at Creighton University Heider College of Business, Omaha, N.E., who specializes in financial psychology.
“Quite literally, the last person to get to Costco doesn’t get the toilet paper, so when the herd is running in a certain direction, we feel a biological imperative to not be that last person. That fear of scarcity actually creates the experience of scarcity,” he explains.
The science behind the stockpile
People are collectively alerted by photos shared on social media showing store shelves stripped of toilet paper. Those images triggered consumers to rush out and buy bathroom tissue, even if they didn’t need it – and that herd behavior created toilet paper shortages.
Now, a year and half into the pandemic, people are hypervigilant to danger. Any hint of a possible toilet paper shortage can provoke anxiety and the desire to stockpile.
, says Dr. Klontz. He advises people to take a deep breath before buying extra toilet paper and then assess whether it is truly needed.
Deep in our brains is the limbic system, a group of structures that rules over emotions, motivation, reward, learning, memory, and the fight-or-flight response to stress and danger. When a person senses danger, the brain activates hormones to raise blood pressure and heart rate, increase blood flow, and boost the breath rate, making the body ready to fight or flee under threat.
Once everything settles, the body activates chemicals like dopamine that bring on positive feelings of well-being, rewarding that flight-or-fight response. In this way, the brain powerfully reinforces a key survival instinct.
This sequence of experiences and the brain chemistry behind them may explain why people panic-buy toilet paper.
“With toilet paper, my limbic system starts thinking about a perceived threat to safety,” says Julie Pike, PhD, a psychologist in Chapel Hill, N.C., who specializes in anxiety, hoarding, and posttraumatic stress disorder.
She notes that, in stockpiling toilet paper, “we avoid a perceived threat and then we are chemically rewarded” with dopamine. A storage closet full of toilet paper after a perceived threat of scarcity – no matter how unfounded – brings on that satisfied feeling.
When the market shifted
Paper producers make hygiene paper for two markets: the commercial (think: those big rolls of thin paper used in offices, schools, and restaurants) and the consumer (the soft paper you likely use at home). In the spring of 2020, the commercial market plummeted, and the consumer market skyrocketed.
Generally, the consumer toilet paper market is steady. The average American uses about 57 toilet sheets a day and about 50 pounds annually. Grocery stores and other retailers keep just enough toilet paper on hand to meet this steady demand, meaning panic buying at the start of the pandemic quickly depleted stocks. Paper makers had to change production to meet higher consumer demand and fewer commercial buyers.
By the end of the summer of 2020, toilet paper makers had adjusted for the market shift and caught up with demand, as consumers worked through their stockpiles of paper. But retail inventories remain lean because toilet paper doesn’t carry huge profit margins. For this reason, even healthy stocks remain sensitive to sudden shifts in consumer demand, Dr. Gonzalez says.
“If people buy more than they should, then they are just buying from other people,” creating an unnecessary scarcity of toilet paper, he says.
The supply chain
It is true that the supply chain is under unprecedented strain, leading to higher prices for many goods, says Katie Denis, vice president of research and industry narrative at the Consumer Brands Association, Washington, which represents toilet paper makers Georgia-Pacific and Procter & Gamble. Consumers should expect toilet paper to be available, but there may be fewer options for product sizes, she says.
Still, Dr. Gonzalez says consumers should not worry too much about the global supply chain affecting the domestic toilet paper supply. The raw material for toilet paper production is available domestically, and more than 97% of the supply on U.S. retailer shelves is made in the United States, he says.
In modern society, toilet paper is a primary link to civilization, health, and hygiene. While there is no easy substitute, alternatives do exist A bidet, for example, is a device that can spray water on the genital area. Other options are reusable cloths, sponges, baby wipes, napkins, towels, and washcloths.
Human health and hygiene
“Compared to many other items, toilet paper can’t really be replaced,” says Frank H. Farley, PhD, a professor of psychological studies in education at Temple University, who studies human motivation. “It is a unique consumer item that is perceived to be extremely necessary. In that way, it plays into that survivor mentality, that having it is necessary for survival.”
Being without it can truly seem like an existential threat.
New York City emergency planner Ira Tannenbaum advises families to assess their usage of essential household supplies like toilet paper (you can do so through this toilet paper calculator) and keep at least a 1-week supply on hand in case of emergency. New York City has posted recommendations to families for emergency planning, including the guidance to “avoid panic buying.”
Dr. Pike says she would stockpile a bit more, something that could be done gradually, before there’s a panic. She says that if people are tempted to buy more out of anxiety, they should remind themselves that shortages arise because of panicky purchasing.
“Leave some for other families – other people have children and partners and siblings just like us,” she says.
A version of this article first appeared on WebMD.com.
How did toilet paper become the unofficial symbol of anxiety during the pandemic? Empty store shelves are a stark reminder of how COVID-19 has taken a toll on people.
At the beginning of the pandemic, stay-at-home orders drove people to buy large amounts of household goods, especially toilet paper. Demand grew to unforeseen heights in March 2020, with $1.45 billion in toilet paper sales in the 4-week period ending March 29, up 112% from the year before, according to IRI, a Chicago-based market research firm.
As the Delta variant drove a COVID-19 resurgence this summer, market research suggests that almost one in two Americans started stockpiling toilet paper again over fears that supply would run out. The higher demand causes ripples through the retail chain, and a growing number of stores are again facing challenges in stocking toilet paper.
Yet there is plenty for everyone if people don’t stockpile too much, according to paper industry market analyst Ronalds Gonzalez, PhD, an associate professor of conversion economics and sustainability at North Carolina State University, Raleigh.
“As long as people buy what they actually need and don’t get into a panic, there won’t be any issue with the supply of hygienic tissue,” he says, adding that “too much” would equate to stockpiling 6-8 months’ worth of toilet paper, as some people did early in the pandemic.
But retailers are worried that history will repeat itself. In late September 2021, warehouse retail giant Costco told Wall Street analysts that it decided to limit customer purchases of essential items like toilet paper and water. Another retailer, Sam’s Club, began limiting customer purchases of supplies like toilet paper at the end of July.
“We are wired to run with the herd,” says Bradley Klontz, PsyD, an associate professor of practice at Creighton University Heider College of Business, Omaha, N.E., who specializes in financial psychology.
“Quite literally, the last person to get to Costco doesn’t get the toilet paper, so when the herd is running in a certain direction, we feel a biological imperative to not be that last person. That fear of scarcity actually creates the experience of scarcity,” he explains.
The science behind the stockpile
People are collectively alerted by photos shared on social media showing store shelves stripped of toilet paper. Those images triggered consumers to rush out and buy bathroom tissue, even if they didn’t need it – and that herd behavior created toilet paper shortages.
Now, a year and half into the pandemic, people are hypervigilant to danger. Any hint of a possible toilet paper shortage can provoke anxiety and the desire to stockpile.
, says Dr. Klontz. He advises people to take a deep breath before buying extra toilet paper and then assess whether it is truly needed.
Deep in our brains is the limbic system, a group of structures that rules over emotions, motivation, reward, learning, memory, and the fight-or-flight response to stress and danger. When a person senses danger, the brain activates hormones to raise blood pressure and heart rate, increase blood flow, and boost the breath rate, making the body ready to fight or flee under threat.
Once everything settles, the body activates chemicals like dopamine that bring on positive feelings of well-being, rewarding that flight-or-fight response. In this way, the brain powerfully reinforces a key survival instinct.
This sequence of experiences and the brain chemistry behind them may explain why people panic-buy toilet paper.
“With toilet paper, my limbic system starts thinking about a perceived threat to safety,” says Julie Pike, PhD, a psychologist in Chapel Hill, N.C., who specializes in anxiety, hoarding, and posttraumatic stress disorder.
She notes that, in stockpiling toilet paper, “we avoid a perceived threat and then we are chemically rewarded” with dopamine. A storage closet full of toilet paper after a perceived threat of scarcity – no matter how unfounded – brings on that satisfied feeling.
When the market shifted
Paper producers make hygiene paper for two markets: the commercial (think: those big rolls of thin paper used in offices, schools, and restaurants) and the consumer (the soft paper you likely use at home). In the spring of 2020, the commercial market plummeted, and the consumer market skyrocketed.
Generally, the consumer toilet paper market is steady. The average American uses about 57 toilet sheets a day and about 50 pounds annually. Grocery stores and other retailers keep just enough toilet paper on hand to meet this steady demand, meaning panic buying at the start of the pandemic quickly depleted stocks. Paper makers had to change production to meet higher consumer demand and fewer commercial buyers.
By the end of the summer of 2020, toilet paper makers had adjusted for the market shift and caught up with demand, as consumers worked through their stockpiles of paper. But retail inventories remain lean because toilet paper doesn’t carry huge profit margins. For this reason, even healthy stocks remain sensitive to sudden shifts in consumer demand, Dr. Gonzalez says.
“If people buy more than they should, then they are just buying from other people,” creating an unnecessary scarcity of toilet paper, he says.
The supply chain
It is true that the supply chain is under unprecedented strain, leading to higher prices for many goods, says Katie Denis, vice president of research and industry narrative at the Consumer Brands Association, Washington, which represents toilet paper makers Georgia-Pacific and Procter & Gamble. Consumers should expect toilet paper to be available, but there may be fewer options for product sizes, she says.
Still, Dr. Gonzalez says consumers should not worry too much about the global supply chain affecting the domestic toilet paper supply. The raw material for toilet paper production is available domestically, and more than 97% of the supply on U.S. retailer shelves is made in the United States, he says.
In modern society, toilet paper is a primary link to civilization, health, and hygiene. While there is no easy substitute, alternatives do exist A bidet, for example, is a device that can spray water on the genital area. Other options are reusable cloths, sponges, baby wipes, napkins, towels, and washcloths.
Human health and hygiene
“Compared to many other items, toilet paper can’t really be replaced,” says Frank H. Farley, PhD, a professor of psychological studies in education at Temple University, who studies human motivation. “It is a unique consumer item that is perceived to be extremely necessary. In that way, it plays into that survivor mentality, that having it is necessary for survival.”
Being without it can truly seem like an existential threat.
New York City emergency planner Ira Tannenbaum advises families to assess their usage of essential household supplies like toilet paper (you can do so through this toilet paper calculator) and keep at least a 1-week supply on hand in case of emergency. New York City has posted recommendations to families for emergency planning, including the guidance to “avoid panic buying.”
Dr. Pike says she would stockpile a bit more, something that could be done gradually, before there’s a panic. She says that if people are tempted to buy more out of anxiety, they should remind themselves that shortages arise because of panicky purchasing.
“Leave some for other families – other people have children and partners and siblings just like us,” she says.
A version of this article first appeared on WebMD.com.
How did toilet paper become the unofficial symbol of anxiety during the pandemic? Empty store shelves are a stark reminder of how COVID-19 has taken a toll on people.
At the beginning of the pandemic, stay-at-home orders drove people to buy large amounts of household goods, especially toilet paper. Demand grew to unforeseen heights in March 2020, with $1.45 billion in toilet paper sales in the 4-week period ending March 29, up 112% from the year before, according to IRI, a Chicago-based market research firm.
As the Delta variant drove a COVID-19 resurgence this summer, market research suggests that almost one in two Americans started stockpiling toilet paper again over fears that supply would run out. The higher demand causes ripples through the retail chain, and a growing number of stores are again facing challenges in stocking toilet paper.
Yet there is plenty for everyone if people don’t stockpile too much, according to paper industry market analyst Ronalds Gonzalez, PhD, an associate professor of conversion economics and sustainability at North Carolina State University, Raleigh.
“As long as people buy what they actually need and don’t get into a panic, there won’t be any issue with the supply of hygienic tissue,” he says, adding that “too much” would equate to stockpiling 6-8 months’ worth of toilet paper, as some people did early in the pandemic.
But retailers are worried that history will repeat itself. In late September 2021, warehouse retail giant Costco told Wall Street analysts that it decided to limit customer purchases of essential items like toilet paper and water. Another retailer, Sam’s Club, began limiting customer purchases of supplies like toilet paper at the end of July.
“We are wired to run with the herd,” says Bradley Klontz, PsyD, an associate professor of practice at Creighton University Heider College of Business, Omaha, N.E., who specializes in financial psychology.
“Quite literally, the last person to get to Costco doesn’t get the toilet paper, so when the herd is running in a certain direction, we feel a biological imperative to not be that last person. That fear of scarcity actually creates the experience of scarcity,” he explains.
The science behind the stockpile
People are collectively alerted by photos shared on social media showing store shelves stripped of toilet paper. Those images triggered consumers to rush out and buy bathroom tissue, even if they didn’t need it – and that herd behavior created toilet paper shortages.
Now, a year and half into the pandemic, people are hypervigilant to danger. Any hint of a possible toilet paper shortage can provoke anxiety and the desire to stockpile.
, says Dr. Klontz. He advises people to take a deep breath before buying extra toilet paper and then assess whether it is truly needed.
Deep in our brains is the limbic system, a group of structures that rules over emotions, motivation, reward, learning, memory, and the fight-or-flight response to stress and danger. When a person senses danger, the brain activates hormones to raise blood pressure and heart rate, increase blood flow, and boost the breath rate, making the body ready to fight or flee under threat.
Once everything settles, the body activates chemicals like dopamine that bring on positive feelings of well-being, rewarding that flight-or-fight response. In this way, the brain powerfully reinforces a key survival instinct.
This sequence of experiences and the brain chemistry behind them may explain why people panic-buy toilet paper.
“With toilet paper, my limbic system starts thinking about a perceived threat to safety,” says Julie Pike, PhD, a psychologist in Chapel Hill, N.C., who specializes in anxiety, hoarding, and posttraumatic stress disorder.
She notes that, in stockpiling toilet paper, “we avoid a perceived threat and then we are chemically rewarded” with dopamine. A storage closet full of toilet paper after a perceived threat of scarcity – no matter how unfounded – brings on that satisfied feeling.
When the market shifted
Paper producers make hygiene paper for two markets: the commercial (think: those big rolls of thin paper used in offices, schools, and restaurants) and the consumer (the soft paper you likely use at home). In the spring of 2020, the commercial market plummeted, and the consumer market skyrocketed.
Generally, the consumer toilet paper market is steady. The average American uses about 57 toilet sheets a day and about 50 pounds annually. Grocery stores and other retailers keep just enough toilet paper on hand to meet this steady demand, meaning panic buying at the start of the pandemic quickly depleted stocks. Paper makers had to change production to meet higher consumer demand and fewer commercial buyers.
By the end of the summer of 2020, toilet paper makers had adjusted for the market shift and caught up with demand, as consumers worked through their stockpiles of paper. But retail inventories remain lean because toilet paper doesn’t carry huge profit margins. For this reason, even healthy stocks remain sensitive to sudden shifts in consumer demand, Dr. Gonzalez says.
“If people buy more than they should, then they are just buying from other people,” creating an unnecessary scarcity of toilet paper, he says.
The supply chain
It is true that the supply chain is under unprecedented strain, leading to higher prices for many goods, says Katie Denis, vice president of research and industry narrative at the Consumer Brands Association, Washington, which represents toilet paper makers Georgia-Pacific and Procter & Gamble. Consumers should expect toilet paper to be available, but there may be fewer options for product sizes, she says.
Still, Dr. Gonzalez says consumers should not worry too much about the global supply chain affecting the domestic toilet paper supply. The raw material for toilet paper production is available domestically, and more than 97% of the supply on U.S. retailer shelves is made in the United States, he says.
In modern society, toilet paper is a primary link to civilization, health, and hygiene. While there is no easy substitute, alternatives do exist A bidet, for example, is a device that can spray water on the genital area. Other options are reusable cloths, sponges, baby wipes, napkins, towels, and washcloths.
Human health and hygiene
“Compared to many other items, toilet paper can’t really be replaced,” says Frank H. Farley, PhD, a professor of psychological studies in education at Temple University, who studies human motivation. “It is a unique consumer item that is perceived to be extremely necessary. In that way, it plays into that survivor mentality, that having it is necessary for survival.”
Being without it can truly seem like an existential threat.
New York City emergency planner Ira Tannenbaum advises families to assess their usage of essential household supplies like toilet paper (you can do so through this toilet paper calculator) and keep at least a 1-week supply on hand in case of emergency. New York City has posted recommendations to families for emergency planning, including the guidance to “avoid panic buying.”
Dr. Pike says she would stockpile a bit more, something that could be done gradually, before there’s a panic. She says that if people are tempted to buy more out of anxiety, they should remind themselves that shortages arise because of panicky purchasing.
“Leave some for other families – other people have children and partners and siblings just like us,” she says.
A version of this article first appeared on WebMD.com.
An integrated response to Surfside: Lessons learned
The catastrophic collapse of the Surfside, Fla., Champlain Towers South left ambiguous loss, trauma, grief, and other psychiatric and psychological sequelae in its wake.
Now that a few months have passed since the tragedy, which took the lives of 98 residents, it is helpful to examine the psychiatric and psychological support efforts that emerged.
We can think of those support efforts as operating on two tracks: one was pursued by mental health professionals representing numerous organizations; the other was pursued by local, regional, and international first responders – specifically, by Israeli Defense Force (IDF) members who came to our community at the request of Surfside families.
Those efforts were guided by existing frameworks for crisis response designed to provide containment amid the naturally disorganizing effects of the trauma and ambiguous loss. In retrospect, it was clear that the mechanisms by which those frameworks coalesced and functioned were more implicit and organically synchronous than explicitly coordinated and agreed upon. key themes emerged and revealed intrinsic links between the first-responder/search and rescue and psychological strategies.
In this article, we discuss relevant themes and parallels between the psychological intervention/strategies and the first-responder disaster response and the practical utility of implementing an integrated strategy. Our hope is that a better understanding of these strategies will help future therapists and responders who respond to crises.
Setting the frame
The importance of setting a psychotherapeutic frame is indisputable regardless of theoretical orientation or therapeutic modality. Predictable, consistent conditions under which therapy takes place support a patient’s capacity to tolerate the ambiguous and unpredictable aspects of the process. Those “rules of engagement” provide a structure where subjective experiences can be formulated, organized, understood, and integrated. Twice-daily briefs held in a centralized location (dubbed the Surfside “family center”) paralleled this frame and served that same containing function by offering structure, order, and predictability amid the palpable chaos of ambiguous loss and traumatic grief. Those briefs provided key information on the status of the operation and described the rescue strategy. These were led by the Miami-Dade assistant fire chief and IDF colonel (E.E.), who presented a unified front and consistent presence.
It is essential that briefings such as these be coordinated (and unified) with clear expectations about ground rules, much like what is involved in therapeutic informed consent. In this context, rules included permissions related to documentation of meetings, information sharing, and rules of communication with the media in an effort to protect the vulnerable.
The centralized meeting location served as an important center of gravity and unified place of waiting and information receipt. It provided a dedicated space to meet with humanitarian aid organizations and government officials, and symbolized continuity, consistency, ease of information transmission, and a place where practical needs could be addressed. Meals, toiletries, and other supplies were provided to simplify and maintain daily routines. Those are otherwise unremarkable practices that seemed impossible to manage amid a crisis, yet can be inherently grounding and emotionally organizing when facing deep psychological fragmentation.
Meeting in person allowed the IDF to offer operational visuals to allow those affected to feel less helpless and cultivate a sense of purpose by being part of the strategy/mission. Their strategy included “population intelligence,” which was aimed at both information gathering to practically facilitate the rescue/recovery process (for example, locating victims, property, and recreating a visual of how the building fell), and inspiring people to participate. This engagement helped many transition from a place of denial/repression to acknowledging loss/grief, and from a passive to active part of the effort, in a way that was safe and realistic – as opposed to going to the site and aiding themselves, as some had requested.
Naturally, a central location made it possible to offer immediate psychological assistance and support. Clinicians responding to crisis should be carefully selected in light of the immense suffering, emotional vulnerability, and heightened reactivity of those affected. People were overwhelmed by deep sorrow, fear, anger, and uncertainty, vacillating between hope and despair, and mobilized by a desire to help. Those providing support need to be interpersonally skilled and able to regulate their own emotions. They must be able to formulate – in real time – an understanding of what is needed, and implement a strategic plan. Like first responders, it is also key for providers to be easily accessible and identifiable in uniform so that people in the grip of a survival response can easily identify and elicit support.
The power of strategy
The Israeli delegation and mental health approaches were aligned with respect to cultivating a team identity and keeping the team spirit elevated. The delegation’s approach was to deemphasize rank during the mission in that everyone was responsible for anything that was needed and no task was below anyone’s rank. The same was true for the mental health support response: Early interventions were focused on addressing practical needs – providing blankets, water, chargers, food, and a calming presence to counter the initial chaos. No task was too small, regardless of title or role. As more structure and order ensued, it was possible to offer more traditional crisis-related interventions aimed at grounding those affected.
Both teams worked to ensure 24-hour coverage, which was crucial given the need for consistency and continuity. Our commitment was to support the victims’ families and survivors by fully embracing the chaos and the situational demands, offering attunement and support, and satisfying both basic and higher-level needs. We divided and conquered work, observed signals of need, offered immediate support where necessary, and coordinated longer-term care plans when possible. The importance of ongoing self-care, consultation, and debriefing while doing this work cannot be overstated. Time to address basic needs and the impact of vicarious trauma as a team must be built in.
Importance of flexibility
This tragedy came with unique complexities and sensitivities that needed to be identified expediently and addressed with a concrete, comprehensive plan. This was true for both the rescue and psychological support efforts, and flexibility was key. There was nothing traditional about our work from a therapeutic perspective – we found quiet corners and empty offices, went for walks, met in lobbies, and checked in by phone. The interventions were brief.
Roles shifted often between aiding in addressing practical needs, advocating for victims and connecting them to appropriate resources, supporting the police in making death notifications, providing support and space for processing during and after briefings, and more.
Similarly, the rescue team constantly reevaluated their strategy because of what they discovered as they dismantled the collapsed building, in addition to managing external impacting factors (heat, rain, lightning, and the threat of the remaining structure falling).
Language matters
The iteration of commitment to the families/victims/mission and to work speedily and efficiently was important for both rescuers and therapists. It was key during the briefings for the chief and colonel (E.E.) to share information in a manner that was professional, discreet, honest and explicit. Their willingness and ability to be vulnerable and to share their personal feelings as active rescuers humanized them. Their approach was matter of fact, yet warm, loving, and containing, all of which conveyed dignity and respect.
Word choice mattered, and the IDF’s intentional choice to refer to recovered victims as “souls,” rather than “bodies,” conveyed their sensitivity to the intensity of anguish, depth of loss, and gravity of the situation. From a psychological perspective, the transition between “rescue” efforts signifying the potential saving of lives to “recovery” of bodies or remains was significant and demarcated a dramatic shift. The weeks-long efforts, once painfully slow, then felt too abrupt to process.
One extraordinary moment was the chief’s response to the families’ discomfort at the news of the switch from rescue to recovery. The families were anxious about losing the structure that the briefings provided and were apprehensive about the handoff from fire to the police department. With great compassion and attunement, he assured them that he would stay with them, and they together, as a family, would decide when to conclude the in-person briefings. The colonel (E.E.), too, provided assurance that neither procedure nor the urgency of the recovery would change. It was both heart-warming and containing that information related to the operation was shared in a clear manner, and that the thought process and rationale behind major decisions (e.g., demolishing the remaining building, decision to pause operations, switch from rescue to recovery) was shared. It was useful for the clinicians to be aware of this rationale in helping individuals metabolize the information and process the associated trauma and grief.
Unification is key
Surfside has left an indelible impact on us. We saw and experienced unity in many respects – clinicians from various backgrounds collaborating, families bonding and caring for one another, community support and solidarity, and the cooperation and coordination of the search and rescue teams. The diverse groups providing support came to feel like a family, and the importance of inter- and intrateam integration cannot be overstated. We were transformed both by our professional collaborations and authentic connections with those affected, and will forever cherish the experience, one another, the families, and the souls lost.
Dr. Feldman is a licensed clinical psychologist in private practice in Miami. She is an adjunct professor in the college of psychology at Nova Southeastern University, Fort Lauderdale, Fla., where she teaches clinical psychology doctoral students. She also serves on the board of directors of The Southeast Florida Association for Psychoanalytic Psychology. Dr. Feldman has no disclosures. Col. Edri is the Israeli Defense Forces District Commander of the Home Front Command Haifa District. He served as the deputy commander for the Israeli Defense Forces Search and Rescue Delegation, which was brought in to provide international aid to the local and domestic forces responding to the Surfside, Fla., building collapse. Col. Edri has no disclosures. Dr. Davidtz is a licensed psychologist and associate professor in the College of Psychology at Nova Southeastern University, Fort Lauderdale, Fla., where she is director of internship training for the Psychology Services Center and director of psychological services for the emotionally distressed, a specialty clinic that serves people with serious mental illness and personality disorders. She also maintains a part-time private practice specializing in the treatment of complex posttraumatic conditions and personality disorders. Dr. Davidtz has no disclosures.
The catastrophic collapse of the Surfside, Fla., Champlain Towers South left ambiguous loss, trauma, grief, and other psychiatric and psychological sequelae in its wake.
Now that a few months have passed since the tragedy, which took the lives of 98 residents, it is helpful to examine the psychiatric and psychological support efforts that emerged.
We can think of those support efforts as operating on two tracks: one was pursued by mental health professionals representing numerous organizations; the other was pursued by local, regional, and international first responders – specifically, by Israeli Defense Force (IDF) members who came to our community at the request of Surfside families.
Those efforts were guided by existing frameworks for crisis response designed to provide containment amid the naturally disorganizing effects of the trauma and ambiguous loss. In retrospect, it was clear that the mechanisms by which those frameworks coalesced and functioned were more implicit and organically synchronous than explicitly coordinated and agreed upon. key themes emerged and revealed intrinsic links between the first-responder/search and rescue and psychological strategies.
In this article, we discuss relevant themes and parallels between the psychological intervention/strategies and the first-responder disaster response and the practical utility of implementing an integrated strategy. Our hope is that a better understanding of these strategies will help future therapists and responders who respond to crises.
Setting the frame
The importance of setting a psychotherapeutic frame is indisputable regardless of theoretical orientation or therapeutic modality. Predictable, consistent conditions under which therapy takes place support a patient’s capacity to tolerate the ambiguous and unpredictable aspects of the process. Those “rules of engagement” provide a structure where subjective experiences can be formulated, organized, understood, and integrated. Twice-daily briefs held in a centralized location (dubbed the Surfside “family center”) paralleled this frame and served that same containing function by offering structure, order, and predictability amid the palpable chaos of ambiguous loss and traumatic grief. Those briefs provided key information on the status of the operation and described the rescue strategy. These were led by the Miami-Dade assistant fire chief and IDF colonel (E.E.), who presented a unified front and consistent presence.
It is essential that briefings such as these be coordinated (and unified) with clear expectations about ground rules, much like what is involved in therapeutic informed consent. In this context, rules included permissions related to documentation of meetings, information sharing, and rules of communication with the media in an effort to protect the vulnerable.
The centralized meeting location served as an important center of gravity and unified place of waiting and information receipt. It provided a dedicated space to meet with humanitarian aid organizations and government officials, and symbolized continuity, consistency, ease of information transmission, and a place where practical needs could be addressed. Meals, toiletries, and other supplies were provided to simplify and maintain daily routines. Those are otherwise unremarkable practices that seemed impossible to manage amid a crisis, yet can be inherently grounding and emotionally organizing when facing deep psychological fragmentation.
Meeting in person allowed the IDF to offer operational visuals to allow those affected to feel less helpless and cultivate a sense of purpose by being part of the strategy/mission. Their strategy included “population intelligence,” which was aimed at both information gathering to practically facilitate the rescue/recovery process (for example, locating victims, property, and recreating a visual of how the building fell), and inspiring people to participate. This engagement helped many transition from a place of denial/repression to acknowledging loss/grief, and from a passive to active part of the effort, in a way that was safe and realistic – as opposed to going to the site and aiding themselves, as some had requested.
Naturally, a central location made it possible to offer immediate psychological assistance and support. Clinicians responding to crisis should be carefully selected in light of the immense suffering, emotional vulnerability, and heightened reactivity of those affected. People were overwhelmed by deep sorrow, fear, anger, and uncertainty, vacillating between hope and despair, and mobilized by a desire to help. Those providing support need to be interpersonally skilled and able to regulate their own emotions. They must be able to formulate – in real time – an understanding of what is needed, and implement a strategic plan. Like first responders, it is also key for providers to be easily accessible and identifiable in uniform so that people in the grip of a survival response can easily identify and elicit support.
The power of strategy
The Israeli delegation and mental health approaches were aligned with respect to cultivating a team identity and keeping the team spirit elevated. The delegation’s approach was to deemphasize rank during the mission in that everyone was responsible for anything that was needed and no task was below anyone’s rank. The same was true for the mental health support response: Early interventions were focused on addressing practical needs – providing blankets, water, chargers, food, and a calming presence to counter the initial chaos. No task was too small, regardless of title or role. As more structure and order ensued, it was possible to offer more traditional crisis-related interventions aimed at grounding those affected.
Both teams worked to ensure 24-hour coverage, which was crucial given the need for consistency and continuity. Our commitment was to support the victims’ families and survivors by fully embracing the chaos and the situational demands, offering attunement and support, and satisfying both basic and higher-level needs. We divided and conquered work, observed signals of need, offered immediate support where necessary, and coordinated longer-term care plans when possible. The importance of ongoing self-care, consultation, and debriefing while doing this work cannot be overstated. Time to address basic needs and the impact of vicarious trauma as a team must be built in.
Importance of flexibility
This tragedy came with unique complexities and sensitivities that needed to be identified expediently and addressed with a concrete, comprehensive plan. This was true for both the rescue and psychological support efforts, and flexibility was key. There was nothing traditional about our work from a therapeutic perspective – we found quiet corners and empty offices, went for walks, met in lobbies, and checked in by phone. The interventions were brief.
Roles shifted often between aiding in addressing practical needs, advocating for victims and connecting them to appropriate resources, supporting the police in making death notifications, providing support and space for processing during and after briefings, and more.
Similarly, the rescue team constantly reevaluated their strategy because of what they discovered as they dismantled the collapsed building, in addition to managing external impacting factors (heat, rain, lightning, and the threat of the remaining structure falling).
Language matters
The iteration of commitment to the families/victims/mission and to work speedily and efficiently was important for both rescuers and therapists. It was key during the briefings for the chief and colonel (E.E.) to share information in a manner that was professional, discreet, honest and explicit. Their willingness and ability to be vulnerable and to share their personal feelings as active rescuers humanized them. Their approach was matter of fact, yet warm, loving, and containing, all of which conveyed dignity and respect.
Word choice mattered, and the IDF’s intentional choice to refer to recovered victims as “souls,” rather than “bodies,” conveyed their sensitivity to the intensity of anguish, depth of loss, and gravity of the situation. From a psychological perspective, the transition between “rescue” efforts signifying the potential saving of lives to “recovery” of bodies or remains was significant and demarcated a dramatic shift. The weeks-long efforts, once painfully slow, then felt too abrupt to process.
One extraordinary moment was the chief’s response to the families’ discomfort at the news of the switch from rescue to recovery. The families were anxious about losing the structure that the briefings provided and were apprehensive about the handoff from fire to the police department. With great compassion and attunement, he assured them that he would stay with them, and they together, as a family, would decide when to conclude the in-person briefings. The colonel (E.E.), too, provided assurance that neither procedure nor the urgency of the recovery would change. It was both heart-warming and containing that information related to the operation was shared in a clear manner, and that the thought process and rationale behind major decisions (e.g., demolishing the remaining building, decision to pause operations, switch from rescue to recovery) was shared. It was useful for the clinicians to be aware of this rationale in helping individuals metabolize the information and process the associated trauma and grief.
Unification is key
Surfside has left an indelible impact on us. We saw and experienced unity in many respects – clinicians from various backgrounds collaborating, families bonding and caring for one another, community support and solidarity, and the cooperation and coordination of the search and rescue teams. The diverse groups providing support came to feel like a family, and the importance of inter- and intrateam integration cannot be overstated. We were transformed both by our professional collaborations and authentic connections with those affected, and will forever cherish the experience, one another, the families, and the souls lost.
Dr. Feldman is a licensed clinical psychologist in private practice in Miami. She is an adjunct professor in the college of psychology at Nova Southeastern University, Fort Lauderdale, Fla., where she teaches clinical psychology doctoral students. She also serves on the board of directors of The Southeast Florida Association for Psychoanalytic Psychology. Dr. Feldman has no disclosures. Col. Edri is the Israeli Defense Forces District Commander of the Home Front Command Haifa District. He served as the deputy commander for the Israeli Defense Forces Search and Rescue Delegation, which was brought in to provide international aid to the local and domestic forces responding to the Surfside, Fla., building collapse. Col. Edri has no disclosures. Dr. Davidtz is a licensed psychologist and associate professor in the College of Psychology at Nova Southeastern University, Fort Lauderdale, Fla., where she is director of internship training for the Psychology Services Center and director of psychological services for the emotionally distressed, a specialty clinic that serves people with serious mental illness and personality disorders. She also maintains a part-time private practice specializing in the treatment of complex posttraumatic conditions and personality disorders. Dr. Davidtz has no disclosures.
The catastrophic collapse of the Surfside, Fla., Champlain Towers South left ambiguous loss, trauma, grief, and other psychiatric and psychological sequelae in its wake.
Now that a few months have passed since the tragedy, which took the lives of 98 residents, it is helpful to examine the psychiatric and psychological support efforts that emerged.
We can think of those support efforts as operating on two tracks: one was pursued by mental health professionals representing numerous organizations; the other was pursued by local, regional, and international first responders – specifically, by Israeli Defense Force (IDF) members who came to our community at the request of Surfside families.
Those efforts were guided by existing frameworks for crisis response designed to provide containment amid the naturally disorganizing effects of the trauma and ambiguous loss. In retrospect, it was clear that the mechanisms by which those frameworks coalesced and functioned were more implicit and organically synchronous than explicitly coordinated and agreed upon. key themes emerged and revealed intrinsic links between the first-responder/search and rescue and psychological strategies.
In this article, we discuss relevant themes and parallels between the psychological intervention/strategies and the first-responder disaster response and the practical utility of implementing an integrated strategy. Our hope is that a better understanding of these strategies will help future therapists and responders who respond to crises.
Setting the frame
The importance of setting a psychotherapeutic frame is indisputable regardless of theoretical orientation or therapeutic modality. Predictable, consistent conditions under which therapy takes place support a patient’s capacity to tolerate the ambiguous and unpredictable aspects of the process. Those “rules of engagement” provide a structure where subjective experiences can be formulated, organized, understood, and integrated. Twice-daily briefs held in a centralized location (dubbed the Surfside “family center”) paralleled this frame and served that same containing function by offering structure, order, and predictability amid the palpable chaos of ambiguous loss and traumatic grief. Those briefs provided key information on the status of the operation and described the rescue strategy. These were led by the Miami-Dade assistant fire chief and IDF colonel (E.E.), who presented a unified front and consistent presence.
It is essential that briefings such as these be coordinated (and unified) with clear expectations about ground rules, much like what is involved in therapeutic informed consent. In this context, rules included permissions related to documentation of meetings, information sharing, and rules of communication with the media in an effort to protect the vulnerable.
The centralized meeting location served as an important center of gravity and unified place of waiting and information receipt. It provided a dedicated space to meet with humanitarian aid organizations and government officials, and symbolized continuity, consistency, ease of information transmission, and a place where practical needs could be addressed. Meals, toiletries, and other supplies were provided to simplify and maintain daily routines. Those are otherwise unremarkable practices that seemed impossible to manage amid a crisis, yet can be inherently grounding and emotionally organizing when facing deep psychological fragmentation.
Meeting in person allowed the IDF to offer operational visuals to allow those affected to feel less helpless and cultivate a sense of purpose by being part of the strategy/mission. Their strategy included “population intelligence,” which was aimed at both information gathering to practically facilitate the rescue/recovery process (for example, locating victims, property, and recreating a visual of how the building fell), and inspiring people to participate. This engagement helped many transition from a place of denial/repression to acknowledging loss/grief, and from a passive to active part of the effort, in a way that was safe and realistic – as opposed to going to the site and aiding themselves, as some had requested.
Naturally, a central location made it possible to offer immediate psychological assistance and support. Clinicians responding to crisis should be carefully selected in light of the immense suffering, emotional vulnerability, and heightened reactivity of those affected. People were overwhelmed by deep sorrow, fear, anger, and uncertainty, vacillating between hope and despair, and mobilized by a desire to help. Those providing support need to be interpersonally skilled and able to regulate their own emotions. They must be able to formulate – in real time – an understanding of what is needed, and implement a strategic plan. Like first responders, it is also key for providers to be easily accessible and identifiable in uniform so that people in the grip of a survival response can easily identify and elicit support.
The power of strategy
The Israeli delegation and mental health approaches were aligned with respect to cultivating a team identity and keeping the team spirit elevated. The delegation’s approach was to deemphasize rank during the mission in that everyone was responsible for anything that was needed and no task was below anyone’s rank. The same was true for the mental health support response: Early interventions were focused on addressing practical needs – providing blankets, water, chargers, food, and a calming presence to counter the initial chaos. No task was too small, regardless of title or role. As more structure and order ensued, it was possible to offer more traditional crisis-related interventions aimed at grounding those affected.
Both teams worked to ensure 24-hour coverage, which was crucial given the need for consistency and continuity. Our commitment was to support the victims’ families and survivors by fully embracing the chaos and the situational demands, offering attunement and support, and satisfying both basic and higher-level needs. We divided and conquered work, observed signals of need, offered immediate support where necessary, and coordinated longer-term care plans when possible. The importance of ongoing self-care, consultation, and debriefing while doing this work cannot be overstated. Time to address basic needs and the impact of vicarious trauma as a team must be built in.
Importance of flexibility
This tragedy came with unique complexities and sensitivities that needed to be identified expediently and addressed with a concrete, comprehensive plan. This was true for both the rescue and psychological support efforts, and flexibility was key. There was nothing traditional about our work from a therapeutic perspective – we found quiet corners and empty offices, went for walks, met in lobbies, and checked in by phone. The interventions were brief.
Roles shifted often between aiding in addressing practical needs, advocating for victims and connecting them to appropriate resources, supporting the police in making death notifications, providing support and space for processing during and after briefings, and more.
Similarly, the rescue team constantly reevaluated their strategy because of what they discovered as they dismantled the collapsed building, in addition to managing external impacting factors (heat, rain, lightning, and the threat of the remaining structure falling).
Language matters
The iteration of commitment to the families/victims/mission and to work speedily and efficiently was important for both rescuers and therapists. It was key during the briefings for the chief and colonel (E.E.) to share information in a manner that was professional, discreet, honest and explicit. Their willingness and ability to be vulnerable and to share their personal feelings as active rescuers humanized them. Their approach was matter of fact, yet warm, loving, and containing, all of which conveyed dignity and respect.
Word choice mattered, and the IDF’s intentional choice to refer to recovered victims as “souls,” rather than “bodies,” conveyed their sensitivity to the intensity of anguish, depth of loss, and gravity of the situation. From a psychological perspective, the transition between “rescue” efforts signifying the potential saving of lives to “recovery” of bodies or remains was significant and demarcated a dramatic shift. The weeks-long efforts, once painfully slow, then felt too abrupt to process.
One extraordinary moment was the chief’s response to the families’ discomfort at the news of the switch from rescue to recovery. The families were anxious about losing the structure that the briefings provided and were apprehensive about the handoff from fire to the police department. With great compassion and attunement, he assured them that he would stay with them, and they together, as a family, would decide when to conclude the in-person briefings. The colonel (E.E.), too, provided assurance that neither procedure nor the urgency of the recovery would change. It was both heart-warming and containing that information related to the operation was shared in a clear manner, and that the thought process and rationale behind major decisions (e.g., demolishing the remaining building, decision to pause operations, switch from rescue to recovery) was shared. It was useful for the clinicians to be aware of this rationale in helping individuals metabolize the information and process the associated trauma and grief.
Unification is key
Surfside has left an indelible impact on us. We saw and experienced unity in many respects – clinicians from various backgrounds collaborating, families bonding and caring for one another, community support and solidarity, and the cooperation and coordination of the search and rescue teams. The diverse groups providing support came to feel like a family, and the importance of inter- and intrateam integration cannot be overstated. We were transformed both by our professional collaborations and authentic connections with those affected, and will forever cherish the experience, one another, the families, and the souls lost.
Dr. Feldman is a licensed clinical psychologist in private practice in Miami. She is an adjunct professor in the college of psychology at Nova Southeastern University, Fort Lauderdale, Fla., where she teaches clinical psychology doctoral students. She also serves on the board of directors of The Southeast Florida Association for Psychoanalytic Psychology. Dr. Feldman has no disclosures. Col. Edri is the Israeli Defense Forces District Commander of the Home Front Command Haifa District. He served as the deputy commander for the Israeli Defense Forces Search and Rescue Delegation, which was brought in to provide international aid to the local and domestic forces responding to the Surfside, Fla., building collapse. Col. Edri has no disclosures. Dr. Davidtz is a licensed psychologist and associate professor in the College of Psychology at Nova Southeastern University, Fort Lauderdale, Fla., where she is director of internship training for the Psychology Services Center and director of psychological services for the emotionally distressed, a specialty clinic that serves people with serious mental illness and personality disorders. She also maintains a part-time private practice specializing in the treatment of complex posttraumatic conditions and personality disorders. Dr. Davidtz has no disclosures.
Neuroimaging may predict cognitive decline after chemotherapy for breast cancer
“Cognitive decline is frequently observed after chemotherapy,” according to Michiel B. de Ruiter, PhD, a research scientist with the Netherlands Cancer Institute in Amsterdam. He specializes in cognitive neuroscience and was the lead author of a study published online Sept. 30, 2021, in the Journal of Clinical Oncology. Dr. de Ruiter and colleagues found that fractional anisotropy may demonstrate a low brain white-matter reserve which could be a risk factor for cognitive decline after chemotherapy for breast cancer treatment.
Cognitive decline after chemotherapy has been reported in 20%-40% of patients with cancer affecting quality of life and daily living skills. Studies have suggested that genetic makeup, advanced age, fatigue, and premorbid intelligence quotient are risk factors for chemotherapy-associated cognitive decline. Changes in the microstructure of brain white matter, known as brain reserve, have been reported after exposure to chemotherapy, but its link to cognitive decline is understudied. Several studies outside of oncology have used MRI to derive fractional anisotropy as a measure for brain reserve.
In the new JCO study, researchers examined fractional anisotropy, as measured by MRI, before chemotherapy. The analysis included 49 patients who underwent neuropsychological tests before treatment with anthracycline-based chemotherapy, then again at 6 months and 2 years after chemotherapy.
The results were compared with those of patients with breast cancer who did not receive systemic therapy and then with a control group consisting of patients without cancer.
A low fractional anisotropy score suggested cognitive decline more than 3 years after receiving chemotherapy treatment. The finding was independent of age, premorbid intelligence quotient, baseline fatigue and baseline cognitive complaints. And, having low premorbid intelligence quotient was an independent risk factor for chemotherapy-associated cognitive decline, which the authors said is in line with previous findings.
Fractional anisotropy did not predict cognitive decline in patients who did not receive systemic therapy, as well as patients in the control group.
The findings could possibly lead to the development a pretreatment assessment to screen for patients who may at risk for cognitive decline, the authors wrote. “Clinically validated assessments of white-matter reserve as assessed with an MRI scan may be part of a pretreatment screening. This could also aid in early identification of cognitive decline after chemotherapy, allowing targeted and early interventions to improve cognitive problems,” such as psychoeducation and cognitive rehabilitation.
No potential conflicts of interest were reported.
“Cognitive decline is frequently observed after chemotherapy,” according to Michiel B. de Ruiter, PhD, a research scientist with the Netherlands Cancer Institute in Amsterdam. He specializes in cognitive neuroscience and was the lead author of a study published online Sept. 30, 2021, in the Journal of Clinical Oncology. Dr. de Ruiter and colleagues found that fractional anisotropy may demonstrate a low brain white-matter reserve which could be a risk factor for cognitive decline after chemotherapy for breast cancer treatment.
Cognitive decline after chemotherapy has been reported in 20%-40% of patients with cancer affecting quality of life and daily living skills. Studies have suggested that genetic makeup, advanced age, fatigue, and premorbid intelligence quotient are risk factors for chemotherapy-associated cognitive decline. Changes in the microstructure of brain white matter, known as brain reserve, have been reported after exposure to chemotherapy, but its link to cognitive decline is understudied. Several studies outside of oncology have used MRI to derive fractional anisotropy as a measure for brain reserve.
In the new JCO study, researchers examined fractional anisotropy, as measured by MRI, before chemotherapy. The analysis included 49 patients who underwent neuropsychological tests before treatment with anthracycline-based chemotherapy, then again at 6 months and 2 years after chemotherapy.
The results were compared with those of patients with breast cancer who did not receive systemic therapy and then with a control group consisting of patients without cancer.
A low fractional anisotropy score suggested cognitive decline more than 3 years after receiving chemotherapy treatment. The finding was independent of age, premorbid intelligence quotient, baseline fatigue and baseline cognitive complaints. And, having low premorbid intelligence quotient was an independent risk factor for chemotherapy-associated cognitive decline, which the authors said is in line with previous findings.
Fractional anisotropy did not predict cognitive decline in patients who did not receive systemic therapy, as well as patients in the control group.
The findings could possibly lead to the development a pretreatment assessment to screen for patients who may at risk for cognitive decline, the authors wrote. “Clinically validated assessments of white-matter reserve as assessed with an MRI scan may be part of a pretreatment screening. This could also aid in early identification of cognitive decline after chemotherapy, allowing targeted and early interventions to improve cognitive problems,” such as psychoeducation and cognitive rehabilitation.
No potential conflicts of interest were reported.
“Cognitive decline is frequently observed after chemotherapy,” according to Michiel B. de Ruiter, PhD, a research scientist with the Netherlands Cancer Institute in Amsterdam. He specializes in cognitive neuroscience and was the lead author of a study published online Sept. 30, 2021, in the Journal of Clinical Oncology. Dr. de Ruiter and colleagues found that fractional anisotropy may demonstrate a low brain white-matter reserve which could be a risk factor for cognitive decline after chemotherapy for breast cancer treatment.
Cognitive decline after chemotherapy has been reported in 20%-40% of patients with cancer affecting quality of life and daily living skills. Studies have suggested that genetic makeup, advanced age, fatigue, and premorbid intelligence quotient are risk factors for chemotherapy-associated cognitive decline. Changes in the microstructure of brain white matter, known as brain reserve, have been reported after exposure to chemotherapy, but its link to cognitive decline is understudied. Several studies outside of oncology have used MRI to derive fractional anisotropy as a measure for brain reserve.
In the new JCO study, researchers examined fractional anisotropy, as measured by MRI, before chemotherapy. The analysis included 49 patients who underwent neuropsychological tests before treatment with anthracycline-based chemotherapy, then again at 6 months and 2 years after chemotherapy.
The results were compared with those of patients with breast cancer who did not receive systemic therapy and then with a control group consisting of patients without cancer.
A low fractional anisotropy score suggested cognitive decline more than 3 years after receiving chemotherapy treatment. The finding was independent of age, premorbid intelligence quotient, baseline fatigue and baseline cognitive complaints. And, having low premorbid intelligence quotient was an independent risk factor for chemotherapy-associated cognitive decline, which the authors said is in line with previous findings.
Fractional anisotropy did not predict cognitive decline in patients who did not receive systemic therapy, as well as patients in the control group.
The findings could possibly lead to the development a pretreatment assessment to screen for patients who may at risk for cognitive decline, the authors wrote. “Clinically validated assessments of white-matter reserve as assessed with an MRI scan may be part of a pretreatment screening. This could also aid in early identification of cognitive decline after chemotherapy, allowing targeted and early interventions to improve cognitive problems,” such as psychoeducation and cognitive rehabilitation.
No potential conflicts of interest were reported.
FROM THE JOURNAL OF CLINICAL ONCOLOGY
Timeless stories
Let me tell you a story. In 5 billion years the sun will run out of hydrogen, the fuel it is currently burning to power my solar panels amongst other things. At that time, the sun will no longer be able to keep its core contracted and will expand into a fiery, red giant, engulfing earth and obliterating any sign that we ever existed. No buildings. No blog posts. No mausoleums. No stories. Nothing of us will remain.
Well, here for a moment anyway, I’ve gotten you to think about something other than COVID. You’re welcome.
Fascinatingly, the image in your mind’s eye right now of a barren scorched landscape was put there by me. Simply by placing a few words together I have caused new thoughts in your head. You might even share this story with someone else – I would have actually changed your behavior through the power of language. This miraculous phenomenon seems to be unique to us humans; we are the only ones who can create whole worlds in another individual’s head just by making a few sounds. We in medicine have the privilege of experiencing this miracle every day.
Last week, a 97-year-old pale, frail, white man saw me for a basal cell carcinoma on his cheek. While performing a simple electrodesiccation and curettage, I asked if he remembers getting a lot of sunburns when he was young. He certainly remembered one. On a blustery sunny day, he fell asleep for hours on the deck of the USS West Virginia while in the Philippines. As a radio man, he was exhausted from days of conflict and he recalled how warm breezes lulled him asleep. He was so sunburned that for days he forgot how afraid he was of the Japanese.
After listening to his story, I had an image in my mind of palm trees swaying in the tropical winds while hundreds of hulking gray castles sat hidden in the vast surrounding oceans awaiting one of the greatest naval conflicts in history. I got to hear it from surely one of the last remaining people in existence to be able to tell that story. Listening to a patient’s tales is one of the benefits of being a physician. Not only do they help bond us with our patients, but also help lessen our burden of having to make diagnosis after diagnosis and write note after note for hours on end. Somehow performing yet another biopsy that day is made just a bit easier if I’m also learning about what it was like at the Battle of Leyte Gulf.
Encouraging patients to talk more can be risky. No physician, not even allergists, can afford to be waylaid by a retiree with nothing else to do today. But meaningful encounters can not only be a vaccine against burnout, they also lead to better patient adherence and satisfaction. Sometimes, there is simply not time. But often there is a little window during a procedure or when you’re reasonably caught up and don’t expect delays ahead. And like every story, they literally transform us, the listener. In a true physical sense, their stories live on in me, and now that I’ve shared this one in writing, also with you for perpetuity. That is at least for the next 5 billion years when it, too, will be swallowed by the sun, leaving only a crispy, smoking rock where we once existed.
Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at [email protected].
Let me tell you a story. In 5 billion years the sun will run out of hydrogen, the fuel it is currently burning to power my solar panels amongst other things. At that time, the sun will no longer be able to keep its core contracted and will expand into a fiery, red giant, engulfing earth and obliterating any sign that we ever existed. No buildings. No blog posts. No mausoleums. No stories. Nothing of us will remain.
Well, here for a moment anyway, I’ve gotten you to think about something other than COVID. You’re welcome.
Fascinatingly, the image in your mind’s eye right now of a barren scorched landscape was put there by me. Simply by placing a few words together I have caused new thoughts in your head. You might even share this story with someone else – I would have actually changed your behavior through the power of language. This miraculous phenomenon seems to be unique to us humans; we are the only ones who can create whole worlds in another individual’s head just by making a few sounds. We in medicine have the privilege of experiencing this miracle every day.
Last week, a 97-year-old pale, frail, white man saw me for a basal cell carcinoma on his cheek. While performing a simple electrodesiccation and curettage, I asked if he remembers getting a lot of sunburns when he was young. He certainly remembered one. On a blustery sunny day, he fell asleep for hours on the deck of the USS West Virginia while in the Philippines. As a radio man, he was exhausted from days of conflict and he recalled how warm breezes lulled him asleep. He was so sunburned that for days he forgot how afraid he was of the Japanese.
After listening to his story, I had an image in my mind of palm trees swaying in the tropical winds while hundreds of hulking gray castles sat hidden in the vast surrounding oceans awaiting one of the greatest naval conflicts in history. I got to hear it from surely one of the last remaining people in existence to be able to tell that story. Listening to a patient’s tales is one of the benefits of being a physician. Not only do they help bond us with our patients, but also help lessen our burden of having to make diagnosis after diagnosis and write note after note for hours on end. Somehow performing yet another biopsy that day is made just a bit easier if I’m also learning about what it was like at the Battle of Leyte Gulf.
Encouraging patients to talk more can be risky. No physician, not even allergists, can afford to be waylaid by a retiree with nothing else to do today. But meaningful encounters can not only be a vaccine against burnout, they also lead to better patient adherence and satisfaction. Sometimes, there is simply not time. But often there is a little window during a procedure or when you’re reasonably caught up and don’t expect delays ahead. And like every story, they literally transform us, the listener. In a true physical sense, their stories live on in me, and now that I’ve shared this one in writing, also with you for perpetuity. That is at least for the next 5 billion years when it, too, will be swallowed by the sun, leaving only a crispy, smoking rock where we once existed.
Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at [email protected].
Let me tell you a story. In 5 billion years the sun will run out of hydrogen, the fuel it is currently burning to power my solar panels amongst other things. At that time, the sun will no longer be able to keep its core contracted and will expand into a fiery, red giant, engulfing earth and obliterating any sign that we ever existed. No buildings. No blog posts. No mausoleums. No stories. Nothing of us will remain.
Well, here for a moment anyway, I’ve gotten you to think about something other than COVID. You’re welcome.
Fascinatingly, the image in your mind’s eye right now of a barren scorched landscape was put there by me. Simply by placing a few words together I have caused new thoughts in your head. You might even share this story with someone else – I would have actually changed your behavior through the power of language. This miraculous phenomenon seems to be unique to us humans; we are the only ones who can create whole worlds in another individual’s head just by making a few sounds. We in medicine have the privilege of experiencing this miracle every day.
Last week, a 97-year-old pale, frail, white man saw me for a basal cell carcinoma on his cheek. While performing a simple electrodesiccation and curettage, I asked if he remembers getting a lot of sunburns when he was young. He certainly remembered one. On a blustery sunny day, he fell asleep for hours on the deck of the USS West Virginia while in the Philippines. As a radio man, he was exhausted from days of conflict and he recalled how warm breezes lulled him asleep. He was so sunburned that for days he forgot how afraid he was of the Japanese.
After listening to his story, I had an image in my mind of palm trees swaying in the tropical winds while hundreds of hulking gray castles sat hidden in the vast surrounding oceans awaiting one of the greatest naval conflicts in history. I got to hear it from surely one of the last remaining people in existence to be able to tell that story. Listening to a patient’s tales is one of the benefits of being a physician. Not only do they help bond us with our patients, but also help lessen our burden of having to make diagnosis after diagnosis and write note after note for hours on end. Somehow performing yet another biopsy that day is made just a bit easier if I’m also learning about what it was like at the Battle of Leyte Gulf.
Encouraging patients to talk more can be risky. No physician, not even allergists, can afford to be waylaid by a retiree with nothing else to do today. But meaningful encounters can not only be a vaccine against burnout, they also lead to better patient adherence and satisfaction. Sometimes, there is simply not time. But often there is a little window during a procedure or when you’re reasonably caught up and don’t expect delays ahead. And like every story, they literally transform us, the listener. In a true physical sense, their stories live on in me, and now that I’ve shared this one in writing, also with you for perpetuity. That is at least for the next 5 billion years when it, too, will be swallowed by the sun, leaving only a crispy, smoking rock where we once existed.
Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at [email protected].
FDA expands use of HIV drug to young children
The new lower dose is approved for children weighing from at least 14 kg (30 pounds) to 25 kg (55 pounds) who are virologically suppressed or new to antiretroviral therapy.
“Children living with HIV are in need of effective and accessible formulations of antiretroviral therapy,” said Merdad Parsey, MD, PhD, chief medical officer of Gilead Sciences, the company that produces Biktarvy, in a press release. “The New Drug Application approval is an important step in fulfilling Gilead’s commitment to a goal of bringing pediatric formulations of Biktarvy to children living with HIV around the world,” he said.
Although advances in treatment for pregnant women with HIV have lowered the likelihood of perinatal HIV transmission, pediatric HIV remains a global public health challenge. In 2020, about 1.7 million children younger than 15 years were living with HIV worldwide; 850 children become infected every day.
The approval, announced October 18, expands the use of Biktarvy to younger children. The medication was originally approved in February 2018 for treatment-naive or virologically suppressed adults. In June 2019, the FDA approved updating of the label to include pediatric patients weighing at least 25 kg. This new lower dose of Biktarvy is for a three-drug combo containing bictegravir 30 mg, emtricitabine 120 mg, and tenofovir alafenamide 15 mg. It is given once a day in tablet form.
The most recent expanded indication was based on data from an open-label, single-arm study that included 22 virologically suppressed children living with HIV. After switching to Biktarvy, 91% of participants (20 of 22) remained virologically suppressed at 24 weeks. HIV-1 RNA was not collected for two patients because of «pandemic-related study disruption,» the press release said.
“As children living with HIV will be on therapy for the foreseeable future and from such a young age, there are a number of factors I weigh as a clinician when prescribing the right HIV treatment option to my pediatric patients,” said Carina Rodriguez, MD, the division chief of pediatric infectious diseases at the University of South Florida, who was one of the study investigators. “Finding an efficacious treatment option is paramount, but tolerability and safety are keys to ensuring treatment success. With this expanded approval, clinicians can add Biktarvy to their arsenal of options to help ensure these children maintain virologic suppression with a treatment option that makes sense for them.”
A version of this article first appeared on Medscape.com.
The new lower dose is approved for children weighing from at least 14 kg (30 pounds) to 25 kg (55 pounds) who are virologically suppressed or new to antiretroviral therapy.
“Children living with HIV are in need of effective and accessible formulations of antiretroviral therapy,” said Merdad Parsey, MD, PhD, chief medical officer of Gilead Sciences, the company that produces Biktarvy, in a press release. “The New Drug Application approval is an important step in fulfilling Gilead’s commitment to a goal of bringing pediatric formulations of Biktarvy to children living with HIV around the world,” he said.
Although advances in treatment for pregnant women with HIV have lowered the likelihood of perinatal HIV transmission, pediatric HIV remains a global public health challenge. In 2020, about 1.7 million children younger than 15 years were living with HIV worldwide; 850 children become infected every day.
The approval, announced October 18, expands the use of Biktarvy to younger children. The medication was originally approved in February 2018 for treatment-naive or virologically suppressed adults. In June 2019, the FDA approved updating of the label to include pediatric patients weighing at least 25 kg. This new lower dose of Biktarvy is for a three-drug combo containing bictegravir 30 mg, emtricitabine 120 mg, and tenofovir alafenamide 15 mg. It is given once a day in tablet form.
The most recent expanded indication was based on data from an open-label, single-arm study that included 22 virologically suppressed children living with HIV. After switching to Biktarvy, 91% of participants (20 of 22) remained virologically suppressed at 24 weeks. HIV-1 RNA was not collected for two patients because of «pandemic-related study disruption,» the press release said.
“As children living with HIV will be on therapy for the foreseeable future and from such a young age, there are a number of factors I weigh as a clinician when prescribing the right HIV treatment option to my pediatric patients,” said Carina Rodriguez, MD, the division chief of pediatric infectious diseases at the University of South Florida, who was one of the study investigators. “Finding an efficacious treatment option is paramount, but tolerability and safety are keys to ensuring treatment success. With this expanded approval, clinicians can add Biktarvy to their arsenal of options to help ensure these children maintain virologic suppression with a treatment option that makes sense for them.”
A version of this article first appeared on Medscape.com.
The new lower dose is approved for children weighing from at least 14 kg (30 pounds) to 25 kg (55 pounds) who are virologically suppressed or new to antiretroviral therapy.
“Children living with HIV are in need of effective and accessible formulations of antiretroviral therapy,” said Merdad Parsey, MD, PhD, chief medical officer of Gilead Sciences, the company that produces Biktarvy, in a press release. “The New Drug Application approval is an important step in fulfilling Gilead’s commitment to a goal of bringing pediatric formulations of Biktarvy to children living with HIV around the world,” he said.
Although advances in treatment for pregnant women with HIV have lowered the likelihood of perinatal HIV transmission, pediatric HIV remains a global public health challenge. In 2020, about 1.7 million children younger than 15 years were living with HIV worldwide; 850 children become infected every day.
The approval, announced October 18, expands the use of Biktarvy to younger children. The medication was originally approved in February 2018 for treatment-naive or virologically suppressed adults. In June 2019, the FDA approved updating of the label to include pediatric patients weighing at least 25 kg. This new lower dose of Biktarvy is for a three-drug combo containing bictegravir 30 mg, emtricitabine 120 mg, and tenofovir alafenamide 15 mg. It is given once a day in tablet form.
The most recent expanded indication was based on data from an open-label, single-arm study that included 22 virologically suppressed children living with HIV. After switching to Biktarvy, 91% of participants (20 of 22) remained virologically suppressed at 24 weeks. HIV-1 RNA was not collected for two patients because of «pandemic-related study disruption,» the press release said.
“As children living with HIV will be on therapy for the foreseeable future and from such a young age, there are a number of factors I weigh as a clinician when prescribing the right HIV treatment option to my pediatric patients,” said Carina Rodriguez, MD, the division chief of pediatric infectious diseases at the University of South Florida, who was one of the study investigators. “Finding an efficacious treatment option is paramount, but tolerability and safety are keys to ensuring treatment success. With this expanded approval, clinicians can add Biktarvy to their arsenal of options to help ensure these children maintain virologic suppression with a treatment option that makes sense for them.”
A version of this article first appeared on Medscape.com.
Prostate Cancer: Prostate-Specific Antigen Testing
Patient loses prostate after biopsy slide switched; more
It’s difficult enough when a patient’s prostate is removed because of cancer. But it’s another thing altogether when the prostate is removed because of a medical error, as a report on 3 CBS Philly, among other news outlets, makes clear.
The patient, Eric Spangs, lives in southeastern Pennsylvania. Testing indicated an elevation in prostate-specific antigen (PSA) level. He subsequently underwent biopsy of the prostate, which appeared to indicate cancer. In time, though, Mr. Spangs learned there had been an error: the tissue section used in the microscopic diagnosis had come from the biopsy specimen of a different patient. Mr. Spangs himself didn’t actually have cancer.
Ordinarily, such news would be cause for celebration. But this was far from a normal situ ation: Following his initial cancer diagnosis, Mr. Spangs underwent a radical laparoscopic prostatectomy at a local hospital.
“It’s devastated me emotionally and physically,” Mr. Spangs said. It has also been emotionally devastating for his wife, Melissa. (The couple has five children.)
Their attorney, Aaron Freiwald, has filed a suit against the health system to which the local hospital belongs and the area’s largest urologic practice.
The Spangs wish to caution other patients not to make the same mistake they did: they failed to get a second opinion from an oncology specialist, as recommended by the American Cancer Society. (Eric Spangs did receive a second opinion from someone at the urologic practice, but that practice doesn’t specialize in oncology.)
The Spangs also worry about the patient who received the false-negative biopsy result. They have been assured, however, that that patient will be properly notified of his actual cancer status.
Fertility specialist uses own sperm to impregnate patients
A suit claims that a Rochester, N.Y., gynecologist and fertility specialist used his own sperm to inseminate multiple patients, according to a story reported by the Associated Press and other news outlets.
The suit was filed last month by the daughter — call her “Harriet Jones” — of one of the women who received fertility services from the doctor during the 1980s. Ms. Jones’s suit alleges that at the time, the doctor told her mother that the sperm donor would be a medical student at the University of Rochester. In fact, the donor was the doctor himself. He kept that fact a secret for years, even after Ms. Jones — his own daughter — sought him out for gynecologic services.
The secret gradually began to come to light in 2016, when Ms. Jones’s nonbiological father — the man who had helped to raise her — died. Curious about her biological father, Ms. Jones sought to learn his identity from the Rochester gynecologist who had treated her mother and was now her own gynecologist. The doctor said he couldn’t be of help; he claimed he hadn’t kept the relevant records.
Ms. Jones then submitted a blood sample to a direct-to-consumer genetic testing company. The results surprised her: Not only did she learn of her ethnicity, but she also discovered the existence of two half siblings, who were donor-conceived in 1984 and 1985, respectively, the very period when her own mother was undergoing insemination procedures. Ms. Jones subsequently discovered the existence of additional half siblings, all born in the first half of the 1980s.
Initially elated by the discoveries, Ms. Jones soon grew despondent and anxious. She suffered from migraine headaches, among other symptoms. Her biological father, it seemed, had been “a serial sperm donor.”
Still, she continued to go to her Rochester doctor for treatment, having no reason to suspect anything untoward about him. Her visits, including those for prolonged menstrual bleeding, involved routine breast and pelvic exams, transvaginal ultrasounds, and intrauterine contraceptive placements under sedation.
Over this period, her doctor was friendly, asking her a variety of questions about her personal life. During one especially strange visit, however, he began chuckling and said, “You’re a really good kid, such a good kid.” During this visit, he invited his wife into the exam room, presumably to meet Ms. Jones.
It was at this moment that Ms. Jones had a revelation: Could her gynecologist actually be her biological father?
In May 2021, Ms. Jones and a half brother with whom she had been in touch contacted the gynecologist’s daughter from his first marriage. All three underwent genetic testing. The results showed a 99.99% chance of a genetic link.
Ms. Jones has said in her suit that “no reasonable woman” would have submitted to pelvic examinations and other examinations by a doctor whom she knew to be her father.
Besides fraud, her suit alleges medical malpractice, battery, infliction of mental distress, and lack of informed consent. She is seeking compensation for all harm caused to her, including past and future economic damages, past unreimbursed medical expenses, and future expenses related to her mental health treatment and care.
The story included no further details about the civil litigation. As for criminal charges, it’s unlikely Ms. Jones’s biological father — her gynecologist — will face criminal charges for his alleged crimes because they fall outside of the state’s statute of limitations.
Parents say daughter’s stroke wasn’t identified
The Georgia parents of a young woman who died from a stroke following a series of alleged misdiagnoses are suing multiple practitioners, reports Legal Newswire and other news outlets
In June 2019, Michaela Smith was training for her job as a detention officer when she began experiencing a variety of symptoms, including headache, shortness of breath, throat swelling, and slurred speech. She was taken to the emergency department (ED) at Hamilton Medical Center, in Dalton, Ga.
There, she was examined by an attending ED doctor, who ordered a CT scan. The results were read by radiologist Michael J. Cooney, MD. In his reading, the Smith family’s lawsuit alleges, Dr. Cooney failed to identify the basilar artery sign, which is a key indicator of a vessel occlusion in stroke patients. Dr. Cooney concluded that Ms. Smith’s scan showed no acute intracranial abnormality. He sent her home without further discharge instructions.
At home, Ms. Smith fell asleep but awoke in an altered mental state, one of several classic stroke symptoms that she had been experiencing. She returned to the ED. This time, she was examined by David F. Hawkins, MD, an ED physician. Although his differential diagnosis identified Ms. Smith’s symptoms as most likely stroke related, Dr. Hawkins allegedly failed to immediately corroborate his findings with additional vascular imaging. Later in the day, Ms. Smith did undergo an MRI, which a second radiologist, Kevin F. Johnson, MD, misread as showing no signs of ischemia in her basilar artery, according to the lawsuit.
That same day, Dr. Hawkins conferred with a second neurologist, Jeffrey T. Glass, MD, who recommended that Ms. Smith be admitted to the hospital because of her deteriorating condition. The Smiths’ suit claims that Dr. Glass also failed to diagnosis their daughter’s underlying condition, although he did sign off on her transfer to Baroness Erlanger Hospital, in Chattanooga, Tenn.
There, Ms. Smith’s condition continued to worsen. She soon required mechanical ventilation and tube feeding. On July 3, 2019, she was pronounced dead.
“This is an egregious case of negligence,” said the attorney representing the Smiths, who are suing the physicians involved and their practices, as well as Hamilton Medical Center and several unnamed defendants.
“Although two radiology studies and her clinical presentation indicated that Michaela was having a catastrophic stroke, her doctors repeatedly misread the studies as normal, failed to diagnose the stroke, and failed to treat her deficits as a neurological emergency,” the family’s lawyer stated.
At press time, there had been no response from any of the defendants or their attorneys.
A version of this article first appeared on Medscape.com.
It’s difficult enough when a patient’s prostate is removed because of cancer. But it’s another thing altogether when the prostate is removed because of a medical error, as a report on 3 CBS Philly, among other news outlets, makes clear.
The patient, Eric Spangs, lives in southeastern Pennsylvania. Testing indicated an elevation in prostate-specific antigen (PSA) level. He subsequently underwent biopsy of the prostate, which appeared to indicate cancer. In time, though, Mr. Spangs learned there had been an error: the tissue section used in the microscopic diagnosis had come from the biopsy specimen of a different patient. Mr. Spangs himself didn’t actually have cancer.
Ordinarily, such news would be cause for celebration. But this was far from a normal situ ation: Following his initial cancer diagnosis, Mr. Spangs underwent a radical laparoscopic prostatectomy at a local hospital.
“It’s devastated me emotionally and physically,” Mr. Spangs said. It has also been emotionally devastating for his wife, Melissa. (The couple has five children.)
Their attorney, Aaron Freiwald, has filed a suit against the health system to which the local hospital belongs and the area’s largest urologic practice.
The Spangs wish to caution other patients not to make the same mistake they did: they failed to get a second opinion from an oncology specialist, as recommended by the American Cancer Society. (Eric Spangs did receive a second opinion from someone at the urologic practice, but that practice doesn’t specialize in oncology.)
The Spangs also worry about the patient who received the false-negative biopsy result. They have been assured, however, that that patient will be properly notified of his actual cancer status.
Fertility specialist uses own sperm to impregnate patients
A suit claims that a Rochester, N.Y., gynecologist and fertility specialist used his own sperm to inseminate multiple patients, according to a story reported by the Associated Press and other news outlets.
The suit was filed last month by the daughter — call her “Harriet Jones” — of one of the women who received fertility services from the doctor during the 1980s. Ms. Jones’s suit alleges that at the time, the doctor told her mother that the sperm donor would be a medical student at the University of Rochester. In fact, the donor was the doctor himself. He kept that fact a secret for years, even after Ms. Jones — his own daughter — sought him out for gynecologic services.
The secret gradually began to come to light in 2016, when Ms. Jones’s nonbiological father — the man who had helped to raise her — died. Curious about her biological father, Ms. Jones sought to learn his identity from the Rochester gynecologist who had treated her mother and was now her own gynecologist. The doctor said he couldn’t be of help; he claimed he hadn’t kept the relevant records.
Ms. Jones then submitted a blood sample to a direct-to-consumer genetic testing company. The results surprised her: Not only did she learn of her ethnicity, but she also discovered the existence of two half siblings, who were donor-conceived in 1984 and 1985, respectively, the very period when her own mother was undergoing insemination procedures. Ms. Jones subsequently discovered the existence of additional half siblings, all born in the first half of the 1980s.
Initially elated by the discoveries, Ms. Jones soon grew despondent and anxious. She suffered from migraine headaches, among other symptoms. Her biological father, it seemed, had been “a serial sperm donor.”
Still, she continued to go to her Rochester doctor for treatment, having no reason to suspect anything untoward about him. Her visits, including those for prolonged menstrual bleeding, involved routine breast and pelvic exams, transvaginal ultrasounds, and intrauterine contraceptive placements under sedation.
Over this period, her doctor was friendly, asking her a variety of questions about her personal life. During one especially strange visit, however, he began chuckling and said, “You’re a really good kid, such a good kid.” During this visit, he invited his wife into the exam room, presumably to meet Ms. Jones.
It was at this moment that Ms. Jones had a revelation: Could her gynecologist actually be her biological father?
In May 2021, Ms. Jones and a half brother with whom she had been in touch contacted the gynecologist’s daughter from his first marriage. All three underwent genetic testing. The results showed a 99.99% chance of a genetic link.
Ms. Jones has said in her suit that “no reasonable woman” would have submitted to pelvic examinations and other examinations by a doctor whom she knew to be her father.
Besides fraud, her suit alleges medical malpractice, battery, infliction of mental distress, and lack of informed consent. She is seeking compensation for all harm caused to her, including past and future economic damages, past unreimbursed medical expenses, and future expenses related to her mental health treatment and care.
The story included no further details about the civil litigation. As for criminal charges, it’s unlikely Ms. Jones’s biological father — her gynecologist — will face criminal charges for his alleged crimes because they fall outside of the state’s statute of limitations.
Parents say daughter’s stroke wasn’t identified
The Georgia parents of a young woman who died from a stroke following a series of alleged misdiagnoses are suing multiple practitioners, reports Legal Newswire and other news outlets
In June 2019, Michaela Smith was training for her job as a detention officer when she began experiencing a variety of symptoms, including headache, shortness of breath, throat swelling, and slurred speech. She was taken to the emergency department (ED) at Hamilton Medical Center, in Dalton, Ga.
There, she was examined by an attending ED doctor, who ordered a CT scan. The results were read by radiologist Michael J. Cooney, MD. In his reading, the Smith family’s lawsuit alleges, Dr. Cooney failed to identify the basilar artery sign, which is a key indicator of a vessel occlusion in stroke patients. Dr. Cooney concluded that Ms. Smith’s scan showed no acute intracranial abnormality. He sent her home without further discharge instructions.
At home, Ms. Smith fell asleep but awoke in an altered mental state, one of several classic stroke symptoms that she had been experiencing. She returned to the ED. This time, she was examined by David F. Hawkins, MD, an ED physician. Although his differential diagnosis identified Ms. Smith’s symptoms as most likely stroke related, Dr. Hawkins allegedly failed to immediately corroborate his findings with additional vascular imaging. Later in the day, Ms. Smith did undergo an MRI, which a second radiologist, Kevin F. Johnson, MD, misread as showing no signs of ischemia in her basilar artery, according to the lawsuit.
That same day, Dr. Hawkins conferred with a second neurologist, Jeffrey T. Glass, MD, who recommended that Ms. Smith be admitted to the hospital because of her deteriorating condition. The Smiths’ suit claims that Dr. Glass also failed to diagnosis their daughter’s underlying condition, although he did sign off on her transfer to Baroness Erlanger Hospital, in Chattanooga, Tenn.
There, Ms. Smith’s condition continued to worsen. She soon required mechanical ventilation and tube feeding. On July 3, 2019, she was pronounced dead.
“This is an egregious case of negligence,” said the attorney representing the Smiths, who are suing the physicians involved and their practices, as well as Hamilton Medical Center and several unnamed defendants.
“Although two radiology studies and her clinical presentation indicated that Michaela was having a catastrophic stroke, her doctors repeatedly misread the studies as normal, failed to diagnose the stroke, and failed to treat her deficits as a neurological emergency,” the family’s lawyer stated.
At press time, there had been no response from any of the defendants or their attorneys.
A version of this article first appeared on Medscape.com.
It’s difficult enough when a patient’s prostate is removed because of cancer. But it’s another thing altogether when the prostate is removed because of a medical error, as a report on 3 CBS Philly, among other news outlets, makes clear.
The patient, Eric Spangs, lives in southeastern Pennsylvania. Testing indicated an elevation in prostate-specific antigen (PSA) level. He subsequently underwent biopsy of the prostate, which appeared to indicate cancer. In time, though, Mr. Spangs learned there had been an error: the tissue section used in the microscopic diagnosis had come from the biopsy specimen of a different patient. Mr. Spangs himself didn’t actually have cancer.
Ordinarily, such news would be cause for celebration. But this was far from a normal situ ation: Following his initial cancer diagnosis, Mr. Spangs underwent a radical laparoscopic prostatectomy at a local hospital.
“It’s devastated me emotionally and physically,” Mr. Spangs said. It has also been emotionally devastating for his wife, Melissa. (The couple has five children.)
Their attorney, Aaron Freiwald, has filed a suit against the health system to which the local hospital belongs and the area’s largest urologic practice.
The Spangs wish to caution other patients not to make the same mistake they did: they failed to get a second opinion from an oncology specialist, as recommended by the American Cancer Society. (Eric Spangs did receive a second opinion from someone at the urologic practice, but that practice doesn’t specialize in oncology.)
The Spangs also worry about the patient who received the false-negative biopsy result. They have been assured, however, that that patient will be properly notified of his actual cancer status.
Fertility specialist uses own sperm to impregnate patients
A suit claims that a Rochester, N.Y., gynecologist and fertility specialist used his own sperm to inseminate multiple patients, according to a story reported by the Associated Press and other news outlets.
The suit was filed last month by the daughter — call her “Harriet Jones” — of one of the women who received fertility services from the doctor during the 1980s. Ms. Jones’s suit alleges that at the time, the doctor told her mother that the sperm donor would be a medical student at the University of Rochester. In fact, the donor was the doctor himself. He kept that fact a secret for years, even after Ms. Jones — his own daughter — sought him out for gynecologic services.
The secret gradually began to come to light in 2016, when Ms. Jones’s nonbiological father — the man who had helped to raise her — died. Curious about her biological father, Ms. Jones sought to learn his identity from the Rochester gynecologist who had treated her mother and was now her own gynecologist. The doctor said he couldn’t be of help; he claimed he hadn’t kept the relevant records.
Ms. Jones then submitted a blood sample to a direct-to-consumer genetic testing company. The results surprised her: Not only did she learn of her ethnicity, but she also discovered the existence of two half siblings, who were donor-conceived in 1984 and 1985, respectively, the very period when her own mother was undergoing insemination procedures. Ms. Jones subsequently discovered the existence of additional half siblings, all born in the first half of the 1980s.
Initially elated by the discoveries, Ms. Jones soon grew despondent and anxious. She suffered from migraine headaches, among other symptoms. Her biological father, it seemed, had been “a serial sperm donor.”
Still, she continued to go to her Rochester doctor for treatment, having no reason to suspect anything untoward about him. Her visits, including those for prolonged menstrual bleeding, involved routine breast and pelvic exams, transvaginal ultrasounds, and intrauterine contraceptive placements under sedation.
Over this period, her doctor was friendly, asking her a variety of questions about her personal life. During one especially strange visit, however, he began chuckling and said, “You’re a really good kid, such a good kid.” During this visit, he invited his wife into the exam room, presumably to meet Ms. Jones.
It was at this moment that Ms. Jones had a revelation: Could her gynecologist actually be her biological father?
In May 2021, Ms. Jones and a half brother with whom she had been in touch contacted the gynecologist’s daughter from his first marriage. All three underwent genetic testing. The results showed a 99.99% chance of a genetic link.
Ms. Jones has said in her suit that “no reasonable woman” would have submitted to pelvic examinations and other examinations by a doctor whom she knew to be her father.
Besides fraud, her suit alleges medical malpractice, battery, infliction of mental distress, and lack of informed consent. She is seeking compensation for all harm caused to her, including past and future economic damages, past unreimbursed medical expenses, and future expenses related to her mental health treatment and care.
The story included no further details about the civil litigation. As for criminal charges, it’s unlikely Ms. Jones’s biological father — her gynecologist — will face criminal charges for his alleged crimes because they fall outside of the state’s statute of limitations.
Parents say daughter’s stroke wasn’t identified
The Georgia parents of a young woman who died from a stroke following a series of alleged misdiagnoses are suing multiple practitioners, reports Legal Newswire and other news outlets
In June 2019, Michaela Smith was training for her job as a detention officer when she began experiencing a variety of symptoms, including headache, shortness of breath, throat swelling, and slurred speech. She was taken to the emergency department (ED) at Hamilton Medical Center, in Dalton, Ga.
There, she was examined by an attending ED doctor, who ordered a CT scan. The results were read by radiologist Michael J. Cooney, MD. In his reading, the Smith family’s lawsuit alleges, Dr. Cooney failed to identify the basilar artery sign, which is a key indicator of a vessel occlusion in stroke patients. Dr. Cooney concluded that Ms. Smith’s scan showed no acute intracranial abnormality. He sent her home without further discharge instructions.
At home, Ms. Smith fell asleep but awoke in an altered mental state, one of several classic stroke symptoms that she had been experiencing. She returned to the ED. This time, she was examined by David F. Hawkins, MD, an ED physician. Although his differential diagnosis identified Ms. Smith’s symptoms as most likely stroke related, Dr. Hawkins allegedly failed to immediately corroborate his findings with additional vascular imaging. Later in the day, Ms. Smith did undergo an MRI, which a second radiologist, Kevin F. Johnson, MD, misread as showing no signs of ischemia in her basilar artery, according to the lawsuit.
That same day, Dr. Hawkins conferred with a second neurologist, Jeffrey T. Glass, MD, who recommended that Ms. Smith be admitted to the hospital because of her deteriorating condition. The Smiths’ suit claims that Dr. Glass also failed to diagnosis their daughter’s underlying condition, although he did sign off on her transfer to Baroness Erlanger Hospital, in Chattanooga, Tenn.
There, Ms. Smith’s condition continued to worsen. She soon required mechanical ventilation and tube feeding. On July 3, 2019, she was pronounced dead.
“This is an egregious case of negligence,” said the attorney representing the Smiths, who are suing the physicians involved and their practices, as well as Hamilton Medical Center and several unnamed defendants.
“Although two radiology studies and her clinical presentation indicated that Michaela was having a catastrophic stroke, her doctors repeatedly misread the studies as normal, failed to diagnose the stroke, and failed to treat her deficits as a neurological emergency,” the family’s lawyer stated.
At press time, there had been no response from any of the defendants or their attorneys.
A version of this article first appeared on Medscape.com.
‘Multimorbidity’ more commonly seen in people with lupus
People with systemic lupus erythematosus (SLE) have a threefold greater likelihood of having up to five or more comorbidities in comparison with people in the general population, according to the results of two separate U.S. population-based studies.
The higher rate of comorbidities seen included many of those commonly reported before, such as cardiovascular and renal disease, but also some that may be less frequently associated with SLE, notably chronic obstructive pulmonary disease (COPD) and cardiac arrhythmias.
“In the past, the characterization of SLE comorbidities has relied on individual comorbidity assessment,” Alí Duarte García, MD, said at the 14th International Congress on Systemic Lupus Erythematosus, held together will the 6th International Congress on Controversies in Rheumatology and Autoimmunity.
“However, a patient-centric approach where a patient as a whole is seen and how many comorbidities they accrue has not been performed.” added Duarte García, who is a rheumatologist at the Mayo Clinic in Rochester, Minn.
Multiple conditions “overrepresented” in SLE patients
Dr. Duarte García reported the findings of one of the studies, both of which used data from the Rochester Epidemiology Project, a record-linkage system that collates clinical and hospital data from individuals who live in 19 counties in southeast Minnesota and eight counties in western Wisconsin; these patients have agreed to share their medical records for research.
The study population included 479 individuals diagnosed with SLE according to joint 2019 European Alliance of Associations for Rheumatology and American College of Rheumatology criteria. These were matched by age, sex, race, and county to 479 individuals without SLE.
The mean age of the study population was 53 years, 82% were women, and 86% were White.
“We defined multimorbidity as those patients who have two or more comorbidities and substantial multimorbidity as those patients who have five or more comorbidities,” Dr. Duarte García explained.
A previously published list of 44 categories of comorbidities was used to classify the multimorbidity seen, and 27 of these were “overrepresented” in patients with SLE.
Patients with SLE averaged 5.3 comorbidities, whereas control study subjects had 2.9. Comparing SLE with non-SLE individuals, the odds ratio for having two or more comorbid conditions was 2.96, and for five or more comorbidities it was 3.06.
The highest odds ratio comparing SLE with non-SLE individuals was seen for pulmonary disorders (39.0).
Dr. Duarte García highlighted four comorbidities that occurred in SLE patients that were perhaps more unusual: congestive heart failure (OR, 13.3), valvular heart disease (OR, 4.2), cardiac arrhythmias (OR, 2.85), and COPD (OR, 2.7).
“Given the association of multimorbidity with poor outcomes, care delivery strategies to manage multimorbidity are needed in SLE,” Dr. Duarte García concluded.
Similar findings seen in cutaneous lupus
There is also an excess of comorbid conditions in people with cutaneous lupus erythematosus (CLE), Mehmet Hocaoglu, MD, said in reporting the findings of the second study.
Dr. Hocaoglu, an internal medicine resident at the University of Maryland Medical Center in Baltimore, and part of the same team of researchers as Dr. Duarte García, noted that in skin-related lupus the risk of multimorbidity was about doubled.
For this separate analysis, a total of 303 patients with cutaneous lupus had been matched to 303 controls from the general population. Odds ratios for having two or more or five or more comorbidities were a respective 2.27 and 1.65.
Among the comorbidities seen that were higher in those with cutaneous lupus than in the general population subjects were fibromyalgia, liver disease, hypertension, anemia, hypothyroidism, and COPD.
“Further research is definitely needed to identify if the driver of this multimorbidity in CLE patients is the disease itself or the treatments CLE patients are receiving or a multifactorial cause that is driving the disease association,” Dr. Hocaoglu said.
Comment and perspective
“Comorbidities that are not appropriate to the general population, compared to SLE,” seem to have been included in the overall SLE and the cutaneous lupus analyses, Raquel Faria, MD, suggested.
Dr. Faria, an internal medicine consultant at Unidade de Imunologia Clínica – Centro Hospitalar Universitário Porto (Portugal), chaired the poster discussion session in which the two studies had been presented.
She wondered if the researchers had analyzed the data while accounting for “the comorbidities that you knew are due to activity in lupus, like anemia?”
The number of patients with SLE who had pulmonary circulation disorders – 7.5% vs. 0.2% of the general population – also caught Dr. Faria’s attention.
That’s “a really huge number,” Dr. Faria pointed out, “I think it is pretty overrepresented.”
Dr. Duarte García acknowledged that they “took a very broad approach” in using a “very large comorbidity index.”
“What we were observing initially is precisely what you’re mentioning,” he responded to Dr. Faria.
“We were pulling patients who were having disease manifestation rather than a comorbidity,” Dr. Duarte-García said.
These are initial and very exploratory data, he stressed. “We have now moved on to modify the index.” Some of the changes that they have made were to incorporate the SLICC Damage Index Score and tighten up the list of ICD codes used.
No outside funding was received for either of the studies. Dr. Duarte García and Dr. Hocaoglu individually stated that they had no actual or potential conflicts of interest in relation to their presentations.
A version of this article first appeared on Medscape.com.
People with systemic lupus erythematosus (SLE) have a threefold greater likelihood of having up to five or more comorbidities in comparison with people in the general population, according to the results of two separate U.S. population-based studies.
The higher rate of comorbidities seen included many of those commonly reported before, such as cardiovascular and renal disease, but also some that may be less frequently associated with SLE, notably chronic obstructive pulmonary disease (COPD) and cardiac arrhythmias.
“In the past, the characterization of SLE comorbidities has relied on individual comorbidity assessment,” Alí Duarte García, MD, said at the 14th International Congress on Systemic Lupus Erythematosus, held together will the 6th International Congress on Controversies in Rheumatology and Autoimmunity.
“However, a patient-centric approach where a patient as a whole is seen and how many comorbidities they accrue has not been performed.” added Duarte García, who is a rheumatologist at the Mayo Clinic in Rochester, Minn.
Multiple conditions “overrepresented” in SLE patients
Dr. Duarte García reported the findings of one of the studies, both of which used data from the Rochester Epidemiology Project, a record-linkage system that collates clinical and hospital data from individuals who live in 19 counties in southeast Minnesota and eight counties in western Wisconsin; these patients have agreed to share their medical records for research.
The study population included 479 individuals diagnosed with SLE according to joint 2019 European Alliance of Associations for Rheumatology and American College of Rheumatology criteria. These were matched by age, sex, race, and county to 479 individuals without SLE.
The mean age of the study population was 53 years, 82% were women, and 86% were White.
“We defined multimorbidity as those patients who have two or more comorbidities and substantial multimorbidity as those patients who have five or more comorbidities,” Dr. Duarte García explained.
A previously published list of 44 categories of comorbidities was used to classify the multimorbidity seen, and 27 of these were “overrepresented” in patients with SLE.
Patients with SLE averaged 5.3 comorbidities, whereas control study subjects had 2.9. Comparing SLE with non-SLE individuals, the odds ratio for having two or more comorbid conditions was 2.96, and for five or more comorbidities it was 3.06.
The highest odds ratio comparing SLE with non-SLE individuals was seen for pulmonary disorders (39.0).
Dr. Duarte García highlighted four comorbidities that occurred in SLE patients that were perhaps more unusual: congestive heart failure (OR, 13.3), valvular heart disease (OR, 4.2), cardiac arrhythmias (OR, 2.85), and COPD (OR, 2.7).
“Given the association of multimorbidity with poor outcomes, care delivery strategies to manage multimorbidity are needed in SLE,” Dr. Duarte García concluded.
Similar findings seen in cutaneous lupus
There is also an excess of comorbid conditions in people with cutaneous lupus erythematosus (CLE), Mehmet Hocaoglu, MD, said in reporting the findings of the second study.
Dr. Hocaoglu, an internal medicine resident at the University of Maryland Medical Center in Baltimore, and part of the same team of researchers as Dr. Duarte García, noted that in skin-related lupus the risk of multimorbidity was about doubled.
For this separate analysis, a total of 303 patients with cutaneous lupus had been matched to 303 controls from the general population. Odds ratios for having two or more or five or more comorbidities were a respective 2.27 and 1.65.
Among the comorbidities seen that were higher in those with cutaneous lupus than in the general population subjects were fibromyalgia, liver disease, hypertension, anemia, hypothyroidism, and COPD.
“Further research is definitely needed to identify if the driver of this multimorbidity in CLE patients is the disease itself or the treatments CLE patients are receiving or a multifactorial cause that is driving the disease association,” Dr. Hocaoglu said.
Comment and perspective
“Comorbidities that are not appropriate to the general population, compared to SLE,” seem to have been included in the overall SLE and the cutaneous lupus analyses, Raquel Faria, MD, suggested.
Dr. Faria, an internal medicine consultant at Unidade de Imunologia Clínica – Centro Hospitalar Universitário Porto (Portugal), chaired the poster discussion session in which the two studies had been presented.
She wondered if the researchers had analyzed the data while accounting for “the comorbidities that you knew are due to activity in lupus, like anemia?”
The number of patients with SLE who had pulmonary circulation disorders – 7.5% vs. 0.2% of the general population – also caught Dr. Faria’s attention.
That’s “a really huge number,” Dr. Faria pointed out, “I think it is pretty overrepresented.”
Dr. Duarte García acknowledged that they “took a very broad approach” in using a “very large comorbidity index.”
“What we were observing initially is precisely what you’re mentioning,” he responded to Dr. Faria.
“We were pulling patients who were having disease manifestation rather than a comorbidity,” Dr. Duarte-García said.
These are initial and very exploratory data, he stressed. “We have now moved on to modify the index.” Some of the changes that they have made were to incorporate the SLICC Damage Index Score and tighten up the list of ICD codes used.
No outside funding was received for either of the studies. Dr. Duarte García and Dr. Hocaoglu individually stated that they had no actual or potential conflicts of interest in relation to their presentations.
A version of this article first appeared on Medscape.com.
People with systemic lupus erythematosus (SLE) have a threefold greater likelihood of having up to five or more comorbidities in comparison with people in the general population, according to the results of two separate U.S. population-based studies.
The higher rate of comorbidities seen included many of those commonly reported before, such as cardiovascular and renal disease, but also some that may be less frequently associated with SLE, notably chronic obstructive pulmonary disease (COPD) and cardiac arrhythmias.
“In the past, the characterization of SLE comorbidities has relied on individual comorbidity assessment,” Alí Duarte García, MD, said at the 14th International Congress on Systemic Lupus Erythematosus, held together will the 6th International Congress on Controversies in Rheumatology and Autoimmunity.
“However, a patient-centric approach where a patient as a whole is seen and how many comorbidities they accrue has not been performed.” added Duarte García, who is a rheumatologist at the Mayo Clinic in Rochester, Minn.
Multiple conditions “overrepresented” in SLE patients
Dr. Duarte García reported the findings of one of the studies, both of which used data from the Rochester Epidemiology Project, a record-linkage system that collates clinical and hospital data from individuals who live in 19 counties in southeast Minnesota and eight counties in western Wisconsin; these patients have agreed to share their medical records for research.
The study population included 479 individuals diagnosed with SLE according to joint 2019 European Alliance of Associations for Rheumatology and American College of Rheumatology criteria. These were matched by age, sex, race, and county to 479 individuals without SLE.
The mean age of the study population was 53 years, 82% were women, and 86% were White.
“We defined multimorbidity as those patients who have two or more comorbidities and substantial multimorbidity as those patients who have five or more comorbidities,” Dr. Duarte García explained.
A previously published list of 44 categories of comorbidities was used to classify the multimorbidity seen, and 27 of these were “overrepresented” in patients with SLE.
Patients with SLE averaged 5.3 comorbidities, whereas control study subjects had 2.9. Comparing SLE with non-SLE individuals, the odds ratio for having two or more comorbid conditions was 2.96, and for five or more comorbidities it was 3.06.
The highest odds ratio comparing SLE with non-SLE individuals was seen for pulmonary disorders (39.0).
Dr. Duarte García highlighted four comorbidities that occurred in SLE patients that were perhaps more unusual: congestive heart failure (OR, 13.3), valvular heart disease (OR, 4.2), cardiac arrhythmias (OR, 2.85), and COPD (OR, 2.7).
“Given the association of multimorbidity with poor outcomes, care delivery strategies to manage multimorbidity are needed in SLE,” Dr. Duarte García concluded.
Similar findings seen in cutaneous lupus
There is also an excess of comorbid conditions in people with cutaneous lupus erythematosus (CLE), Mehmet Hocaoglu, MD, said in reporting the findings of the second study.
Dr. Hocaoglu, an internal medicine resident at the University of Maryland Medical Center in Baltimore, and part of the same team of researchers as Dr. Duarte García, noted that in skin-related lupus the risk of multimorbidity was about doubled.
For this separate analysis, a total of 303 patients with cutaneous lupus had been matched to 303 controls from the general population. Odds ratios for having two or more or five or more comorbidities were a respective 2.27 and 1.65.
Among the comorbidities seen that were higher in those with cutaneous lupus than in the general population subjects were fibromyalgia, liver disease, hypertension, anemia, hypothyroidism, and COPD.
“Further research is definitely needed to identify if the driver of this multimorbidity in CLE patients is the disease itself or the treatments CLE patients are receiving or a multifactorial cause that is driving the disease association,” Dr. Hocaoglu said.
Comment and perspective
“Comorbidities that are not appropriate to the general population, compared to SLE,” seem to have been included in the overall SLE and the cutaneous lupus analyses, Raquel Faria, MD, suggested.
Dr. Faria, an internal medicine consultant at Unidade de Imunologia Clínica – Centro Hospitalar Universitário Porto (Portugal), chaired the poster discussion session in which the two studies had been presented.
She wondered if the researchers had analyzed the data while accounting for “the comorbidities that you knew are due to activity in lupus, like anemia?”
The number of patients with SLE who had pulmonary circulation disorders – 7.5% vs. 0.2% of the general population – also caught Dr. Faria’s attention.
That’s “a really huge number,” Dr. Faria pointed out, “I think it is pretty overrepresented.”
Dr. Duarte García acknowledged that they “took a very broad approach” in using a “very large comorbidity index.”
“What we were observing initially is precisely what you’re mentioning,” he responded to Dr. Faria.
“We were pulling patients who were having disease manifestation rather than a comorbidity,” Dr. Duarte-García said.
These are initial and very exploratory data, he stressed. “We have now moved on to modify the index.” Some of the changes that they have made were to incorporate the SLICC Damage Index Score and tighten up the list of ICD codes used.
No outside funding was received for either of the studies. Dr. Duarte García and Dr. Hocaoglu individually stated that they had no actual or potential conflicts of interest in relation to their presentations.
A version of this article first appeared on Medscape.com.