Diaphragmatic endometriosis is often diagnosed several years after the start of symptoms – mainly moderate to severe pain – and this is potentially because of general lack of awareness of diaphragmatic endometriosis among the general population and medical professionals.

Findings of the international survey that explored the diagnosis and treatment of diaphragmatic endometriosis were presented at this year’s Royal College of Obstetricians and Gynecologists 2021 Virtual World Congress by medical student Rachel Piccus, MSc, based at the University of Birmingham (England). Robert Sutcliffe, MD, consultant in hepatobiliary and pancreatic surgery, at Queen Elizabeth Hospital Birmingham was senior author. Results were also published in the May 2021 issue of the European Journal of Obstetrics and Gynaecology and Reproductive Biology.

The study found that it took an average of five visits to a primary physician before referral to a gynecologist.

“Late diagnosis could also be due to the idea that diaphragmatic endometriosis symptoms often present before pelvic symptoms and therefore the site of pain is considered atypical for pelvic endometriosis,” Ms. Piccus said, adding that “clinicians are screening for cyclical pain, which is typical of endometriosis, but our study has shown that pain can in fact be more frequent – daily and weekly.”

These significant diagnostic delays, seen from the time of the initial primary care and gynecology consultation has the potential to significantly affect quality of life as seen in pelvic endometriosis, said Ms. Piccus. “These delays are partly due to a lack of awareness among gynecologists, but could also be due to pelvic laparoscopy being insufficient to examine the diaphragm behind the liver.”

Justin Clark, MD, consultant gynaecologist, Birmingham (England) Women’s and Children Hospital, moderated the session and agreed that the study highlights the need for greater awareness of this variant of endometriosis. “Whilst endometriosis affecting the diaphragm, subdiaphragm, and thorax is rare, the condition causes substantial morbidity.”

“Greater knowledge of thoracic endometriosis amongst clinicians in both primary and secondary care is needed to ensure accurate and timely diagnosis,” he added.

Diaphragmatic endometriosis is estimated to affect 1%-1.5% of all endometriosis patients and presents as cyclical pain in the chest, abdomen, and shoulder tip, as well as other respiratory symptoms such as catamenial pneumothorax and difficulty breathing.

“Cross-sectional imaging has shown low sensitivity so upper abdominal laparoscopy is the gold standard; however, this has implications for diagnostic delay because a strong clinical suspicion is required to refer for this invasive procedure,” explained Ms. Piccus referring to one of the reasons underpinning the need for the study.

When successfully diagnosed, treatment requires excision or ablation surgery and studies show symptomatic relief in 75%-100% of cases.

To gauge the extent of delayed diagnosis as well as treatment outcomes from a patient perspective, Ms. Piccus circulated an anonymous online survey among women with a previous history of surgery for diaphragmatic endometriosis.
 

Diaphragmatic endometriosis pain – daily and weekly as well as cyclical

A total of 137 participants responded to the survey, with a median age of 34 years (range, 19-53). Median age of diaphragmatic endometriosis onset was 27 years (range, 11-50), and importantly, diaphragmatic endometriosis symptoms started before pelvic symptoms in 90 respondents (66%).

The dominant symptom was pain. A total of 38% reported cyclical pain (related to endometrial shedding during menstruation), 15% weekly pain, and 47% daily pain, both of which were worse during the menstrual cycle. Furthermore, 14% reported other symptoms including catamenial pneumothorax, difficulty breathing, and hemoptysis.

“Whilst this cyclical pain is typical of endometriosis, we see that diagnostic delays may be due to misdiagnosis because clinicians are screening for this cyclical pain whilst our study has shown that pain can in fact be more frequent, being daily and weekly,” noted Ms. Piccus. Moderate to severe pain was reported in 67% of respondents and moderate in 31%, only 2% reported pain as mild.

Location of pain comprised moderate to severe pain in the upper abdomen (68%), chest (64%) and shoulder (54%). Pain was right-sided in 54%, left-sided in 11% and bilateral in 35%. Upper back and neck were also reported as sites of pain.

Indirectly providing a measure of the lack of awareness of diaphragmatic endometriosis on behalf of primary care, 122 participants reported initially visiting their primary care physician for help and 65 were given a diagnosis – in only 14 cases was that diaphragmatic endometriosis. There were a range of other gynecologic (e.g. ovarian cyst, two), respiratory (spontaneous pneumothorax, seven), gastrointestinal (gastritis/reflux, eight), musculoskeletal (six), and psychological (anxiety/stress, four) diagnoses.

A median of 5 primary care consultations (range, 1-100) were required before referral to a gynecologist, with 30% seeing a primary care physician over 10 times. A further 14 patients self-referred to gynecologist.

“These findings have implications for diagnostic delay, added Ms. Piccus. “While the majority of respondents were diagnosed less than a year from the first GP visit, the median delay was 2 years, with 31% diagnosed after 5 or more years. One took 23 years for an initial diagnosis.”

Most cases were diagnosed at the time of surgery – 93%, with 52% at pelvic laparoscopy, 35% upper abdominal laparoscopy, with 30% requiring two or more laparoscopies before they were diagnosed with diaphragmatic endometriosis. A total of 7% were diagnosed via cross-sectional imaging prior to surgery.
 

Treatment outcomes for diaphragmatic endometriosis

Reflecting the literature, surgery to remove the endometriosis lesions was mainly laparoscopic with 47% abdominal excisions, and 29% abdominal ablations; 6% received open abdominal procedures, and 18% received open thoracotomy or video-assisted thoracoscopic surgery.

The survey asked about postoperative symptoms 6 months after surgery and at the time of survey. Symptoms at 6 months post surgery had completely resolved in 18%, shown significant improvement in 48%, and no improvement in 20%. Worsening of symptoms was seen in 14%. Long-term pain was reported by 21% as severe, 27% as moderate, 35% as mild, and 17% had no symptoms.

Further findings included that 23% underwent additional procedures to treat their diaphragmatic endometriosis, and that there was no significant difference between excision and ablation, nor between age of onset of symptoms or length of diagnostic delay.

“Surgical treatment to remove these extra pelvic deposits of endometriosis will depend upon the type and distribution of thoracic endometriosis and a variety of surgical specialties may need to be involved including gynecologists, cardiothoracic, and upper gastrointestinal/liver surgeons,” Dr. Clark said.

He added that familiar hormonal medical treatments for more typical pelvic endometriosis should also be considered for primary and maintenance treatment. “These data suggest a high symptomatic recurrence rate after surgical treatment and so medical treatments should be considered to try and minimize the risks of endometriosis symptoms returning.”

Dr. Clark also pointed out that multidisciplinary clinical teams should be established in specialized centers to plan surgical and medical management to enhance clinical outcomes and collect data to better understand this enigmatic condition.

Ms. Piccus and Dr. Clark have no relevant conflicts of interest.

Diaphragmatic endometriosis is often diagnosed several years after the start of symptoms – mainly moderate to severe pain – and this is potentially because of general lack of awareness of diaphragmatic endometriosis among the general population and medical professionals.

Findings of the international survey that explored the diagnosis and treatment of diaphragmatic endometriosis were presented at this year’s Royal College of Obstetricians and Gynecologists 2021 Virtual World Congress by medical student Rachel Piccus, MSc, based at the University of Birmingham (England). Robert Sutcliffe, MD, consultant in hepatobiliary and pancreatic surgery, at Queen Elizabeth Hospital Birmingham was senior author. Results were also published in the May 2021 issue of the European Journal of Obstetrics and Gynaecology and Reproductive Biology.

The study found that it took an average of five visits to a primary physician before referral to a gynecologist.

“Late diagnosis could also be due to the idea that diaphragmatic endometriosis symptoms often present before pelvic symptoms and therefore the site of pain is considered atypical for pelvic endometriosis,” Ms. Piccus said, adding that “clinicians are screening for cyclical pain, which is typical of endometriosis, but our study has shown that pain can in fact be more frequent – daily and weekly.”

These significant diagnostic delays, seen from the time of the initial primary care and gynecology consultation has the potential to significantly affect quality of life as seen in pelvic endometriosis, said Ms. Piccus. “These delays are partly due to a lack of awareness among gynecologists, but could also be due to pelvic laparoscopy being insufficient to examine the diaphragm behind the liver.”

Justin Clark, MD, consultant gynaecologist, Birmingham (England) Women’s and Children Hospital, moderated the session and agreed that the study highlights the need for greater awareness of this variant of endometriosis. “Whilst endometriosis affecting the diaphragm, subdiaphragm, and thorax is rare, the condition causes substantial morbidity.”

“Greater knowledge of thoracic endometriosis amongst clinicians in both primary and secondary care is needed to ensure accurate and timely diagnosis,” he added.

Diaphragmatic endometriosis is estimated to affect 1%-1.5% of all endometriosis patients and presents as cyclical pain in the chest, abdomen, and shoulder tip, as well as other respiratory symptoms such as catamenial pneumothorax and difficulty breathing.

“Cross-sectional imaging has shown low sensitivity so upper abdominal laparoscopy is the gold standard; however, this has implications for diagnostic delay because a strong clinical suspicion is required to refer for this invasive procedure,” explained Ms. Piccus referring to one of the reasons underpinning the need for the study.

When successfully diagnosed, treatment requires excision or ablation surgery and studies show symptomatic relief in 75%-100% of cases.

To gauge the extent of delayed diagnosis as well as treatment outcomes from a patient perspective, Ms. Piccus circulated an anonymous online survey among women with a previous history of surgery for diaphragmatic endometriosis.
 

Diaphragmatic endometriosis pain – daily and weekly as well as cyclical

A total of 137 participants responded to the survey, with a median age of 34 years (range, 19-53). Median age of diaphragmatic endometriosis onset was 27 years (range, 11-50), and importantly, diaphragmatic endometriosis symptoms started before pelvic symptoms in 90 respondents (66%).

The dominant symptom was pain. A total of 38% reported cyclical pain (related to endometrial shedding during menstruation), 15% weekly pain, and 47% daily pain, both of which were worse during the menstrual cycle. Furthermore, 14% reported other symptoms including catamenial pneumothorax, difficulty breathing, and hemoptysis.

“Whilst this cyclical pain is typical of endometriosis, we see that diagnostic delays may be due to misdiagnosis because clinicians are screening for this cyclical pain whilst our study has shown that pain can in fact be more frequent, being daily and weekly,” noted Ms. Piccus. Moderate to severe pain was reported in 67% of respondents and moderate in 31%, only 2% reported pain as mild.

Location of pain comprised moderate to severe pain in the upper abdomen (68%), chest (64%) and shoulder (54%). Pain was right-sided in 54%, left-sided in 11% and bilateral in 35%. Upper back and neck were also reported as sites of pain.

Indirectly providing a measure of the lack of awareness of diaphragmatic endometriosis on behalf of primary care, 122 participants reported initially visiting their primary care physician for help and 65 were given a diagnosis – in only 14 cases was that diaphragmatic endometriosis. There were a range of other gynecologic (e.g. ovarian cyst, two), respiratory (spontaneous pneumothorax, seven), gastrointestinal (gastritis/reflux, eight), musculoskeletal (six), and psychological (anxiety/stress, four) diagnoses.

A median of 5 primary care consultations (range, 1-100) were required before referral to a gynecologist, with 30% seeing a primary care physician over 10 times. A further 14 patients self-referred to gynecologist.

“These findings have implications for diagnostic delay, added Ms. Piccus. “While the majority of respondents were diagnosed less than a year from the first GP visit, the median delay was 2 years, with 31% diagnosed after 5 or more years. One took 23 years for an initial diagnosis.”

Most cases were diagnosed at the time of surgery – 93%, with 52% at pelvic laparoscopy, 35% upper abdominal laparoscopy, with 30% requiring two or more laparoscopies before they were diagnosed with diaphragmatic endometriosis. A total of 7% were diagnosed via cross-sectional imaging prior to surgery.
 

Treatment outcomes for diaphragmatic endometriosis

Reflecting the literature, surgery to remove the endometriosis lesions was mainly laparoscopic with 47% abdominal excisions, and 29% abdominal ablations; 6% received open abdominal procedures, and 18% received open thoracotomy or video-assisted thoracoscopic surgery.

The survey asked about postoperative symptoms 6 months after surgery and at the time of survey. Symptoms at 6 months post surgery had completely resolved in 18%, shown significant improvement in 48%, and no improvement in 20%. Worsening of symptoms was seen in 14%. Long-term pain was reported by 21% as severe, 27% as moderate, 35% as mild, and 17% had no symptoms.

Further findings included that 23% underwent additional procedures to treat their diaphragmatic endometriosis, and that there was no significant difference between excision and ablation, nor between age of onset of symptoms or length of diagnostic delay.

“Surgical treatment to remove these extra pelvic deposits of endometriosis will depend upon the type and distribution of thoracic endometriosis and a variety of surgical specialties may need to be involved including gynecologists, cardiothoracic, and upper gastrointestinal/liver surgeons,” Dr. Clark said.

He added that familiar hormonal medical treatments for more typical pelvic endometriosis should also be considered for primary and maintenance treatment. “These data suggest a high symptomatic recurrence rate after surgical treatment and so medical treatments should be considered to try and minimize the risks of endometriosis symptoms returning.”

Dr. Clark also pointed out that multidisciplinary clinical teams should be established in specialized centers to plan surgical and medical management to enhance clinical outcomes and collect data to better understand this enigmatic condition.

Ms. Piccus and Dr. Clark have no relevant conflicts of interest.

Diaphragmatic endometriosis is often diagnosed several years after the start of symptoms – mainly moderate to severe pain – and this is potentially because of general lack of awareness of diaphragmatic endometriosis among the general population and medical professionals.

Findings of the international survey that explored the diagnosis and treatment of diaphragmatic endometriosis were presented at this year’s Royal College of Obstetricians and Gynecologists 2021 Virtual World Congress by medical student Rachel Piccus, MSc, based at the University of Birmingham (England). Robert Sutcliffe, MD, consultant in hepatobiliary and pancreatic surgery, at Queen Elizabeth Hospital Birmingham was senior author. Results were also published in the May 2021 issue of the European Journal of Obstetrics and Gynaecology and Reproductive Biology.

The study found that it took an average of five visits to a primary physician before referral to a gynecologist.

“Late diagnosis could also be due to the idea that diaphragmatic endometriosis symptoms often present before pelvic symptoms and therefore the site of pain is considered atypical for pelvic endometriosis,” Ms. Piccus said, adding that “clinicians are screening for cyclical pain, which is typical of endometriosis, but our study has shown that pain can in fact be more frequent – daily and weekly.”

These significant diagnostic delays, seen from the time of the initial primary care and gynecology consultation has the potential to significantly affect quality of life as seen in pelvic endometriosis, said Ms. Piccus. “These delays are partly due to a lack of awareness among gynecologists, but could also be due to pelvic laparoscopy being insufficient to examine the diaphragm behind the liver.”

Justin Clark, MD, consultant gynaecologist, Birmingham (England) Women’s and Children Hospital, moderated the session and agreed that the study highlights the need for greater awareness of this variant of endometriosis. “Whilst endometriosis affecting the diaphragm, subdiaphragm, and thorax is rare, the condition causes substantial morbidity.”

“Greater knowledge of thoracic endometriosis amongst clinicians in both primary and secondary care is needed to ensure accurate and timely diagnosis,” he added.

Diaphragmatic endometriosis is estimated to affect 1%-1.5% of all endometriosis patients and presents as cyclical pain in the chest, abdomen, and shoulder tip, as well as other respiratory symptoms such as catamenial pneumothorax and difficulty breathing.

“Cross-sectional imaging has shown low sensitivity so upper abdominal laparoscopy is the gold standard; however, this has implications for diagnostic delay because a strong clinical suspicion is required to refer for this invasive procedure,” explained Ms. Piccus referring to one of the reasons underpinning the need for the study.

When successfully diagnosed, treatment requires excision or ablation surgery and studies show symptomatic relief in 75%-100% of cases.

To gauge the extent of delayed diagnosis as well as treatment outcomes from a patient perspective, Ms. Piccus circulated an anonymous online survey among women with a previous history of surgery for diaphragmatic endometriosis.
 

Diaphragmatic endometriosis pain – daily and weekly as well as cyclical

A total of 137 participants responded to the survey, with a median age of 34 years (range, 19-53). Median age of diaphragmatic endometriosis onset was 27 years (range, 11-50), and importantly, diaphragmatic endometriosis symptoms started before pelvic symptoms in 90 respondents (66%).

The dominant symptom was pain. A total of 38% reported cyclical pain (related to endometrial shedding during menstruation), 15% weekly pain, and 47% daily pain, both of which were worse during the menstrual cycle. Furthermore, 14% reported other symptoms including catamenial pneumothorax, difficulty breathing, and hemoptysis.

“Whilst this cyclical pain is typical of endometriosis, we see that diagnostic delays may be due to misdiagnosis because clinicians are screening for this cyclical pain whilst our study has shown that pain can in fact be more frequent, being daily and weekly,” noted Ms. Piccus. Moderate to severe pain was reported in 67% of respondents and moderate in 31%, only 2% reported pain as mild.

Location of pain comprised moderate to severe pain in the upper abdomen (68%), chest (64%) and shoulder (54%). Pain was right-sided in 54%, left-sided in 11% and bilateral in 35%. Upper back and neck were also reported as sites of pain.

Indirectly providing a measure of the lack of awareness of diaphragmatic endometriosis on behalf of primary care, 122 participants reported initially visiting their primary care physician for help and 65 were given a diagnosis – in only 14 cases was that diaphragmatic endometriosis. There were a range of other gynecologic (e.g. ovarian cyst, two), respiratory (spontaneous pneumothorax, seven), gastrointestinal (gastritis/reflux, eight), musculoskeletal (six), and psychological (anxiety/stress, four) diagnoses.

A median of 5 primary care consultations (range, 1-100) were required before referral to a gynecologist, with 30% seeing a primary care physician over 10 times. A further 14 patients self-referred to gynecologist.

“These findings have implications for diagnostic delay, added Ms. Piccus. “While the majority of respondents were diagnosed less than a year from the first GP visit, the median delay was 2 years, with 31% diagnosed after 5 or more years. One took 23 years for an initial diagnosis.”

Most cases were diagnosed at the time of surgery – 93%, with 52% at pelvic laparoscopy, 35% upper abdominal laparoscopy, with 30% requiring two or more laparoscopies before they were diagnosed with diaphragmatic endometriosis. A total of 7% were diagnosed via cross-sectional imaging prior to surgery.
 

Treatment outcomes for diaphragmatic endometriosis

Reflecting the literature, surgery to remove the endometriosis lesions was mainly laparoscopic with 47% abdominal excisions, and 29% abdominal ablations; 6% received open abdominal procedures, and 18% received open thoracotomy or video-assisted thoracoscopic surgery.

The survey asked about postoperative symptoms 6 months after surgery and at the time of survey. Symptoms at 6 months post surgery had completely resolved in 18%, shown significant improvement in 48%, and no improvement in 20%. Worsening of symptoms was seen in 14%. Long-term pain was reported by 21% as severe, 27% as moderate, 35% as mild, and 17% had no symptoms.

Further findings included that 23% underwent additional procedures to treat their diaphragmatic endometriosis, and that there was no significant difference between excision and ablation, nor between age of onset of symptoms or length of diagnostic delay.

“Surgical treatment to remove these extra pelvic deposits of endometriosis will depend upon the type and distribution of thoracic endometriosis and a variety of surgical specialties may need to be involved including gynecologists, cardiothoracic, and upper gastrointestinal/liver surgeons,” Dr. Clark said.

He added that familiar hormonal medical treatments for more typical pelvic endometriosis should also be considered for primary and maintenance treatment. “These data suggest a high symptomatic recurrence rate after surgical treatment and so medical treatments should be considered to try and minimize the risks of endometriosis symptoms returning.”

Dr. Clark also pointed out that multidisciplinary clinical teams should be established in specialized centers to plan surgical and medical management to enhance clinical outcomes and collect data to better understand this enigmatic condition.

Ms. Piccus and Dr. Clark have no relevant conflicts of interest.

Allergic conjunctivitis harms quality of life for children and their parents, apparently causing greater day-to-day worries than potentially blinding diseases, researchers report.

Parents worry especially that treatments might not be effective, according to Shi-yao Zhang, MD, and colleagues from Sun Yat-sen University, Guangzhou, China. “This finding suggests that more communication with parents regarding treatment and prognosis is needed,” they write in an article published online June 10 in JAMA Ophthalmology.

One of the most prevalent eye disorders in children, allergic conjunctivitis is often chronic, leading patients to ask repeatedly for help from physicians. It can take an emotional toll and can cause children to miss school.

“With any sign of a slightly pink eye [or a] runny nose, which are very common with allergies, children are being sent home, because everyone’s concerned about COVID,” said Yi Ning J. Strube, MD, an associate professor of ophthalmology and pediatrics at Queen’s University, Kingston, Canada, whose commentary appears in the same issue of JAMA Ophthalmology.

Adolescents are also sometimes accused of smoking cannabis because of their red eyes, she said.

However, little research has examined the effects of allergic conjunctivitis on the quality of life of children and their guardians, Dr. Zhang and colleagues write. To fill that gap, the researchers administered the Pediatric Quality of Life Inventory (PedsQL) to 92 children with allergic conjunctivitis and their parents. The children were aged 5 to 18 years.

The researchers administered the same questionnaire to 96 healthy children of the same ages, along with their parents. These participants served as a control group.

On a scale of 0 to 100, in which a higher score signifies a better quality of life, the median total PedsQL score was 69.6 for children with allergic conjunctivitis versus 96.7 for the control group.

Subscores of physical, emotional, social, and especially school functioning were all significantly lower for the children with allergic conjunctivitis than for the control persons. “Because children generally spend most of their time in the school environment, this outcome raises an issue regarding whether children have a poorer performance in their education,” Dr. Zhang and colleagues write.

Dr. Strube recommends that physicians educate their patients about allergic conjunctivitis using handouts or high-quality websites. She often refers patients and their families to the allergic conjunctivitis webpage of the American Academy of Pediatric Ophthalmology and Strabismus.

She tells parents to have their child “take a shower and wash their hair when they get home before they rub their pollen-filled hair on their pillowcase and make their allergy symptoms worse.”

Parents and schools should try to filter pollen and other allergens from indoor air, she added.

Parents of the children with allergic conjunctivitis in the study also reported lower quality of life; they scored 68.8, versus 96.5 for parents of children in the control group. The differences for both parents and children were statistically significant (P < .001). Overall, the parents’ quality-of-life scores correlated with their children’s (correlation coefficient, r = 0.59; P < .001).

Children with vernal or atopic keratoconjunctivitis scored 3.3 points lower on health-related quality of life than those with seasonal allergic conjunctivitis.

Children with higher corneal fluorescein staining scores also had lower quality-of-life scores. Parents whose children had higher corneal fluorescein staining scores and also those who had multiple consultations with health care practitioners also reported lower quality of life.

The quality-of-life scores of the children with allergic conjunctivitis were lower than scores in previous studies for children with vision-threatening diseases, such as glaucoma and congenital cataract. This may be because glaucoma and cataracts do not typically cause discomfort even if they impair the patient’s vision, said Dr. Strube.

She pointed out one potential flaw in the study: In the cohort with allergic conjunctivitis, 83.7% were boys, compared to 42.7% of the control group. Vernal keratoconjunctivitis affects more boys than girls, and not controlling for this factor could have confounded the data, Dr. Strube said.

It could also be useful to replicate the study in other countries to see whether geographic or cultural factors affected the results, she said. “A lot of these big centers around the world, including in China, have poor air quality, so that may be contributing to patients’ symptoms,” she said. “With regards to reported health quality of life and impact on education, results from different parts of the world may be different, due to parenting styles and education styles,” she said.

The study was supported by the National Natural Science Foundation of China and the Science Foundation of Guangdong Province. Dr. Zhang and colleagues reported no relevant financial relationships. Dr. Strube reported receiving personal fees from Santen Canada Advisory Board Consultant outside the submitted work.

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

Allergic conjunctivitis harms quality of life for children and their parents, apparently causing greater day-to-day worries than potentially blinding diseases, researchers report.

Parents worry especially that treatments might not be effective, according to Shi-yao Zhang, MD, and colleagues from Sun Yat-sen University, Guangzhou, China. “This finding suggests that more communication with parents regarding treatment and prognosis is needed,” they write in an article published online June 10 in JAMA Ophthalmology.

One of the most prevalent eye disorders in children, allergic conjunctivitis is often chronic, leading patients to ask repeatedly for help from physicians. It can take an emotional toll and can cause children to miss school.

“With any sign of a slightly pink eye [or a] runny nose, which are very common with allergies, children are being sent home, because everyone’s concerned about COVID,” said Yi Ning J. Strube, MD, an associate professor of ophthalmology and pediatrics at Queen’s University, Kingston, Canada, whose commentary appears in the same issue of JAMA Ophthalmology.

Adolescents are also sometimes accused of smoking cannabis because of their red eyes, she said.

However, little research has examined the effects of allergic conjunctivitis on the quality of life of children and their guardians, Dr. Zhang and colleagues write. To fill that gap, the researchers administered the Pediatric Quality of Life Inventory (PedsQL) to 92 children with allergic conjunctivitis and their parents. The children were aged 5 to 18 years.

The researchers administered the same questionnaire to 96 healthy children of the same ages, along with their parents. These participants served as a control group.

On a scale of 0 to 100, in which a higher score signifies a better quality of life, the median total PedsQL score was 69.6 for children with allergic conjunctivitis versus 96.7 for the control group.

Subscores of physical, emotional, social, and especially school functioning were all significantly lower for the children with allergic conjunctivitis than for the control persons. “Because children generally spend most of their time in the school environment, this outcome raises an issue regarding whether children have a poorer performance in their education,” Dr. Zhang and colleagues write.

Dr. Strube recommends that physicians educate their patients about allergic conjunctivitis using handouts or high-quality websites. She often refers patients and their families to the allergic conjunctivitis webpage of the American Academy of Pediatric Ophthalmology and Strabismus.

She tells parents to have their child “take a shower and wash their hair when they get home before they rub their pollen-filled hair on their pillowcase and make their allergy symptoms worse.”

Parents and schools should try to filter pollen and other allergens from indoor air, she added.

Parents of the children with allergic conjunctivitis in the study also reported lower quality of life; they scored 68.8, versus 96.5 for parents of children in the control group. The differences for both parents and children were statistically significant (P < .001). Overall, the parents’ quality-of-life scores correlated with their children’s (correlation coefficient, r = 0.59; P < .001).

Children with vernal or atopic keratoconjunctivitis scored 3.3 points lower on health-related quality of life than those with seasonal allergic conjunctivitis.

Children with higher corneal fluorescein staining scores also had lower quality-of-life scores. Parents whose children had higher corneal fluorescein staining scores and also those who had multiple consultations with health care practitioners also reported lower quality of life.

The quality-of-life scores of the children with allergic conjunctivitis were lower than scores in previous studies for children with vision-threatening diseases, such as glaucoma and congenital cataract. This may be because glaucoma and cataracts do not typically cause discomfort even if they impair the patient’s vision, said Dr. Strube.

She pointed out one potential flaw in the study: In the cohort with allergic conjunctivitis, 83.7% were boys, compared to 42.7% of the control group. Vernal keratoconjunctivitis affects more boys than girls, and not controlling for this factor could have confounded the data, Dr. Strube said.

It could also be useful to replicate the study in other countries to see whether geographic or cultural factors affected the results, she said. “A lot of these big centers around the world, including in China, have poor air quality, so that may be contributing to patients’ symptoms,” she said. “With regards to reported health quality of life and impact on education, results from different parts of the world may be different, due to parenting styles and education styles,” she said.

The study was supported by the National Natural Science Foundation of China and the Science Foundation of Guangdong Province. Dr. Zhang and colleagues reported no relevant financial relationships. Dr. Strube reported receiving personal fees from Santen Canada Advisory Board Consultant outside the submitted work.

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

Allergic conjunctivitis harms quality of life for children and their parents, apparently causing greater day-to-day worries than potentially blinding diseases, researchers report.

Parents worry especially that treatments might not be effective, according to Shi-yao Zhang, MD, and colleagues from Sun Yat-sen University, Guangzhou, China. “This finding suggests that more communication with parents regarding treatment and prognosis is needed,” they write in an article published online June 10 in JAMA Ophthalmology.

One of the most prevalent eye disorders in children, allergic conjunctivitis is often chronic, leading patients to ask repeatedly for help from physicians. It can take an emotional toll and can cause children to miss school.

“With any sign of a slightly pink eye [or a] runny nose, which are very common with allergies, children are being sent home, because everyone’s concerned about COVID,” said Yi Ning J. Strube, MD, an associate professor of ophthalmology and pediatrics at Queen’s University, Kingston, Canada, whose commentary appears in the same issue of JAMA Ophthalmology.

Adolescents are also sometimes accused of smoking cannabis because of their red eyes, she said.

However, little research has examined the effects of allergic conjunctivitis on the quality of life of children and their guardians, Dr. Zhang and colleagues write. To fill that gap, the researchers administered the Pediatric Quality of Life Inventory (PedsQL) to 92 children with allergic conjunctivitis and their parents. The children were aged 5 to 18 years.

The researchers administered the same questionnaire to 96 healthy children of the same ages, along with their parents. These participants served as a control group.

On a scale of 0 to 100, in which a higher score signifies a better quality of life, the median total PedsQL score was 69.6 for children with allergic conjunctivitis versus 96.7 for the control group.

Subscores of physical, emotional, social, and especially school functioning were all significantly lower for the children with allergic conjunctivitis than for the control persons. “Because children generally spend most of their time in the school environment, this outcome raises an issue regarding whether children have a poorer performance in their education,” Dr. Zhang and colleagues write.

Dr. Strube recommends that physicians educate their patients about allergic conjunctivitis using handouts or high-quality websites. She often refers patients and their families to the allergic conjunctivitis webpage of the American Academy of Pediatric Ophthalmology and Strabismus.

She tells parents to have their child “take a shower and wash their hair when they get home before they rub their pollen-filled hair on their pillowcase and make their allergy symptoms worse.”

Parents and schools should try to filter pollen and other allergens from indoor air, she added.

Parents of the children with allergic conjunctivitis in the study also reported lower quality of life; they scored 68.8, versus 96.5 for parents of children in the control group. The differences for both parents and children were statistically significant (P < .001). Overall, the parents’ quality-of-life scores correlated with their children’s (correlation coefficient, r = 0.59; P < .001).

Children with vernal or atopic keratoconjunctivitis scored 3.3 points lower on health-related quality of life than those with seasonal allergic conjunctivitis.

Children with higher corneal fluorescein staining scores also had lower quality-of-life scores. Parents whose children had higher corneal fluorescein staining scores and also those who had multiple consultations with health care practitioners also reported lower quality of life.

The quality-of-life scores of the children with allergic conjunctivitis were lower than scores in previous studies for children with vision-threatening diseases, such as glaucoma and congenital cataract. This may be because glaucoma and cataracts do not typically cause discomfort even if they impair the patient’s vision, said Dr. Strube.

She pointed out one potential flaw in the study: In the cohort with allergic conjunctivitis, 83.7% were boys, compared to 42.7% of the control group. Vernal keratoconjunctivitis affects more boys than girls, and not controlling for this factor could have confounded the data, Dr. Strube said.

It could also be useful to replicate the study in other countries to see whether geographic or cultural factors affected the results, she said. “A lot of these big centers around the world, including in China, have poor air quality, so that may be contributing to patients’ symptoms,” she said. “With regards to reported health quality of life and impact on education, results from different parts of the world may be different, due to parenting styles and education styles,” she said.

The study was supported by the National Natural Science Foundation of China and the Science Foundation of Guangdong Province. Dr. Zhang and colleagues reported no relevant financial relationships. Dr. Strube reported receiving personal fees from Santen Canada Advisory Board Consultant outside the submitted work.

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

Nearly all Americans say that sun protection is important, but almost half don’t use sunscreen regularly and more than a third believe that tanning is healthy, according to the results of a recent survey commissioned by the American Academy of Dermatology.

With the pandemic seemingly behind it, the United States enters the summer months facing the paradox of sun protection. Four out of five adults know that sunscreen should be reapplied every 2 hours when they’re outdoors, but only one in three make the actual effort, and 77% are likely to use sunscreen at the beach or a pool, compared with 41% when they’re gardening or working outside on their homes, the AAD reported.

“These findings are surprising and seem to suggest that many people do not take skin cancer seriously or perhaps believe skin cancer won’t happen to them,” Robert T. Brodell, MD, professor of dermatology at the University of Mississippi Medical Center, Jackson, said in a written statement from the AAD, adding that “unprotected exposure to ultraviolet rays is the most preventable risk factor for skin cancer, including melanoma.”

A quarter of all survey respondents reported getting sunburned in 2020, with the youngest adults most likely to feel the wrath of the sun. Sunburn was reported by 43% of those aged 18-23 years, 37% of those aged 24-39, 25% of the 40- to 55-year-olds, 12% of the 56- to 74-year-olds, and 7% of those aged 75 and older. More than a quarter of those who got sunburned said that it was bad enough to make their clothes feel uncomfortable, the academy said.

“Americans see the damaging effects of the sun on their skin as they get older, and two out of three look back and wish they had been more careful. But when it comes to cancer, specifically, most feel unconcerned in spite of their own risk,” according to a statement from Versta Research, which conducted the poll on behalf of the AAD. The survey was conducted from Feb. 22 to March 10, 2021, and involved 1,056 respondents, with a ±3% margin of error.

The lack of concern for skin cancer looks like this: More than two-thirds of the respondents (69%) have at least one possible risk factor – lighter skin tone, blue or green eyes, more than 50 moles, family history – but only 36% expressed concern about developing it. “Indeed, half of survey respondents (49%) say they are more worried about avoiding sunburn than they are about preventing skin cancer, and a third (32%) are more worried about avoiding premature wrinkles than they are about preventing cancer,” the AAD said.

The AAD is considering the creation of a social media quiz or interactive tool, and if the results of this survey were recast as a potential “Knowledge and Awareness Quiz” and graded with a traditional scheme (A = 90%-100%, B = 80%-89%, etc.), then 34% of the respondents would have failed, 15% would have gotten a D, and only 5% would have earned an A, the academy noted.

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Nearly all Americans say that sun protection is important, but almost half don’t use sunscreen regularly and more than a third believe that tanning is healthy, according to the results of a recent survey commissioned by the American Academy of Dermatology.

With the pandemic seemingly behind it, the United States enters the summer months facing the paradox of sun protection. Four out of five adults know that sunscreen should be reapplied every 2 hours when they’re outdoors, but only one in three make the actual effort, and 77% are likely to use sunscreen at the beach or a pool, compared with 41% when they’re gardening or working outside on their homes, the AAD reported.

“These findings are surprising and seem to suggest that many people do not take skin cancer seriously or perhaps believe skin cancer won’t happen to them,” Robert T. Brodell, MD, professor of dermatology at the University of Mississippi Medical Center, Jackson, said in a written statement from the AAD, adding that “unprotected exposure to ultraviolet rays is the most preventable risk factor for skin cancer, including melanoma.”

A quarter of all survey respondents reported getting sunburned in 2020, with the youngest adults most likely to feel the wrath of the sun. Sunburn was reported by 43% of those aged 18-23 years, 37% of those aged 24-39, 25% of the 40- to 55-year-olds, 12% of the 56- to 74-year-olds, and 7% of those aged 75 and older. More than a quarter of those who got sunburned said that it was bad enough to make their clothes feel uncomfortable, the academy said.

“Americans see the damaging effects of the sun on their skin as they get older, and two out of three look back and wish they had been more careful. But when it comes to cancer, specifically, most feel unconcerned in spite of their own risk,” according to a statement from Versta Research, which conducted the poll on behalf of the AAD. The survey was conducted from Feb. 22 to March 10, 2021, and involved 1,056 respondents, with a ±3% margin of error.

The lack of concern for skin cancer looks like this: More than two-thirds of the respondents (69%) have at least one possible risk factor – lighter skin tone, blue or green eyes, more than 50 moles, family history – but only 36% expressed concern about developing it. “Indeed, half of survey respondents (49%) say they are more worried about avoiding sunburn than they are about preventing skin cancer, and a third (32%) are more worried about avoiding premature wrinkles than they are about preventing cancer,” the AAD said.

The AAD is considering the creation of a social media quiz or interactive tool, and if the results of this survey were recast as a potential “Knowledge and Awareness Quiz” and graded with a traditional scheme (A = 90%-100%, B = 80%-89%, etc.), then 34% of the respondents would have failed, 15% would have gotten a D, and only 5% would have earned an A, the academy noted.

[email protected]

Nearly all Americans say that sun protection is important, but almost half don’t use sunscreen regularly and more than a third believe that tanning is healthy, according to the results of a recent survey commissioned by the American Academy of Dermatology.

With the pandemic seemingly behind it, the United States enters the summer months facing the paradox of sun protection. Four out of five adults know that sunscreen should be reapplied every 2 hours when they’re outdoors, but only one in three make the actual effort, and 77% are likely to use sunscreen at the beach or a pool, compared with 41% when they’re gardening or working outside on their homes, the AAD reported.

“These findings are surprising and seem to suggest that many people do not take skin cancer seriously or perhaps believe skin cancer won’t happen to them,” Robert T. Brodell, MD, professor of dermatology at the University of Mississippi Medical Center, Jackson, said in a written statement from the AAD, adding that “unprotected exposure to ultraviolet rays is the most preventable risk factor for skin cancer, including melanoma.”

A quarter of all survey respondents reported getting sunburned in 2020, with the youngest adults most likely to feel the wrath of the sun. Sunburn was reported by 43% of those aged 18-23 years, 37% of those aged 24-39, 25% of the 40- to 55-year-olds, 12% of the 56- to 74-year-olds, and 7% of those aged 75 and older. More than a quarter of those who got sunburned said that it was bad enough to make their clothes feel uncomfortable, the academy said.

“Americans see the damaging effects of the sun on their skin as they get older, and two out of three look back and wish they had been more careful. But when it comes to cancer, specifically, most feel unconcerned in spite of their own risk,” according to a statement from Versta Research, which conducted the poll on behalf of the AAD. The survey was conducted from Feb. 22 to March 10, 2021, and involved 1,056 respondents, with a ±3% margin of error.

The lack of concern for skin cancer looks like this: More than two-thirds of the respondents (69%) have at least one possible risk factor – lighter skin tone, blue or green eyes, more than 50 moles, family history – but only 36% expressed concern about developing it. “Indeed, half of survey respondents (49%) say they are more worried about avoiding sunburn than they are about preventing skin cancer, and a third (32%) are more worried about avoiding premature wrinkles than they are about preventing cancer,” the AAD said.

The AAD is considering the creation of a social media quiz or interactive tool, and if the results of this survey were recast as a potential “Knowledge and Awareness Quiz” and graded with a traditional scheme (A = 90%-100%, B = 80%-89%, etc.), then 34% of the respondents would have failed, 15% would have gotten a D, and only 5% would have earned an A, the academy noted.

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The majority of patients with chronic rhinosinusitis with nasal polyps (CRSwNP) have both upper and lower airway comorbidities such as asthma, allergic rhinosinusitis, and GERD. Recent data show that more than 50% of patients with CRSwNP have concurrent asthma. 

Comorbidities in CRSwNP increase the risk for refractory disease, lead to repeated surgical procedures, and adversely affect patients' quality of life.

Dr Anju Peters, from Northwestern University Feinberg School of Medicine, discusses the importance of identifying comorbidities in patients with CRSwNP in order to create a more effective and personalized treatment plan.
 

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Anju T. Peters, MD, MSci, Professor, Department of Medicine, Division of Allergy-Immunology, Northwestern University Feinberg School of Medicine; Director of Clinical Research, Associate Chief of Research, Education, and Clinical Affairs, Division of Allergy-Immunology, Northwestern Medicine, Chicago, Illinois.

Anju T. Peters, MD, MSci, has disclosed the following relevant financial relationships: 
Serve(d) on the advisory board for: Sanofi Regeneron; Optinose; AstraZeneca. Received research grant from: AstraZeneca; Optinose.

The majority of patients with chronic rhinosinusitis with nasal polyps (CRSwNP) have both upper and lower airway comorbidities such as asthma, allergic rhinosinusitis, and GERD. Recent data show that more than 50% of patients with CRSwNP have concurrent asthma. 

Comorbidities in CRSwNP increase the risk for refractory disease, lead to repeated surgical procedures, and adversely affect patients' quality of life.

Dr Anju Peters, from Northwestern University Feinberg School of Medicine, discusses the importance of identifying comorbidities in patients with CRSwNP in order to create a more effective and personalized treatment plan.
 

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Anju T. Peters, MD, MSci, Professor, Department of Medicine, Division of Allergy-Immunology, Northwestern University Feinberg School of Medicine; Director of Clinical Research, Associate Chief of Research, Education, and Clinical Affairs, Division of Allergy-Immunology, Northwestern Medicine, Chicago, Illinois.

Anju T. Peters, MD, MSci, has disclosed the following relevant financial relationships: 
Serve(d) on the advisory board for: Sanofi Regeneron; Optinose; AstraZeneca. Received research grant from: AstraZeneca; Optinose.

The majority of patients with chronic rhinosinusitis with nasal polyps (CRSwNP) have both upper and lower airway comorbidities such as asthma, allergic rhinosinusitis, and GERD. Recent data show that more than 50% of patients with CRSwNP have concurrent asthma. 

Comorbidities in CRSwNP increase the risk for refractory disease, lead to repeated surgical procedures, and adversely affect patients' quality of life.

Dr Anju Peters, from Northwestern University Feinberg School of Medicine, discusses the importance of identifying comorbidities in patients with CRSwNP in order to create a more effective and personalized treatment plan.
 

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Anju T. Peters, MD, MSci, Professor, Department of Medicine, Division of Allergy-Immunology, Northwestern University Feinberg School of Medicine; Director of Clinical Research, Associate Chief of Research, Education, and Clinical Affairs, Division of Allergy-Immunology, Northwestern Medicine, Chicago, Illinois.

Anju T. Peters, MD, MSci, has disclosed the following relevant financial relationships: 
Serve(d) on the advisory board for: Sanofi Regeneron; Optinose; AstraZeneca. Received research grant from: AstraZeneca; Optinose.

American Gastroenterological Association, American College of Gastroenterology, and American Society for Gastrointestinal Endoscopy issued a statement of support that also notes our Multi-Society Task Force on Colorectal Cancer is finalizing our own recommendation to start screening at 45 years of age as well. 

Incoming AGA President John M. Inadomi, MD, AGAF, notes that, “We expect this important change to save lives and improve the health of the U.S. population.” 

AGA fully supports the decision of the U.S. Preventive Services Task Force to reduce the age at which to initiate screening among individuals at average risk for development of colorectal cancer to 45 years. This decision harmonizes the recommendations between the major U.S. screening guidelines including the American Cancer Society and American College of Physicians.  

“The analysis by the USPSTF is timely and incredibly helpful to population health and to gastroenterologists and other providers,” says Bishr Omary, MD, PhD, AGAF, president of AGA. “We now have clear guidance to start colorectal cancer screening at age 45 for those with average risk and discontinue screening after age 85.”

American Gastroenterological Association, American College of Gastroenterology, and American Society for Gastrointestinal Endoscopy issued a statement of support that also notes our Multi-Society Task Force on Colorectal Cancer is finalizing our own recommendation to start screening at 45 years of age as well. 

Incoming AGA President John M. Inadomi, MD, AGAF, notes that, “We expect this important change to save lives and improve the health of the U.S. population.” 

AGA fully supports the decision of the U.S. Preventive Services Task Force to reduce the age at which to initiate screening among individuals at average risk for development of colorectal cancer to 45 years. This decision harmonizes the recommendations between the major U.S. screening guidelines including the American Cancer Society and American College of Physicians.  

“The analysis by the USPSTF is timely and incredibly helpful to population health and to gastroenterologists and other providers,” says Bishr Omary, MD, PhD, AGAF, president of AGA. “We now have clear guidance to start colorectal cancer screening at age 45 for those with average risk and discontinue screening after age 85.”

American Gastroenterological Association, American College of Gastroenterology, and American Society for Gastrointestinal Endoscopy issued a statement of support that also notes our Multi-Society Task Force on Colorectal Cancer is finalizing our own recommendation to start screening at 45 years of age as well. 

Incoming AGA President John M. Inadomi, MD, AGAF, notes that, “We expect this important change to save lives and improve the health of the U.S. population.” 

AGA fully supports the decision of the U.S. Preventive Services Task Force to reduce the age at which to initiate screening among individuals at average risk for development of colorectal cancer to 45 years. This decision harmonizes the recommendations between the major U.S. screening guidelines including the American Cancer Society and American College of Physicians.  

“The analysis by the USPSTF is timely and incredibly helpful to population health and to gastroenterologists and other providers,” says Bishr Omary, MD, PhD, AGAF, president of AGA. “We now have clear guidance to start colorectal cancer screening at age 45 for those with average risk and discontinue screening after age 85.”

We are pleased to announce that the AGA Research Foundation’s research awards cycle is now open.

The cycle begins with our two specialty awards focused on digestive and gastric cancers – applications are due on July 21. 

AGA–Caroline Craig Augustyn & Damian Augustyn Award in Digestive Cancer: One $40,000 award supports an early career investigator who holds a career development award devoted to digestive cancer research.

AGA–R. Robert & Sally Funderburg Research Award in Gastric Cancer One $100,000 award supports an established investigator working on novel approaches in gastric cancer research.

In addition to our usual awards portfolio focused on a broad range of digestive diseases, we have established several new awards that will fund research focused on health and health care disparities. Click on the links below to learn more about each award and application requirements. 

• Pilot Research Awards: Currently accepting applications
• Research Scholar Awards: Open Aug. 12 

We are pleased to announce that the AGA Research Foundation’s research awards cycle is now open.

The cycle begins with our two specialty awards focused on digestive and gastric cancers – applications are due on July 21. 

AGA–Caroline Craig Augustyn & Damian Augustyn Award in Digestive Cancer: One $40,000 award supports an early career investigator who holds a career development award devoted to digestive cancer research.

AGA–R. Robert & Sally Funderburg Research Award in Gastric Cancer One $100,000 award supports an established investigator working on novel approaches in gastric cancer research.

In addition to our usual awards portfolio focused on a broad range of digestive diseases, we have established several new awards that will fund research focused on health and health care disparities. Click on the links below to learn more about each award and application requirements. 

• Pilot Research Awards: Currently accepting applications
• Research Scholar Awards: Open Aug. 12 

We are pleased to announce that the AGA Research Foundation’s research awards cycle is now open.

The cycle begins with our two specialty awards focused on digestive and gastric cancers – applications are due on July 21. 

AGA–Caroline Craig Augustyn & Damian Augustyn Award in Digestive Cancer: One $40,000 award supports an early career investigator who holds a career development award devoted to digestive cancer research.

AGA–R. Robert & Sally Funderburg Research Award in Gastric Cancer One $100,000 award supports an established investigator working on novel approaches in gastric cancer research.

In addition to our usual awards portfolio focused on a broad range of digestive diseases, we have established several new awards that will fund research focused on health and health care disparities. Click on the links below to learn more about each award and application requirements. 

• Pilot Research Awards: Currently accepting applications
• Research Scholar Awards: Open Aug. 12