DENVER — Patients with pediatric-onset multiple sclerosis (POMS) are often prescribed low-efficacy disease-modifying therapies (DMTs), but a new retrospective analysis suggests that, like adults, this patient population may benefit from early treatment with high-efficacy DMTs.

“I think it’s very important to highlight that we are seeing that traditionally, kids are just started on lower-efficacy treatments and they keep relapsing. If we can show that when they get transitioned to high-efficacy treatments, the relapses are lessening, I’m hoping that can then push for better clinical trials with pediatric patients included,” said Frederick Bassal, DO, who presented the study during a poster session at the 2024 annual meeting of the American Academy of Neurology. He is a pediatric neurologist at University of California, Davis.

The first line for POMS is generally low-efficacy DMTs like interferon-beta and glatiramer acetate, but these medications may not effectively control disease progression, according to the study authors, and this could lead to pediatric patients being changed to more potent therapies. That can include moderate-efficacy drugs like S1P inhibitors and fumarates, or high-efficacy DMTS such as B cell depletors and alpha 4 integrin receptor antibodies.
 

Treatment Strategies

“Right now what we’re seeing is the conservative approach — starting low and working up with the younger and adolescent patients. I’m speculating, and I want to look more into it. Is [it maybe] because of insurance approval?” said study coauthor Amara Miller, a medical student at the University of Arizona College of Medicine in Phoenix.

The findings aren’t surprising, according to Barbara Giesser, MD, who was asked to comment on the study. “It is in line with what we think we know about people with adult MS — that if you start early on with a more effective therapy, you tend to have better outcomes,” said Dr. Giesser, director of the MS program at the Pacific Neuroscience Institute.

Another reason to consider higher-efficacy DMTs is that children with MS can have cognitive problems and delays. “There’s a suggestion that if you treat with highly-effective DMT that you might be able to abrogate some of that,” said Dr. Giesser.

Among the approximately two dozen FDA-approved disease-modifying therapies for MS, only fingolimod (Gilenya, Novartis) is approved for children and adolescents. “All of the others are used off label, but I think perhaps, if you have more studies that [show] that children do better if you treat with more effective therapies early on, perhaps we might see more on-label indications for use in a pediatric population,” said Dr. Giesser.

The finding that obesity was associated with a higher likelihood of having multiple therapies is also interesting, she said. “We’re beginning to see that obesity in adults as well seems to portend less favorable neurologic outcomes.”
 

Study Methodology

The researchers analyzed data from 135 POMS patients between 2012 and 2023.

The mean age of participants was 15 years, 60% were female, and 120 of 135 were White, while 76 were of Hispanic ethnicity. Overweight and obesity were common, with 36 and 43 participants in each category. The initial therapy was a low-efficacy DMT in 23.0% of participants, moderate-efficacy in 37.0%, and high-efficacy in 24.4%, while 1.5% received some other kind of medication and 14.1% received no medication. The annualized relapse rate was 0.932, and the mean EDSS score was 0.88.

Patients who underwent three or medication changes had lower EDSS scores than those who underwent zero to 2 (P = .00607).

Over the course of the study, the percentage of patients who received high-efficacy DMTs rose from 25.9% to 48.9%, largely due to changes in medication. Of those initially prescribed low-efficacy DMTs, 77.4% were eventually switched to high-efficacy DMTs.

Every patient who underwent three or more medication changes was initially prescribed a low-efficacy DMT.

Patients started on low-efficacy drugs had a mean of 1.42 medication changes, compared with 0.94 in the moderate-efficacy group and 0.51 in the high-efficacy group. The reasons for changing from the first medication included relapse (36), side effects (11), patient choice or compliance (8), and pregnancy (2).

Patients 10 years or younger were more likely to be initially prescribed a low-efficacy therapy (odds ratio [OR], 5.72; P = .0366), while older patients were more likely to be prescribed moderate- or high-efficacy therapies (OR, 14.44; P = .0012).

There were more total medication changes in the low-efficacy group than the high initial DMT group (P = .000305).

Asked what advice they would give to physicians treating POMS patients, Ms. Miller suggested a top-down approach. “We want to look at if maybe we can start with higher efficacy DMT’s and maybe titering it down. That may be an option,” said Ms. Miller.

Dr. Bassal highlighted the importance of shared decision-making. “We want to go over the options, that we recommend higher-efficacy [DMTs] for these reasons. But every individual is different. And there may be fears that are very reasonable that families have. I think in those cases, it’s also reasonable to make a shared decision. And if that means going with something like an oral, moderate- to lower-efficacy [therapy], that’s okay, because compliance is key, and if you start something where the family is afraid of side effects, or there are side effects, then you kind of lost that opportunity,” he said.

Dr. Bassal, Dr. Giesser, and Ms. Miller have no relevant financial disclosures.

DENVER — Patients with pediatric-onset multiple sclerosis (POMS) are often prescribed low-efficacy disease-modifying therapies (DMTs), but a new retrospective analysis suggests that, like adults, this patient population may benefit from early treatment with high-efficacy DMTs.

“I think it’s very important to highlight that we are seeing that traditionally, kids are just started on lower-efficacy treatments and they keep relapsing. If we can show that when they get transitioned to high-efficacy treatments, the relapses are lessening, I’m hoping that can then push for better clinical trials with pediatric patients included,” said Frederick Bassal, DO, who presented the study during a poster session at the 2024 annual meeting of the American Academy of Neurology. He is a pediatric neurologist at University of California, Davis.

The first line for POMS is generally low-efficacy DMTs like interferon-beta and glatiramer acetate, but these medications may not effectively control disease progression, according to the study authors, and this could lead to pediatric patients being changed to more potent therapies. That can include moderate-efficacy drugs like S1P inhibitors and fumarates, or high-efficacy DMTS such as B cell depletors and alpha 4 integrin receptor antibodies.
 

Treatment Strategies

“Right now what we’re seeing is the conservative approach — starting low and working up with the younger and adolescent patients. I’m speculating, and I want to look more into it. Is [it maybe] because of insurance approval?” said study coauthor Amara Miller, a medical student at the University of Arizona College of Medicine in Phoenix.

The findings aren’t surprising, according to Barbara Giesser, MD, who was asked to comment on the study. “It is in line with what we think we know about people with adult MS — that if you start early on with a more effective therapy, you tend to have better outcomes,” said Dr. Giesser, director of the MS program at the Pacific Neuroscience Institute.

Another reason to consider higher-efficacy DMTs is that children with MS can have cognitive problems and delays. “There’s a suggestion that if you treat with highly-effective DMT that you might be able to abrogate some of that,” said Dr. Giesser.

Among the approximately two dozen FDA-approved disease-modifying therapies for MS, only fingolimod (Gilenya, Novartis) is approved for children and adolescents. “All of the others are used off label, but I think perhaps, if you have more studies that [show] that children do better if you treat with more effective therapies early on, perhaps we might see more on-label indications for use in a pediatric population,” said Dr. Giesser.

The finding that obesity was associated with a higher likelihood of having multiple therapies is also interesting, she said. “We’re beginning to see that obesity in adults as well seems to portend less favorable neurologic outcomes.”
 

Study Methodology

The researchers analyzed data from 135 POMS patients between 2012 and 2023.

The mean age of participants was 15 years, 60% were female, and 120 of 135 were White, while 76 were of Hispanic ethnicity. Overweight and obesity were common, with 36 and 43 participants in each category. The initial therapy was a low-efficacy DMT in 23.0% of participants, moderate-efficacy in 37.0%, and high-efficacy in 24.4%, while 1.5% received some other kind of medication and 14.1% received no medication. The annualized relapse rate was 0.932, and the mean EDSS score was 0.88.

Patients who underwent three or medication changes had lower EDSS scores than those who underwent zero to 2 (P = .00607).

Over the course of the study, the percentage of patients who received high-efficacy DMTs rose from 25.9% to 48.9%, largely due to changes in medication. Of those initially prescribed low-efficacy DMTs, 77.4% were eventually switched to high-efficacy DMTs.

Every patient who underwent three or more medication changes was initially prescribed a low-efficacy DMT.

Patients started on low-efficacy drugs had a mean of 1.42 medication changes, compared with 0.94 in the moderate-efficacy group and 0.51 in the high-efficacy group. The reasons for changing from the first medication included relapse (36), side effects (11), patient choice or compliance (8), and pregnancy (2).

Patients 10 years or younger were more likely to be initially prescribed a low-efficacy therapy (odds ratio [OR], 5.72; P = .0366), while older patients were more likely to be prescribed moderate- or high-efficacy therapies (OR, 14.44; P = .0012).

There were more total medication changes in the low-efficacy group than the high initial DMT group (P = .000305).

Asked what advice they would give to physicians treating POMS patients, Ms. Miller suggested a top-down approach. “We want to look at if maybe we can start with higher efficacy DMT’s and maybe titering it down. That may be an option,” said Ms. Miller.

Dr. Bassal highlighted the importance of shared decision-making. “We want to go over the options, that we recommend higher-efficacy [DMTs] for these reasons. But every individual is different. And there may be fears that are very reasonable that families have. I think in those cases, it’s also reasonable to make a shared decision. And if that means going with something like an oral, moderate- to lower-efficacy [therapy], that’s okay, because compliance is key, and if you start something where the family is afraid of side effects, or there are side effects, then you kind of lost that opportunity,” he said.

Dr. Bassal, Dr. Giesser, and Ms. Miller have no relevant financial disclosures.

DENVER — Patients with pediatric-onset multiple sclerosis (POMS) are often prescribed low-efficacy disease-modifying therapies (DMTs), but a new retrospective analysis suggests that, like adults, this patient population may benefit from early treatment with high-efficacy DMTs.

“I think it’s very important to highlight that we are seeing that traditionally, kids are just started on lower-efficacy treatments and they keep relapsing. If we can show that when they get transitioned to high-efficacy treatments, the relapses are lessening, I’m hoping that can then push for better clinical trials with pediatric patients included,” said Frederick Bassal, DO, who presented the study during a poster session at the 2024 annual meeting of the American Academy of Neurology. He is a pediatric neurologist at University of California, Davis.

The first line for POMS is generally low-efficacy DMTs like interferon-beta and glatiramer acetate, but these medications may not effectively control disease progression, according to the study authors, and this could lead to pediatric patients being changed to more potent therapies. That can include moderate-efficacy drugs like S1P inhibitors and fumarates, or high-efficacy DMTS such as B cell depletors and alpha 4 integrin receptor antibodies.
 

Treatment Strategies

“Right now what we’re seeing is the conservative approach — starting low and working up with the younger and adolescent patients. I’m speculating, and I want to look more into it. Is [it maybe] because of insurance approval?” said study coauthor Amara Miller, a medical student at the University of Arizona College of Medicine in Phoenix.

The findings aren’t surprising, according to Barbara Giesser, MD, who was asked to comment on the study. “It is in line with what we think we know about people with adult MS — that if you start early on with a more effective therapy, you tend to have better outcomes,” said Dr. Giesser, director of the MS program at the Pacific Neuroscience Institute.

Another reason to consider higher-efficacy DMTs is that children with MS can have cognitive problems and delays. “There’s a suggestion that if you treat with highly-effective DMT that you might be able to abrogate some of that,” said Dr. Giesser.

Among the approximately two dozen FDA-approved disease-modifying therapies for MS, only fingolimod (Gilenya, Novartis) is approved for children and adolescents. “All of the others are used off label, but I think perhaps, if you have more studies that [show] that children do better if you treat with more effective therapies early on, perhaps we might see more on-label indications for use in a pediatric population,” said Dr. Giesser.

The finding that obesity was associated with a higher likelihood of having multiple therapies is also interesting, she said. “We’re beginning to see that obesity in adults as well seems to portend less favorable neurologic outcomes.”
 

Study Methodology

The researchers analyzed data from 135 POMS patients between 2012 and 2023.

The mean age of participants was 15 years, 60% were female, and 120 of 135 were White, while 76 were of Hispanic ethnicity. Overweight and obesity were common, with 36 and 43 participants in each category. The initial therapy was a low-efficacy DMT in 23.0% of participants, moderate-efficacy in 37.0%, and high-efficacy in 24.4%, while 1.5% received some other kind of medication and 14.1% received no medication. The annualized relapse rate was 0.932, and the mean EDSS score was 0.88.

Patients who underwent three or medication changes had lower EDSS scores than those who underwent zero to 2 (P = .00607).

Over the course of the study, the percentage of patients who received high-efficacy DMTs rose from 25.9% to 48.9%, largely due to changes in medication. Of those initially prescribed low-efficacy DMTs, 77.4% were eventually switched to high-efficacy DMTs.

Every patient who underwent three or more medication changes was initially prescribed a low-efficacy DMT.

Patients started on low-efficacy drugs had a mean of 1.42 medication changes, compared with 0.94 in the moderate-efficacy group and 0.51 in the high-efficacy group. The reasons for changing from the first medication included relapse (36), side effects (11), patient choice or compliance (8), and pregnancy (2).

Patients 10 years or younger were more likely to be initially prescribed a low-efficacy therapy (odds ratio [OR], 5.72; P = .0366), while older patients were more likely to be prescribed moderate- or high-efficacy therapies (OR, 14.44; P = .0012).

There were more total medication changes in the low-efficacy group than the high initial DMT group (P = .000305).

Asked what advice they would give to physicians treating POMS patients, Ms. Miller suggested a top-down approach. “We want to look at if maybe we can start with higher efficacy DMT’s and maybe titering it down. That may be an option,” said Ms. Miller.

Dr. Bassal highlighted the importance of shared decision-making. “We want to go over the options, that we recommend higher-efficacy [DMTs] for these reasons. But every individual is different. And there may be fears that are very reasonable that families have. I think in those cases, it’s also reasonable to make a shared decision. And if that means going with something like an oral, moderate- to lower-efficacy [therapy], that’s okay, because compliance is key, and if you start something where the family is afraid of side effects, or there are side effects, then you kind of lost that opportunity,” he said.

Dr. Bassal, Dr. Giesser, and Ms. Miller have no relevant financial disclosures.

PARIS — Irritable bowel syndrome (IBS) is a common brain-gut axis disorder, and patients are often dissatisfied with conventional treatments.

The role of the microbiota in IBS is now well established, and patients frequently take probiotics on their own initiative or on the advice of a physician or pharmacist. However, not all probiotics have equal efficacy, so which ones should be recommended?

Jean-Marc Sabaté, MD, PhD, a gastroenterologist at Avicenne Hospital in Bobigny, France, shared insights about probiotics at the Francophone Days of Hepatology, Gastroenterology, and Digestive Oncology.

IBS, according to the Rome IV symptom-based classification, is a “disorder of brain-gut axis interactions” with a prevalence of about 4% in the adult population. In France, during an average care pathway of about 8 years, patients try an average of five therapeutic strategies (and as many as 11), including antispasmodics (85%), diets (78%), and probiotics. In addition, 66.4% of patients had either taken or were taking probiotics at the time of a recent survey.

While the 2022 recommendations from the American College of Gastroenterology on the diagnosis and management of IBS do not support the use of probiotics for overall symptom relief — a recommendation for which they cite a low level of evidence — “there is nevertheless a rationale for prescribing probiotics in IBS due to the significant role of the microbiota (or dysbiosis) in this condition,” said Dr. Sabaté.
 

Microbiota in IBS 

Evidence indicating that antibiotics exacerbate IBS symptoms and revealing chronic bacterial overgrowth in the small intestine of patients with IBS supports the role of the microbiota. Studies using a molecular approach (16s rRNA) have settled the debate, confirming differences in the intestinal flora between patients with IBS and healthy subjects. Data also indicate differences in flora between patient subtypes, such as an increased Firmicutes to Bacteroidetes ratio. However, one subgroup, which can represent as much as a third of patients, seems to harbor a “normal” microbiota. 

Nonetheless, the microbiota plays a significant role in IBS. A Swedish study highlighted the influence of bacterial enterotypes on transit type associated with IBS and symptom severity, independent of diet composition or medication use. 

This dysbiosis could play a significant role as it interacts with other mechanisms involved in IBS, including changes in intestinal motility related to diet (related to fermentable carbohydrates, for example). Moreover, the microbiota seems to induce a low level of immune activation in patients with IBS, leading to microinflammation and increased intestinal permeability, especially after an infection.

Furthermore, alterations in the regulation of bile acid deconjugation by the microbiota partly explain the frequency and consistency of stools in diarrhea-predominant IBS patients.

In addition, colonic gas production is higher in these patients. Those complaining of flatulence have poor tolerance to intestinal gases after a flatulent meal, associated with microbiota instability.

Data regarding the interaction between the microbiota and central mechanisms mainly come from animal studies. In rodents, microbiota constituents seem to affect brain development, function, and morphology. Emotional and physical traumas during childhood appear to be risk factors. Moreover, even brief exposure to broad-spectrum antibiotics in neonates could cause subsequent visceral hypersensitivity.

Lastly, the role of the microbiota in changes in medullary pain control after visceral stimulation (eg, rectal distension) has still not been demonstrated in humans.
 

Recent Guideline 

In its February 2023 Global Guideline “Probiotics and Prebiotics” for IBS, the World Gastroenterology Organization looked at the level of evidence for probiotics.

Three strains, as well as a combination of several strains, were supported by level 2 evidence, meaning at least two randomized studies with converging results. These are Bifidobacterium bifidum MIMBb75, which improves overall symptoms and quality of life; Lactobacillus plantarum 299v (DSM 9843), which acts on the severity of abdominal pain and bloating; and B infantis 35624 (new name: B longum 35624), which improves the overall assessment of IBS symptoms, as does the multistrain product containing L rhamnosus GG, L rhamnosus LC705, Propionibacterium freudenreichii ssp shermanii JS DSM 7067, and B animalis ssp lactis B012 DSM 15954.
 

Efficacy and Availability 

Probiotics belonging to the category of dietary supplements or medical devices are not required to provide evidence for a mechanism of action or even efficacy to be marketed. Thus, for most probiotics sold, there are no human or even animal studies available.

Dr. Sabaté proposed a choice of probiotics based on the literature and the presence of at least one randomized placebo-controlled trial conducted in patients with IBS showing positive results.

“Probiotic efficacy largely depends on the bacterial species, strain, and clinical situation treated. Only probiotics with demonstrated clinical efficacy in randomized placebo-controlled trials should be recommended,” he emphasized. The parameters that can be improved include symptom severity, quality of life, abdominal pain, and bloating.
 

Effective Probiotics 

B longum 35624, which was developed with researchers from University College Cork in Ireland, is probably the most studied in animals and humans. Research has encompassed the mechanistic, clinical, and safety aspects of the probiotic. It has shown good results on the IBS-Symptom Severity Score (SSS), quality of life, abdominal pain, bowel disturbances, and bloating. The treatment duration in studies is 4-8 weeks.

L plantarum 299v (DSM 9843) affects the frequency of abdominal pain and pain score. The treatment duration in studies is 4 weeks.

The multistrain product that includes L plantarum CECT 7484/L plantarum CECT 7485/ Pediococcus acidilactici CECT 7483 allows for an improvement in quality of life and anxiety related to digestive symptoms. No positive effect has been described on digestive symptoms, especially diarrhea. The treatment duration is 6 weeks.

B bifidum MIMBb75 (both normal and heat-inactivated forms) is beneficial for pain, the composite IBS-SSS score, and quality of life. The treatment duration is 4-8 weeks.

“Except for the multistrain combination, which is more suited to patients with diarrhea-predominant IBS, the other three probiotics can be prescribed regardless of the IBS subtype,” said Dr. Sabaté. “Treatment durations are typically 4 weeks, but it is possible to continue up to 8 weeks, which is the maximum duration of these studies. In practice, there are no tolerance issues with probiotics prescribed for IBS based on the literature. These should be tested under the conditions and for the duration of the published studies and should only be continued if there is individual benefit on symptoms or quality of life.”

Note that microbiota analyses conducted for individual purposes are of no help in choosing probiotics.
 

Mechanisms of Action 

In a murine model, but not in humans, some strains, especially L acidophilus NCFM, have shown an antinociceptive effect by inducing opioid and cannabinoid receptors.

Only in animals to date, L farciminis and B lactis CNCM I-2494 have shown prevention of induced hypersensitivity (ie, inhibition of the cytoskeleton contraction of colon epithelial cells and subsequent opening of tight junctions).

B infantis 35624 has an anti-inflammatory action by modifying the IL-10 and IL-12 cytokine ratio in animals and humans. It has an immunomodulatory action by increasing dendritic cells in the mucosa and decreasing Th1 and Th7 helper T cells.

B infantis 35624 and L farciminis are two strains that decrease visceral sensitivity in mice.

Escherichia coli Nissle 1917 acts on lipopeptide production with an antinociceptive effect, as observed in mice, by decreasing visceral sensitivity through calcium nociceptor flux blockade (action on GABA type B receptor).

Acting on dysbiosis by modifying fecal microbiota during probiotic intake is possible but depends on the probiotics, like B infantis 35624. In humans, B longum NCC 3001 could modify brain activations.

Dr. Sabaté disclosed financial relationships with Mayoly Spindler, Kyowa Kirin, Tillotts, Servier, Norgine, Biocodex, Merck, Viatris, Abivax, and Inventiva.

This story was translated from the Medscape French edition using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article appeared on Medscape.com.

PARIS — Irritable bowel syndrome (IBS) is a common brain-gut axis disorder, and patients are often dissatisfied with conventional treatments.

The role of the microbiota in IBS is now well established, and patients frequently take probiotics on their own initiative or on the advice of a physician or pharmacist. However, not all probiotics have equal efficacy, so which ones should be recommended?

Jean-Marc Sabaté, MD, PhD, a gastroenterologist at Avicenne Hospital in Bobigny, France, shared insights about probiotics at the Francophone Days of Hepatology, Gastroenterology, and Digestive Oncology.

IBS, according to the Rome IV symptom-based classification, is a “disorder of brain-gut axis interactions” with a prevalence of about 4% in the adult population. In France, during an average care pathway of about 8 years, patients try an average of five therapeutic strategies (and as many as 11), including antispasmodics (85%), diets (78%), and probiotics. In addition, 66.4% of patients had either taken or were taking probiotics at the time of a recent survey.

While the 2022 recommendations from the American College of Gastroenterology on the diagnosis and management of IBS do not support the use of probiotics for overall symptom relief — a recommendation for which they cite a low level of evidence — “there is nevertheless a rationale for prescribing probiotics in IBS due to the significant role of the microbiota (or dysbiosis) in this condition,” said Dr. Sabaté.
 

Microbiota in IBS 

Evidence indicating that antibiotics exacerbate IBS symptoms and revealing chronic bacterial overgrowth in the small intestine of patients with IBS supports the role of the microbiota. Studies using a molecular approach (16s rRNA) have settled the debate, confirming differences in the intestinal flora between patients with IBS and healthy subjects. Data also indicate differences in flora between patient subtypes, such as an increased Firmicutes to Bacteroidetes ratio. However, one subgroup, which can represent as much as a third of patients, seems to harbor a “normal” microbiota. 

Nonetheless, the microbiota plays a significant role in IBS. A Swedish study highlighted the influence of bacterial enterotypes on transit type associated with IBS and symptom severity, independent of diet composition or medication use. 

This dysbiosis could play a significant role as it interacts with other mechanisms involved in IBS, including changes in intestinal motility related to diet (related to fermentable carbohydrates, for example). Moreover, the microbiota seems to induce a low level of immune activation in patients with IBS, leading to microinflammation and increased intestinal permeability, especially after an infection.

Furthermore, alterations in the regulation of bile acid deconjugation by the microbiota partly explain the frequency and consistency of stools in diarrhea-predominant IBS patients.

In addition, colonic gas production is higher in these patients. Those complaining of flatulence have poor tolerance to intestinal gases after a flatulent meal, associated with microbiota instability.

Data regarding the interaction between the microbiota and central mechanisms mainly come from animal studies. In rodents, microbiota constituents seem to affect brain development, function, and morphology. Emotional and physical traumas during childhood appear to be risk factors. Moreover, even brief exposure to broad-spectrum antibiotics in neonates could cause subsequent visceral hypersensitivity.

Lastly, the role of the microbiota in changes in medullary pain control after visceral stimulation (eg, rectal distension) has still not been demonstrated in humans.
 

Recent Guideline 

In its February 2023 Global Guideline “Probiotics and Prebiotics” for IBS, the World Gastroenterology Organization looked at the level of evidence for probiotics.

Three strains, as well as a combination of several strains, were supported by level 2 evidence, meaning at least two randomized studies with converging results. These are Bifidobacterium bifidum MIMBb75, which improves overall symptoms and quality of life; Lactobacillus plantarum 299v (DSM 9843), which acts on the severity of abdominal pain and bloating; and B infantis 35624 (new name: B longum 35624), which improves the overall assessment of IBS symptoms, as does the multistrain product containing L rhamnosus GG, L rhamnosus LC705, Propionibacterium freudenreichii ssp shermanii JS DSM 7067, and B animalis ssp lactis B012 DSM 15954.
 

Efficacy and Availability 

Probiotics belonging to the category of dietary supplements or medical devices are not required to provide evidence for a mechanism of action or even efficacy to be marketed. Thus, for most probiotics sold, there are no human or even animal studies available.

Dr. Sabaté proposed a choice of probiotics based on the literature and the presence of at least one randomized placebo-controlled trial conducted in patients with IBS showing positive results.

“Probiotic efficacy largely depends on the bacterial species, strain, and clinical situation treated. Only probiotics with demonstrated clinical efficacy in randomized placebo-controlled trials should be recommended,” he emphasized. The parameters that can be improved include symptom severity, quality of life, abdominal pain, and bloating.
 

Effective Probiotics 

B longum 35624, which was developed with researchers from University College Cork in Ireland, is probably the most studied in animals and humans. Research has encompassed the mechanistic, clinical, and safety aspects of the probiotic. It has shown good results on the IBS-Symptom Severity Score (SSS), quality of life, abdominal pain, bowel disturbances, and bloating. The treatment duration in studies is 4-8 weeks.

L plantarum 299v (DSM 9843) affects the frequency of abdominal pain and pain score. The treatment duration in studies is 4 weeks.

The multistrain product that includes L plantarum CECT 7484/L plantarum CECT 7485/ Pediococcus acidilactici CECT 7483 allows for an improvement in quality of life and anxiety related to digestive symptoms. No positive effect has been described on digestive symptoms, especially diarrhea. The treatment duration is 6 weeks.

B bifidum MIMBb75 (both normal and heat-inactivated forms) is beneficial for pain, the composite IBS-SSS score, and quality of life. The treatment duration is 4-8 weeks.

“Except for the multistrain combination, which is more suited to patients with diarrhea-predominant IBS, the other three probiotics can be prescribed regardless of the IBS subtype,” said Dr. Sabaté. “Treatment durations are typically 4 weeks, but it is possible to continue up to 8 weeks, which is the maximum duration of these studies. In practice, there are no tolerance issues with probiotics prescribed for IBS based on the literature. These should be tested under the conditions and for the duration of the published studies and should only be continued if there is individual benefit on symptoms or quality of life.”

Note that microbiota analyses conducted for individual purposes are of no help in choosing probiotics.
 

Mechanisms of Action 

In a murine model, but not in humans, some strains, especially L acidophilus NCFM, have shown an antinociceptive effect by inducing opioid and cannabinoid receptors.

Only in animals to date, L farciminis and B lactis CNCM I-2494 have shown prevention of induced hypersensitivity (ie, inhibition of the cytoskeleton contraction of colon epithelial cells and subsequent opening of tight junctions).

B infantis 35624 has an anti-inflammatory action by modifying the IL-10 and IL-12 cytokine ratio in animals and humans. It has an immunomodulatory action by increasing dendritic cells in the mucosa and decreasing Th1 and Th7 helper T cells.

B infantis 35624 and L farciminis are two strains that decrease visceral sensitivity in mice.

Escherichia coli Nissle 1917 acts on lipopeptide production with an antinociceptive effect, as observed in mice, by decreasing visceral sensitivity through calcium nociceptor flux blockade (action on GABA type B receptor).

Acting on dysbiosis by modifying fecal microbiota during probiotic intake is possible but depends on the probiotics, like B infantis 35624. In humans, B longum NCC 3001 could modify brain activations.

Dr. Sabaté disclosed financial relationships with Mayoly Spindler, Kyowa Kirin, Tillotts, Servier, Norgine, Biocodex, Merck, Viatris, Abivax, and Inventiva.

This story was translated from the Medscape French edition using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article appeared on Medscape.com.

PARIS — Irritable bowel syndrome (IBS) is a common brain-gut axis disorder, and patients are often dissatisfied with conventional treatments.

The role of the microbiota in IBS is now well established, and patients frequently take probiotics on their own initiative or on the advice of a physician or pharmacist. However, not all probiotics have equal efficacy, so which ones should be recommended?

Jean-Marc Sabaté, MD, PhD, a gastroenterologist at Avicenne Hospital in Bobigny, France, shared insights about probiotics at the Francophone Days of Hepatology, Gastroenterology, and Digestive Oncology.

IBS, according to the Rome IV symptom-based classification, is a “disorder of brain-gut axis interactions” with a prevalence of about 4% in the adult population. In France, during an average care pathway of about 8 years, patients try an average of five therapeutic strategies (and as many as 11), including antispasmodics (85%), diets (78%), and probiotics. In addition, 66.4% of patients had either taken or were taking probiotics at the time of a recent survey.

While the 2022 recommendations from the American College of Gastroenterology on the diagnosis and management of IBS do not support the use of probiotics for overall symptom relief — a recommendation for which they cite a low level of evidence — “there is nevertheless a rationale for prescribing probiotics in IBS due to the significant role of the microbiota (or dysbiosis) in this condition,” said Dr. Sabaté.
 

Microbiota in IBS 

Evidence indicating that antibiotics exacerbate IBS symptoms and revealing chronic bacterial overgrowth in the small intestine of patients with IBS supports the role of the microbiota. Studies using a molecular approach (16s rRNA) have settled the debate, confirming differences in the intestinal flora between patients with IBS and healthy subjects. Data also indicate differences in flora between patient subtypes, such as an increased Firmicutes to Bacteroidetes ratio. However, one subgroup, which can represent as much as a third of patients, seems to harbor a “normal” microbiota. 

Nonetheless, the microbiota plays a significant role in IBS. A Swedish study highlighted the influence of bacterial enterotypes on transit type associated with IBS and symptom severity, independent of diet composition or medication use. 

This dysbiosis could play a significant role as it interacts with other mechanisms involved in IBS, including changes in intestinal motility related to diet (related to fermentable carbohydrates, for example). Moreover, the microbiota seems to induce a low level of immune activation in patients with IBS, leading to microinflammation and increased intestinal permeability, especially after an infection.

Furthermore, alterations in the regulation of bile acid deconjugation by the microbiota partly explain the frequency and consistency of stools in diarrhea-predominant IBS patients.

In addition, colonic gas production is higher in these patients. Those complaining of flatulence have poor tolerance to intestinal gases after a flatulent meal, associated with microbiota instability.

Data regarding the interaction between the microbiota and central mechanisms mainly come from animal studies. In rodents, microbiota constituents seem to affect brain development, function, and morphology. Emotional and physical traumas during childhood appear to be risk factors. Moreover, even brief exposure to broad-spectrum antibiotics in neonates could cause subsequent visceral hypersensitivity.

Lastly, the role of the microbiota in changes in medullary pain control after visceral stimulation (eg, rectal distension) has still not been demonstrated in humans.
 

Recent Guideline 

In its February 2023 Global Guideline “Probiotics and Prebiotics” for IBS, the World Gastroenterology Organization looked at the level of evidence for probiotics.

Three strains, as well as a combination of several strains, were supported by level 2 evidence, meaning at least two randomized studies with converging results. These are Bifidobacterium bifidum MIMBb75, which improves overall symptoms and quality of life; Lactobacillus plantarum 299v (DSM 9843), which acts on the severity of abdominal pain and bloating; and B infantis 35624 (new name: B longum 35624), which improves the overall assessment of IBS symptoms, as does the multistrain product containing L rhamnosus GG, L rhamnosus LC705, Propionibacterium freudenreichii ssp shermanii JS DSM 7067, and B animalis ssp lactis B012 DSM 15954.
 

Efficacy and Availability 

Probiotics belonging to the category of dietary supplements or medical devices are not required to provide evidence for a mechanism of action or even efficacy to be marketed. Thus, for most probiotics sold, there are no human or even animal studies available.

Dr. Sabaté proposed a choice of probiotics based on the literature and the presence of at least one randomized placebo-controlled trial conducted in patients with IBS showing positive results.

“Probiotic efficacy largely depends on the bacterial species, strain, and clinical situation treated. Only probiotics with demonstrated clinical efficacy in randomized placebo-controlled trials should be recommended,” he emphasized. The parameters that can be improved include symptom severity, quality of life, abdominal pain, and bloating.
 

Effective Probiotics 

B longum 35624, which was developed with researchers from University College Cork in Ireland, is probably the most studied in animals and humans. Research has encompassed the mechanistic, clinical, and safety aspects of the probiotic. It has shown good results on the IBS-Symptom Severity Score (SSS), quality of life, abdominal pain, bowel disturbances, and bloating. The treatment duration in studies is 4-8 weeks.

L plantarum 299v (DSM 9843) affects the frequency of abdominal pain and pain score. The treatment duration in studies is 4 weeks.

The multistrain product that includes L plantarum CECT 7484/L plantarum CECT 7485/ Pediococcus acidilactici CECT 7483 allows for an improvement in quality of life and anxiety related to digestive symptoms. No positive effect has been described on digestive symptoms, especially diarrhea. The treatment duration is 6 weeks.

B bifidum MIMBb75 (both normal and heat-inactivated forms) is beneficial for pain, the composite IBS-SSS score, and quality of life. The treatment duration is 4-8 weeks.

“Except for the multistrain combination, which is more suited to patients with diarrhea-predominant IBS, the other three probiotics can be prescribed regardless of the IBS subtype,” said Dr. Sabaté. “Treatment durations are typically 4 weeks, but it is possible to continue up to 8 weeks, which is the maximum duration of these studies. In practice, there are no tolerance issues with probiotics prescribed for IBS based on the literature. These should be tested under the conditions and for the duration of the published studies and should only be continued if there is individual benefit on symptoms or quality of life.”

Note that microbiota analyses conducted for individual purposes are of no help in choosing probiotics.
 

Mechanisms of Action 

In a murine model, but not in humans, some strains, especially L acidophilus NCFM, have shown an antinociceptive effect by inducing opioid and cannabinoid receptors.

Only in animals to date, L farciminis and B lactis CNCM I-2494 have shown prevention of induced hypersensitivity (ie, inhibition of the cytoskeleton contraction of colon epithelial cells and subsequent opening of tight junctions).

B infantis 35624 has an anti-inflammatory action by modifying the IL-10 and IL-12 cytokine ratio in animals and humans. It has an immunomodulatory action by increasing dendritic cells in the mucosa and decreasing Th1 and Th7 helper T cells.

B infantis 35624 and L farciminis are two strains that decrease visceral sensitivity in mice.

Escherichia coli Nissle 1917 acts on lipopeptide production with an antinociceptive effect, as observed in mice, by decreasing visceral sensitivity through calcium nociceptor flux blockade (action on GABA type B receptor).

Acting on dysbiosis by modifying fecal microbiota during probiotic intake is possible but depends on the probiotics, like B infantis 35624. In humans, B longum NCC 3001 could modify brain activations.

Dr. Sabaté disclosed financial relationships with Mayoly Spindler, Kyowa Kirin, Tillotts, Servier, Norgine, Biocodex, Merck, Viatris, Abivax, and Inventiva.

This story was translated from the Medscape French edition using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article appeared on Medscape.com.

FROM AAD 2024

SAN DIEGO — Moderate to severe atopic dermatitis reduces linear growth in children younger than 12 years, results from an ongoing 10-year observational study showed.

“We need to sort out whether this is reversed by newer treatments, especially in the 6- to 11-year-olds, as well as the factors that underlie it in atopic dermatitis,” said the study’s first author Amy S. Paller, MD, chair of dermatology, Northwestern University, Chicago, Illinois, following the annual meeting of the American Academy of Dermatology, where the study was presented during a poster session.
 

Atopic Dermatitis Impacts Growth

In the ongoing international study called PEDISTAD, researchers enrolled 1326 children younger than 12 years with moderate to severe atopic dermatitis inadequately controlled by topical therapies who were candidates to receive systemic medications. They assessed the percentage of patients above the 50th percentile and the mean percentiles for height, weight, and body mass index (BMI) at baseline against the Centers for Disease Control and Prevention’s (CDC’s) Learning Management System reference healthy population, by age in months, and compared results to the CDC’s standardized growth curves for healthy children aged 0-12 years.

The investigators found that at baseline, compared with the age-specific population norms, 50% of men and 51% of women in the PEDISTAD study were above the 50th percentile for weight, but only 38% and 52%, respectively, were above the 50th percentile for height. Among patients aged 5-12 years, only 28% of men and 47% of women were above the 50th percentile for height, while 69% of men and 71% of women were above the 50th percentile for BMI.

Dr. Paller said that she was “not really surprised by the reduction in linear growth, since there are so many factors that may contribute,” including chronic inflammation, poor sleep, and the use of topical and systemic steroids. “But [it’s] good to have this data as an opportunity to see if our improved therapies can reverse this.”

She said that she was “a bit surprised by the increase in weight and body mass index, but this could reflect less physical activity/sports [participation and] deserves more investigation,” and added that the findings “mesh nicely with new attention on bone growth with good control of atopic dermatitis in this age group.”

Dr. Paller acknowledged certain limitations of the study, including the fact that those enrolled are a heterogeneous cohort with variable treatment regimens.
 

Some Answers, More Questions

Adam Friedman, MD, professor and chair of dermatology at George Washington University, Washington, DC, who was asked to comment on the findings, said that atopic dermatitis “should be considered the cutaneous manifestations of a systemic inflammatory disease, though even if it were not, the impact on daily and nightly activities [such as sleep] could indirectly have systemic medical consequences.”

The data presented “highlights that children with moderate to severe disease have higher BMIs and shorter height than matched counterparts, likely owing to the treasure trove of direct and indirect consequences of uncontrolled type 2 inflammation,” he said. “What I would like to know, and as the authors astutely noted, could treatment, and especially early intervention, prevent or even alter this impact?”

Dr. Paller disclosed that she is a consultant for several pharmaceutical companies, including Sanofi and Regeneron, the study sponsor. She is also an investigator for AbbVie, Dermavant, Eli Lilly, Incyte, Janssen, Krystal, LEO Pharma, and UCB and is a member of the data monitoring safety board for AbbVie, Abeona, Catawba, Galderma, and InMed. Dr. Friedman, who was not involved with the study, had no relevant disclosures.

A version of this article appeared on Medscape.com.

FROM AAD 2024

SAN DIEGO — Moderate to severe atopic dermatitis reduces linear growth in children younger than 12 years, results from an ongoing 10-year observational study showed.

“We need to sort out whether this is reversed by newer treatments, especially in the 6- to 11-year-olds, as well as the factors that underlie it in atopic dermatitis,” said the study’s first author Amy S. Paller, MD, chair of dermatology, Northwestern University, Chicago, Illinois, following the annual meeting of the American Academy of Dermatology, where the study was presented during a poster session.
 

Atopic Dermatitis Impacts Growth

In the ongoing international study called PEDISTAD, researchers enrolled 1326 children younger than 12 years with moderate to severe atopic dermatitis inadequately controlled by topical therapies who were candidates to receive systemic medications. They assessed the percentage of patients above the 50th percentile and the mean percentiles for height, weight, and body mass index (BMI) at baseline against the Centers for Disease Control and Prevention’s (CDC’s) Learning Management System reference healthy population, by age in months, and compared results to the CDC’s standardized growth curves for healthy children aged 0-12 years.

The investigators found that at baseline, compared with the age-specific population norms, 50% of men and 51% of women in the PEDISTAD study were above the 50th percentile for weight, but only 38% and 52%, respectively, were above the 50th percentile for height. Among patients aged 5-12 years, only 28% of men and 47% of women were above the 50th percentile for height, while 69% of men and 71% of women were above the 50th percentile for BMI.

Dr. Paller said that she was “not really surprised by the reduction in linear growth, since there are so many factors that may contribute,” including chronic inflammation, poor sleep, and the use of topical and systemic steroids. “But [it’s] good to have this data as an opportunity to see if our improved therapies can reverse this.”

She said that she was “a bit surprised by the increase in weight and body mass index, but this could reflect less physical activity/sports [participation and] deserves more investigation,” and added that the findings “mesh nicely with new attention on bone growth with good control of atopic dermatitis in this age group.”

Dr. Paller acknowledged certain limitations of the study, including the fact that those enrolled are a heterogeneous cohort with variable treatment regimens.
 

Some Answers, More Questions

Adam Friedman, MD, professor and chair of dermatology at George Washington University, Washington, DC, who was asked to comment on the findings, said that atopic dermatitis “should be considered the cutaneous manifestations of a systemic inflammatory disease, though even if it were not, the impact on daily and nightly activities [such as sleep] could indirectly have systemic medical consequences.”

The data presented “highlights that children with moderate to severe disease have higher BMIs and shorter height than matched counterparts, likely owing to the treasure trove of direct and indirect consequences of uncontrolled type 2 inflammation,” he said. “What I would like to know, and as the authors astutely noted, could treatment, and especially early intervention, prevent or even alter this impact?”

Dr. Paller disclosed that she is a consultant for several pharmaceutical companies, including Sanofi and Regeneron, the study sponsor. She is also an investigator for AbbVie, Dermavant, Eli Lilly, Incyte, Janssen, Krystal, LEO Pharma, and UCB and is a member of the data monitoring safety board for AbbVie, Abeona, Catawba, Galderma, and InMed. Dr. Friedman, who was not involved with the study, had no relevant disclosures.

A version of this article appeared on Medscape.com.

FROM AAD 2024

SAN DIEGO — Moderate to severe atopic dermatitis reduces linear growth in children younger than 12 years, results from an ongoing 10-year observational study showed.

“We need to sort out whether this is reversed by newer treatments, especially in the 6- to 11-year-olds, as well as the factors that underlie it in atopic dermatitis,” said the study’s first author Amy S. Paller, MD, chair of dermatology, Northwestern University, Chicago, Illinois, following the annual meeting of the American Academy of Dermatology, where the study was presented during a poster session.
 

Atopic Dermatitis Impacts Growth

In the ongoing international study called PEDISTAD, researchers enrolled 1326 children younger than 12 years with moderate to severe atopic dermatitis inadequately controlled by topical therapies who were candidates to receive systemic medications. They assessed the percentage of patients above the 50th percentile and the mean percentiles for height, weight, and body mass index (BMI) at baseline against the Centers for Disease Control and Prevention’s (CDC’s) Learning Management System reference healthy population, by age in months, and compared results to the CDC’s standardized growth curves for healthy children aged 0-12 years.

The investigators found that at baseline, compared with the age-specific population norms, 50% of men and 51% of women in the PEDISTAD study were above the 50th percentile for weight, but only 38% and 52%, respectively, were above the 50th percentile for height. Among patients aged 5-12 years, only 28% of men and 47% of women were above the 50th percentile for height, while 69% of men and 71% of women were above the 50th percentile for BMI.

Dr. Paller said that she was “not really surprised by the reduction in linear growth, since there are so many factors that may contribute,” including chronic inflammation, poor sleep, and the use of topical and systemic steroids. “But [it’s] good to have this data as an opportunity to see if our improved therapies can reverse this.”

She said that she was “a bit surprised by the increase in weight and body mass index, but this could reflect less physical activity/sports [participation and] deserves more investigation,” and added that the findings “mesh nicely with new attention on bone growth with good control of atopic dermatitis in this age group.”

Dr. Paller acknowledged certain limitations of the study, including the fact that those enrolled are a heterogeneous cohort with variable treatment regimens.
 

Some Answers, More Questions

Adam Friedman, MD, professor and chair of dermatology at George Washington University, Washington, DC, who was asked to comment on the findings, said that atopic dermatitis “should be considered the cutaneous manifestations of a systemic inflammatory disease, though even if it were not, the impact on daily and nightly activities [such as sleep] could indirectly have systemic medical consequences.”

The data presented “highlights that children with moderate to severe disease have higher BMIs and shorter height than matched counterparts, likely owing to the treasure trove of direct and indirect consequences of uncontrolled type 2 inflammation,” he said. “What I would like to know, and as the authors astutely noted, could treatment, and especially early intervention, prevent or even alter this impact?”

Dr. Paller disclosed that she is a consultant for several pharmaceutical companies, including Sanofi and Regeneron, the study sponsor. She is also an investigator for AbbVie, Dermavant, Eli Lilly, Incyte, Janssen, Krystal, LEO Pharma, and UCB and is a member of the data monitoring safety board for AbbVie, Abeona, Catawba, Galderma, and InMed. Dr. Friedman, who was not involved with the study, had no relevant disclosures.

A version of this article appeared on Medscape.com.

BUDAPEST, HUNGARY — Self-perceived loneliness during childhood is linked to a more than twofold increased risk for subsequent first-episode psychosis (FEP) — new findings that may point to a novel marker for the disorder.

The association between loneliness and FEP “appears to extend beyond the effects of objective social isolation,” said study presenter Covadonga M. Díaz-Caneja, MD, PhD, Institute of Psychiatry and Mental Health, Hospital General Universitario Gregorio Marañón, Madrid, and “is particularly pronounced in females.”

“These findings suggest the potential of childhood loneliness as an early risk marker for psychosis that could help guide targeted interventions,” she added.

The results were presented at the European Psychiatric Association 2024 Congress.
 

Isolation a Major Risk Factor

There are two components to isolation, both of which are “major risk factors” for morbidity, mortality, and the onset of mental disorders, said Dr. Díaz-Caneja.

The first is “objective social isolation,” which consists of a demonstrable lack of social connections, including social interactions, contacts, and relationships, while the other is a perceived sense of isolation, or “loneliness,” defined as a “subjective feeling of distress associated with a lack of meaningful relationships,” regardless of the amount of actual social contact an individual experiences.

Childhood loneliness occurs before age 12 and is becoming increasingly prevalent, said Dr. Díaz-Caneja. A recent survey shows that approximately one third of children report they often feel lonely.

Genetic and observational research has shown there is a bidirectional relationship between loneliness and psychosis and that patients with schizophrenia are more likely to report loneliness than is the general population.

Dr. Díaz-Caneja noted that there is no previous research that has assessed the potential association between childhood loneliness and subsequent psychosis.

To investigate, the researchers conducted an observational, case-control study in seven university hospitals in Madrid. It included individuals aged 7-40 years, including FEP patients with a psychosis duration of less than 2 years, and healthy controls from the same geographic areas.

They assessed childhood objective social isolation using the Premorbid Adjustment Scale and examined childhood loneliness with the single item: “Have you ever felt lonely for more than 6 months before the age of 12?”

A range of measures and questionnaires were also administered to assess participants’ symptom scores, alongside the Global Assessment of Functioning (GAF).
 

Alone vs Lonely

Two hundred eighty-five patients with FEP participated in the study. They had a mean age of 24.5 years, and 32.6% were female. The study also included 261 healthy controls (average age, 25.9 years; 48.7% female).

After the researchers adjusted for age, gender, ethnicity, and socioeconomic status, loneliness during childhood was associated with a significantly increased risk for FEP (odds ratio [OR], 2.17; 95% CI, 1.40-3.51), which increased (OR, 2.70; 95% CI, 1.58-4.62) after further adjustment for objective social isolation.

Further analysis revealed that in those who did not have objective social isolation in childhood, loneliness was associated with a significantly increased risk for FEP (OR, 2.68; 95% CI, 1.56-4.60).

However, the relationship between loneliness and FEP was not significant in participants who were objectively socially isolated during childhood (OR, 0.33; 95% CI, 0.08-1.45).

Compared with males, females reporting loneliness had a markedly increased risk for FEP (OR, 4.74; 95% CI, 2.23-10.05 vs OR, 1.17; 95% CI, 0.63-2.19).

However, females had a reduced risk of receiving a diagnosis of schizophrenia spectrum disorder (OR, 0.155; 95% CI, 0.048-0.506), indicating that loneliness influenced the type of diagnosis, she noted.

There was a significant positive relationship between loneliness in childhood and symptom scores in men, and a negative association with GAF scores in men.

Dr. Díaz-Caneja noted that the study is preliminary and a “work in progress.” The investigators plan to increase the sample size and will conduct more complex analyses, she said.

“We also of course have to bear in mind that it is a cross-sectional study and that there may be some kind of recall biases [because] we are asking patients now about what happened in the past.”

She noted that it’s unclear whether the results can be extrapolated to individuals who are currently experiencing loneliness because “the determinants of loneliness 10 years ago or 15 years ago may be different.”
 

How, When to Intervene

Session chair Judit Lazáry, MD, PhD, Department of Clinical and Theoretical Mental Health, Kútvölgyi Clinical Center, Semmelweis University, Budapest, Hungary, told this news organization that the association between loneliness and FEP was “not surprising.”

She explained there are a lot of data indicating that premorbid symptoms in childhood are “predictive signs for the later onset of psychosis,” and loneliness may be “a part of that.”

Individuals experiencing loneliness are more anxious and have difficulties in cultivating and maintaining relationships. In addition, they tend to socially isolate, she said.

The key question, said Dr. Lazáry, is: “How can we intervene to prevent the onset of psychosis? What is the point at which we can support the young person?”

This is challenging, she added, because while “you can detect that a kid is always alone, you cannot detect the feeling of loneliness,” and children can’t always easily express themselves.

Another potential confounder is that in adults with current psychosis, the self-perception that they were lonely during childhood may be a consequence of the disorder.

In addition, she said, individuals with psychosis often experience cognitive impairment, which could affect memory reliability.

Nevertheless, said Dr. Lazáry, the study’s findings suggest that a young person reporting loneliness in childhood may be “another symptom that we have to investigate.”

No funding was declared.

Dr. Díaz-Caneja declared a relationship with Angelini, Janssen, and Viatris and grant support from Instituto de Salud Carlos III, the Spanish Ministry of Science and Innovation, and the European Commission.
 

A version of this article appeared on Medscape.com.

BUDAPEST, HUNGARY — Self-perceived loneliness during childhood is linked to a more than twofold increased risk for subsequent first-episode psychosis (FEP) — new findings that may point to a novel marker for the disorder.

The association between loneliness and FEP “appears to extend beyond the effects of objective social isolation,” said study presenter Covadonga M. Díaz-Caneja, MD, PhD, Institute of Psychiatry and Mental Health, Hospital General Universitario Gregorio Marañón, Madrid, and “is particularly pronounced in females.”

“These findings suggest the potential of childhood loneliness as an early risk marker for psychosis that could help guide targeted interventions,” she added.

The results were presented at the European Psychiatric Association 2024 Congress.
 

Isolation a Major Risk Factor

There are two components to isolation, both of which are “major risk factors” for morbidity, mortality, and the onset of mental disorders, said Dr. Díaz-Caneja.

The first is “objective social isolation,” which consists of a demonstrable lack of social connections, including social interactions, contacts, and relationships, while the other is a perceived sense of isolation, or “loneliness,” defined as a “subjective feeling of distress associated with a lack of meaningful relationships,” regardless of the amount of actual social contact an individual experiences.

Childhood loneliness occurs before age 12 and is becoming increasingly prevalent, said Dr. Díaz-Caneja. A recent survey shows that approximately one third of children report they often feel lonely.

Genetic and observational research has shown there is a bidirectional relationship between loneliness and psychosis and that patients with schizophrenia are more likely to report loneliness than is the general population.

Dr. Díaz-Caneja noted that there is no previous research that has assessed the potential association between childhood loneliness and subsequent psychosis.

To investigate, the researchers conducted an observational, case-control study in seven university hospitals in Madrid. It included individuals aged 7-40 years, including FEP patients with a psychosis duration of less than 2 years, and healthy controls from the same geographic areas.

They assessed childhood objective social isolation using the Premorbid Adjustment Scale and examined childhood loneliness with the single item: “Have you ever felt lonely for more than 6 months before the age of 12?”

A range of measures and questionnaires were also administered to assess participants’ symptom scores, alongside the Global Assessment of Functioning (GAF).
 

Alone vs Lonely

Two hundred eighty-five patients with FEP participated in the study. They had a mean age of 24.5 years, and 32.6% were female. The study also included 261 healthy controls (average age, 25.9 years; 48.7% female).

After the researchers adjusted for age, gender, ethnicity, and socioeconomic status, loneliness during childhood was associated with a significantly increased risk for FEP (odds ratio [OR], 2.17; 95% CI, 1.40-3.51), which increased (OR, 2.70; 95% CI, 1.58-4.62) after further adjustment for objective social isolation.

Further analysis revealed that in those who did not have objective social isolation in childhood, loneliness was associated with a significantly increased risk for FEP (OR, 2.68; 95% CI, 1.56-4.60).

However, the relationship between loneliness and FEP was not significant in participants who were objectively socially isolated during childhood (OR, 0.33; 95% CI, 0.08-1.45).

Compared with males, females reporting loneliness had a markedly increased risk for FEP (OR, 4.74; 95% CI, 2.23-10.05 vs OR, 1.17; 95% CI, 0.63-2.19).

However, females had a reduced risk of receiving a diagnosis of schizophrenia spectrum disorder (OR, 0.155; 95% CI, 0.048-0.506), indicating that loneliness influenced the type of diagnosis, she noted.

There was a significant positive relationship between loneliness in childhood and symptom scores in men, and a negative association with GAF scores in men.

Dr. Díaz-Caneja noted that the study is preliminary and a “work in progress.” The investigators plan to increase the sample size and will conduct more complex analyses, she said.

“We also of course have to bear in mind that it is a cross-sectional study and that there may be some kind of recall biases [because] we are asking patients now about what happened in the past.”

She noted that it’s unclear whether the results can be extrapolated to individuals who are currently experiencing loneliness because “the determinants of loneliness 10 years ago or 15 years ago may be different.”
 

How, When to Intervene

Session chair Judit Lazáry, MD, PhD, Department of Clinical and Theoretical Mental Health, Kútvölgyi Clinical Center, Semmelweis University, Budapest, Hungary, told this news organization that the association between loneliness and FEP was “not surprising.”

She explained there are a lot of data indicating that premorbid symptoms in childhood are “predictive signs for the later onset of psychosis,” and loneliness may be “a part of that.”

Individuals experiencing loneliness are more anxious and have difficulties in cultivating and maintaining relationships. In addition, they tend to socially isolate, she said.

The key question, said Dr. Lazáry, is: “How can we intervene to prevent the onset of psychosis? What is the point at which we can support the young person?”

This is challenging, she added, because while “you can detect that a kid is always alone, you cannot detect the feeling of loneliness,” and children can’t always easily express themselves.

Another potential confounder is that in adults with current psychosis, the self-perception that they were lonely during childhood may be a consequence of the disorder.

In addition, she said, individuals with psychosis often experience cognitive impairment, which could affect memory reliability.

Nevertheless, said Dr. Lazáry, the study’s findings suggest that a young person reporting loneliness in childhood may be “another symptom that we have to investigate.”

No funding was declared.

Dr. Díaz-Caneja declared a relationship with Angelini, Janssen, and Viatris and grant support from Instituto de Salud Carlos III, the Spanish Ministry of Science and Innovation, and the European Commission.
 

A version of this article appeared on Medscape.com.

BUDAPEST, HUNGARY — Self-perceived loneliness during childhood is linked to a more than twofold increased risk for subsequent first-episode psychosis (FEP) — new findings that may point to a novel marker for the disorder.

The association between loneliness and FEP “appears to extend beyond the effects of objective social isolation,” said study presenter Covadonga M. Díaz-Caneja, MD, PhD, Institute of Psychiatry and Mental Health, Hospital General Universitario Gregorio Marañón, Madrid, and “is particularly pronounced in females.”

“These findings suggest the potential of childhood loneliness as an early risk marker for psychosis that could help guide targeted interventions,” she added.

The results were presented at the European Psychiatric Association 2024 Congress.
 

Isolation a Major Risk Factor

There are two components to isolation, both of which are “major risk factors” for morbidity, mortality, and the onset of mental disorders, said Dr. Díaz-Caneja.

The first is “objective social isolation,” which consists of a demonstrable lack of social connections, including social interactions, contacts, and relationships, while the other is a perceived sense of isolation, or “loneliness,” defined as a “subjective feeling of distress associated with a lack of meaningful relationships,” regardless of the amount of actual social contact an individual experiences.

Childhood loneliness occurs before age 12 and is becoming increasingly prevalent, said Dr. Díaz-Caneja. A recent survey shows that approximately one third of children report they often feel lonely.

Genetic and observational research has shown there is a bidirectional relationship between loneliness and psychosis and that patients with schizophrenia are more likely to report loneliness than is the general population.

Dr. Díaz-Caneja noted that there is no previous research that has assessed the potential association between childhood loneliness and subsequent psychosis.

To investigate, the researchers conducted an observational, case-control study in seven university hospitals in Madrid. It included individuals aged 7-40 years, including FEP patients with a psychosis duration of less than 2 years, and healthy controls from the same geographic areas.

They assessed childhood objective social isolation using the Premorbid Adjustment Scale and examined childhood loneliness with the single item: “Have you ever felt lonely for more than 6 months before the age of 12?”

A range of measures and questionnaires were also administered to assess participants’ symptom scores, alongside the Global Assessment of Functioning (GAF).
 

Alone vs Lonely

Two hundred eighty-five patients with FEP participated in the study. They had a mean age of 24.5 years, and 32.6% were female. The study also included 261 healthy controls (average age, 25.9 years; 48.7% female).

After the researchers adjusted for age, gender, ethnicity, and socioeconomic status, loneliness during childhood was associated with a significantly increased risk for FEP (odds ratio [OR], 2.17; 95% CI, 1.40-3.51), which increased (OR, 2.70; 95% CI, 1.58-4.62) after further adjustment for objective social isolation.

Further analysis revealed that in those who did not have objective social isolation in childhood, loneliness was associated with a significantly increased risk for FEP (OR, 2.68; 95% CI, 1.56-4.60).

However, the relationship between loneliness and FEP was not significant in participants who were objectively socially isolated during childhood (OR, 0.33; 95% CI, 0.08-1.45).

Compared with males, females reporting loneliness had a markedly increased risk for FEP (OR, 4.74; 95% CI, 2.23-10.05 vs OR, 1.17; 95% CI, 0.63-2.19).

However, females had a reduced risk of receiving a diagnosis of schizophrenia spectrum disorder (OR, 0.155; 95% CI, 0.048-0.506), indicating that loneliness influenced the type of diagnosis, she noted.

There was a significant positive relationship between loneliness in childhood and symptom scores in men, and a negative association with GAF scores in men.

Dr. Díaz-Caneja noted that the study is preliminary and a “work in progress.” The investigators plan to increase the sample size and will conduct more complex analyses, she said.

“We also of course have to bear in mind that it is a cross-sectional study and that there may be some kind of recall biases [because] we are asking patients now about what happened in the past.”

She noted that it’s unclear whether the results can be extrapolated to individuals who are currently experiencing loneliness because “the determinants of loneliness 10 years ago or 15 years ago may be different.”
 

How, When to Intervene

Session chair Judit Lazáry, MD, PhD, Department of Clinical and Theoretical Mental Health, Kútvölgyi Clinical Center, Semmelweis University, Budapest, Hungary, told this news organization that the association between loneliness and FEP was “not surprising.”

She explained there are a lot of data indicating that premorbid symptoms in childhood are “predictive signs for the later onset of psychosis,” and loneliness may be “a part of that.”

Individuals experiencing loneliness are more anxious and have difficulties in cultivating and maintaining relationships. In addition, they tend to socially isolate, she said.

The key question, said Dr. Lazáry, is: “How can we intervene to prevent the onset of psychosis? What is the point at which we can support the young person?”

This is challenging, she added, because while “you can detect that a kid is always alone, you cannot detect the feeling of loneliness,” and children can’t always easily express themselves.

Another potential confounder is that in adults with current psychosis, the self-perception that they were lonely during childhood may be a consequence of the disorder.

In addition, she said, individuals with psychosis often experience cognitive impairment, which could affect memory reliability.

Nevertheless, said Dr. Lazáry, the study’s findings suggest that a young person reporting loneliness in childhood may be “another symptom that we have to investigate.”

No funding was declared.

Dr. Díaz-Caneja declared a relationship with Angelini, Janssen, and Viatris and grant support from Instituto de Salud Carlos III, the Spanish Ministry of Science and Innovation, and the European Commission.
 

A version of this article appeared on Medscape.com.

The first peer-reviewed consensus statement on healthcare for children with neurodevelopmental disabilities (NDDs) is meant to start correcting the inequitable access to appropriate care that these children experience compared with their peers without NDDs. The statement was published in Pediatrics.

The disparities in healthcare culture, mindset, and practice often start in childhood for young people with conditions including autism spectrum disorder (ASD), intellectual disability, and attention-deficit/hyperactivity disorder (ADHD), wrote co–first authors Carol Weitzman, MD, co-director of the Autism Spectrum Center at Boston Children’s Hospital, Boston, Massachusetts, and Cy Nadler, PhD, section chief of Autism Psychology at Children’s Mercy in Kansas City, Missouri, and colleagues.

Without better access to safe and appropriate care, people with NDDs experience more seclusion, accidents, restraints, and injury in healthcare encounters, the researchers wrote.
 

‘Accessible, Humane, Effective Care’

“At the heart of this consensus statement is an affirmation that all people are entitled to healthcare that is accessible, humane, and effective,” they wrote.

The consensus statement was developed as part of the Supporting Access for Everyone (SAFE) Initiative, launched by the Developmental Behavioral Pediatric Research Network and the Association of University Centers on Disability. The consensus panel comprised professionals, caregivers, and adults with NDDs. After a 2-day public forum, the consensus panel held a conference and developed a statement on SAFE care, an NDD Health Care Bill of Rights and Transition Considerations. They developed 10 statements across five domains: training; communication; access and planning; diversity, equity, inclusion, belonging, and anti-ableism; and policy and structural change.
 

Asking the Patient ‘What do You Need?’

One theme in the statement that may have the most impact is “the importance of asking the person in front of you what they need,” and building a care plan around that, said senior author Marilyn Augustyn, MD, Director of the Division of Developmental and Behavioral Pediatrics at Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts. “The medical community hasn’t done that very well for individuals with neurodevelopmental disabilities.”

Dr. Weitzman added: “Traditionally in healthcare settings, we’ve asked people to check their disabilities at the door.” Many people with neurodevelopmental disabilities often have “invisible disabilities,” she said, explaining that patients may have accommodation needs that aren’t immediately obvious, but could improve their access to care, so asking them what they need is critical.
 

Examples of ‘Ableism’

The consensus statement also calls attention to structural “ableism” or policies or practices that favor able-bodied people over those with disabilities and details the need for more training and changed policies.

The paper gives some examples of ableism, such as inappropriately excluding people with NDDs from research; staff assuming nonspeaking patients have no capacity for communication; or lack of awareness of sensory needs before using cold stethoscopes or flashing direct light into eyes.

Dr. Weitzman says this work is just the beginning of a complex process. It is intended to be the driver for developing curriculum to train all clinicians and others working with patients about neurodevelopmental disabilities. The hope is it will lead to more research to formalize best practices and make policies mandatory rather than optional.

The urgency in highlighting these issues is partly related to the prevalence of children and adolescents with neurodevelopmental disabilities, which the paper states is approximately 1 in 6.

But there are personal reasons as well for the team who developed the statement.

“We just believe that it is just a human right,” Dr. Weitzman said. “Having a neurodevelopmental disability does not make you any less entitled to good care. “

Dr. Augustyn added, “The children I’ve had the honor of caring for for the last 30 years deserve all this care and more. I think it’s time.”

This work was supported by the Developmental Behavioral Pediatric Research Network and the Association of University Centers on Disability. Dr. Weitzman is a past consultant for Helios/Meliora. The other authors report no relevant financial relationships.

The first peer-reviewed consensus statement on healthcare for children with neurodevelopmental disabilities (NDDs) is meant to start correcting the inequitable access to appropriate care that these children experience compared with their peers without NDDs. The statement was published in Pediatrics.

The disparities in healthcare culture, mindset, and practice often start in childhood for young people with conditions including autism spectrum disorder (ASD), intellectual disability, and attention-deficit/hyperactivity disorder (ADHD), wrote co–first authors Carol Weitzman, MD, co-director of the Autism Spectrum Center at Boston Children’s Hospital, Boston, Massachusetts, and Cy Nadler, PhD, section chief of Autism Psychology at Children’s Mercy in Kansas City, Missouri, and colleagues.

Without better access to safe and appropriate care, people with NDDs experience more seclusion, accidents, restraints, and injury in healthcare encounters, the researchers wrote.
 

‘Accessible, Humane, Effective Care’

“At the heart of this consensus statement is an affirmation that all people are entitled to healthcare that is accessible, humane, and effective,” they wrote.

The consensus statement was developed as part of the Supporting Access for Everyone (SAFE) Initiative, launched by the Developmental Behavioral Pediatric Research Network and the Association of University Centers on Disability. The consensus panel comprised professionals, caregivers, and adults with NDDs. After a 2-day public forum, the consensus panel held a conference and developed a statement on SAFE care, an NDD Health Care Bill of Rights and Transition Considerations. They developed 10 statements across five domains: training; communication; access and planning; diversity, equity, inclusion, belonging, and anti-ableism; and policy and structural change.
 

Asking the Patient ‘What do You Need?’

One theme in the statement that may have the most impact is “the importance of asking the person in front of you what they need,” and building a care plan around that, said senior author Marilyn Augustyn, MD, Director of the Division of Developmental and Behavioral Pediatrics at Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts. “The medical community hasn’t done that very well for individuals with neurodevelopmental disabilities.”

Dr. Weitzman added: “Traditionally in healthcare settings, we’ve asked people to check their disabilities at the door.” Many people with neurodevelopmental disabilities often have “invisible disabilities,” she said, explaining that patients may have accommodation needs that aren’t immediately obvious, but could improve their access to care, so asking them what they need is critical.
 

Examples of ‘Ableism’

The consensus statement also calls attention to structural “ableism” or policies or practices that favor able-bodied people over those with disabilities and details the need for more training and changed policies.

The paper gives some examples of ableism, such as inappropriately excluding people with NDDs from research; staff assuming nonspeaking patients have no capacity for communication; or lack of awareness of sensory needs before using cold stethoscopes or flashing direct light into eyes.

Dr. Weitzman says this work is just the beginning of a complex process. It is intended to be the driver for developing curriculum to train all clinicians and others working with patients about neurodevelopmental disabilities. The hope is it will lead to more research to formalize best practices and make policies mandatory rather than optional.

The urgency in highlighting these issues is partly related to the prevalence of children and adolescents with neurodevelopmental disabilities, which the paper states is approximately 1 in 6.

But there are personal reasons as well for the team who developed the statement.

“We just believe that it is just a human right,” Dr. Weitzman said. “Having a neurodevelopmental disability does not make you any less entitled to good care. “

Dr. Augustyn added, “The children I’ve had the honor of caring for for the last 30 years deserve all this care and more. I think it’s time.”

This work was supported by the Developmental Behavioral Pediatric Research Network and the Association of University Centers on Disability. Dr. Weitzman is a past consultant for Helios/Meliora. The other authors report no relevant financial relationships.

The first peer-reviewed consensus statement on healthcare for children with neurodevelopmental disabilities (NDDs) is meant to start correcting the inequitable access to appropriate care that these children experience compared with their peers without NDDs. The statement was published in Pediatrics.

The disparities in healthcare culture, mindset, and practice often start in childhood for young people with conditions including autism spectrum disorder (ASD), intellectual disability, and attention-deficit/hyperactivity disorder (ADHD), wrote co–first authors Carol Weitzman, MD, co-director of the Autism Spectrum Center at Boston Children’s Hospital, Boston, Massachusetts, and Cy Nadler, PhD, section chief of Autism Psychology at Children’s Mercy in Kansas City, Missouri, and colleagues.

Without better access to safe and appropriate care, people with NDDs experience more seclusion, accidents, restraints, and injury in healthcare encounters, the researchers wrote.
 

‘Accessible, Humane, Effective Care’

“At the heart of this consensus statement is an affirmation that all people are entitled to healthcare that is accessible, humane, and effective,” they wrote.

The consensus statement was developed as part of the Supporting Access for Everyone (SAFE) Initiative, launched by the Developmental Behavioral Pediatric Research Network and the Association of University Centers on Disability. The consensus panel comprised professionals, caregivers, and adults with NDDs. After a 2-day public forum, the consensus panel held a conference and developed a statement on SAFE care, an NDD Health Care Bill of Rights and Transition Considerations. They developed 10 statements across five domains: training; communication; access and planning; diversity, equity, inclusion, belonging, and anti-ableism; and policy and structural change.
 

Asking the Patient ‘What do You Need?’

One theme in the statement that may have the most impact is “the importance of asking the person in front of you what they need,” and building a care plan around that, said senior author Marilyn Augustyn, MD, Director of the Division of Developmental and Behavioral Pediatrics at Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts. “The medical community hasn’t done that very well for individuals with neurodevelopmental disabilities.”

Dr. Weitzman added: “Traditionally in healthcare settings, we’ve asked people to check their disabilities at the door.” Many people with neurodevelopmental disabilities often have “invisible disabilities,” she said, explaining that patients may have accommodation needs that aren’t immediately obvious, but could improve their access to care, so asking them what they need is critical.
 

Examples of ‘Ableism’

The consensus statement also calls attention to structural “ableism” or policies or practices that favor able-bodied people over those with disabilities and details the need for more training and changed policies.

The paper gives some examples of ableism, such as inappropriately excluding people with NDDs from research; staff assuming nonspeaking patients have no capacity for communication; or lack of awareness of sensory needs before using cold stethoscopes or flashing direct light into eyes.

Dr. Weitzman says this work is just the beginning of a complex process. It is intended to be the driver for developing curriculum to train all clinicians and others working with patients about neurodevelopmental disabilities. The hope is it will lead to more research to formalize best practices and make policies mandatory rather than optional.

The urgency in highlighting these issues is partly related to the prevalence of children and adolescents with neurodevelopmental disabilities, which the paper states is approximately 1 in 6.

But there are personal reasons as well for the team who developed the statement.

“We just believe that it is just a human right,” Dr. Weitzman said. “Having a neurodevelopmental disability does not make you any less entitled to good care. “

Dr. Augustyn added, “The children I’ve had the honor of caring for for the last 30 years deserve all this care and more. I think it’s time.”

This work was supported by the Developmental Behavioral Pediatric Research Network and the Association of University Centers on Disability. Dr. Weitzman is a past consultant for Helios/Meliora. The other authors report no relevant financial relationships.

TOPLINE:

The time interval between onset of interstitial lung disease (ILD) and diagnosis of anti–melanoma differentiation-associated gene 5 (MDA5) antibody-positive dermatomyositis (DM) “has not been well described,” the authors say.

METHODOLOGY:

• MDA5 antibody-positive DM is a rare DM subtype associated with ILD, which is categorized into rapidly progressive ILD (RPILD) and chronic ILD, with the former having a particularly high mortality rate.
• In this retrospective cohort study using electronic medical records, researchers evaluated 774 patients with DM between 2008 and 2023 to learn more about the time interval between ILD and the time of an MDA5 antibody-positive DM diagnosis, which has not been well described.
• The primary outcome was ILD diagnosis and time in days between documented ILD and MDA5 antibody-positive DM diagnoses.

TAKEAWAY:

• Overall, 14 patients with DM (1.8%) were diagnosed with MDA5 antibody-positive DM in dermatology, rheumatology, or pulmonology departments (nine women and five men; age, 24-77 years; 79% were White and 7% were Black).
• ILD was diagnosed in 9 of the 14 patients (64%); 6 of the 14 (43%) met the criteria for RPILD. Two cases were diagnosed concurrently and two prior to MDA5 antibody-positive DM diagnosis.
• The median time between ILD and MDA5 antibody-positive DM diagnoses was 163 days.
• Gottron papules/sign and midfacial erythema were the most common dermatologic findings, and no association was seen between cutaneous signs and type of ILD.

IN PRACTICE:

“Establishing an accurate timeline between MDA5 antibody-positive DM and ILD can promote urgency among dermatologists to evaluate extracutaneous manifestations in their management of patients with DM for more accurate risk stratification and appropriate treatment,” the authors wrote.

SOURCE:

This study, led by Rachel R. Lin, from the University of Miami, Miami, Florida, was published online as a research letter in JAMA Dermatology.

LIMITATIONS:

Study limitations were the study’s retrospective design and small sample size.

DISCLOSURES:

No information on study funding was provided. One author reported personal fees from argenX outside this submitted work. Other authors did not disclose any competing interests.

A version of this article appeared on Medscape.com.

TOPLINE:

The time interval between onset of interstitial lung disease (ILD) and diagnosis of anti–melanoma differentiation-associated gene 5 (MDA5) antibody-positive dermatomyositis (DM) “has not been well described,” the authors say.

METHODOLOGY:

• MDA5 antibody-positive DM is a rare DM subtype associated with ILD, which is categorized into rapidly progressive ILD (RPILD) and chronic ILD, with the former having a particularly high mortality rate.
• In this retrospective cohort study using electronic medical records, researchers evaluated 774 patients with DM between 2008 and 2023 to learn more about the time interval between ILD and the time of an MDA5 antibody-positive DM diagnosis, which has not been well described.
• The primary outcome was ILD diagnosis and time in days between documented ILD and MDA5 antibody-positive DM diagnoses.

TAKEAWAY:

• Overall, 14 patients with DM (1.8%) were diagnosed with MDA5 antibody-positive DM in dermatology, rheumatology, or pulmonology departments (nine women and five men; age, 24-77 years; 79% were White and 7% were Black).
• ILD was diagnosed in 9 of the 14 patients (64%); 6 of the 14 (43%) met the criteria for RPILD. Two cases were diagnosed concurrently and two prior to MDA5 antibody-positive DM diagnosis.
• The median time between ILD and MDA5 antibody-positive DM diagnoses was 163 days.
• Gottron papules/sign and midfacial erythema were the most common dermatologic findings, and no association was seen between cutaneous signs and type of ILD.

IN PRACTICE:

“Establishing an accurate timeline between MDA5 antibody-positive DM and ILD can promote urgency among dermatologists to evaluate extracutaneous manifestations in their management of patients with DM for more accurate risk stratification and appropriate treatment,” the authors wrote.

SOURCE:

This study, led by Rachel R. Lin, from the University of Miami, Miami, Florida, was published online as a research letter in JAMA Dermatology.

LIMITATIONS:

Study limitations were the study’s retrospective design and small sample size.

DISCLOSURES:

No information on study funding was provided. One author reported personal fees from argenX outside this submitted work. Other authors did not disclose any competing interests.

A version of this article appeared on Medscape.com.

TOPLINE:

The time interval between onset of interstitial lung disease (ILD) and diagnosis of anti–melanoma differentiation-associated gene 5 (MDA5) antibody-positive dermatomyositis (DM) “has not been well described,” the authors say.

METHODOLOGY:

• MDA5 antibody-positive DM is a rare DM subtype associated with ILD, which is categorized into rapidly progressive ILD (RPILD) and chronic ILD, with the former having a particularly high mortality rate.
• In this retrospective cohort study using electronic medical records, researchers evaluated 774 patients with DM between 2008 and 2023 to learn more about the time interval between ILD and the time of an MDA5 antibody-positive DM diagnosis, which has not been well described.
• The primary outcome was ILD diagnosis and time in days between documented ILD and MDA5 antibody-positive DM diagnoses.

TAKEAWAY:

• Overall, 14 patients with DM (1.8%) were diagnosed with MDA5 antibody-positive DM in dermatology, rheumatology, or pulmonology departments (nine women and five men; age, 24-77 years; 79% were White and 7% were Black).
• ILD was diagnosed in 9 of the 14 patients (64%); 6 of the 14 (43%) met the criteria for RPILD. Two cases were diagnosed concurrently and two prior to MDA5 antibody-positive DM diagnosis.
• The median time between ILD and MDA5 antibody-positive DM diagnoses was 163 days.
• Gottron papules/sign and midfacial erythema were the most common dermatologic findings, and no association was seen between cutaneous signs and type of ILD.

IN PRACTICE:

“Establishing an accurate timeline between MDA5 antibody-positive DM and ILD can promote urgency among dermatologists to evaluate extracutaneous manifestations in their management of patients with DM for more accurate risk stratification and appropriate treatment,” the authors wrote.

SOURCE:

This study, led by Rachel R. Lin, from the University of Miami, Miami, Florida, was published online as a research letter in JAMA Dermatology.

LIMITATIONS:

Study limitations were the study’s retrospective design and small sample size.

DISCLOSURES:

No information on study funding was provided. One author reported personal fees from argenX outside this submitted work. Other authors did not disclose any competing interests.

A version of this article appeared on Medscape.com.

TOPLINE:

Botulinum toxin and dermal fillers are safe as cosmetic and antiaging treatments in individuals with skin of color (SOC), with the largest amount of data supporting its use in Asians, and more data on Black and Latinx populations are needed, according to a literature review.

METHODOLOGY:

• Understanding the efficacy and safety of cosmetic injectables in diverse skin types is important because individuals identifying as racial and ethnic minorities accounted for 18% of neuromodulator procedures and 22% of soft tissue augmentation procedures in 2020 in the United States.
• Researchers reviewed available literature on the usability and efficacy of neuromodulators and soft tissue augmentation in individuals with SOC because of the limited data available in these populations, particularly non-Asian, SOC populations.
• Overall, 88 studies in English were included, which were either dedicated to discussing safety and/or efficacy of injectables in SOC populations or enrolled more than 20% of participants from SOC populations.
• High-quality level I and II evidence was found in 50 studies, and 9940 patients were analyzed in this review.

TAKEAWAY:

• Studies considered high quality indicated that botulinum toxin is safe and effective for treating glabellar lines in Asians; tailored guidelines recommended specific strategies; and adverse events, such as eyelid issues, were more common in Asians.
• Hyaluronic acid fillers showed significant improvement in moderate to severe cases of nasolabial folds in Asians, and adverse effects like swelling and pain were mild to moderate — some cases of granuloma formation and vascular compromise have been reported.
• In Black individuals, botulinum toxin was well tolerated; hyaluronic acid fillers showed favorable safety, with mild to moderate adverse events; and measures like slower injections and subdermal techniques minimized risks.
• In Latinx populations, there was a lack of robust study data on safety and efficacy of botulinum toxin, whereas hyaluronic acid and poly-L-lactic acid fillers were well tolerated.

IN PRACTICE:

“Neuromodulators and dermal fillers are useful and safe as cosmetic and antiaging treatments in SOC populations, with the greatest amount of data supporting its use in Asian populations,” although more data on Black and Latinx populations are needed, the authors concluded. “During cosmetic consultations, physicians should consider the impact of different cultural beauty norms on the aesthetic goals of diverse patient populations,” they added.

SOURCE:

This study led by Shanice McKenzie, MD, from the Department of Dermatology, University of Southern California, Los Angeles, California, was published online in the Journal of Cosmetic Dermatology.

LIMITATIONS:

Most of the recent data and formal consensus guidelines on injectables in the review came from Asian countries, and there was “a relative paucity of research on Black and Latinx populations,” the authors noted.

DISCLOSURES:

The study did not receive any funding. Two authors declared serving as a consultant, investigator, and/or speaker for various companies; the rest had no disclosures to report.

A version of this article appeared on Medscape.com.

TOPLINE:

Botulinum toxin and dermal fillers are safe as cosmetic and antiaging treatments in individuals with skin of color (SOC), with the largest amount of data supporting its use in Asians, and more data on Black and Latinx populations are needed, according to a literature review.

METHODOLOGY:

• Understanding the efficacy and safety of cosmetic injectables in diverse skin types is important because individuals identifying as racial and ethnic minorities accounted for 18% of neuromodulator procedures and 22% of soft tissue augmentation procedures in 2020 in the United States.
• Researchers reviewed available literature on the usability and efficacy of neuromodulators and soft tissue augmentation in individuals with SOC because of the limited data available in these populations, particularly non-Asian, SOC populations.
• Overall, 88 studies in English were included, which were either dedicated to discussing safety and/or efficacy of injectables in SOC populations or enrolled more than 20% of participants from SOC populations.
• High-quality level I and II evidence was found in 50 studies, and 9940 patients were analyzed in this review.

TAKEAWAY:

• Studies considered high quality indicated that botulinum toxin is safe and effective for treating glabellar lines in Asians; tailored guidelines recommended specific strategies; and adverse events, such as eyelid issues, were more common in Asians.
• Hyaluronic acid fillers showed significant improvement in moderate to severe cases of nasolabial folds in Asians, and adverse effects like swelling and pain were mild to moderate — some cases of granuloma formation and vascular compromise have been reported.
• In Black individuals, botulinum toxin was well tolerated; hyaluronic acid fillers showed favorable safety, with mild to moderate adverse events; and measures like slower injections and subdermal techniques minimized risks.
• In Latinx populations, there was a lack of robust study data on safety and efficacy of botulinum toxin, whereas hyaluronic acid and poly-L-lactic acid fillers were well tolerated.

IN PRACTICE:

“Neuromodulators and dermal fillers are useful and safe as cosmetic and antiaging treatments in SOC populations, with the greatest amount of data supporting its use in Asian populations,” although more data on Black and Latinx populations are needed, the authors concluded. “During cosmetic consultations, physicians should consider the impact of different cultural beauty norms on the aesthetic goals of diverse patient populations,” they added.

SOURCE:

This study led by Shanice McKenzie, MD, from the Department of Dermatology, University of Southern California, Los Angeles, California, was published online in the Journal of Cosmetic Dermatology.

LIMITATIONS:

Most of the recent data and formal consensus guidelines on injectables in the review came from Asian countries, and there was “a relative paucity of research on Black and Latinx populations,” the authors noted.

DISCLOSURES:

The study did not receive any funding. Two authors declared serving as a consultant, investigator, and/or speaker for various companies; the rest had no disclosures to report.

A version of this article appeared on Medscape.com.

TOPLINE:

Botulinum toxin and dermal fillers are safe as cosmetic and antiaging treatments in individuals with skin of color (SOC), with the largest amount of data supporting its use in Asians, and more data on Black and Latinx populations are needed, according to a literature review.

METHODOLOGY:

• Understanding the efficacy and safety of cosmetic injectables in diverse skin types is important because individuals identifying as racial and ethnic minorities accounted for 18% of neuromodulator procedures and 22% of soft tissue augmentation procedures in 2020 in the United States.
• Researchers reviewed available literature on the usability and efficacy of neuromodulators and soft tissue augmentation in individuals with SOC because of the limited data available in these populations, particularly non-Asian, SOC populations.
• Overall, 88 studies in English were included, which were either dedicated to discussing safety and/or efficacy of injectables in SOC populations or enrolled more than 20% of participants from SOC populations.
• High-quality level I and II evidence was found in 50 studies, and 9940 patients were analyzed in this review.

TAKEAWAY:

• Studies considered high quality indicated that botulinum toxin is safe and effective for treating glabellar lines in Asians; tailored guidelines recommended specific strategies; and adverse events, such as eyelid issues, were more common in Asians.
• Hyaluronic acid fillers showed significant improvement in moderate to severe cases of nasolabial folds in Asians, and adverse effects like swelling and pain were mild to moderate — some cases of granuloma formation and vascular compromise have been reported.
• In Black individuals, botulinum toxin was well tolerated; hyaluronic acid fillers showed favorable safety, with mild to moderate adverse events; and measures like slower injections and subdermal techniques minimized risks.
• In Latinx populations, there was a lack of robust study data on safety and efficacy of botulinum toxin, whereas hyaluronic acid and poly-L-lactic acid fillers were well tolerated.

IN PRACTICE:

“Neuromodulators and dermal fillers are useful and safe as cosmetic and antiaging treatments in SOC populations, with the greatest amount of data supporting its use in Asian populations,” although more data on Black and Latinx populations are needed, the authors concluded. “During cosmetic consultations, physicians should consider the impact of different cultural beauty norms on the aesthetic goals of diverse patient populations,” they added.

SOURCE:

This study led by Shanice McKenzie, MD, from the Department of Dermatology, University of Southern California, Los Angeles, California, was published online in the Journal of Cosmetic Dermatology.

LIMITATIONS:

Most of the recent data and formal consensus guidelines on injectables in the review came from Asian countries, and there was “a relative paucity of research on Black and Latinx populations,” the authors noted.

DISCLOSURES:

The study did not receive any funding. Two authors declared serving as a consultant, investigator, and/or speaker for various companies; the rest had no disclosures to report.

A version of this article appeared on Medscape.com.

TOPLINE:

Signals for keratoacanthoma and cutaneous squamous cell carcinoma (cSCC) with programmed cell death 1 (PD-1) and programmed cell death ligand 1 (PD-L1) inhibitors were detected in an analysis of adverse events (AEs) reported to the US Food and Drug Administration (FDA).

METHODOLOGY:

• The risk for dermatologic immune-related side effects may be increased with immunologic-modifying drugs.
• To determine if there are significant signals between keratoacanthomas and cSCCs and PD-1/PD-L1 inhibitors, researchers analyzed AEs associated with these agents reported to the FDA’s Adverse Event Reporting System (FAERS) between January 2004 and May 2023.
• Pharmacovigilance signals were identified, and a significant signal was defined as the lower 95% CI of a reporting odds ratio (ROR) greater than one or the lower 95% CI of an information component (IC) greater than 0.

TAKEAWAY:

• Of the 158,000 reports of PD-1/PD-L1 inhibitor use, 43 were in patients who developed a keratoacanthoma (mean age, 77 years; 39% women) and 83 were in patients who developed cSCC (mean age, 71 years; 41% women). Patients aged 60-79 years were most likely to develop keratoacanthomas and cSCC on these treatments.
• A PD-1/PD-L1 inhibitor was listed as the suspect drug in all 43 keratoacanthoma reports and in 70 of 83 cSCC reports (the remaining 13 listed them as the concomitant drug).
• Significant signals were reported for both keratoacanthoma (ROR, 9.7; IC, 1.9) and cSCC (ROR, 3.0; IC, 0.9) with PD-1/PD-L1 inhibitor use.
• Of the reports where this information was available, all 10 cases of PD-1/PD-L1 inhibitor–linked keratoacanthoma and 10 of 17 cases (59%) of PD-1/PD-L1 inhibitor–linked cSCC, resolution was noted following discontinuation or dose reduction of the inhibitor.

IN PRACTICE:

“Given the large number of patients receiving immunotherapy, FAERS recording only 43 patients developing keratoacanthoma and 83 patients developing cSCC highlights that these conditions are relatively rare adverse events,” the authors wrote but added that more studies are needed to confirm these results.

SOURCE:

The study, led by Pushkar Aggarwal, MD, MBA, of the Department of Dermatology, University of Cincinnati, Cincinnati, Ohio, was published online in JAMA Dermatology.

LIMITATIONS:

The data obtained from FAERS did not contain information on all AEs from drugs. In addition, a causal association could not be determined.

DISCLOSURES:

The funding source was not reported. The authors did not report any conflicts of interest.

A version of this article appeared on Medscape.com.

TOPLINE:

Signals for keratoacanthoma and cutaneous squamous cell carcinoma (cSCC) with programmed cell death 1 (PD-1) and programmed cell death ligand 1 (PD-L1) inhibitors were detected in an analysis of adverse events (AEs) reported to the US Food and Drug Administration (FDA).

METHODOLOGY:

• The risk for dermatologic immune-related side effects may be increased with immunologic-modifying drugs.
• To determine if there are significant signals between keratoacanthomas and cSCCs and PD-1/PD-L1 inhibitors, researchers analyzed AEs associated with these agents reported to the FDA’s Adverse Event Reporting System (FAERS) between January 2004 and May 2023.
• Pharmacovigilance signals were identified, and a significant signal was defined as the lower 95% CI of a reporting odds ratio (ROR) greater than one or the lower 95% CI of an information component (IC) greater than 0.

TAKEAWAY:

• Of the 158,000 reports of PD-1/PD-L1 inhibitor use, 43 were in patients who developed a keratoacanthoma (mean age, 77 years; 39% women) and 83 were in patients who developed cSCC (mean age, 71 years; 41% women). Patients aged 60-79 years were most likely to develop keratoacanthomas and cSCC on these treatments.
• A PD-1/PD-L1 inhibitor was listed as the suspect drug in all 43 keratoacanthoma reports and in 70 of 83 cSCC reports (the remaining 13 listed them as the concomitant drug).
• Significant signals were reported for both keratoacanthoma (ROR, 9.7; IC, 1.9) and cSCC (ROR, 3.0; IC, 0.9) with PD-1/PD-L1 inhibitor use.
• Of the reports where this information was available, all 10 cases of PD-1/PD-L1 inhibitor–linked keratoacanthoma and 10 of 17 cases (59%) of PD-1/PD-L1 inhibitor–linked cSCC, resolution was noted following discontinuation or dose reduction of the inhibitor.

IN PRACTICE:

“Given the large number of patients receiving immunotherapy, FAERS recording only 43 patients developing keratoacanthoma and 83 patients developing cSCC highlights that these conditions are relatively rare adverse events,” the authors wrote but added that more studies are needed to confirm these results.

SOURCE:

The study, led by Pushkar Aggarwal, MD, MBA, of the Department of Dermatology, University of Cincinnati, Cincinnati, Ohio, was published online in JAMA Dermatology.

LIMITATIONS:

The data obtained from FAERS did not contain information on all AEs from drugs. In addition, a causal association could not be determined.

DISCLOSURES:

The funding source was not reported. The authors did not report any conflicts of interest.

A version of this article appeared on Medscape.com.

TOPLINE:

Signals for keratoacanthoma and cutaneous squamous cell carcinoma (cSCC) with programmed cell death 1 (PD-1) and programmed cell death ligand 1 (PD-L1) inhibitors were detected in an analysis of adverse events (AEs) reported to the US Food and Drug Administration (FDA).

METHODOLOGY:

• The risk for dermatologic immune-related side effects may be increased with immunologic-modifying drugs.
• To determine if there are significant signals between keratoacanthomas and cSCCs and PD-1/PD-L1 inhibitors, researchers analyzed AEs associated with these agents reported to the FDA’s Adverse Event Reporting System (FAERS) between January 2004 and May 2023.
• Pharmacovigilance signals were identified, and a significant signal was defined as the lower 95% CI of a reporting odds ratio (ROR) greater than one or the lower 95% CI of an information component (IC) greater than 0.

TAKEAWAY:

• Of the 158,000 reports of PD-1/PD-L1 inhibitor use, 43 were in patients who developed a keratoacanthoma (mean age, 77 years; 39% women) and 83 were in patients who developed cSCC (mean age, 71 years; 41% women). Patients aged 60-79 years were most likely to develop keratoacanthomas and cSCC on these treatments.
• A PD-1/PD-L1 inhibitor was listed as the suspect drug in all 43 keratoacanthoma reports and in 70 of 83 cSCC reports (the remaining 13 listed them as the concomitant drug).
• Significant signals were reported for both keratoacanthoma (ROR, 9.7; IC, 1.9) and cSCC (ROR, 3.0; IC, 0.9) with PD-1/PD-L1 inhibitor use.
• Of the reports where this information was available, all 10 cases of PD-1/PD-L1 inhibitor–linked keratoacanthoma and 10 of 17 cases (59%) of PD-1/PD-L1 inhibitor–linked cSCC, resolution was noted following discontinuation or dose reduction of the inhibitor.

IN PRACTICE:

“Given the large number of patients receiving immunotherapy, FAERS recording only 43 patients developing keratoacanthoma and 83 patients developing cSCC highlights that these conditions are relatively rare adverse events,” the authors wrote but added that more studies are needed to confirm these results.

SOURCE:

The study, led by Pushkar Aggarwal, MD, MBA, of the Department of Dermatology, University of Cincinnati, Cincinnati, Ohio, was published online in JAMA Dermatology.

LIMITATIONS:

The data obtained from FAERS did not contain information on all AEs from drugs. In addition, a causal association could not be determined.

DISCLOSURES:

The funding source was not reported. The authors did not report any conflicts of interest.

A version of this article appeared on Medscape.com.

TOPLINE:

Combined pediatric dermatology-rheumatology clinics can improve patient care and patient satisfaction, a survey of dermatologists suggested.

METHODOLOGY:

• Combined pediatric dermatology-rheumatology clinics can improve patient outcomes and experiences, particularly for pediatric autoimmune conditions presenting with both cutaneous and systemic manifestations.
• The researchers surveyed 208 pediatric dermatologists working in combined pediatric dermatology-rheumatology clinics.
• A total of 13 member responses were recorded from three countries: 10 from the United States, two from Mexico, and one from Canada.

TAKEAWAY:

• Perceived benefits of combined clinics were improved patient care through coordinated treatment decisions and timely communication between providers.
• Patient satisfaction was favorable, and patients and families endorsed the combined clinic approach.
• Barriers to clinic establishment included differences in the pace between dermatology and rheumatology clinic flow, the need to generate more relative value units, resistance from colleagues, and limited time.
• Areas that needed improvement included more time for patient visits, dedicated research assistants, new patient referrals, additional patient rooms, resources for research, and patient care infrastructure.

IN PRACTICE:

The insights from this survey “will hopefully inspire further development of these combined clinics,” the authors wrote.

SOURCE:

The investigation, led by Olga S. Cherepakhin, BS, University of Washington, Seattle, Washington, was published in Pediatric Dermatology.

LIMITATIONS:

Limitations included the subjective nature, lack of some information, selection bias, and small number of respondents, and the survey reflected the perspective of the pediatric dermatologists only.

DISCLOSURES:

The study was supported by the National Center for Advancing Translational Sciences of the National Institutes of Health. One author reported full-time employment at Janssen R&D, and the other authors had no disclosures.

A version of this article appeared on Medscape.com.

TOPLINE:

Combined pediatric dermatology-rheumatology clinics can improve patient care and patient satisfaction, a survey of dermatologists suggested.

METHODOLOGY:

• Combined pediatric dermatology-rheumatology clinics can improve patient outcomes and experiences, particularly for pediatric autoimmune conditions presenting with both cutaneous and systemic manifestations.
• The researchers surveyed 208 pediatric dermatologists working in combined pediatric dermatology-rheumatology clinics.
• A total of 13 member responses were recorded from three countries: 10 from the United States, two from Mexico, and one from Canada.

TAKEAWAY:

• Perceived benefits of combined clinics were improved patient care through coordinated treatment decisions and timely communication between providers.
• Patient satisfaction was favorable, and patients and families endorsed the combined clinic approach.
• Barriers to clinic establishment included differences in the pace between dermatology and rheumatology clinic flow, the need to generate more relative value units, resistance from colleagues, and limited time.
• Areas that needed improvement included more time for patient visits, dedicated research assistants, new patient referrals, additional patient rooms, resources for research, and patient care infrastructure.

IN PRACTICE:

The insights from this survey “will hopefully inspire further development of these combined clinics,” the authors wrote.

SOURCE:

The investigation, led by Olga S. Cherepakhin, BS, University of Washington, Seattle, Washington, was published in Pediatric Dermatology.

LIMITATIONS:

Limitations included the subjective nature, lack of some information, selection bias, and small number of respondents, and the survey reflected the perspective of the pediatric dermatologists only.

DISCLOSURES:

The study was supported by the National Center for Advancing Translational Sciences of the National Institutes of Health. One author reported full-time employment at Janssen R&D, and the other authors had no disclosures.

A version of this article appeared on Medscape.com.

TOPLINE:

Combined pediatric dermatology-rheumatology clinics can improve patient care and patient satisfaction, a survey of dermatologists suggested.

METHODOLOGY:

• Combined pediatric dermatology-rheumatology clinics can improve patient outcomes and experiences, particularly for pediatric autoimmune conditions presenting with both cutaneous and systemic manifestations.
• The researchers surveyed 208 pediatric dermatologists working in combined pediatric dermatology-rheumatology clinics.
• A total of 13 member responses were recorded from three countries: 10 from the United States, two from Mexico, and one from Canada.

TAKEAWAY:

• Perceived benefits of combined clinics were improved patient care through coordinated treatment decisions and timely communication between providers.
• Patient satisfaction was favorable, and patients and families endorsed the combined clinic approach.
• Barriers to clinic establishment included differences in the pace between dermatology and rheumatology clinic flow, the need to generate more relative value units, resistance from colleagues, and limited time.
• Areas that needed improvement included more time for patient visits, dedicated research assistants, new patient referrals, additional patient rooms, resources for research, and patient care infrastructure.

IN PRACTICE:

The insights from this survey “will hopefully inspire further development of these combined clinics,” the authors wrote.

SOURCE:

The investigation, led by Olga S. Cherepakhin, BS, University of Washington, Seattle, Washington, was published in Pediatric Dermatology.

LIMITATIONS:

Limitations included the subjective nature, lack of some information, selection bias, and small number of respondents, and the survey reflected the perspective of the pediatric dermatologists only.

DISCLOSURES:

The study was supported by the National Center for Advancing Translational Sciences of the National Institutes of Health. One author reported full-time employment at Janssen R&D, and the other authors had no disclosures.

A version of this article appeared on Medscape.com.

In last month’s column, I discussed employees who are “clock watchers” and how to address this issue in your practice if it exists. Here’s another scenario you may encounter from the Office Politics Forum at the recent American Academy of Dermatology annual meeting:

A 40-year-old dermatologist has practiced in the same office since residency and is loved by patients and staff. He remained with the practice through its takeover by a local hospital three years previously. Recently, over a 3-month period, everyone in the office notices a change in this dermatologist’s behavior. He no longer appears happy, is argumentative with staff and patients alike, often dismisses patients’ concerns, and calls in sick during the practice’s busiest days.

It is not difficult to recognize these changes as hallmarks of burnout, which continues to be pervasive across all practice settings and specialties. According to the American Medical Association’s National Burnout Benchmarking report, over 50% of physicians report some characteristics of burnout, which include emotional exhaustion, depersonalization, and a feeling of decreased personal achievement.

olm26250/Thinkstock

Addressing physician burnout requires a systems-based approach that targets these root causes at all levels, from individual coping strategies to organizational and systemic changes in the healthcare industry. Here are some strategies that have worked for me and others:

Optimize Practice Efficiency: This is the consistent theme of this column over several decades: Streamline office processes to enhance the quality of care while reducing unnecessary workload. This can involve adopting efficient patient scheduling systems, improving clinic flow, and utilizing technology like patient portals judiciously to avoid increasing the task load without compensation.

Promote Work-Life Balance: Encourage a culture that values work-life balance. This can include flexible scheduling, respecting off-duty hours by limiting non-emergency work communications, and using your vacation time. Remember Eastern’s First Law: Your last words will NOT be, “I wish I had spent more time in the office.”

Implement Medical Scribes: I’ve written frequently about this, including a recent column on the new artificial intelligence (AI) scribes, such as DeepCura, DeepScribe, Nuance, Suki, Augmedix, Tali AI, Iodine Software, ScribeLink, and Amazon Web Services’ new HealthScribe product. Utilizing medical scribes to handle documentation can significantly reduce the administrative burden, allowing physicians to focus more on patient care rather than paperwork, potentially improving both physician and patient satisfaction. (As always, I have no financial interest in any product or service mentioned in this column.)

Provide Professional Development Opportunities: Offer opportunities for professional growth and development. This can include attending conferences, participating in research, or providing time and resources for continuing education. Such opportunities can reinvigorate a physician’s passion for medicine and improve job satisfaction.

Foster a Supportive Work Environment: Create a supportive work culture where staff and physicians feel comfortable discussing challenges and seeking support. Regular meetings or check-ins can help identify early signs of burnout and address them proactively.

Evaluate and Adjust Workloads: Regularly assess physician workloads to ensure they are manageable. Adjusting patient loads, redistributing tasks among team members, or hiring additional staff can help prevent burnout.

Leadership Training and Support: Provide training for leaders within the practice on recognizing signs of burnout and effective management strategies. Supportive leadership is crucial in creating an environment where physicians feel valued and heard.

Peer Support and Mentorship Programs: Establish peer support or mentorship programs where physicians can share experiences, offer advice, and provide emotional support to each other.

Feedback and Continuous Improvement: Managers should regularly solicit feedback from physicians regarding their workload, job satisfaction, and suggestions for improvements. Actively work on implementing feasible changes to address concerns.

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at [email protected].

In last month’s column, I discussed employees who are “clock watchers” and how to address this issue in your practice if it exists. Here’s another scenario you may encounter from the Office Politics Forum at the recent American Academy of Dermatology annual meeting:

A 40-year-old dermatologist has practiced in the same office since residency and is loved by patients and staff. He remained with the practice through its takeover by a local hospital three years previously. Recently, over a 3-month period, everyone in the office notices a change in this dermatologist’s behavior. He no longer appears happy, is argumentative with staff and patients alike, often dismisses patients’ concerns, and calls in sick during the practice’s busiest days.

It is not difficult to recognize these changes as hallmarks of burnout, which continues to be pervasive across all practice settings and specialties. According to the American Medical Association’s National Burnout Benchmarking report, over 50% of physicians report some characteristics of burnout, which include emotional exhaustion, depersonalization, and a feeling of decreased personal achievement.

olm26250/Thinkstock

Addressing physician burnout requires a systems-based approach that targets these root causes at all levels, from individual coping strategies to organizational and systemic changes in the healthcare industry. Here are some strategies that have worked for me and others:

Optimize Practice Efficiency: This is the consistent theme of this column over several decades: Streamline office processes to enhance the quality of care while reducing unnecessary workload. This can involve adopting efficient patient scheduling systems, improving clinic flow, and utilizing technology like patient portals judiciously to avoid increasing the task load without compensation.

Promote Work-Life Balance: Encourage a culture that values work-life balance. This can include flexible scheduling, respecting off-duty hours by limiting non-emergency work communications, and using your vacation time. Remember Eastern’s First Law: Your last words will NOT be, “I wish I had spent more time in the office.”

Implement Medical Scribes: I’ve written frequently about this, including a recent column on the new artificial intelligence (AI) scribes, such as DeepCura, DeepScribe, Nuance, Suki, Augmedix, Tali AI, Iodine Software, ScribeLink, and Amazon Web Services’ new HealthScribe product. Utilizing medical scribes to handle documentation can significantly reduce the administrative burden, allowing physicians to focus more on patient care rather than paperwork, potentially improving both physician and patient satisfaction. (As always, I have no financial interest in any product or service mentioned in this column.)

Provide Professional Development Opportunities: Offer opportunities for professional growth and development. This can include attending conferences, participating in research, or providing time and resources for continuing education. Such opportunities can reinvigorate a physician’s passion for medicine and improve job satisfaction.

Foster a Supportive Work Environment: Create a supportive work culture where staff and physicians feel comfortable discussing challenges and seeking support. Regular meetings or check-ins can help identify early signs of burnout and address them proactively.

Evaluate and Adjust Workloads: Regularly assess physician workloads to ensure they are manageable. Adjusting patient loads, redistributing tasks among team members, or hiring additional staff can help prevent burnout.

Leadership Training and Support: Provide training for leaders within the practice on recognizing signs of burnout and effective management strategies. Supportive leadership is crucial in creating an environment where physicians feel valued and heard.

Peer Support and Mentorship Programs: Establish peer support or mentorship programs where physicians can share experiences, offer advice, and provide emotional support to each other.

Feedback and Continuous Improvement: Managers should regularly solicit feedback from physicians regarding their workload, job satisfaction, and suggestions for improvements. Actively work on implementing feasible changes to address concerns.

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at [email protected].

In last month’s column, I discussed employees who are “clock watchers” and how to address this issue in your practice if it exists. Here’s another scenario you may encounter from the Office Politics Forum at the recent American Academy of Dermatology annual meeting:

A 40-year-old dermatologist has practiced in the same office since residency and is loved by patients and staff. He remained with the practice through its takeover by a local hospital three years previously. Recently, over a 3-month period, everyone in the office notices a change in this dermatologist’s behavior. He no longer appears happy, is argumentative with staff and patients alike, often dismisses patients’ concerns, and calls in sick during the practice’s busiest days.

It is not difficult to recognize these changes as hallmarks of burnout, which continues to be pervasive across all practice settings and specialties. According to the American Medical Association’s National Burnout Benchmarking report, over 50% of physicians report some characteristics of burnout, which include emotional exhaustion, depersonalization, and a feeling of decreased personal achievement.

olm26250/Thinkstock

Addressing physician burnout requires a systems-based approach that targets these root causes at all levels, from individual coping strategies to organizational and systemic changes in the healthcare industry. Here are some strategies that have worked for me and others:

Optimize Practice Efficiency: This is the consistent theme of this column over several decades: Streamline office processes to enhance the quality of care while reducing unnecessary workload. This can involve adopting efficient patient scheduling systems, improving clinic flow, and utilizing technology like patient portals judiciously to avoid increasing the task load without compensation.

Promote Work-Life Balance: Encourage a culture that values work-life balance. This can include flexible scheduling, respecting off-duty hours by limiting non-emergency work communications, and using your vacation time. Remember Eastern’s First Law: Your last words will NOT be, “I wish I had spent more time in the office.”

Implement Medical Scribes: I’ve written frequently about this, including a recent column on the new artificial intelligence (AI) scribes, such as DeepCura, DeepScribe, Nuance, Suki, Augmedix, Tali AI, Iodine Software, ScribeLink, and Amazon Web Services’ new HealthScribe product. Utilizing medical scribes to handle documentation can significantly reduce the administrative burden, allowing physicians to focus more on patient care rather than paperwork, potentially improving both physician and patient satisfaction. (As always, I have no financial interest in any product or service mentioned in this column.)

Provide Professional Development Opportunities: Offer opportunities for professional growth and development. This can include attending conferences, participating in research, or providing time and resources for continuing education. Such opportunities can reinvigorate a physician’s passion for medicine and improve job satisfaction.

Foster a Supportive Work Environment: Create a supportive work culture where staff and physicians feel comfortable discussing challenges and seeking support. Regular meetings or check-ins can help identify early signs of burnout and address them proactively.

Evaluate and Adjust Workloads: Regularly assess physician workloads to ensure they are manageable. Adjusting patient loads, redistributing tasks among team members, or hiring additional staff can help prevent burnout.

Leadership Training and Support: Provide training for leaders within the practice on recognizing signs of burnout and effective management strategies. Supportive leadership is crucial in creating an environment where physicians feel valued and heard.

Peer Support and Mentorship Programs: Establish peer support or mentorship programs where physicians can share experiences, offer advice, and provide emotional support to each other.

Feedback and Continuous Improvement: Managers should regularly solicit feedback from physicians regarding their workload, job satisfaction, and suggestions for improvements. Actively work on implementing feasible changes to address concerns.

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at [email protected].