Physical activity mitigated the impact of high body mass index (BMI) on cardiovascular risk factors, but not overall cardiovascular disease risk, according to an observational study of half a million individuals.

Despite the historically high rates of overweight and obesity worldwide, some evidence suggests that cardiorespiratory fitness could reduce the effects of excess weight on cardiovascular disease risk, wrote Pedro L. Valenzuela, PhD, of the University of Alcalá, Madrid, and colleagues.

“To clarify the existence of the ‘fat-but-fit’ [or ‘elevated BMI but active’] paradox, in this observational study, we assessed the joint association between different BMI categories and physical activity levels, respectively, and the prevalence of major CVD risk factors,” they said.

In a population-based cohort study published in the European Journal of Preventive Cardiology, the researchers identified 527,662 adults aged 18-64 years who were insured by an occupational risk–prevention company and underwent annual medical exams as part of their coverage. The average age of the participants was 42 years, 32% were women, and the average BMI was 26.2 kg/m².

The participants were categorized as normal weight (42%), overweight (41%), and obese (18%), and their activity levels were categorized as inactive (64%), insufficiently active (12%), and regularly active (24%). In addition, 30% had hypercholesterolemia, 15% had hypertension, and 3% had diabetes.

Overall, compared with inactivity, insufficient activity or regular activity reduced CVD risk factors within each BMI category, and subgroups. “However, regular/insufficient PA did not compensate for the negative effects of overweight/obesity, as individuals with overweight/obesity were at greater CVD risk than their peers with normal weight, irrespective of PA levels,” the researchers said. Compared with active normal-weight men, the odds ratios for hypertension in active overweight men and active obese men were 1.98 and 4.93, respectively; the odds ratios for hypercholesterolemia were 1.61 and 2.03, respectively, and the odds ratios for diabetes were 1.33 and 3.62, respectively (P < .001 for all). Trends were similar for women.

The study results were limited by the cross-sectional design; inability to control for participants’ diet, and the reliance of self-reports of leisure-time physical activity. However, the findings were strengthened by the large sample size and “refute the notion that a physically active lifestyle can completely negate the deleterious effects of overweight/obesity,” the researchers said.

Although increasing physical activity should remain a priority for health policies, “weight loss per se should remain a primary target for health policies aimed at reducing CVD risk in people with overweight/obesity,” they concluded.
 

Interpret findings with caution

“With the ever-increasing public health problem of overweight and obesity, it is useful to assess any measure or measures that can have a favorable or adverse effect on cardiometabolic risk factors and the risk of CVD” Prakash Deedwania, MD, of the University of California, San Francisco, said in an interview.

Dr. Deedwania said he was not entirely surprised by the study findings. “The investigators have correlated only the self-reported level of physical activity (which is not always reliable) to the presence of three cardiac risk factors: hypertension, hypercholesterolemia, and diabetes.”

The study “is not comparable to prior reports that had shown a favorable impact of carefully assessed cardiorespiratory fitness with the risk of CVD,” Dr. Deedwania noted. “However, this is one of the largest population-wide surveillance studies of more than a half million active workers across Spain, and it does show that, despite self-reported physical activity, overweight and obesity are associated with higher risks of hypertension, diabetes, and hypercholesterolemia,” he explained.

“The main message of these findings is that, although physical activity does have a dose-dependent favorable impact on CV risk, the main public health intervention to reduce the risk of CV risk should focus on weight loss in overweight and obese individuals,” Dr. Deedwania emphasized.

“Future studies should focus on comparing various levels of daily activities and routine exercise such as walking, bicycling, etc., with the beneficial impact on cardiometabolic risk factors in overweight and obese individuals,” he said.

Dr. Valenzuela disclosed support from the University of Alcalá. Research by corresponding author Dr. Lucia was funded by grants from Spanish Ministry of Science and Innovation and Fondos FEDER. Dr. Deedwania had no financial conflicts to disclose.

Physical activity mitigated the impact of high body mass index (BMI) on cardiovascular risk factors, but not overall cardiovascular disease risk, according to an observational study of half a million individuals.

Despite the historically high rates of overweight and obesity worldwide, some evidence suggests that cardiorespiratory fitness could reduce the effects of excess weight on cardiovascular disease risk, wrote Pedro L. Valenzuela, PhD, of the University of Alcalá, Madrid, and colleagues.

“To clarify the existence of the ‘fat-but-fit’ [or ‘elevated BMI but active’] paradox, in this observational study, we assessed the joint association between different BMI categories and physical activity levels, respectively, and the prevalence of major CVD risk factors,” they said.

In a population-based cohort study published in the European Journal of Preventive Cardiology, the researchers identified 527,662 adults aged 18-64 years who were insured by an occupational risk–prevention company and underwent annual medical exams as part of their coverage. The average age of the participants was 42 years, 32% were women, and the average BMI was 26.2 kg/m².

The participants were categorized as normal weight (42%), overweight (41%), and obese (18%), and their activity levels were categorized as inactive (64%), insufficiently active (12%), and regularly active (24%). In addition, 30% had hypercholesterolemia, 15% had hypertension, and 3% had diabetes.

Overall, compared with inactivity, insufficient activity or regular activity reduced CVD risk factors within each BMI category, and subgroups. “However, regular/insufficient PA did not compensate for the negative effects of overweight/obesity, as individuals with overweight/obesity were at greater CVD risk than their peers with normal weight, irrespective of PA levels,” the researchers said. Compared with active normal-weight men, the odds ratios for hypertension in active overweight men and active obese men were 1.98 and 4.93, respectively; the odds ratios for hypercholesterolemia were 1.61 and 2.03, respectively, and the odds ratios for diabetes were 1.33 and 3.62, respectively (P < .001 for all). Trends were similar for women.

The study results were limited by the cross-sectional design; inability to control for participants’ diet, and the reliance of self-reports of leisure-time physical activity. However, the findings were strengthened by the large sample size and “refute the notion that a physically active lifestyle can completely negate the deleterious effects of overweight/obesity,” the researchers said.

Although increasing physical activity should remain a priority for health policies, “weight loss per se should remain a primary target for health policies aimed at reducing CVD risk in people with overweight/obesity,” they concluded.
 

Interpret findings with caution

“With the ever-increasing public health problem of overweight and obesity, it is useful to assess any measure or measures that can have a favorable or adverse effect on cardiometabolic risk factors and the risk of CVD” Prakash Deedwania, MD, of the University of California, San Francisco, said in an interview.

Dr. Deedwania said he was not entirely surprised by the study findings. “The investigators have correlated only the self-reported level of physical activity (which is not always reliable) to the presence of three cardiac risk factors: hypertension, hypercholesterolemia, and diabetes.”

The study “is not comparable to prior reports that had shown a favorable impact of carefully assessed cardiorespiratory fitness with the risk of CVD,” Dr. Deedwania noted. “However, this is one of the largest population-wide surveillance studies of more than a half million active workers across Spain, and it does show that, despite self-reported physical activity, overweight and obesity are associated with higher risks of hypertension, diabetes, and hypercholesterolemia,” he explained.

“The main message of these findings is that, although physical activity does have a dose-dependent favorable impact on CV risk, the main public health intervention to reduce the risk of CV risk should focus on weight loss in overweight and obese individuals,” Dr. Deedwania emphasized.

“Future studies should focus on comparing various levels of daily activities and routine exercise such as walking, bicycling, etc., with the beneficial impact on cardiometabolic risk factors in overweight and obese individuals,” he said.

Dr. Valenzuela disclosed support from the University of Alcalá. Research by corresponding author Dr. Lucia was funded by grants from Spanish Ministry of Science and Innovation and Fondos FEDER. Dr. Deedwania had no financial conflicts to disclose.

Physical activity mitigated the impact of high body mass index (BMI) on cardiovascular risk factors, but not overall cardiovascular disease risk, according to an observational study of half a million individuals.

Despite the historically high rates of overweight and obesity worldwide, some evidence suggests that cardiorespiratory fitness could reduce the effects of excess weight on cardiovascular disease risk, wrote Pedro L. Valenzuela, PhD, of the University of Alcalá, Madrid, and colleagues.

“To clarify the existence of the ‘fat-but-fit’ [or ‘elevated BMI but active’] paradox, in this observational study, we assessed the joint association between different BMI categories and physical activity levels, respectively, and the prevalence of major CVD risk factors,” they said.

In a population-based cohort study published in the European Journal of Preventive Cardiology, the researchers identified 527,662 adults aged 18-64 years who were insured by an occupational risk–prevention company and underwent annual medical exams as part of their coverage. The average age of the participants was 42 years, 32% were women, and the average BMI was 26.2 kg/m².

The participants were categorized as normal weight (42%), overweight (41%), and obese (18%), and their activity levels were categorized as inactive (64%), insufficiently active (12%), and regularly active (24%). In addition, 30% had hypercholesterolemia, 15% had hypertension, and 3% had diabetes.

Overall, compared with inactivity, insufficient activity or regular activity reduced CVD risk factors within each BMI category, and subgroups. “However, regular/insufficient PA did not compensate for the negative effects of overweight/obesity, as individuals with overweight/obesity were at greater CVD risk than their peers with normal weight, irrespective of PA levels,” the researchers said. Compared with active normal-weight men, the odds ratios for hypertension in active overweight men and active obese men were 1.98 and 4.93, respectively; the odds ratios for hypercholesterolemia were 1.61 and 2.03, respectively, and the odds ratios for diabetes were 1.33 and 3.62, respectively (P < .001 for all). Trends were similar for women.

The study results were limited by the cross-sectional design; inability to control for participants’ diet, and the reliance of self-reports of leisure-time physical activity. However, the findings were strengthened by the large sample size and “refute the notion that a physically active lifestyle can completely negate the deleterious effects of overweight/obesity,” the researchers said.

Although increasing physical activity should remain a priority for health policies, “weight loss per se should remain a primary target for health policies aimed at reducing CVD risk in people with overweight/obesity,” they concluded.
 

Interpret findings with caution

“With the ever-increasing public health problem of overweight and obesity, it is useful to assess any measure or measures that can have a favorable or adverse effect on cardiometabolic risk factors and the risk of CVD” Prakash Deedwania, MD, of the University of California, San Francisco, said in an interview.

Dr. Deedwania said he was not entirely surprised by the study findings. “The investigators have correlated only the self-reported level of physical activity (which is not always reliable) to the presence of three cardiac risk factors: hypertension, hypercholesterolemia, and diabetes.”

The study “is not comparable to prior reports that had shown a favorable impact of carefully assessed cardiorespiratory fitness with the risk of CVD,” Dr. Deedwania noted. “However, this is one of the largest population-wide surveillance studies of more than a half million active workers across Spain, and it does show that, despite self-reported physical activity, overweight and obesity are associated with higher risks of hypertension, diabetes, and hypercholesterolemia,” he explained.

“The main message of these findings is that, although physical activity does have a dose-dependent favorable impact on CV risk, the main public health intervention to reduce the risk of CV risk should focus on weight loss in overweight and obese individuals,” Dr. Deedwania emphasized.

“Future studies should focus on comparing various levels of daily activities and routine exercise such as walking, bicycling, etc., with the beneficial impact on cardiometabolic risk factors in overweight and obese individuals,” he said.

Dr. Valenzuela disclosed support from the University of Alcalá. Research by corresponding author Dr. Lucia was funded by grants from Spanish Ministry of Science and Innovation and Fondos FEDER. Dr. Deedwania had no financial conflicts to disclose.

The prevalence of systemic lupus erythematosus (SLE) appears to be much lower than previously believed and may pose “a potential risk to research funding for the disease,” according to results of a meta-analysis involving a network of population-based registries.

“When we started this study, a widely cited lupus statistic was that approximately 1.5 million Americans were affected. Our meta-analysis found the actual prevalence to be slightly more than 200,000: a number that approaches the [Food and Drug Administration’s] definition of a rare disease,” Emily Somers, PhD, ScM, senior author and associate professor of rheumatology and environmental health sciences at the University of Michigan, Ann Arbor, said in a written statement.

Their estimates, published online in Arthritis & Rheumatology, put the overall SLE prevalence in the United States at 72.8 per 100,000 person-years in 2018, with nearly nine times more females affected (128.7 cases per 100,000) than males (14.6 per 100,000). Race and ethnicity also play a role, as prevalence was highest among American Indian/Alaska Native and Black females, with Hispanic females lower but still higher than White and Asian/Pacific Islander females, Peter M. Izmirly, MD, MSc, of New York University, the lead author, and associates said.

SLE prevalence was distributed similarly in men, although there was a greater relative margin between American Indians/Alaska Natives (53.8 cases per 100,000 person-years) and Blacks (26.7 per 100,000), and Asians/Pacific Islanders were higher than Whites (11.2 vs. 8.9), the investigators reported.

The meta-analysis leveraged data from the Centers for Disease Control and Prevention’s national lupus registries, which include four state-specific SLE registries and a fifth in the Indian Health Service. All cases of SLE occurred in 2002-2009, and the data were age adjusted to the 2000 U.S. population and separately extrapolated to the 2018 U.S. Census population, they explained.

The analysis was funded by cooperative agreements between the New York City Department of Health and Mental Hygiene and New York University, and the CDC and National Institute of Health.

[email protected]

The prevalence of systemic lupus erythematosus (SLE) appears to be much lower than previously believed and may pose “a potential risk to research funding for the disease,” according to results of a meta-analysis involving a network of population-based registries.

“When we started this study, a widely cited lupus statistic was that approximately 1.5 million Americans were affected. Our meta-analysis found the actual prevalence to be slightly more than 200,000: a number that approaches the [Food and Drug Administration’s] definition of a rare disease,” Emily Somers, PhD, ScM, senior author and associate professor of rheumatology and environmental health sciences at the University of Michigan, Ann Arbor, said in a written statement.

Their estimates, published online in Arthritis & Rheumatology, put the overall SLE prevalence in the United States at 72.8 per 100,000 person-years in 2018, with nearly nine times more females affected (128.7 cases per 100,000) than males (14.6 per 100,000). Race and ethnicity also play a role, as prevalence was highest among American Indian/Alaska Native and Black females, with Hispanic females lower but still higher than White and Asian/Pacific Islander females, Peter M. Izmirly, MD, MSc, of New York University, the lead author, and associates said.

SLE prevalence was distributed similarly in men, although there was a greater relative margin between American Indians/Alaska Natives (53.8 cases per 100,000 person-years) and Blacks (26.7 per 100,000), and Asians/Pacific Islanders were higher than Whites (11.2 vs. 8.9), the investigators reported.

The meta-analysis leveraged data from the Centers for Disease Control and Prevention’s national lupus registries, which include four state-specific SLE registries and a fifth in the Indian Health Service. All cases of SLE occurred in 2002-2009, and the data were age adjusted to the 2000 U.S. population and separately extrapolated to the 2018 U.S. Census population, they explained.

The analysis was funded by cooperative agreements between the New York City Department of Health and Mental Hygiene and New York University, and the CDC and National Institute of Health.

[email protected]

The prevalence of systemic lupus erythematosus (SLE) appears to be much lower than previously believed and may pose “a potential risk to research funding for the disease,” according to results of a meta-analysis involving a network of population-based registries.

“When we started this study, a widely cited lupus statistic was that approximately 1.5 million Americans were affected. Our meta-analysis found the actual prevalence to be slightly more than 200,000: a number that approaches the [Food and Drug Administration’s] definition of a rare disease,” Emily Somers, PhD, ScM, senior author and associate professor of rheumatology and environmental health sciences at the University of Michigan, Ann Arbor, said in a written statement.

Their estimates, published online in Arthritis & Rheumatology, put the overall SLE prevalence in the United States at 72.8 per 100,000 person-years in 2018, with nearly nine times more females affected (128.7 cases per 100,000) than males (14.6 per 100,000). Race and ethnicity also play a role, as prevalence was highest among American Indian/Alaska Native and Black females, with Hispanic females lower but still higher than White and Asian/Pacific Islander females, Peter M. Izmirly, MD, MSc, of New York University, the lead author, and associates said.

SLE prevalence was distributed similarly in men, although there was a greater relative margin between American Indians/Alaska Natives (53.8 cases per 100,000 person-years) and Blacks (26.7 per 100,000), and Asians/Pacific Islanders were higher than Whites (11.2 vs. 8.9), the investigators reported.

The meta-analysis leveraged data from the Centers for Disease Control and Prevention’s national lupus registries, which include four state-specific SLE registries and a fifth in the Indian Health Service. All cases of SLE occurred in 2002-2009, and the data were age adjusted to the 2000 U.S. population and separately extrapolated to the 2018 U.S. Census population, they explained.

The analysis was funded by cooperative agreements between the New York City Department of Health and Mental Hygiene and New York University, and the CDC and National Institute of Health.

[email protected]

Physicians treating patients with IBD typically focus on disease and symptom management along with quality of life measures, but the latter are not the final word on patient well-being. Social well-being is another outcome that can more accurately portray a patient’s satisfaction with their treatment.

That was the message delivered by Laurie Keefer, PhD, at a session on diet, stress, health literacy, and disparities in IBD treatment at the annual congress of the Crohn’s & Colitis Foundation and the American Gastroenterological Association. “When we talk about disease management, we’re talking about these outcomes of mucosal healing, remission, and lack of hospitalizations, but we don’t always talk about wellness,” said Dr. Keefer, director of psychobehavioral research in the department of gastroenterology at Icahn School of Medicine at Mount Sinai, New York.

Dr. Keefer advocated for incorporating measures that focus on the patient’s ability to feel fulfilled, pursue happiness, and contribute to the community. “Wellness is defined as a state of complete physical, mental, and social well-being. It’s a holistic definition, not merely the absence of those things,” she said during her talk.

Social determinants of health, such as income, inequality, health literacy, numeracy, financial stress, social connections, community, place of resonance, and housing coresidents, play important roles.

“Subjective well-being is a state in which an individual feels they are able to do work productively and creatively, have relationships, and contribute to their community. We want them to thrive. We want them to live well. We want them to reach their potential. There’s no reason you cannot reach your potential even though you’re living with IBD,” said Dr. Keefer.

Subjective well-being doesn’t replace quality of life assessment. “Absolutely, quality of life is an important metric, [but I want to] make a plug that maybe we should start to add subjective well-being into these outcome measures,” said Dr. Keefer.

The approach does away with specific measures of health, employment, financial security, or even living situation. “It takes away all of those things we just assume are part of being well. It measures it differently. It measures what makes us happy, divided by the degree of happiness we obtain,” said Dr. Keefer. She presented examples from a study her group is conducting that showed patients’ responses to what made them want to be well. “Some people want to be well to take care of their children or families or a parent, some people want to be well so they can go adventure skydiving, other people just want to be able to exercise and take care of their health. That’s what the target needs to be for wellness. In that sense, wellness is an achievement of best health possible in all domains, not just one. It’s a lifelong pursuit. It forces us to ask not just ‘Are my patient’s symptoms gone? Are they in clinical remission? Are they in histological remission? Are they in deep remission?’ but ‘Is my patient thriving? Are they meeting their potential? Are they getting what they want out of treatment? Are they happy?’ ”

Quality of life measures can provide some insight, but they are limited because they are anchored in physical symptoms, and they focus on a narrow, recent window, usually the past week. “You can imagine that as symptoms improve, those metrics kind of improve, and it looks like quality of life is great. But that’s not always the case, and we’re really missing an opportunity to go deeper. It’s also less sensitive when somebody is in remission, so it’s also very difficult to continue that proactive [approach] of thriving and living well when you’re already coming up positive on quality of life indices,” said Dr. Keefer.

Subjective well-being measures ignore physical symptoms, and focus instead on questions like the patient’s ability to work, socialize, and maintain relationships with family, and whether the patient feels able to contribute meaningfully to society. The measure is insensitive to factors such as inflammation, trauma, or changes to medication. As a result, measures can be used much less frequently – every 6 months, or even once a year.

Subjective well-being can also rely on the patient to define well-being, and that makes it more culturally sensitive. “It can allow for people to be well in whatever way they think they want to be well,” said Dr. Keefer.

There are various resources for measuring subjective well-being. The Organization for Economic Cooperation and Development has guidelines for measuring subjective well-being. The National Institutes of Health PROMIS includes useful measures of psychological well-being, positive affect, and general life satisfaction; they are available for free and include 6-8 items. Other useful measures include the Satisfaction with Life scale, the Positive and Negative Affect scale, and the Harmony in Life scale. “All of those have been well validated and used internationally as measures of well-being,” said Dr. Keefer.

Physicians can also address patients directly, asking them about how satisfied they are with their life. “You’re opening up that discussion to ask them not just, ‘How is your IBD and how is your IBD affecting your work?’ but ‘How is your life going?’ You’re proactively trying to help your patients thrive,” said Dr. Keefer.

Session moderators praised Dr. Keefer’s presentation as an appropriate wrap-up to talks that looked at stress, diet, economic disparities, health literacy, and numeracy.

“We capped it all with a discussion around what is well-being. We often talk about biologics or medicines or surgery when it comes to Crohn’s disease and ulcerative colitis, but what about holistic wellness? It’s all of this. It’s the medication piece, but it’s all of these other pillars involved in the process as well. I think looking at this from many different angles is very important so that patients can achieve the best quality of life possible,” said comoderator Tina Aswani Omprakash, a patient advocate who is pursuing a master’s degree in public health at Mount Sinai’s Icahn School of Medicine.

Physicians treating patients with IBD typically focus on disease and symptom management along with quality of life measures, but the latter are not the final word on patient well-being. Social well-being is another outcome that can more accurately portray a patient’s satisfaction with their treatment.

That was the message delivered by Laurie Keefer, PhD, at a session on diet, stress, health literacy, and disparities in IBD treatment at the annual congress of the Crohn’s & Colitis Foundation and the American Gastroenterological Association. “When we talk about disease management, we’re talking about these outcomes of mucosal healing, remission, and lack of hospitalizations, but we don’t always talk about wellness,” said Dr. Keefer, director of psychobehavioral research in the department of gastroenterology at Icahn School of Medicine at Mount Sinai, New York.

Dr. Keefer advocated for incorporating measures that focus on the patient’s ability to feel fulfilled, pursue happiness, and contribute to the community. “Wellness is defined as a state of complete physical, mental, and social well-being. It’s a holistic definition, not merely the absence of those things,” she said during her talk.

Social determinants of health, such as income, inequality, health literacy, numeracy, financial stress, social connections, community, place of resonance, and housing coresidents, play important roles.

“Subjective well-being is a state in which an individual feels they are able to do work productively and creatively, have relationships, and contribute to their community. We want them to thrive. We want them to live well. We want them to reach their potential. There’s no reason you cannot reach your potential even though you’re living with IBD,” said Dr. Keefer.

Subjective well-being doesn’t replace quality of life assessment. “Absolutely, quality of life is an important metric, [but I want to] make a plug that maybe we should start to add subjective well-being into these outcome measures,” said Dr. Keefer.

The approach does away with specific measures of health, employment, financial security, or even living situation. “It takes away all of those things we just assume are part of being well. It measures it differently. It measures what makes us happy, divided by the degree of happiness we obtain,” said Dr. Keefer. She presented examples from a study her group is conducting that showed patients’ responses to what made them want to be well. “Some people want to be well to take care of their children or families or a parent, some people want to be well so they can go adventure skydiving, other people just want to be able to exercise and take care of their health. That’s what the target needs to be for wellness. In that sense, wellness is an achievement of best health possible in all domains, not just one. It’s a lifelong pursuit. It forces us to ask not just ‘Are my patient’s symptoms gone? Are they in clinical remission? Are they in histological remission? Are they in deep remission?’ but ‘Is my patient thriving? Are they meeting their potential? Are they getting what they want out of treatment? Are they happy?’ ”

Quality of life measures can provide some insight, but they are limited because they are anchored in physical symptoms, and they focus on a narrow, recent window, usually the past week. “You can imagine that as symptoms improve, those metrics kind of improve, and it looks like quality of life is great. But that’s not always the case, and we’re really missing an opportunity to go deeper. It’s also less sensitive when somebody is in remission, so it’s also very difficult to continue that proactive [approach] of thriving and living well when you’re already coming up positive on quality of life indices,” said Dr. Keefer.

Subjective well-being measures ignore physical symptoms, and focus instead on questions like the patient’s ability to work, socialize, and maintain relationships with family, and whether the patient feels able to contribute meaningfully to society. The measure is insensitive to factors such as inflammation, trauma, or changes to medication. As a result, measures can be used much less frequently – every 6 months, or even once a year.

Subjective well-being can also rely on the patient to define well-being, and that makes it more culturally sensitive. “It can allow for people to be well in whatever way they think they want to be well,” said Dr. Keefer.

There are various resources for measuring subjective well-being. The Organization for Economic Cooperation and Development has guidelines for measuring subjective well-being. The National Institutes of Health PROMIS includes useful measures of psychological well-being, positive affect, and general life satisfaction; they are available for free and include 6-8 items. Other useful measures include the Satisfaction with Life scale, the Positive and Negative Affect scale, and the Harmony in Life scale. “All of those have been well validated and used internationally as measures of well-being,” said Dr. Keefer.

Physicians can also address patients directly, asking them about how satisfied they are with their life. “You’re opening up that discussion to ask them not just, ‘How is your IBD and how is your IBD affecting your work?’ but ‘How is your life going?’ You’re proactively trying to help your patients thrive,” said Dr. Keefer.

Session moderators praised Dr. Keefer’s presentation as an appropriate wrap-up to talks that looked at stress, diet, economic disparities, health literacy, and numeracy.

“We capped it all with a discussion around what is well-being. We often talk about biologics or medicines or surgery when it comes to Crohn’s disease and ulcerative colitis, but what about holistic wellness? It’s all of this. It’s the medication piece, but it’s all of these other pillars involved in the process as well. I think looking at this from many different angles is very important so that patients can achieve the best quality of life possible,” said comoderator Tina Aswani Omprakash, a patient advocate who is pursuing a master’s degree in public health at Mount Sinai’s Icahn School of Medicine.

Physicians treating patients with IBD typically focus on disease and symptom management along with quality of life measures, but the latter are not the final word on patient well-being. Social well-being is another outcome that can more accurately portray a patient’s satisfaction with their treatment.

That was the message delivered by Laurie Keefer, PhD, at a session on diet, stress, health literacy, and disparities in IBD treatment at the annual congress of the Crohn’s & Colitis Foundation and the American Gastroenterological Association. “When we talk about disease management, we’re talking about these outcomes of mucosal healing, remission, and lack of hospitalizations, but we don’t always talk about wellness,” said Dr. Keefer, director of psychobehavioral research in the department of gastroenterology at Icahn School of Medicine at Mount Sinai, New York.

Dr. Keefer advocated for incorporating measures that focus on the patient’s ability to feel fulfilled, pursue happiness, and contribute to the community. “Wellness is defined as a state of complete physical, mental, and social well-being. It’s a holistic definition, not merely the absence of those things,” she said during her talk.

Social determinants of health, such as income, inequality, health literacy, numeracy, financial stress, social connections, community, place of resonance, and housing coresidents, play important roles.

“Subjective well-being is a state in which an individual feels they are able to do work productively and creatively, have relationships, and contribute to their community. We want them to thrive. We want them to live well. We want them to reach their potential. There’s no reason you cannot reach your potential even though you’re living with IBD,” said Dr. Keefer.

Subjective well-being doesn’t replace quality of life assessment. “Absolutely, quality of life is an important metric, [but I want to] make a plug that maybe we should start to add subjective well-being into these outcome measures,” said Dr. Keefer.

The approach does away with specific measures of health, employment, financial security, or even living situation. “It takes away all of those things we just assume are part of being well. It measures it differently. It measures what makes us happy, divided by the degree of happiness we obtain,” said Dr. Keefer. She presented examples from a study her group is conducting that showed patients’ responses to what made them want to be well. “Some people want to be well to take care of their children or families or a parent, some people want to be well so they can go adventure skydiving, other people just want to be able to exercise and take care of their health. That’s what the target needs to be for wellness. In that sense, wellness is an achievement of best health possible in all domains, not just one. It’s a lifelong pursuit. It forces us to ask not just ‘Are my patient’s symptoms gone? Are they in clinical remission? Are they in histological remission? Are they in deep remission?’ but ‘Is my patient thriving? Are they meeting their potential? Are they getting what they want out of treatment? Are they happy?’ ”

Quality of life measures can provide some insight, but they are limited because they are anchored in physical symptoms, and they focus on a narrow, recent window, usually the past week. “You can imagine that as symptoms improve, those metrics kind of improve, and it looks like quality of life is great. But that’s not always the case, and we’re really missing an opportunity to go deeper. It’s also less sensitive when somebody is in remission, so it’s also very difficult to continue that proactive [approach] of thriving and living well when you’re already coming up positive on quality of life indices,” said Dr. Keefer.

Subjective well-being measures ignore physical symptoms, and focus instead on questions like the patient’s ability to work, socialize, and maintain relationships with family, and whether the patient feels able to contribute meaningfully to society. The measure is insensitive to factors such as inflammation, trauma, or changes to medication. As a result, measures can be used much less frequently – every 6 months, or even once a year.

Subjective well-being can also rely on the patient to define well-being, and that makes it more culturally sensitive. “It can allow for people to be well in whatever way they think they want to be well,” said Dr. Keefer.

There are various resources for measuring subjective well-being. The Organization for Economic Cooperation and Development has guidelines for measuring subjective well-being. The National Institutes of Health PROMIS includes useful measures of psychological well-being, positive affect, and general life satisfaction; they are available for free and include 6-8 items. Other useful measures include the Satisfaction with Life scale, the Positive and Negative Affect scale, and the Harmony in Life scale. “All of those have been well validated and used internationally as measures of well-being,” said Dr. Keefer.

Physicians can also address patients directly, asking them about how satisfied they are with their life. “You’re opening up that discussion to ask them not just, ‘How is your IBD and how is your IBD affecting your work?’ but ‘How is your life going?’ You’re proactively trying to help your patients thrive,” said Dr. Keefer.

Session moderators praised Dr. Keefer’s presentation as an appropriate wrap-up to talks that looked at stress, diet, economic disparities, health literacy, and numeracy.

“We capped it all with a discussion around what is well-being. We often talk about biologics or medicines or surgery when it comes to Crohn’s disease and ulcerative colitis, but what about holistic wellness? It’s all of this. It’s the medication piece, but it’s all of these other pillars involved in the process as well. I think looking at this from many different angles is very important so that patients can achieve the best quality of life possible,” said comoderator Tina Aswani Omprakash, a patient advocate who is pursuing a master’s degree in public health at Mount Sinai’s Icahn School of Medicine.

The incidence of autoimmune hepatitis (AIH) may be rising, according to a prospective population-based study conducted in New Zealand.

From 2008 to 2016, the rising incidence of AIH led to a 40% increase in point prevalence, reported lead author Mehul Lamba, MD, of Christchurch (New Zealand) Hospital and colleagues.

The present study, which also assessed rates of primary biliary cholangitis (PBC) and primary sclerosing cholangitis (PSC), adds data to an area of inquiry historically characterized by limited and inconsistent results, the investigators wrote in Clinical Gastroenterology and Hepatology. They suggested that mixed findings from previous studies may be because of differences in population and environmental factors, but also varying diagnostic criteria.

“The epidemiological trends of these autoimmune liver diseases therefore remain incompletely understood,” wrote Dr. Lamba and colleagues.

Their study evaluated trends in autoimmune liver diseases over a 9-year time frame in Canterbury, New Zealand. According to the investigators, this region is well suited to an epidemiological investigation because it is a clearly defined geographic area with approximately 600,000 people, most of whom rely on one tertiary care center: Christchurch Hospital. The bulk of the data therefore came from this center, while a minority of cases were gathered from local private gastroenterology practices, “making complete case ascertainment possible.”

Incidence of AIH, PBC, and PSC was assessed at three time points: 2008-2010, 2011-2013, and 2014-2016. AIH had the highest overall incidence, at 1.93 cases per 100,000 people, followed by PSC (0.92) and PBC (0.51).

While the rates of PBC and PSC did not change significantly over time, the incidence of AIH rose from 1.37 cases per 100,000 people in the period from 2008-2010 to 2.39 per 100,000 in 2014-2016 (P = .04), which computes to an incidence rate ratio of 1.69 (95% confidence interval, 1.02-2.84). Point prevalence was also significantly higher in 2016, compared with 2008, at 27.5 per 100,000 versus 19.7 per 100,000 (P < .01). The investigators described a bimodal age of presentation, with the first peak among patients younger than 20 years, and a second, larger peak among individuals aged 50-69 years.

According to the investigators, these findings “are concordant with the results observed in the European cohort,” citing a Danish study spanning 1994-2012 and a Dutch study spanning 2000-2010. They noted that the Danish study also reported a bimodal distribution of age incidence, as did a Swedish study, and another study from New Zealand. The stable levels of PBC and PSC align with two recent retrospective studies conducted in the United States and, they added.

“We believe that the observed differential trends in the incidence of these autoimmune liver diseases truly reflects their contemporary epidemiology,” the investigators wrote. They went on to suggest that the findings did not stem from an increase in diagnostic scrutiny because the study period did not include any significant changes in gastroenterology service, coding, or diagnostic criteria in the region studied.

“The increased incidence of AIH parallels rising incidence and prevalence of other autoimmune disorders such as [inflammatory bowel disease], type 1 diabetes, and multiple sclerosis in New Zealand, and it is unclear whether these autoimmune conditions share a common local environmental trigger,” they wrote. “Environmental factors likely play a central role augmenting phenotypic expression in genetically predisposed individuals.”

While Dr. Lamba and colleagues proposed several possible factors, such as increased exposure to pharmaceuticals, definitive factors remain elusive, which the authors cited as one limitation of their study. Another limitation they cited is the possibility that other etiologies were mistakenly classified as “probable” AIH; however, the chances of that are small, and the proportion of probable versus definitive AIH noted in this study do reflect those seen in other epidemiological studies.

“The reason for observed differential change in incidence of these autoimmune liver diseases is unclear,” they wrote, “and future collaborative prospective epidemiological study would be required to assess this further.”

The investigators reported no conflicts of interest.

The incidence of autoimmune hepatitis (AIH) may be rising, according to a prospective population-based study conducted in New Zealand.

From 2008 to 2016, the rising incidence of AIH led to a 40% increase in point prevalence, reported lead author Mehul Lamba, MD, of Christchurch (New Zealand) Hospital and colleagues.

The present study, which also assessed rates of primary biliary cholangitis (PBC) and primary sclerosing cholangitis (PSC), adds data to an area of inquiry historically characterized by limited and inconsistent results, the investigators wrote in Clinical Gastroenterology and Hepatology. They suggested that mixed findings from previous studies may be because of differences in population and environmental factors, but also varying diagnostic criteria.

“The epidemiological trends of these autoimmune liver diseases therefore remain incompletely understood,” wrote Dr. Lamba and colleagues.

Their study evaluated trends in autoimmune liver diseases over a 9-year time frame in Canterbury, New Zealand. According to the investigators, this region is well suited to an epidemiological investigation because it is a clearly defined geographic area with approximately 600,000 people, most of whom rely on one tertiary care center: Christchurch Hospital. The bulk of the data therefore came from this center, while a minority of cases were gathered from local private gastroenterology practices, “making complete case ascertainment possible.”

Incidence of AIH, PBC, and PSC was assessed at three time points: 2008-2010, 2011-2013, and 2014-2016. AIH had the highest overall incidence, at 1.93 cases per 100,000 people, followed by PSC (0.92) and PBC (0.51).

While the rates of PBC and PSC did not change significantly over time, the incidence of AIH rose from 1.37 cases per 100,000 people in the period from 2008-2010 to 2.39 per 100,000 in 2014-2016 (P = .04), which computes to an incidence rate ratio of 1.69 (95% confidence interval, 1.02-2.84). Point prevalence was also significantly higher in 2016, compared with 2008, at 27.5 per 100,000 versus 19.7 per 100,000 (P < .01). The investigators described a bimodal age of presentation, with the first peak among patients younger than 20 years, and a second, larger peak among individuals aged 50-69 years.

According to the investigators, these findings “are concordant with the results observed in the European cohort,” citing a Danish study spanning 1994-2012 and a Dutch study spanning 2000-2010. They noted that the Danish study also reported a bimodal distribution of age incidence, as did a Swedish study, and another study from New Zealand. The stable levels of PBC and PSC align with two recent retrospective studies conducted in the United States and, they added.

“We believe that the observed differential trends in the incidence of these autoimmune liver diseases truly reflects their contemporary epidemiology,” the investigators wrote. They went on to suggest that the findings did not stem from an increase in diagnostic scrutiny because the study period did not include any significant changes in gastroenterology service, coding, or diagnostic criteria in the region studied.

“The increased incidence of AIH parallels rising incidence and prevalence of other autoimmune disorders such as [inflammatory bowel disease], type 1 diabetes, and multiple sclerosis in New Zealand, and it is unclear whether these autoimmune conditions share a common local environmental trigger,” they wrote. “Environmental factors likely play a central role augmenting phenotypic expression in genetically predisposed individuals.”

While Dr. Lamba and colleagues proposed several possible factors, such as increased exposure to pharmaceuticals, definitive factors remain elusive, which the authors cited as one limitation of their study. Another limitation they cited is the possibility that other etiologies were mistakenly classified as “probable” AIH; however, the chances of that are small, and the proportion of probable versus definitive AIH noted in this study do reflect those seen in other epidemiological studies.

“The reason for observed differential change in incidence of these autoimmune liver diseases is unclear,” they wrote, “and future collaborative prospective epidemiological study would be required to assess this further.”

The investigators reported no conflicts of interest.

The incidence of autoimmune hepatitis (AIH) may be rising, according to a prospective population-based study conducted in New Zealand.

From 2008 to 2016, the rising incidence of AIH led to a 40% increase in point prevalence, reported lead author Mehul Lamba, MD, of Christchurch (New Zealand) Hospital and colleagues.

The present study, which also assessed rates of primary biliary cholangitis (PBC) and primary sclerosing cholangitis (PSC), adds data to an area of inquiry historically characterized by limited and inconsistent results, the investigators wrote in Clinical Gastroenterology and Hepatology. They suggested that mixed findings from previous studies may be because of differences in population and environmental factors, but also varying diagnostic criteria.

“The epidemiological trends of these autoimmune liver diseases therefore remain incompletely understood,” wrote Dr. Lamba and colleagues.

Their study evaluated trends in autoimmune liver diseases over a 9-year time frame in Canterbury, New Zealand. According to the investigators, this region is well suited to an epidemiological investigation because it is a clearly defined geographic area with approximately 600,000 people, most of whom rely on one tertiary care center: Christchurch Hospital. The bulk of the data therefore came from this center, while a minority of cases were gathered from local private gastroenterology practices, “making complete case ascertainment possible.”

Incidence of AIH, PBC, and PSC was assessed at three time points: 2008-2010, 2011-2013, and 2014-2016. AIH had the highest overall incidence, at 1.93 cases per 100,000 people, followed by PSC (0.92) and PBC (0.51).

While the rates of PBC and PSC did not change significantly over time, the incidence of AIH rose from 1.37 cases per 100,000 people in the period from 2008-2010 to 2.39 per 100,000 in 2014-2016 (P = .04), which computes to an incidence rate ratio of 1.69 (95% confidence interval, 1.02-2.84). Point prevalence was also significantly higher in 2016, compared with 2008, at 27.5 per 100,000 versus 19.7 per 100,000 (P < .01). The investigators described a bimodal age of presentation, with the first peak among patients younger than 20 years, and a second, larger peak among individuals aged 50-69 years.

According to the investigators, these findings “are concordant with the results observed in the European cohort,” citing a Danish study spanning 1994-2012 and a Dutch study spanning 2000-2010. They noted that the Danish study also reported a bimodal distribution of age incidence, as did a Swedish study, and another study from New Zealand. The stable levels of PBC and PSC align with two recent retrospective studies conducted in the United States and, they added.

“We believe that the observed differential trends in the incidence of these autoimmune liver diseases truly reflects their contemporary epidemiology,” the investigators wrote. They went on to suggest that the findings did not stem from an increase in diagnostic scrutiny because the study period did not include any significant changes in gastroenterology service, coding, or diagnostic criteria in the region studied.

“The increased incidence of AIH parallels rising incidence and prevalence of other autoimmune disorders such as [inflammatory bowel disease], type 1 diabetes, and multiple sclerosis in New Zealand, and it is unclear whether these autoimmune conditions share a common local environmental trigger,” they wrote. “Environmental factors likely play a central role augmenting phenotypic expression in genetically predisposed individuals.”

While Dr. Lamba and colleagues proposed several possible factors, such as increased exposure to pharmaceuticals, definitive factors remain elusive, which the authors cited as one limitation of their study. Another limitation they cited is the possibility that other etiologies were mistakenly classified as “probable” AIH; however, the chances of that are small, and the proportion of probable versus definitive AIH noted in this study do reflect those seen in other epidemiological studies.

“The reason for observed differential change in incidence of these autoimmune liver diseases is unclear,” they wrote, “and future collaborative prospective epidemiological study would be required to assess this further.”

The investigators reported no conflicts of interest.

Background: Delirium is a common disorder in hospitalized adults and is associated with poor outcomes. Antipsychotics are used clinically to treat delirium, but benefits and harms remain unclear.

Limitations include heterogeneous use of agents, routes, dose, and measurement tools, which limits generalization of evidence. Multiple RCTs excluded patients with underlying cardiac and neurologic conditions that likely led to underrepresentation of harm in routine use. Insufficient evidence still exists for multiple clinically relevant outcomes including long-term cognitive function.

Bottom line: Evidence from several studies does not support the use of haloperidol or newer antipsychotics to treat delirium.

Citation: Nikooie R et al. Antipsychotics for delirium treatment in adults: A systematic review. Ann Intern Med. 2019 Oct 1;171(7):485-95.

Dr. Berry is assistant professor of medicine, hospital medicine, at the Rocky Mountain Veterans Affairs Regional Medical Center, Aurora, Colo.

Background: Delirium is a common disorder in hospitalized adults and is associated with poor outcomes. Antipsychotics are used clinically to treat delirium, but benefits and harms remain unclear.

Limitations include heterogeneous use of agents, routes, dose, and measurement tools, which limits generalization of evidence. Multiple RCTs excluded patients with underlying cardiac and neurologic conditions that likely led to underrepresentation of harm in routine use. Insufficient evidence still exists for multiple clinically relevant outcomes including long-term cognitive function.

Bottom line: Evidence from several studies does not support the use of haloperidol or newer antipsychotics to treat delirium.

Citation: Nikooie R et al. Antipsychotics for delirium treatment in adults: A systematic review. Ann Intern Med. 2019 Oct 1;171(7):485-95.

Dr. Berry is assistant professor of medicine, hospital medicine, at the Rocky Mountain Veterans Affairs Regional Medical Center, Aurora, Colo.

Background: Delirium is a common disorder in hospitalized adults and is associated with poor outcomes. Antipsychotics are used clinically to treat delirium, but benefits and harms remain unclear.

Limitations include heterogeneous use of agents, routes, dose, and measurement tools, which limits generalization of evidence. Multiple RCTs excluded patients with underlying cardiac and neurologic conditions that likely led to underrepresentation of harm in routine use. Insufficient evidence still exists for multiple clinically relevant outcomes including long-term cognitive function.

Bottom line: Evidence from several studies does not support the use of haloperidol or newer antipsychotics to treat delirium.

Citation: Nikooie R et al. Antipsychotics for delirium treatment in adults: A systematic review. Ann Intern Med. 2019 Oct 1;171(7):485-95.

Dr. Berry is assistant professor of medicine, hospital medicine, at the Rocky Mountain Veterans Affairs Regional Medical Center, Aurora, Colo.

Q2. Correct answer: E  

Rationale  
This patient has nausea and vomiting of pregnancy (NVP), and has tried conservative management. Doxylamine and vitamin B6 have been found to be safe and effective for NVP and are considered first-line therapy. Further testing with gastric-emptying study is not necessary because NVP has a high prevalence at weeks 4-6 of gestation and peaks at week 9-16. A nuclear test such as gastric emptying is not appropriate during pregnancy, though decreased gastric emptying due to estrogen and progesterone is thought to be related to NVP. Upper endoscopy would be considered if the nausea and vomiting is refractory. Ondansetron can be considered, but there have been some questions raised regarding safety and it is not considered first line. Meals high in protein have been found to decrease nausea more that carbohydrate-rich meals.  
 
Reference  
ACOG Committee on Practice Bulletins-Obstetrics. Obstet Gynecol. 2018 Jan;131(1):e15-e30.

Q2. Correct answer: E  

Rationale  
This patient has nausea and vomiting of pregnancy (NVP), and has tried conservative management. Doxylamine and vitamin B6 have been found to be safe and effective for NVP and are considered first-line therapy. Further testing with gastric-emptying study is not necessary because NVP has a high prevalence at weeks 4-6 of gestation and peaks at week 9-16. A nuclear test such as gastric emptying is not appropriate during pregnancy, though decreased gastric emptying due to estrogen and progesterone is thought to be related to NVP. Upper endoscopy would be considered if the nausea and vomiting is refractory. Ondansetron can be considered, but there have been some questions raised regarding safety and it is not considered first line. Meals high in protein have been found to decrease nausea more that carbohydrate-rich meals.  
 
Reference  
ACOG Committee on Practice Bulletins-Obstetrics. Obstet Gynecol. 2018 Jan;131(1):e15-e30.

Q2. Correct answer: E  

Rationale  
This patient has nausea and vomiting of pregnancy (NVP), and has tried conservative management. Doxylamine and vitamin B6 have been found to be safe and effective for NVP and are considered first-line therapy. Further testing with gastric-emptying study is not necessary because NVP has a high prevalence at weeks 4-6 of gestation and peaks at week 9-16. A nuclear test such as gastric emptying is not appropriate during pregnancy, though decreased gastric emptying due to estrogen and progesterone is thought to be related to NVP. Upper endoscopy would be considered if the nausea and vomiting is refractory. Ondansetron can be considered, but there have been some questions raised regarding safety and it is not considered first line. Meals high in protein have been found to decrease nausea more that carbohydrate-rich meals.  
 
Reference  
ACOG Committee on Practice Bulletins-Obstetrics. Obstet Gynecol. 2018 Jan;131(1):e15-e30.

Q1. Correct answer: E 

Rationale  
Transient lower esophageal sphincter relaxation (TLESR) is a physiologic phenomenon that allows venting of swallowed air from the stomach in response to distension of the proximal stomach. Patients with GERD typically reflux gastric content through a compliant esophagogastric junction into the esophagus during a TLESR; the frequency of TLESRs may also be higher in patients with GERD. TLESRs are suppressed during deep sleep, and are less frequent when LES relaxation is abnormal (e.g., esophageal outflow obstruction). Baclofen, a GABAB receptor agonist, can reduce TLESR frequency, and can reduce reflux episodes in patients with reflux. Obese patients and those with obstructive sleep apnea can have increased frequency of TLESRs. The frequency of TLESR is not related to degree of gastric acid secretion in the stomach.  
 
References  
Kuribayashi S et al. Neurogastroenterol Motil. 2010 Jun;22(6):611-e172.  
Hershcovici T et al. Neurogastroenterol Motil. 2011 Sep;23(9):819-30.

Q1. Correct answer: E 

Rationale  
Transient lower esophageal sphincter relaxation (TLESR) is a physiologic phenomenon that allows venting of swallowed air from the stomach in response to distension of the proximal stomach. Patients with GERD typically reflux gastric content through a compliant esophagogastric junction into the esophagus during a TLESR; the frequency of TLESRs may also be higher in patients with GERD. TLESRs are suppressed during deep sleep, and are less frequent when LES relaxation is abnormal (e.g., esophageal outflow obstruction). Baclofen, a GABAB receptor agonist, can reduce TLESR frequency, and can reduce reflux episodes in patients with reflux. Obese patients and those with obstructive sleep apnea can have increased frequency of TLESRs. The frequency of TLESR is not related to degree of gastric acid secretion in the stomach.  
 
References  
Kuribayashi S et al. Neurogastroenterol Motil. 2010 Jun;22(6):611-e172.  
Hershcovici T et al. Neurogastroenterol Motil. 2011 Sep;23(9):819-30.

Q1. Correct answer: E 

Rationale  
Transient lower esophageal sphincter relaxation (TLESR) is a physiologic phenomenon that allows venting of swallowed air from the stomach in response to distension of the proximal stomach. Patients with GERD typically reflux gastric content through a compliant esophagogastric junction into the esophagus during a TLESR; the frequency of TLESRs may also be higher in patients with GERD. TLESRs are suppressed during deep sleep, and are less frequent when LES relaxation is abnormal (e.g., esophageal outflow obstruction). Baclofen, a GABAB receptor agonist, can reduce TLESR frequency, and can reduce reflux episodes in patients with reflux. Obese patients and those with obstructive sleep apnea can have increased frequency of TLESRs. The frequency of TLESR is not related to degree of gastric acid secretion in the stomach.  
 
References  
Kuribayashi S et al. Neurogastroenterol Motil. 2010 Jun;22(6):611-e172.  
Hershcovici T et al. Neurogastroenterol Motil. 2011 Sep;23(9):819-30.

COVID-19 infection altered the gut microbiota of adult patients and caused depletion of several types of bacteria with known immunomodulatory properties, based on data from a cohort study of 100 patients with confirmed COVID-19 infections from two hospitals.

“As the GI tract is the largest immunological organ in the body and its resident microbiota are known to modulate host immune responses, we hypothesized that the gut microbiota is associated with host inflammatory immune responses in COVID19,” wrote Yun Kit Yeoh, PhD, of the Chinese University of Hong Kong, and colleagues.

In a study published in Gut, the researchers investigated patient microbiota by collecting blood, stool, and patient records between February and May 2020 from 100 confirmed SARS-CoV-2–infected patients in Hong Kong during hospitalization, as well as follow-up stool samples from 27 patients up to 30 days after they cleared the COVID-19 virus; these observations were compared with 78 non–COVID-19 controls.

Overall, 274 stool samples were sequenced. Samples collected from patients during hospitalization for COVID-19 were compared with non–COVID-19 controls. The presence of phylum Bacteroidetes was significantly higher in COVID-19 patients compared with controls (23.9% vs. 12.8%; P < .001), as were Actinobacteria (26.1% vs. 19.0%; P < .001).

After controlling for antibiotics, the investigators found that “differences between cohorts were primarily linked to enrichment of taxa such as Parabacteroides, Sutterella wadsworthensis, and Bacteroides caccae and depletion of Adlercreutzia equolifaciens, Dorea formicigenerans, and Clostridium leptum in COVID-19 relative to non-COVID-19” (P < .05). In addition, Faecalibacterium prausnitzii and Bifidobacterium bifidum were negatively correlated with COVID-19 severity after investigators controlled for patient age and antibiotic use (P < .05).

The researchers also examined bacteria in COVID-19 patients and controls in the context of cytokines and other inflammatory markers. “We hypothesized that these compositional changes play a role in exacerbating disease by contributing to dysregulation of the immune response,” they said.

In fact, species depleted in COVID-19 patients including included B. adolescentis, E. rectale, and F. prausnitzii were negatively correlated with inflammatory markers including CXCL10, IL-10, TNF-alpha, and CCL2.

In addition, 42 stool samples from 27 patients showed significantly distinct gut microbiota from controls up to 30 days (median, 6 days) after virus clearance, regardless of antibiotics use (P < .05), the researchers said.
 

Long-term data needed

The study findings were limited by several factors, including the potential confounding of microbial signatures associated with COVID-19 because of heterogeneous patient management in the clinical setting and the potential that gut microbiota reflects a patient’s health with no impact on disease severity, as well as lack of data on the role of antibiotics for severe and critical patients, the researchers noted. In addition, “gut microbiota composition is highly heterogeneous across human populations and changes in compositions reported here may not necessarily be reflected in patients with COVID-19 from other biogeographies,” they wrote.

The “longer follow-up of patients with COVID-19 (e.g., 3 months to 1 year after clearing the virus) is needed to address questions related to the duration of gut microbiota dysbiosis post recovery, link between microbiota dysbiosis and long-term persistent symptoms, and whether the dysbiosis or enrichment/depletion of specific gut microorganisms predisposes recovered individuals to future health problems,” they wrote.

However, the results suggest a likely role for gut microorganisms in host inflammatory responses to COVID-19 infection, and “underscore an urgent need to understand the specific roles of gut microorganisms in human immune function and systemic inflammation,” they concluded.
 

More than infectious

“A growing body of evidence suggests that severity of illness from COVID-19 is largely determined by the patient’s aberrant immune response to the virus,” Jatin Roper, MD, of Duke University, Durham, N.C., said in an interview. “Therefore, a critical question is: What patient factors determine this immune response? The gut microbiota closely interact with the host immune system and are altered in many immunological diseases,” he said. “Furthermore, the SARS-CoV-2 virus infects enterocytes in the intestine and causes symptomatic gastrointestinal disease in a subset of patients. Therefore, understanding a possible association between gut microbiota and COVID-19 may reveal microbial species involved in disease pathogenesis,” he emphasized.   

In the current study, “I was surprised to find that COVID-19 infection is associated with depletion of immunomodulatory gut bacteria,” said Dr. Roper. “An open question is whether these changes are caused by the SARS-CoV-2 virus and then result in altered immune response. Alternatively, the changes in gut microbiota may be a result of the immune response or other changes associated with the disease,” he said.

“COVID-19 is an immunological disease, not just an infectious disease,” explained Dr. Roper. “The gut microbiota may play an important role in the pathogenesis of the disease. Thus, specific gut microbes could one day be analyzed to risk stratify patients, or even modified to treat the disease,” he noted.
 

Beyond COVID-19

“Given the impact of the gut microbiota on health and disease, as well as the impact of diseases on the microbiota, I am not at all surprised to find that there were significant changes in the microbiota of COVID-19 patients and that these changes are associated with inflammatory cytokines, chemokines, and blood markers of tissue damage,” said Anthony Sung, MD, also of Duke University.

According to Dr. Sung, researchers have already been investigating possible connections between gut microbiota and other conditions such as Alzheimer’s disease, and it’s been hypothesized that these connections are mediated by interactions between the gut microbiota and the immune system.

“While this is an important paper in our understanding of COVID-19, and highlights the microbiome as a potential therapeutic target, we need to conduct clinical trials of microbiota-based interventions before we can fully realize the clinical implications of these findings,” he said.

The study was supported by the Health and Medical Research Fund, the Food and Health Bureau, The Government of the Hong Kong Special Administrative Region, and donations from Hui Hoy & Chow Sin Lan Charity Fund Limited, Pine and Crane Company Limited, Mr. Hui Ming, and The D.H. Chen Foundation. The researchers had no financial conflicts to disclose. Dr. Roper and Dr. Sung had no financial conflicts to disclose.

COVID-19 infection altered the gut microbiota of adult patients and caused depletion of several types of bacteria with known immunomodulatory properties, based on data from a cohort study of 100 patients with confirmed COVID-19 infections from two hospitals.

“As the GI tract is the largest immunological organ in the body and its resident microbiota are known to modulate host immune responses, we hypothesized that the gut microbiota is associated with host inflammatory immune responses in COVID19,” wrote Yun Kit Yeoh, PhD, of the Chinese University of Hong Kong, and colleagues.

In a study published in Gut, the researchers investigated patient microbiota by collecting blood, stool, and patient records between February and May 2020 from 100 confirmed SARS-CoV-2–infected patients in Hong Kong during hospitalization, as well as follow-up stool samples from 27 patients up to 30 days after they cleared the COVID-19 virus; these observations were compared with 78 non–COVID-19 controls.

Overall, 274 stool samples were sequenced. Samples collected from patients during hospitalization for COVID-19 were compared with non–COVID-19 controls. The presence of phylum Bacteroidetes was significantly higher in COVID-19 patients compared with controls (23.9% vs. 12.8%; P < .001), as were Actinobacteria (26.1% vs. 19.0%; P < .001).

After controlling for antibiotics, the investigators found that “differences between cohorts were primarily linked to enrichment of taxa such as Parabacteroides, Sutterella wadsworthensis, and Bacteroides caccae and depletion of Adlercreutzia equolifaciens, Dorea formicigenerans, and Clostridium leptum in COVID-19 relative to non-COVID-19” (P < .05). In addition, Faecalibacterium prausnitzii and Bifidobacterium bifidum were negatively correlated with COVID-19 severity after investigators controlled for patient age and antibiotic use (P < .05).

The researchers also examined bacteria in COVID-19 patients and controls in the context of cytokines and other inflammatory markers. “We hypothesized that these compositional changes play a role in exacerbating disease by contributing to dysregulation of the immune response,” they said.

In fact, species depleted in COVID-19 patients including included B. adolescentis, E. rectale, and F. prausnitzii were negatively correlated with inflammatory markers including CXCL10, IL-10, TNF-alpha, and CCL2.

In addition, 42 stool samples from 27 patients showed significantly distinct gut microbiota from controls up to 30 days (median, 6 days) after virus clearance, regardless of antibiotics use (P < .05), the researchers said.
 

Long-term data needed

The study findings were limited by several factors, including the potential confounding of microbial signatures associated with COVID-19 because of heterogeneous patient management in the clinical setting and the potential that gut microbiota reflects a patient’s health with no impact on disease severity, as well as lack of data on the role of antibiotics for severe and critical patients, the researchers noted. In addition, “gut microbiota composition is highly heterogeneous across human populations and changes in compositions reported here may not necessarily be reflected in patients with COVID-19 from other biogeographies,” they wrote.

The “longer follow-up of patients with COVID-19 (e.g., 3 months to 1 year after clearing the virus) is needed to address questions related to the duration of gut microbiota dysbiosis post recovery, link between microbiota dysbiosis and long-term persistent symptoms, and whether the dysbiosis or enrichment/depletion of specific gut microorganisms predisposes recovered individuals to future health problems,” they wrote.

However, the results suggest a likely role for gut microorganisms in host inflammatory responses to COVID-19 infection, and “underscore an urgent need to understand the specific roles of gut microorganisms in human immune function and systemic inflammation,” they concluded.
 

More than infectious

“A growing body of evidence suggests that severity of illness from COVID-19 is largely determined by the patient’s aberrant immune response to the virus,” Jatin Roper, MD, of Duke University, Durham, N.C., said in an interview. “Therefore, a critical question is: What patient factors determine this immune response? The gut microbiota closely interact with the host immune system and are altered in many immunological diseases,” he said. “Furthermore, the SARS-CoV-2 virus infects enterocytes in the intestine and causes symptomatic gastrointestinal disease in a subset of patients. Therefore, understanding a possible association between gut microbiota and COVID-19 may reveal microbial species involved in disease pathogenesis,” he emphasized.   

In the current study, “I was surprised to find that COVID-19 infection is associated with depletion of immunomodulatory gut bacteria,” said Dr. Roper. “An open question is whether these changes are caused by the SARS-CoV-2 virus and then result in altered immune response. Alternatively, the changes in gut microbiota may be a result of the immune response or other changes associated with the disease,” he said.

“COVID-19 is an immunological disease, not just an infectious disease,” explained Dr. Roper. “The gut microbiota may play an important role in the pathogenesis of the disease. Thus, specific gut microbes could one day be analyzed to risk stratify patients, or even modified to treat the disease,” he noted.
 

Beyond COVID-19

“Given the impact of the gut microbiota on health and disease, as well as the impact of diseases on the microbiota, I am not at all surprised to find that there were significant changes in the microbiota of COVID-19 patients and that these changes are associated with inflammatory cytokines, chemokines, and blood markers of tissue damage,” said Anthony Sung, MD, also of Duke University.

According to Dr. Sung, researchers have already been investigating possible connections between gut microbiota and other conditions such as Alzheimer’s disease, and it’s been hypothesized that these connections are mediated by interactions between the gut microbiota and the immune system.

“While this is an important paper in our understanding of COVID-19, and highlights the microbiome as a potential therapeutic target, we need to conduct clinical trials of microbiota-based interventions before we can fully realize the clinical implications of these findings,” he said.

The study was supported by the Health and Medical Research Fund, the Food and Health Bureau, The Government of the Hong Kong Special Administrative Region, and donations from Hui Hoy & Chow Sin Lan Charity Fund Limited, Pine and Crane Company Limited, Mr. Hui Ming, and The D.H. Chen Foundation. The researchers had no financial conflicts to disclose. Dr. Roper and Dr. Sung had no financial conflicts to disclose.

COVID-19 infection altered the gut microbiota of adult patients and caused depletion of several types of bacteria with known immunomodulatory properties, based on data from a cohort study of 100 patients with confirmed COVID-19 infections from two hospitals.

“As the GI tract is the largest immunological organ in the body and its resident microbiota are known to modulate host immune responses, we hypothesized that the gut microbiota is associated with host inflammatory immune responses in COVID19,” wrote Yun Kit Yeoh, PhD, of the Chinese University of Hong Kong, and colleagues.

In a study published in Gut, the researchers investigated patient microbiota by collecting blood, stool, and patient records between February and May 2020 from 100 confirmed SARS-CoV-2–infected patients in Hong Kong during hospitalization, as well as follow-up stool samples from 27 patients up to 30 days after they cleared the COVID-19 virus; these observations were compared with 78 non–COVID-19 controls.

Overall, 274 stool samples were sequenced. Samples collected from patients during hospitalization for COVID-19 were compared with non–COVID-19 controls. The presence of phylum Bacteroidetes was significantly higher in COVID-19 patients compared with controls (23.9% vs. 12.8%; P < .001), as were Actinobacteria (26.1% vs. 19.0%; P < .001).

After controlling for antibiotics, the investigators found that “differences between cohorts were primarily linked to enrichment of taxa such as Parabacteroides, Sutterella wadsworthensis, and Bacteroides caccae and depletion of Adlercreutzia equolifaciens, Dorea formicigenerans, and Clostridium leptum in COVID-19 relative to non-COVID-19” (P < .05). In addition, Faecalibacterium prausnitzii and Bifidobacterium bifidum were negatively correlated with COVID-19 severity after investigators controlled for patient age and antibiotic use (P < .05).

The researchers also examined bacteria in COVID-19 patients and controls in the context of cytokines and other inflammatory markers. “We hypothesized that these compositional changes play a role in exacerbating disease by contributing to dysregulation of the immune response,” they said.

In fact, species depleted in COVID-19 patients including included B. adolescentis, E. rectale, and F. prausnitzii were negatively correlated with inflammatory markers including CXCL10, IL-10, TNF-alpha, and CCL2.

In addition, 42 stool samples from 27 patients showed significantly distinct gut microbiota from controls up to 30 days (median, 6 days) after virus clearance, regardless of antibiotics use (P < .05), the researchers said.
 

Long-term data needed

The study findings were limited by several factors, including the potential confounding of microbial signatures associated with COVID-19 because of heterogeneous patient management in the clinical setting and the potential that gut microbiota reflects a patient’s health with no impact on disease severity, as well as lack of data on the role of antibiotics for severe and critical patients, the researchers noted. In addition, “gut microbiota composition is highly heterogeneous across human populations and changes in compositions reported here may not necessarily be reflected in patients with COVID-19 from other biogeographies,” they wrote.

The “longer follow-up of patients with COVID-19 (e.g., 3 months to 1 year after clearing the virus) is needed to address questions related to the duration of gut microbiota dysbiosis post recovery, link between microbiota dysbiosis and long-term persistent symptoms, and whether the dysbiosis or enrichment/depletion of specific gut microorganisms predisposes recovered individuals to future health problems,” they wrote.

However, the results suggest a likely role for gut microorganisms in host inflammatory responses to COVID-19 infection, and “underscore an urgent need to understand the specific roles of gut microorganisms in human immune function and systemic inflammation,” they concluded.
 

More than infectious

“A growing body of evidence suggests that severity of illness from COVID-19 is largely determined by the patient’s aberrant immune response to the virus,” Jatin Roper, MD, of Duke University, Durham, N.C., said in an interview. “Therefore, a critical question is: What patient factors determine this immune response? The gut microbiota closely interact with the host immune system and are altered in many immunological diseases,” he said. “Furthermore, the SARS-CoV-2 virus infects enterocytes in the intestine and causes symptomatic gastrointestinal disease in a subset of patients. Therefore, understanding a possible association between gut microbiota and COVID-19 may reveal microbial species involved in disease pathogenesis,” he emphasized.   

In the current study, “I was surprised to find that COVID-19 infection is associated with depletion of immunomodulatory gut bacteria,” said Dr. Roper. “An open question is whether these changes are caused by the SARS-CoV-2 virus and then result in altered immune response. Alternatively, the changes in gut microbiota may be a result of the immune response or other changes associated with the disease,” he said.

“COVID-19 is an immunological disease, not just an infectious disease,” explained Dr. Roper. “The gut microbiota may play an important role in the pathogenesis of the disease. Thus, specific gut microbes could one day be analyzed to risk stratify patients, or even modified to treat the disease,” he noted.
 

Beyond COVID-19

“Given the impact of the gut microbiota on health and disease, as well as the impact of diseases on the microbiota, I am not at all surprised to find that there were significant changes in the microbiota of COVID-19 patients and that these changes are associated with inflammatory cytokines, chemokines, and blood markers of tissue damage,” said Anthony Sung, MD, also of Duke University.

According to Dr. Sung, researchers have already been investigating possible connections between gut microbiota and other conditions such as Alzheimer’s disease, and it’s been hypothesized that these connections are mediated by interactions between the gut microbiota and the immune system.

“While this is an important paper in our understanding of COVID-19, and highlights the microbiome as a potential therapeutic target, we need to conduct clinical trials of microbiota-based interventions before we can fully realize the clinical implications of these findings,” he said.

The study was supported by the Health and Medical Research Fund, the Food and Health Bureau, The Government of the Hong Kong Special Administrative Region, and donations from Hui Hoy & Chow Sin Lan Charity Fund Limited, Pine and Crane Company Limited, Mr. Hui Ming, and The D.H. Chen Foundation. The researchers had no financial conflicts to disclose. Dr. Roper and Dr. Sung had no financial conflicts to disclose.

A test that uses machine learning may improve the management of patients with pancreatic cysts, sparing some of them unnecessary surgery, a cohort study suggests.

The test, called CompCyst, integrates clinical, imaging, and biomarker data. It proved more accurate than the current standard of care for correctly determining whether patients should be discharged from follow-up, immediately operated on, or monitored.

Rachel Karchin, PhD, of the Johns Hopkins Whiting School of Engineering in Baltimore, reported these results at the AACR Virtual Special Conference: Artificial Intelligence, Diagnosis, and Imaging (Abstract IA-13).

“Preoperative diagnosis of pancreatic cysts and managing patients who present with a cyst are a clinical conundrum because pancreatic cancer is so deadly, while the decision to surgically resect a cyst is complicated by the danger of the surgery, which has high morbidity and mortality,” Dr. Karchin explained. “The challenge of the diagnostic test is to place patients into one of three groups: those who should be discharged, who should be operated on, and who should be monitored.”

High sensitivity is important for the operate and monitor groups to ensure identification of all patients needing these approaches, whereas higher specificity is important for the discharge group to avoid falsely classifying premalignant cysts, Dr. Karchin said.

She and her colleagues applied machine learning to this classification challenge, using data from 862 patients who had undergone resection of pancreatic cysts at 16 centers in the United States, Europe, and Asia. All patients had a known cyst histopathology, which served as the gold standard, and a known clinical management strategy (discharge, operate, or monitor).

The investigators used a multivariate organization of combinatorial alterations algorithm that integrates clinical features, imaging characteristics, cyst fluid genetics, and serum biomarkers to create classifiers. This algorithm can be trained to maximize sensitivity, maximize specificity, or balance these metrics, Dr. Karchin noted.

The resulting test, CompCyst, was trained using data from 436 of the patients and then validated in the remaining 426 patients.

In the validation cohort, for classifying patients who should be discharged from care, the test had a sensitivity of 46% and a specificity of 100%, according to results reported at the conference and published previously (Sci Transl Med. 2019 Jul 19. doi: 10.1126/scitranslmed.aav4772).

For immediately operating, CompCyst had a sensitivity of 91% and a specificity of 54%. And for monitoring the patient, the test had a sensitivity of 99% and a specificity of 30%.

When CompCyst was compared against the standard of care based on conventional clinical and imaging criteria alone, the former was more accurate. CompCyst correctly identified larger shares of patients who should have been discharged (60% vs. 19%) and who should have been monitored (49% vs. 34%), and the test identified a similar share of patients who should have immediately had an operation (91% vs. 89%).

“The takeaway from this is that standard of care is sending too many patients unnecessarily to surgery,” Dr. Karchin commented. “The CompCyst test, with application of the three classifiers sequentially – discharge, operate, or monitor – could reduce unnecessary surgery by 60% or more based on our calculations.”

“While our study was retrospective, it shows promising results in reducing unnecessary surgeries, compared to current standard of care,” she said, adding that a prospective study is planned next.

“In 10-12 weeks, this CompCyst diagnostic test is going to be available at Johns Hopkins for patients. I’m very excited about that,” Dr. Karchin concluded. “We hope that our study shows the potential of combining clinical, imaging, and genetic features with machine learning to improve clinical judgment about many diseases.”

Dr. Karchin disclosed no conflicts of interest. The study was supported by the Lustgarten Foundation for Pancreatic Cancer Research, the Virginia and D.K. Ludwig Fund for Cancer Research, the Sol Goldman Pancreatic Cancer Research Center, the Michael Rolfe Pancreatic Cancer Research Foundation, the Benjamin Baker Scholarship, and the National Institutes of Health.

A test that uses machine learning may improve the management of patients with pancreatic cysts, sparing some of them unnecessary surgery, a cohort study suggests.

The test, called CompCyst, integrates clinical, imaging, and biomarker data. It proved more accurate than the current standard of care for correctly determining whether patients should be discharged from follow-up, immediately operated on, or monitored.

Rachel Karchin, PhD, of the Johns Hopkins Whiting School of Engineering in Baltimore, reported these results at the AACR Virtual Special Conference: Artificial Intelligence, Diagnosis, and Imaging (Abstract IA-13).

“Preoperative diagnosis of pancreatic cysts and managing patients who present with a cyst are a clinical conundrum because pancreatic cancer is so deadly, while the decision to surgically resect a cyst is complicated by the danger of the surgery, which has high morbidity and mortality,” Dr. Karchin explained. “The challenge of the diagnostic test is to place patients into one of three groups: those who should be discharged, who should be operated on, and who should be monitored.”

High sensitivity is important for the operate and monitor groups to ensure identification of all patients needing these approaches, whereas higher specificity is important for the discharge group to avoid falsely classifying premalignant cysts, Dr. Karchin said.

She and her colleagues applied machine learning to this classification challenge, using data from 862 patients who had undergone resection of pancreatic cysts at 16 centers in the United States, Europe, and Asia. All patients had a known cyst histopathology, which served as the gold standard, and a known clinical management strategy (discharge, operate, or monitor).

The investigators used a multivariate organization of combinatorial alterations algorithm that integrates clinical features, imaging characteristics, cyst fluid genetics, and serum biomarkers to create classifiers. This algorithm can be trained to maximize sensitivity, maximize specificity, or balance these metrics, Dr. Karchin noted.

The resulting test, CompCyst, was trained using data from 436 of the patients and then validated in the remaining 426 patients.

In the validation cohort, for classifying patients who should be discharged from care, the test had a sensitivity of 46% and a specificity of 100%, according to results reported at the conference and published previously (Sci Transl Med. 2019 Jul 19. doi: 10.1126/scitranslmed.aav4772).

For immediately operating, CompCyst had a sensitivity of 91% and a specificity of 54%. And for monitoring the patient, the test had a sensitivity of 99% and a specificity of 30%.

When CompCyst was compared against the standard of care based on conventional clinical and imaging criteria alone, the former was more accurate. CompCyst correctly identified larger shares of patients who should have been discharged (60% vs. 19%) and who should have been monitored (49% vs. 34%), and the test identified a similar share of patients who should have immediately had an operation (91% vs. 89%).

“The takeaway from this is that standard of care is sending too many patients unnecessarily to surgery,” Dr. Karchin commented. “The CompCyst test, with application of the three classifiers sequentially – discharge, operate, or monitor – could reduce unnecessary surgery by 60% or more based on our calculations.”

“While our study was retrospective, it shows promising results in reducing unnecessary surgeries, compared to current standard of care,” she said, adding that a prospective study is planned next.

“In 10-12 weeks, this CompCyst diagnostic test is going to be available at Johns Hopkins for patients. I’m very excited about that,” Dr. Karchin concluded. “We hope that our study shows the potential of combining clinical, imaging, and genetic features with machine learning to improve clinical judgment about many diseases.”

Dr. Karchin disclosed no conflicts of interest. The study was supported by the Lustgarten Foundation for Pancreatic Cancer Research, the Virginia and D.K. Ludwig Fund for Cancer Research, the Sol Goldman Pancreatic Cancer Research Center, the Michael Rolfe Pancreatic Cancer Research Foundation, the Benjamin Baker Scholarship, and the National Institutes of Health.

A test that uses machine learning may improve the management of patients with pancreatic cysts, sparing some of them unnecessary surgery, a cohort study suggests.

The test, called CompCyst, integrates clinical, imaging, and biomarker data. It proved more accurate than the current standard of care for correctly determining whether patients should be discharged from follow-up, immediately operated on, or monitored.

Rachel Karchin, PhD, of the Johns Hopkins Whiting School of Engineering in Baltimore, reported these results at the AACR Virtual Special Conference: Artificial Intelligence, Diagnosis, and Imaging (Abstract IA-13).

“Preoperative diagnosis of pancreatic cysts and managing patients who present with a cyst are a clinical conundrum because pancreatic cancer is so deadly, while the decision to surgically resect a cyst is complicated by the danger of the surgery, which has high morbidity and mortality,” Dr. Karchin explained. “The challenge of the diagnostic test is to place patients into one of three groups: those who should be discharged, who should be operated on, and who should be monitored.”

High sensitivity is important for the operate and monitor groups to ensure identification of all patients needing these approaches, whereas higher specificity is important for the discharge group to avoid falsely classifying premalignant cysts, Dr. Karchin said.

She and her colleagues applied machine learning to this classification challenge, using data from 862 patients who had undergone resection of pancreatic cysts at 16 centers in the United States, Europe, and Asia. All patients had a known cyst histopathology, which served as the gold standard, and a known clinical management strategy (discharge, operate, or monitor).

The investigators used a multivariate organization of combinatorial alterations algorithm that integrates clinical features, imaging characteristics, cyst fluid genetics, and serum biomarkers to create classifiers. This algorithm can be trained to maximize sensitivity, maximize specificity, or balance these metrics, Dr. Karchin noted.

The resulting test, CompCyst, was trained using data from 436 of the patients and then validated in the remaining 426 patients.

In the validation cohort, for classifying patients who should be discharged from care, the test had a sensitivity of 46% and a specificity of 100%, according to results reported at the conference and published previously (Sci Transl Med. 2019 Jul 19. doi: 10.1126/scitranslmed.aav4772).

For immediately operating, CompCyst had a sensitivity of 91% and a specificity of 54%. And for monitoring the patient, the test had a sensitivity of 99% and a specificity of 30%.

When CompCyst was compared against the standard of care based on conventional clinical and imaging criteria alone, the former was more accurate. CompCyst correctly identified larger shares of patients who should have been discharged (60% vs. 19%) and who should have been monitored (49% vs. 34%), and the test identified a similar share of patients who should have immediately had an operation (91% vs. 89%).

“The takeaway from this is that standard of care is sending too many patients unnecessarily to surgery,” Dr. Karchin commented. “The CompCyst test, with application of the three classifiers sequentially – discharge, operate, or monitor – could reduce unnecessary surgery by 60% or more based on our calculations.”

“While our study was retrospective, it shows promising results in reducing unnecessary surgeries, compared to current standard of care,” she said, adding that a prospective study is planned next.

“In 10-12 weeks, this CompCyst diagnostic test is going to be available at Johns Hopkins for patients. I’m very excited about that,” Dr. Karchin concluded. “We hope that our study shows the potential of combining clinical, imaging, and genetic features with machine learning to improve clinical judgment about many diseases.”

Dr. Karchin disclosed no conflicts of interest. The study was supported by the Lustgarten Foundation for Pancreatic Cancer Research, the Virginia and D.K. Ludwig Fund for Cancer Research, the Sol Goldman Pancreatic Cancer Research Center, the Michael Rolfe Pancreatic Cancer Research Foundation, the Benjamin Baker Scholarship, and the National Institutes of Health.

COVID has changed our world very rapidly. There are good changes, such as cleaner air and the ability to use telehealth widely. But there are devastating changes. As we are all aware, we have lost more than 400,000 people in America, and that number is climbing.

How can we mitigate some of the psychological effects of the pandemic? It is time to bring lessons learned on the battlefield to civilian psychiatrists and health care systems.

Despite having participated in mass casualty drills, no health system was trained or psychologically prepared for this once-in-a-century event.

The military dictum, “train like you fight; fight like you train” falls short considering the speed of viral replication, the serious flaws and disparities in our health care system revealed by COVID-19, and the public’s disturbingly variable adherence to preventive measures.

Like combat troops, health care workers put the needs of others ahead of their own. They suck up strain and step back from their own needs in favor of the mission.

Whether in combat or pandemic, leaders have valuable opportunities to promote the effectiveness of those on the front lines by caring for them. Those in charge may, themselves, be profoundly affected. While other team members focus on defined roles, leaders are forced to deal with many unknowns. They must often act without adequate information or resources.

Some of us have worked at hospitals treating many COVID patients and have been on “the front lines” for almost a year. We are asked a lot of questions, to which we often answer, "I don't know" or "there are no good choices."

All leaders work hard to model strength, but a difficult lesson that the military has had to learn is that leaders may strengthen cohesion by showing their grief, modeling self-care, drawing attention to even small successes in the face of overwhelming loss, and, when necessary, finding words for those losses.

Peer support is particularly important in high-stress situations. Mental health providers are uniquely qualified to share information, pick up on signs of severe stress, and provide support at the point of need.

Military combat stress control doctrine does, however, provide best practices that can be implemented across civilian health care systems. Its key elements are:

• Confidence in leadership at all levels – requiring visibility (“battlespace circulation”) of leaders who listen and share timely, accurate information.
• Realistic training – especially for those who, because of staff shortages, assume unfamiliar duties.
• Self-care – including regular meals, adequate sleep, and ongoing contact with family and friends. Here of course, the contact should be virtual as much as possible.
• Belief in the Mission – compassion satisfaction is a buffer against burnout.
• Esprit de corps – cohesive teams suffer significantly fewer combat stress casualties.

It is true that these principles have more often been tested in short-term crisis rather than the long slog that is COVID-19. This pandemic is more like an ongoing civil war than a distant battlefield because your home and those close to you share the risk.

There is no easy path ahead for America’s civilian health care system. These military principles, tested under fire, offer valuable opportunities in the ongoing battle against COVID-19.

Dr. Ritchie practices psychiatry in Washington. She has no disclosures.

Dr. Kudler is associate consulting professor of psychiatry and behavioral sciences at Duke University in Durham. N.C., and recently retired from his post as chief consultant for mental health, at the Department of Veterans Affairs. He has no relevant financial relationships.

Dr. Yehuda is professor of psychiatry and neuroscience and director of the traumatic stress studies division at the Mount Sinai School of Medicine, New York. She also serves as director of mental health at the James J. Peters Veterans Affairs Medical Center, also in New York. Dr. Yehuda has no disclosures.

Dr. Koffman is the senior consultant for Integrative Medicine & Behavioral Health at the National Intrepid Center of Excellence, Bethesda, Md. He has no disclosures.

COVID has changed our world very rapidly. There are good changes, such as cleaner air and the ability to use telehealth widely. But there are devastating changes. As we are all aware, we have lost more than 400,000 people in America, and that number is climbing.

How can we mitigate some of the psychological effects of the pandemic? It is time to bring lessons learned on the battlefield to civilian psychiatrists and health care systems.

Despite having participated in mass casualty drills, no health system was trained or psychologically prepared for this once-in-a-century event.

The military dictum, “train like you fight; fight like you train” falls short considering the speed of viral replication, the serious flaws and disparities in our health care system revealed by COVID-19, and the public’s disturbingly variable adherence to preventive measures.

Like combat troops, health care workers put the needs of others ahead of their own. They suck up strain and step back from their own needs in favor of the mission.

Whether in combat or pandemic, leaders have valuable opportunities to promote the effectiveness of those on the front lines by caring for them. Those in charge may, themselves, be profoundly affected. While other team members focus on defined roles, leaders are forced to deal with many unknowns. They must often act without adequate information or resources.

Some of us have worked at hospitals treating many COVID patients and have been on “the front lines” for almost a year. We are asked a lot of questions, to which we often answer, "I don't know" or "there are no good choices."

All leaders work hard to model strength, but a difficult lesson that the military has had to learn is that leaders may strengthen cohesion by showing their grief, modeling self-care, drawing attention to even small successes in the face of overwhelming loss, and, when necessary, finding words for those losses.

Peer support is particularly important in high-stress situations. Mental health providers are uniquely qualified to share information, pick up on signs of severe stress, and provide support at the point of need.

Military combat stress control doctrine does, however, provide best practices that can be implemented across civilian health care systems. Its key elements are:

• Confidence in leadership at all levels – requiring visibility (“battlespace circulation”) of leaders who listen and share timely, accurate information.
• Realistic training – especially for those who, because of staff shortages, assume unfamiliar duties.
• Self-care – including regular meals, adequate sleep, and ongoing contact with family and friends. Here of course, the contact should be virtual as much as possible.
• Belief in the Mission – compassion satisfaction is a buffer against burnout.
• Esprit de corps – cohesive teams suffer significantly fewer combat stress casualties.

It is true that these principles have more often been tested in short-term crisis rather than the long slog that is COVID-19. This pandemic is more like an ongoing civil war than a distant battlefield because your home and those close to you share the risk.

There is no easy path ahead for America’s civilian health care system. These military principles, tested under fire, offer valuable opportunities in the ongoing battle against COVID-19.

Dr. Ritchie practices psychiatry in Washington. She has no disclosures.

Dr. Kudler is associate consulting professor of psychiatry and behavioral sciences at Duke University in Durham. N.C., and recently retired from his post as chief consultant for mental health, at the Department of Veterans Affairs. He has no relevant financial relationships.

Dr. Yehuda is professor of psychiatry and neuroscience and director of the traumatic stress studies division at the Mount Sinai School of Medicine, New York. She also serves as director of mental health at the James J. Peters Veterans Affairs Medical Center, also in New York. Dr. Yehuda has no disclosures.

Dr. Koffman is the senior consultant for Integrative Medicine & Behavioral Health at the National Intrepid Center of Excellence, Bethesda, Md. He has no disclosures.

COVID has changed our world very rapidly. There are good changes, such as cleaner air and the ability to use telehealth widely. But there are devastating changes. As we are all aware, we have lost more than 400,000 people in America, and that number is climbing.

How can we mitigate some of the psychological effects of the pandemic? It is time to bring lessons learned on the battlefield to civilian psychiatrists and health care systems.

Despite having participated in mass casualty drills, no health system was trained or psychologically prepared for this once-in-a-century event.

The military dictum, “train like you fight; fight like you train” falls short considering the speed of viral replication, the serious flaws and disparities in our health care system revealed by COVID-19, and the public’s disturbingly variable adherence to preventive measures.

Like combat troops, health care workers put the needs of others ahead of their own. They suck up strain and step back from their own needs in favor of the mission.

Whether in combat or pandemic, leaders have valuable opportunities to promote the effectiveness of those on the front lines by caring for them. Those in charge may, themselves, be profoundly affected. While other team members focus on defined roles, leaders are forced to deal with many unknowns. They must often act without adequate information or resources.

Some of us have worked at hospitals treating many COVID patients and have been on “the front lines” for almost a year. We are asked a lot of questions, to which we often answer, "I don't know" or "there are no good choices."

All leaders work hard to model strength, but a difficult lesson that the military has had to learn is that leaders may strengthen cohesion by showing their grief, modeling self-care, drawing attention to even small successes in the face of overwhelming loss, and, when necessary, finding words for those losses.

Peer support is particularly important in high-stress situations. Mental health providers are uniquely qualified to share information, pick up on signs of severe stress, and provide support at the point of need.

Military combat stress control doctrine does, however, provide best practices that can be implemented across civilian health care systems. Its key elements are:

• Confidence in leadership at all levels – requiring visibility (“battlespace circulation”) of leaders who listen and share timely, accurate information.
• Realistic training – especially for those who, because of staff shortages, assume unfamiliar duties.
• Self-care – including regular meals, adequate sleep, and ongoing contact with family and friends. Here of course, the contact should be virtual as much as possible.
• Belief in the Mission – compassion satisfaction is a buffer against burnout.
• Esprit de corps – cohesive teams suffer significantly fewer combat stress casualties.

It is true that these principles have more often been tested in short-term crisis rather than the long slog that is COVID-19. This pandemic is more like an ongoing civil war than a distant battlefield because your home and those close to you share the risk.

There is no easy path ahead for America’s civilian health care system. These military principles, tested under fire, offer valuable opportunities in the ongoing battle against COVID-19.

Dr. Ritchie practices psychiatry in Washington. She has no disclosures.

Dr. Kudler is associate consulting professor of psychiatry and behavioral sciences at Duke University in Durham. N.C., and recently retired from his post as chief consultant for mental health, at the Department of Veterans Affairs. He has no relevant financial relationships.

Dr. Yehuda is professor of psychiatry and neuroscience and director of the traumatic stress studies division at the Mount Sinai School of Medicine, New York. She also serves as director of mental health at the James J. Peters Veterans Affairs Medical Center, also in New York. Dr. Yehuda has no disclosures.

Dr. Koffman is the senior consultant for Integrative Medicine & Behavioral Health at the National Intrepid Center of Excellence, Bethesda, Md. He has no disclosures.