Triglyceride levels are a measure of cardiovascular risk and a target for therapy, but a focus on TG levels as a bad guy in CV risk assessments may be missing the mark, a population-based cohort study suggests.
 

It concluded, very preliminarily, that it may be the vigor of TG metabolism more than plasma levels that are associated with bad outcomes.

The analysis, based on 30,000 participants in the Copenhagen General Population Study, saw sharply increased risks for all-cause mortality, CV mortality, and cancer mortality over 10 years among those with robust TG metabolism.

Those significant risks, gauged by concentrations of two molecules considered markers of TG metabolic rate, were independent of body mass index (BMI) and a range of other TG-linked risk factors, including plasma TG levels themselves.

All-cause mortality jumped 31% for plasma levels of glycerol in the highest versus lowest quartiles and rose 18% for highest-quartile levels of beta-hydroxybutyrate. In parallel, CV mortality climbed 37% for glycerol and 18% for beta-hydroxybutyrate in the study, published in the European Heart Journal.

The findings “implicate triglyceride metabolic rate as a risk factor for mortality not explained by high plasma triglycerides or high BMI,” the report states. The study, it continues, may be the first to link increased mortality to more active TG metabolism – according to levels of the two biomarkers – in the general population.

The results were “really, really surprising,” senior author Børge G. Nordestgaard, MD, DMSc, said in an interview. They are “completely novel” and “may make people think differently” about TG and mortality risk.

Given their unexpected findings, the group conducted further analyses for evidence that the metabolite-mortality associations weren’t independent. “We tried to stratify them away, but they stayed,” said Dr. Nordestgaard, of the University of Copenhagen.

In a weight-stratified analysis, for example, findings were similar in people with normal weight and with overweight and who were obese, Dr. Nordestgaard observed. “Even in the ones with normal weight by World Health Organization criteria, we saw the same and maybe even stronger relationships” between TG metabolism and mortality.

The study authors were is careful to note the retrospective cohort study’s limitations, but its findings “at most support an association, not causation,” Michael Miller, MD, Hospital of the University of Pennsylvania, Philadelphia, observed in an interview. Therefore, it can’t answer “whether and to what extent glycerol and/or beta-hydroxybutyrate independently contribute to mortality beyond triglyceride levels per se.”

Assessing levels of the two biomarkers “was an interesting way to indirectly assess whole-body TG metabolism,” but they were not fasting levels, said Dr. Miller, who wasn’t part of the study.

Also, the analysis doesn’t account for heparinization and other factors “that artificially raise glycerol levels” and suffers in other ways “from the inherent limitations of residual confounding,” said Dr. Miller, who is also chief of medicine at Corporal Michael J Crescenz VA Medical Center, Philadelphia.

The analysis tracked 30,000 men and women, participants in the much larger Copenhagen General Population Study cohort, for a median of 10.7 years. During that time, 9,897 of them died.

Plasma levels of glycerol and beta-hydroxybutyrate, the study authors noted, were measured using high-throughput nuclear magnetic resonance spectroscopy.

Glycerol levels greater than 80 mcmol/L represented the highest quartile and those less than 52 mcmol/L the lowest quartile. The corresponding beta-hydroxybutyrate quartiles were greater than 154 mcmol/L and less than 91 mcmol/L, respectively.

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

Triglyceride levels are a measure of cardiovascular risk and a target for therapy, but a focus on TG levels as a bad guy in CV risk assessments may be missing the mark, a population-based cohort study suggests.
 

It concluded, very preliminarily, that it may be the vigor of TG metabolism more than plasma levels that are associated with bad outcomes.

The analysis, based on 30,000 participants in the Copenhagen General Population Study, saw sharply increased risks for all-cause mortality, CV mortality, and cancer mortality over 10 years among those with robust TG metabolism.

Those significant risks, gauged by concentrations of two molecules considered markers of TG metabolic rate, were independent of body mass index (BMI) and a range of other TG-linked risk factors, including plasma TG levels themselves.

All-cause mortality jumped 31% for plasma levels of glycerol in the highest versus lowest quartiles and rose 18% for highest-quartile levels of beta-hydroxybutyrate. In parallel, CV mortality climbed 37% for glycerol and 18% for beta-hydroxybutyrate in the study, published in the European Heart Journal.

The findings “implicate triglyceride metabolic rate as a risk factor for mortality not explained by high plasma triglycerides or high BMI,” the report states. The study, it continues, may be the first to link increased mortality to more active TG metabolism – according to levels of the two biomarkers – in the general population.

The results were “really, really surprising,” senior author Børge G. Nordestgaard, MD, DMSc, said in an interview. They are “completely novel” and “may make people think differently” about TG and mortality risk.

Given their unexpected findings, the group conducted further analyses for evidence that the metabolite-mortality associations weren’t independent. “We tried to stratify them away, but they stayed,” said Dr. Nordestgaard, of the University of Copenhagen.

In a weight-stratified analysis, for example, findings were similar in people with normal weight and with overweight and who were obese, Dr. Nordestgaard observed. “Even in the ones with normal weight by World Health Organization criteria, we saw the same and maybe even stronger relationships” between TG metabolism and mortality.

The study authors were is careful to note the retrospective cohort study’s limitations, but its findings “at most support an association, not causation,” Michael Miller, MD, Hospital of the University of Pennsylvania, Philadelphia, observed in an interview. Therefore, it can’t answer “whether and to what extent glycerol and/or beta-hydroxybutyrate independently contribute to mortality beyond triglyceride levels per se.”

Assessing levels of the two biomarkers “was an interesting way to indirectly assess whole-body TG metabolism,” but they were not fasting levels, said Dr. Miller, who wasn’t part of the study.

Also, the analysis doesn’t account for heparinization and other factors “that artificially raise glycerol levels” and suffers in other ways “from the inherent limitations of residual confounding,” said Dr. Miller, who is also chief of medicine at Corporal Michael J Crescenz VA Medical Center, Philadelphia.

The analysis tracked 30,000 men and women, participants in the much larger Copenhagen General Population Study cohort, for a median of 10.7 years. During that time, 9,897 of them died.

Plasma levels of glycerol and beta-hydroxybutyrate, the study authors noted, were measured using high-throughput nuclear magnetic resonance spectroscopy.

Glycerol levels greater than 80 mcmol/L represented the highest quartile and those less than 52 mcmol/L the lowest quartile. The corresponding beta-hydroxybutyrate quartiles were greater than 154 mcmol/L and less than 91 mcmol/L, respectively.

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

Triglyceride levels are a measure of cardiovascular risk and a target for therapy, but a focus on TG levels as a bad guy in CV risk assessments may be missing the mark, a population-based cohort study suggests.
 

It concluded, very preliminarily, that it may be the vigor of TG metabolism more than plasma levels that are associated with bad outcomes.

The analysis, based on 30,000 participants in the Copenhagen General Population Study, saw sharply increased risks for all-cause mortality, CV mortality, and cancer mortality over 10 years among those with robust TG metabolism.

Those significant risks, gauged by concentrations of two molecules considered markers of TG metabolic rate, were independent of body mass index (BMI) and a range of other TG-linked risk factors, including plasma TG levels themselves.

All-cause mortality jumped 31% for plasma levels of glycerol in the highest versus lowest quartiles and rose 18% for highest-quartile levels of beta-hydroxybutyrate. In parallel, CV mortality climbed 37% for glycerol and 18% for beta-hydroxybutyrate in the study, published in the European Heart Journal.

The findings “implicate triglyceride metabolic rate as a risk factor for mortality not explained by high plasma triglycerides or high BMI,” the report states. The study, it continues, may be the first to link increased mortality to more active TG metabolism – according to levels of the two biomarkers – in the general population.

The results were “really, really surprising,” senior author Børge G. Nordestgaard, MD, DMSc, said in an interview. They are “completely novel” and “may make people think differently” about TG and mortality risk.

Given their unexpected findings, the group conducted further analyses for evidence that the metabolite-mortality associations weren’t independent. “We tried to stratify them away, but they stayed,” said Dr. Nordestgaard, of the University of Copenhagen.

In a weight-stratified analysis, for example, findings were similar in people with normal weight and with overweight and who were obese, Dr. Nordestgaard observed. “Even in the ones with normal weight by World Health Organization criteria, we saw the same and maybe even stronger relationships” between TG metabolism and mortality.

The study authors were is careful to note the retrospective cohort study’s limitations, but its findings “at most support an association, not causation,” Michael Miller, MD, Hospital of the University of Pennsylvania, Philadelphia, observed in an interview. Therefore, it can’t answer “whether and to what extent glycerol and/or beta-hydroxybutyrate independently contribute to mortality beyond triglyceride levels per se.”

Assessing levels of the two biomarkers “was an interesting way to indirectly assess whole-body TG metabolism,” but they were not fasting levels, said Dr. Miller, who wasn’t part of the study.

Also, the analysis doesn’t account for heparinization and other factors “that artificially raise glycerol levels” and suffers in other ways “from the inherent limitations of residual confounding,” said Dr. Miller, who is also chief of medicine at Corporal Michael J Crescenz VA Medical Center, Philadelphia.

The analysis tracked 30,000 men and women, participants in the much larger Copenhagen General Population Study cohort, for a median of 10.7 years. During that time, 9,897 of them died.

Plasma levels of glycerol and beta-hydroxybutyrate, the study authors noted, were measured using high-throughput nuclear magnetic resonance spectroscopy.

Glycerol levels greater than 80 mcmol/L represented the highest quartile and those less than 52 mcmol/L the lowest quartile. The corresponding beta-hydroxybutyrate quartiles were greater than 154 mcmol/L and less than 91 mcmol/L, respectively.

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

In patients with heart failure, mid-upper arm circumference (MUAC) and arm muscle circumference (AMC) are more significantly associated with prognosis than guideline-recommended skeletal muscle mass index (SMI) or calf circumference (CC) measurements, research suggests.
 

In a single-center, retrospective study that included more than 800 patients, high MUAC (hazard ratio for combined events, 0.590) and high AMC (HR for combined events, 0.529) were associated with significantly better prognoses than low MUAC and low AMC.

The findings were “surprising,” Kentaro Kamiya, PT, PhD, and Shota Uchida, PT, PhD, of Kitasato University School of Allied Health Sciences in Kanagawa, Japan, said in an interview.

“These findings challenge the current recommendations found in sarcopenia guidelines,” they noted. The European Working Group on Sarcopenia in Older People and the Asian Working Group for Sarcopenia recommend SMI, as measured by bioelectrical impedance analysis (BIA), and CC as methods for screening skeletal muscle mass.

The study was published online in the Canadian Journal of Cardiology.
 

Arm measures prognostic

Sarcopenia, which is marked by a loss of skeletal muscle mass and strength, is associated with risks of adverse outcomes. Patients with heart failure have a high rate of sarcopenia, but assessing skeletal muscle mass in these patients is difficult because of the fluid retention they often have.

The investigators examined the association between skeletal muscle mass metrics, measured using bioelectrical impedance analysis, and anthropometric measures and prognosis in patients with heart failure.

SMI was calculated using the BIA by dividing appendicular skeletal muscle mass by height squared. MUAC and CC were measured to the nearest 1 mm using a plastic tape measure. AMC was calculated as follows: MUAC (cm) − (0.314 x triceps skinfold [TSF]). The TSF was measured to the nearest 2 mm with a skinfold caliper. The measuring spot for TSF was the same measuring spot for MUAC. MUAC, CC, and TSF were measured by trained physiotherapists or nurses.

The investigators identified 1,930 consecutive patients with heart failure who underwent cardiac rehabilitation during their hospitalization. They excluded from their analysis 1,013 patients who did not undergo a skeletal mass metrics evaluation and 48 who could not be followed up.

The analysis included 869 patients (median age, 73 years; 62% men). Patients were separated into three groups on the basis of the sex-specific tertiles of skeletal muscle mass. The study endpoint was all-cause death or readmission due to heart failure, and the median follow-up period was 1.24 years.

After the investigators adjusted the data for age, sex, New York Heart Association functional class III or IV, left ventricular ejection fraction (LVEF), ischemic etiology, prior heart failure, diabetes, chronic obstructive pulmonary disease, log-transformed B-type natriuretic peptide (BNP), and estimated glomerular filtration rate (eGFR), the high MUAC and high AMC groups were associated with significantly better prognoses than their respective low groups. By contrast, high SMI and high CC were not associated with better prognoses.

Subgroup analyses showed no interactions between MUAC and age, sex, LVEF, BNP, eGFR, prior heart failure, beta-blocker use, and angiotensin-converting enzyme inhibitor or angiotensin II receptor blocker use. However, diuretic agents significantly interacted with AMC (P = .03).

“These results support the use of MUAC and AMC to determine the risk stratification of sarcopenia and a poor prognosis in patients with heart failure and suggest that they may be useful in developing treatment strategies in patients with heart failure,” wrote the authors.

“When caring for patients with heart failure, it seems that the often overlooked and simple measure of arm circumference might carry significant prognostic value,” said Dr. Kamiya and Dr. Uchida. “So, as you cuff the arm for routine blood pressure measurement, it might be worthwhile to also pay attention to arm girth.”

Although the findings provide valuable insights, they should be approached with caution, Dr. Kamiya and Dr. Uchida added. “Before considering them practice-changing, further research is needed to validate these results in diverse patient cohorts.”
 

Prospective study needed

Commenting on the study for this news organization, Jonathan H. Whiteson, MD, vice chair of clinical operations and medical director of cardiac and pulmonary rehabilitation at NYU Langone Health’s Rusk Rehabilitation in New York, expressed concerns about the study methodology.

Methodologic weaknesses include the retrospective, observational nature of the study and the fact that incomplete data collection led to the exclusion of more than half of the potential participants, he said. In addition, “anthropometric measurements are prone to inter-rater error. It is not clear if the same or different researchers conducted these measurements.

“Furthermore, hospitalized patients may not be clinically stable when discharged,” said Dr. Whiteson. “It is recommended that biometrics for muscle mass and fluid retention be done when patients are at an optimized clinical state: that is, stabilized outpatients.”

For now, Dr. Whiteson concluded, the findings should be considered “interesting and suggestive of further study.” What’s needed is “a prospective study including all patients admitted with heart failure, but measurements done when the patient is stabilized as an outpatient.”

The study was partially supported by the Japan Society for the Promotion of Science KAKENHI. Dr. Kamiya, Dr. Uchida, and Dr. Whiteson reported no conflicts of interest.

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

In patients with heart failure, mid-upper arm circumference (MUAC) and arm muscle circumference (AMC) are more significantly associated with prognosis than guideline-recommended skeletal muscle mass index (SMI) or calf circumference (CC) measurements, research suggests.
 

In a single-center, retrospective study that included more than 800 patients, high MUAC (hazard ratio for combined events, 0.590) and high AMC (HR for combined events, 0.529) were associated with significantly better prognoses than low MUAC and low AMC.

The findings were “surprising,” Kentaro Kamiya, PT, PhD, and Shota Uchida, PT, PhD, of Kitasato University School of Allied Health Sciences in Kanagawa, Japan, said in an interview.

“These findings challenge the current recommendations found in sarcopenia guidelines,” they noted. The European Working Group on Sarcopenia in Older People and the Asian Working Group for Sarcopenia recommend SMI, as measured by bioelectrical impedance analysis (BIA), and CC as methods for screening skeletal muscle mass.

The study was published online in the Canadian Journal of Cardiology.
 

Arm measures prognostic

Sarcopenia, which is marked by a loss of skeletal muscle mass and strength, is associated with risks of adverse outcomes. Patients with heart failure have a high rate of sarcopenia, but assessing skeletal muscle mass in these patients is difficult because of the fluid retention they often have.

The investigators examined the association between skeletal muscle mass metrics, measured using bioelectrical impedance analysis, and anthropometric measures and prognosis in patients with heart failure.

SMI was calculated using the BIA by dividing appendicular skeletal muscle mass by height squared. MUAC and CC were measured to the nearest 1 mm using a plastic tape measure. AMC was calculated as follows: MUAC (cm) − (0.314 x triceps skinfold [TSF]). The TSF was measured to the nearest 2 mm with a skinfold caliper. The measuring spot for TSF was the same measuring spot for MUAC. MUAC, CC, and TSF were measured by trained physiotherapists or nurses.

The investigators identified 1,930 consecutive patients with heart failure who underwent cardiac rehabilitation during their hospitalization. They excluded from their analysis 1,013 patients who did not undergo a skeletal mass metrics evaluation and 48 who could not be followed up.

The analysis included 869 patients (median age, 73 years; 62% men). Patients were separated into three groups on the basis of the sex-specific tertiles of skeletal muscle mass. The study endpoint was all-cause death or readmission due to heart failure, and the median follow-up period was 1.24 years.

After the investigators adjusted the data for age, sex, New York Heart Association functional class III or IV, left ventricular ejection fraction (LVEF), ischemic etiology, prior heart failure, diabetes, chronic obstructive pulmonary disease, log-transformed B-type natriuretic peptide (BNP), and estimated glomerular filtration rate (eGFR), the high MUAC and high AMC groups were associated with significantly better prognoses than their respective low groups. By contrast, high SMI and high CC were not associated with better prognoses.

Subgroup analyses showed no interactions between MUAC and age, sex, LVEF, BNP, eGFR, prior heart failure, beta-blocker use, and angiotensin-converting enzyme inhibitor or angiotensin II receptor blocker use. However, diuretic agents significantly interacted with AMC (P = .03).

“These results support the use of MUAC and AMC to determine the risk stratification of sarcopenia and a poor prognosis in patients with heart failure and suggest that they may be useful in developing treatment strategies in patients with heart failure,” wrote the authors.

“When caring for patients with heart failure, it seems that the often overlooked and simple measure of arm circumference might carry significant prognostic value,” said Dr. Kamiya and Dr. Uchida. “So, as you cuff the arm for routine blood pressure measurement, it might be worthwhile to also pay attention to arm girth.”

Although the findings provide valuable insights, they should be approached with caution, Dr. Kamiya and Dr. Uchida added. “Before considering them practice-changing, further research is needed to validate these results in diverse patient cohorts.”
 

Prospective study needed

Commenting on the study for this news organization, Jonathan H. Whiteson, MD, vice chair of clinical operations and medical director of cardiac and pulmonary rehabilitation at NYU Langone Health’s Rusk Rehabilitation in New York, expressed concerns about the study methodology.

Methodologic weaknesses include the retrospective, observational nature of the study and the fact that incomplete data collection led to the exclusion of more than half of the potential participants, he said. In addition, “anthropometric measurements are prone to inter-rater error. It is not clear if the same or different researchers conducted these measurements.

“Furthermore, hospitalized patients may not be clinically stable when discharged,” said Dr. Whiteson. “It is recommended that biometrics for muscle mass and fluid retention be done when patients are at an optimized clinical state: that is, stabilized outpatients.”

For now, Dr. Whiteson concluded, the findings should be considered “interesting and suggestive of further study.” What’s needed is “a prospective study including all patients admitted with heart failure, but measurements done when the patient is stabilized as an outpatient.”

The study was partially supported by the Japan Society for the Promotion of Science KAKENHI. Dr. Kamiya, Dr. Uchida, and Dr. Whiteson reported no conflicts of interest.

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

In patients with heart failure, mid-upper arm circumference (MUAC) and arm muscle circumference (AMC) are more significantly associated with prognosis than guideline-recommended skeletal muscle mass index (SMI) or calf circumference (CC) measurements, research suggests.
 

In a single-center, retrospective study that included more than 800 patients, high MUAC (hazard ratio for combined events, 0.590) and high AMC (HR for combined events, 0.529) were associated with significantly better prognoses than low MUAC and low AMC.

The findings were “surprising,” Kentaro Kamiya, PT, PhD, and Shota Uchida, PT, PhD, of Kitasato University School of Allied Health Sciences in Kanagawa, Japan, said in an interview.

“These findings challenge the current recommendations found in sarcopenia guidelines,” they noted. The European Working Group on Sarcopenia in Older People and the Asian Working Group for Sarcopenia recommend SMI, as measured by bioelectrical impedance analysis (BIA), and CC as methods for screening skeletal muscle mass.

The study was published online in the Canadian Journal of Cardiology.
 

Arm measures prognostic

Sarcopenia, which is marked by a loss of skeletal muscle mass and strength, is associated with risks of adverse outcomes. Patients with heart failure have a high rate of sarcopenia, but assessing skeletal muscle mass in these patients is difficult because of the fluid retention they often have.

The investigators examined the association between skeletal muscle mass metrics, measured using bioelectrical impedance analysis, and anthropometric measures and prognosis in patients with heart failure.

SMI was calculated using the BIA by dividing appendicular skeletal muscle mass by height squared. MUAC and CC were measured to the nearest 1 mm using a plastic tape measure. AMC was calculated as follows: MUAC (cm) − (0.314 x triceps skinfold [TSF]). The TSF was measured to the nearest 2 mm with a skinfold caliper. The measuring spot for TSF was the same measuring spot for MUAC. MUAC, CC, and TSF were measured by trained physiotherapists or nurses.

The investigators identified 1,930 consecutive patients with heart failure who underwent cardiac rehabilitation during their hospitalization. They excluded from their analysis 1,013 patients who did not undergo a skeletal mass metrics evaluation and 48 who could not be followed up.

The analysis included 869 patients (median age, 73 years; 62% men). Patients were separated into three groups on the basis of the sex-specific tertiles of skeletal muscle mass. The study endpoint was all-cause death or readmission due to heart failure, and the median follow-up period was 1.24 years.

After the investigators adjusted the data for age, sex, New York Heart Association functional class III or IV, left ventricular ejection fraction (LVEF), ischemic etiology, prior heart failure, diabetes, chronic obstructive pulmonary disease, log-transformed B-type natriuretic peptide (BNP), and estimated glomerular filtration rate (eGFR), the high MUAC and high AMC groups were associated with significantly better prognoses than their respective low groups. By contrast, high SMI and high CC were not associated with better prognoses.

Subgroup analyses showed no interactions between MUAC and age, sex, LVEF, BNP, eGFR, prior heart failure, beta-blocker use, and angiotensin-converting enzyme inhibitor or angiotensin II receptor blocker use. However, diuretic agents significantly interacted with AMC (P = .03).

“These results support the use of MUAC and AMC to determine the risk stratification of sarcopenia and a poor prognosis in patients with heart failure and suggest that they may be useful in developing treatment strategies in patients with heart failure,” wrote the authors.

“When caring for patients with heart failure, it seems that the often overlooked and simple measure of arm circumference might carry significant prognostic value,” said Dr. Kamiya and Dr. Uchida. “So, as you cuff the arm for routine blood pressure measurement, it might be worthwhile to also pay attention to arm girth.”

Although the findings provide valuable insights, they should be approached with caution, Dr. Kamiya and Dr. Uchida added. “Before considering them practice-changing, further research is needed to validate these results in diverse patient cohorts.”
 

Prospective study needed

Commenting on the study for this news organization, Jonathan H. Whiteson, MD, vice chair of clinical operations and medical director of cardiac and pulmonary rehabilitation at NYU Langone Health’s Rusk Rehabilitation in New York, expressed concerns about the study methodology.

Methodologic weaknesses include the retrospective, observational nature of the study and the fact that incomplete data collection led to the exclusion of more than half of the potential participants, he said. In addition, “anthropometric measurements are prone to inter-rater error. It is not clear if the same or different researchers conducted these measurements.

“Furthermore, hospitalized patients may not be clinically stable when discharged,” said Dr. Whiteson. “It is recommended that biometrics for muscle mass and fluid retention be done when patients are at an optimized clinical state: that is, stabilized outpatients.”

For now, Dr. Whiteson concluded, the findings should be considered “interesting and suggestive of further study.” What’s needed is “a prospective study including all patients admitted with heart failure, but measurements done when the patient is stabilized as an outpatient.”

The study was partially supported by the Japan Society for the Promotion of Science KAKENHI. Dr. Kamiya, Dr. Uchida, and Dr. Whiteson reported no conflicts of interest.

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

For the first time in the fall of 2023, families will be offered season-long protection for infants and some children against respiratory syncytial virus (RSV).

The Food and Drug Administration in July approved a prevention called nirsevimab (Beyfortus, AstraZeneca/Sanofi) and it is expected to be widely rolled out in the coming weeks as the RSV season begins.

It’s not a vaccine, but a monoclonal antibody used for prevention. That may cause confusion because a vaccine for RSV was approved just 3 months ago for adults aged 60 and older. And monoclonal antibodies are often used for treatment rather than prevention.

Adding to potential confusion is the fact the Centers for Disease Control and Prevention has included nirsevimab in the Vaccines for Children program, which covers the costs for uninsured kids and makes it more accessible.

Nirsevimab is approved for infants (up to 8 months old) born during or entering their first RSV season, and in children up to 2 years of age who are still vulnerable to severe RSV through their second season.

It’s recommended that all infants get one injection in their first 8 months for prevention instead of the previous monthly shots used to help prevent kids at high risk from getting severe RSV.

If monoclonal antibodies can be used for preventing disease in infants, could they become a viable vaccine alternative for adults?

Specialists say no.

That’s partly because of the difference in body size. Although an injection is an option for a newborn, pediatricians suggest, it would take far too much of the treatment to work as a shot for adults.

Ruth Karron, MD, an expert in pediatric infectious diseases at Johns Hopkins Medicine, Baltimore, said that, while vaccines come in small amounts and activate immune cells, monoclonal antibodies are more like a drug, with the dose based on weight.

“You’d have to give it intravenously,” for larger doses, she explained, which has never been studied before and would also be very expensive. “It really couldn’t be an option for adults.”
 

What’s the difference between vaccines and antibodies?

Monoclonal antibodies are proteins made in a lab to mimic the immune system’s ability to fight pathogens such as viruses.

Dr. Karron explained that a wide variety of monoclonal antibodies have long been used to treat diseases such as cancers and autoimmune disease. In recent years, the antibodies have been used to treat COVID.

Monoclonal antibodies have also been used to treat RSV in children, but the effects don’t last long – they confer passive immunity and “when it’s gone, it’s gone,” Dr. Karron said.

That means kids at high risk for severe RSV have had to get monthly injections.

But with nirsevimab, the mutated antibodies stay in circulation longer so they can last 5 or 6 months, enough to cover the RSV season, Dr. Karron explained. “It’s highly, highly effective.”
 

Vaccines train the body

“The idea with vaccines is that you engage the individual’s immune system. You teach it to make antibodies,” Dr. Karron said. Conversely, “you give an antibody and it’s good for as long as the antibody lasts. It’s not teaching your body anything.”

Frank Esper, MD, a pediatric infectious disease specialist at Cleveland Clinic Children’s Hospital, said monoclonal antibody protection for RSV is particularly welcome. “We’ve been trying to make an RSV vaccine since the 1960s and have done nothing but fail miserably.”

“The best thing is always a vaccine,” Dr. Esper said, explaining that vaccines teach the body to make its own antibodies and confer long-term protection and are “probably more efficacious than anything that’s ever manmade.

“But since we’ve really not done very well for pediatric RSV vaccines, nirsevimab is certainly something I’m looking forward to,” he said.
 

Fast-acting monoclonal antibodies

An advantage for monoclonal antibodies is that they start working almost immediately.

Children can get sick with RSV in the first few months of life so the speed of the monoclonal antibodies to begin protection is important, Dr. Esper said, adding that RSV “is the worst during the first year of life.”

The peak age for babies getting infected enough to require hospitalization is about 2 months, he said.

By 14 months, he said, kids’ immune systems and airways have matured enough “that it’s not nearly as bad.”

To get protection from a vaccine, he added, “usually takes 2-4 weeks from the time you get your shot to the time you see some benefit. With an antibody, you’re bypassing the processing that the body has to do, and it goes straight to ‘protection’ mode,” Dr. Esper said. “You get protected pretty much as soon as you get the antibody.”

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

For the first time in the fall of 2023, families will be offered season-long protection for infants and some children against respiratory syncytial virus (RSV).

The Food and Drug Administration in July approved a prevention called nirsevimab (Beyfortus, AstraZeneca/Sanofi) and it is expected to be widely rolled out in the coming weeks as the RSV season begins.

It’s not a vaccine, but a monoclonal antibody used for prevention. That may cause confusion because a vaccine for RSV was approved just 3 months ago for adults aged 60 and older. And monoclonal antibodies are often used for treatment rather than prevention.

Adding to potential confusion is the fact the Centers for Disease Control and Prevention has included nirsevimab in the Vaccines for Children program, which covers the costs for uninsured kids and makes it more accessible.

Nirsevimab is approved for infants (up to 8 months old) born during or entering their first RSV season, and in children up to 2 years of age who are still vulnerable to severe RSV through their second season.

It’s recommended that all infants get one injection in their first 8 months for prevention instead of the previous monthly shots used to help prevent kids at high risk from getting severe RSV.

If monoclonal antibodies can be used for preventing disease in infants, could they become a viable vaccine alternative for adults?

Specialists say no.

That’s partly because of the difference in body size. Although an injection is an option for a newborn, pediatricians suggest, it would take far too much of the treatment to work as a shot for adults.

Ruth Karron, MD, an expert in pediatric infectious diseases at Johns Hopkins Medicine, Baltimore, said that, while vaccines come in small amounts and activate immune cells, monoclonal antibodies are more like a drug, with the dose based on weight.

“You’d have to give it intravenously,” for larger doses, she explained, which has never been studied before and would also be very expensive. “It really couldn’t be an option for adults.”
 

What’s the difference between vaccines and antibodies?

Monoclonal antibodies are proteins made in a lab to mimic the immune system’s ability to fight pathogens such as viruses.

Dr. Karron explained that a wide variety of monoclonal antibodies have long been used to treat diseases such as cancers and autoimmune disease. In recent years, the antibodies have been used to treat COVID.

Monoclonal antibodies have also been used to treat RSV in children, but the effects don’t last long – they confer passive immunity and “when it’s gone, it’s gone,” Dr. Karron said.

That means kids at high risk for severe RSV have had to get monthly injections.

But with nirsevimab, the mutated antibodies stay in circulation longer so they can last 5 or 6 months, enough to cover the RSV season, Dr. Karron explained. “It’s highly, highly effective.”
 

Vaccines train the body

“The idea with vaccines is that you engage the individual’s immune system. You teach it to make antibodies,” Dr. Karron said. Conversely, “you give an antibody and it’s good for as long as the antibody lasts. It’s not teaching your body anything.”

Frank Esper, MD, a pediatric infectious disease specialist at Cleveland Clinic Children’s Hospital, said monoclonal antibody protection for RSV is particularly welcome. “We’ve been trying to make an RSV vaccine since the 1960s and have done nothing but fail miserably.”

“The best thing is always a vaccine,” Dr. Esper said, explaining that vaccines teach the body to make its own antibodies and confer long-term protection and are “probably more efficacious than anything that’s ever manmade.

“But since we’ve really not done very well for pediatric RSV vaccines, nirsevimab is certainly something I’m looking forward to,” he said.
 

Fast-acting monoclonal antibodies

An advantage for monoclonal antibodies is that they start working almost immediately.

Children can get sick with RSV in the first few months of life so the speed of the monoclonal antibodies to begin protection is important, Dr. Esper said, adding that RSV “is the worst during the first year of life.”

The peak age for babies getting infected enough to require hospitalization is about 2 months, he said.

By 14 months, he said, kids’ immune systems and airways have matured enough “that it’s not nearly as bad.”

To get protection from a vaccine, he added, “usually takes 2-4 weeks from the time you get your shot to the time you see some benefit. With an antibody, you’re bypassing the processing that the body has to do, and it goes straight to ‘protection’ mode,” Dr. Esper said. “You get protected pretty much as soon as you get the antibody.”

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

For the first time in the fall of 2023, families will be offered season-long protection for infants and some children against respiratory syncytial virus (RSV).

The Food and Drug Administration in July approved a prevention called nirsevimab (Beyfortus, AstraZeneca/Sanofi) and it is expected to be widely rolled out in the coming weeks as the RSV season begins.

It’s not a vaccine, but a monoclonal antibody used for prevention. That may cause confusion because a vaccine for RSV was approved just 3 months ago for adults aged 60 and older. And monoclonal antibodies are often used for treatment rather than prevention.

Adding to potential confusion is the fact the Centers for Disease Control and Prevention has included nirsevimab in the Vaccines for Children program, which covers the costs for uninsured kids and makes it more accessible.

Nirsevimab is approved for infants (up to 8 months old) born during or entering their first RSV season, and in children up to 2 years of age who are still vulnerable to severe RSV through their second season.

It’s recommended that all infants get one injection in their first 8 months for prevention instead of the previous monthly shots used to help prevent kids at high risk from getting severe RSV.

If monoclonal antibodies can be used for preventing disease in infants, could they become a viable vaccine alternative for adults?

Specialists say no.

That’s partly because of the difference in body size. Although an injection is an option for a newborn, pediatricians suggest, it would take far too much of the treatment to work as a shot for adults.

Ruth Karron, MD, an expert in pediatric infectious diseases at Johns Hopkins Medicine, Baltimore, said that, while vaccines come in small amounts and activate immune cells, monoclonal antibodies are more like a drug, with the dose based on weight.

“You’d have to give it intravenously,” for larger doses, she explained, which has never been studied before and would also be very expensive. “It really couldn’t be an option for adults.”
 

What’s the difference between vaccines and antibodies?

Monoclonal antibodies are proteins made in a lab to mimic the immune system’s ability to fight pathogens such as viruses.

Dr. Karron explained that a wide variety of monoclonal antibodies have long been used to treat diseases such as cancers and autoimmune disease. In recent years, the antibodies have been used to treat COVID.

Monoclonal antibodies have also been used to treat RSV in children, but the effects don’t last long – they confer passive immunity and “when it’s gone, it’s gone,” Dr. Karron said.

That means kids at high risk for severe RSV have had to get monthly injections.

But with nirsevimab, the mutated antibodies stay in circulation longer so they can last 5 or 6 months, enough to cover the RSV season, Dr. Karron explained. “It’s highly, highly effective.”
 

Vaccines train the body

“The idea with vaccines is that you engage the individual’s immune system. You teach it to make antibodies,” Dr. Karron said. Conversely, “you give an antibody and it’s good for as long as the antibody lasts. It’s not teaching your body anything.”

Frank Esper, MD, a pediatric infectious disease specialist at Cleveland Clinic Children’s Hospital, said monoclonal antibody protection for RSV is particularly welcome. “We’ve been trying to make an RSV vaccine since the 1960s and have done nothing but fail miserably.”

“The best thing is always a vaccine,” Dr. Esper said, explaining that vaccines teach the body to make its own antibodies and confer long-term protection and are “probably more efficacious than anything that’s ever manmade.

“But since we’ve really not done very well for pediatric RSV vaccines, nirsevimab is certainly something I’m looking forward to,” he said.
 

Fast-acting monoclonal antibodies

An advantage for monoclonal antibodies is that they start working almost immediately.

Children can get sick with RSV in the first few months of life so the speed of the monoclonal antibodies to begin protection is important, Dr. Esper said, adding that RSV “is the worst during the first year of life.”

The peak age for babies getting infected enough to require hospitalization is about 2 months, he said.

By 14 months, he said, kids’ immune systems and airways have matured enough “that it’s not nearly as bad.”

To get protection from a vaccine, he added, “usually takes 2-4 weeks from the time you get your shot to the time you see some benefit. With an antibody, you’re bypassing the processing that the body has to do, and it goes straight to ‘protection’ mode,” Dr. Esper said. “You get protected pretty much as soon as you get the antibody.”

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

PARIS – Oxygen therapy is used too often in patients with respiratory difficulties, says one expert, and should be given only when oxygen saturation levels (SpO₂) drop below 93%, as per the current guidelines. Florian Negrello, MD, an emergency medicine specialist at University Hospital of Martinique in Fort-de-France, reiterated this message at the 2023 conference held by France’s emergency medicine society (Urgences 2023). The recommendation is intended to prevent hyperoxia; increasing evidence indicates the harmful effects of such a state on the body. 

“This is a real problem. Oxygen therapy is given all too readily despite studies now showing that excess oxygen is harmful, especially in patients with head trauma, ischemic stroke, or cardiac arrest,” stated the session’s moderator, Patrick Plaisance, MD, PhD, a doctor at Lariboisière Hospital in Paris. 
 

No proven hypoxia

Described as difficulty breathing or shortness of breath, dyspnea is common in the emergency department, occurring in 5%-9% of patients. Close to 20% of intensive care unit admissions involve patients with dyspnea. “Since this is a very subjective symptom, it’s possible it’s being underdiagnosed,” said Dr. Negrello.

Lower respiratory tract infection, acute heart failure, chronic obstructive pulmonary disease, and exacerbation of asthma are the four main diagnoses linked to dyspnea, but this symptom is also seen in several medical conditions (gastrointestinal, metabolic, neurologic, etc.), he noted. 

Often seen as a harmless treatment option, oxygen therapy is commonly administered to patients with breathing difficulties even when no hypoxemia is documented. This is particularly the case for patients brought into hospital via ambulance who are treated with oxygen without even having had their blood oxygen levels, SpO₂, and partial pressure of oxygen checked. 

In the United States, one of the few studies published on the topic showed that one-third of patients transported via ambulance are put on oxygen, with SpO₂ being measured in just 5% of these cases. Finally, just 17% of patients receiving oxygen were experiencing hypoxia, defined as SpO₂ < 94%. 
 

Oxidative stress 

Recently, several research studies have revealed the potential dangers of unjustified use of oxygen, which can lead to hyperoxia and increased mortality in hospitalized patients. 

A meta-analysis reported a linear relationship between severe hyperoxia, in-hospital mortality, and length of stay in intensive care. Another study revealed a greater mortality rate in patients with acute respiratory distress syndrome (ARDS) experiencing an episode of hyperoxia, regardless of the severity of ARDS. 

Oxygen toxicity in intensive care is said to be linked to oxidative stress caused by increased growth of reactive oxygen species but also to the systemic inflammation caused by hyperoxia, explained Dr. Negrello. Excess oxygen may also cause lung lesions with necrosis, the severity of which is proportional to the fraction of inspired oxygen and the length of exposure. 

According to the most up-to-date international recommendations published in 2018 on the use of oxygen therapy in treating acute conditions, oxygen should not be used when SpO₂ ≥ 93%. When treatment has been started, it must be stopped when SpO₂ reaches 96%. SpO₂ cannot be maintained above 96%, according to experts. 

These threshold values can be found in the COVID-19 treatment guidelines produced by the French-Language Society of Respiratory Medicine, with oxygen therapy being recommended when SpO₂ < 92%, added Dr. Negrello. The aim is to maintain normal oxygen levels, with SpO₂ between 92% and 96%. 
 

Use sparingly 

For patients with COPD, the target levels are lower, due to the risk of hypercapnia (higher than normal carbon dioxide levels in the blood). Oxygen saturation levels should then be kept between 88% and 92%, “by using the minimum amount of oxygen necessary,” per the guidelines. 

“Oxygen should be used sparingly,” concluded Dr. Negrello. “To treat our patients without harming them, we must be able to use it at the right time, meaning when a patient really has low blood oxygen, by focusing on normal saturation levels as the end goal.”

SpO₂ measurement is the first step to be taken to determine oxygen requirements, followed by, if necessary, blood gas analysis once the patient has been admitted, he explained. 

Questioned at the end of his session on how long oxygen therapy can be given for, Dr. Negrello reiterated that the risk for death is correlated with the length of time spent in a state of hyperoxia but that it is difficult to establish a maximum timeframe to be adhered to strictly. 

Given that excess oxygen is harmful to patients in intensive care, “it would be better, when in doubt, to focus on physiological levels” and simply stop treatment when target saturation levels are reached. 

This article was translated from the Medscape French Edition. A version appeared on Medscape.com.

PARIS – Oxygen therapy is used too often in patients with respiratory difficulties, says one expert, and should be given only when oxygen saturation levels (SpO₂) drop below 93%, as per the current guidelines. Florian Negrello, MD, an emergency medicine specialist at University Hospital of Martinique in Fort-de-France, reiterated this message at the 2023 conference held by France’s emergency medicine society (Urgences 2023). The recommendation is intended to prevent hyperoxia; increasing evidence indicates the harmful effects of such a state on the body. 

“This is a real problem. Oxygen therapy is given all too readily despite studies now showing that excess oxygen is harmful, especially in patients with head trauma, ischemic stroke, or cardiac arrest,” stated the session’s moderator, Patrick Plaisance, MD, PhD, a doctor at Lariboisière Hospital in Paris. 
 

No proven hypoxia

Described as difficulty breathing or shortness of breath, dyspnea is common in the emergency department, occurring in 5%-9% of patients. Close to 20% of intensive care unit admissions involve patients with dyspnea. “Since this is a very subjective symptom, it’s possible it’s being underdiagnosed,” said Dr. Negrello.

Lower respiratory tract infection, acute heart failure, chronic obstructive pulmonary disease, and exacerbation of asthma are the four main diagnoses linked to dyspnea, but this symptom is also seen in several medical conditions (gastrointestinal, metabolic, neurologic, etc.), he noted. 

Often seen as a harmless treatment option, oxygen therapy is commonly administered to patients with breathing difficulties even when no hypoxemia is documented. This is particularly the case for patients brought into hospital via ambulance who are treated with oxygen without even having had their blood oxygen levels, SpO₂, and partial pressure of oxygen checked. 

In the United States, one of the few studies published on the topic showed that one-third of patients transported via ambulance are put on oxygen, with SpO₂ being measured in just 5% of these cases. Finally, just 17% of patients receiving oxygen were experiencing hypoxia, defined as SpO₂ < 94%. 
 

Oxidative stress 

Recently, several research studies have revealed the potential dangers of unjustified use of oxygen, which can lead to hyperoxia and increased mortality in hospitalized patients. 

A meta-analysis reported a linear relationship between severe hyperoxia, in-hospital mortality, and length of stay in intensive care. Another study revealed a greater mortality rate in patients with acute respiratory distress syndrome (ARDS) experiencing an episode of hyperoxia, regardless of the severity of ARDS. 

Oxygen toxicity in intensive care is said to be linked to oxidative stress caused by increased growth of reactive oxygen species but also to the systemic inflammation caused by hyperoxia, explained Dr. Negrello. Excess oxygen may also cause lung lesions with necrosis, the severity of which is proportional to the fraction of inspired oxygen and the length of exposure. 

According to the most up-to-date international recommendations published in 2018 on the use of oxygen therapy in treating acute conditions, oxygen should not be used when SpO₂ ≥ 93%. When treatment has been started, it must be stopped when SpO₂ reaches 96%. SpO₂ cannot be maintained above 96%, according to experts. 

These threshold values can be found in the COVID-19 treatment guidelines produced by the French-Language Society of Respiratory Medicine, with oxygen therapy being recommended when SpO₂ < 92%, added Dr. Negrello. The aim is to maintain normal oxygen levels, with SpO₂ between 92% and 96%. 
 

Use sparingly 

For patients with COPD, the target levels are lower, due to the risk of hypercapnia (higher than normal carbon dioxide levels in the blood). Oxygen saturation levels should then be kept between 88% and 92%, “by using the minimum amount of oxygen necessary,” per the guidelines. 

“Oxygen should be used sparingly,” concluded Dr. Negrello. “To treat our patients without harming them, we must be able to use it at the right time, meaning when a patient really has low blood oxygen, by focusing on normal saturation levels as the end goal.”

SpO₂ measurement is the first step to be taken to determine oxygen requirements, followed by, if necessary, blood gas analysis once the patient has been admitted, he explained. 

Questioned at the end of his session on how long oxygen therapy can be given for, Dr. Negrello reiterated that the risk for death is correlated with the length of time spent in a state of hyperoxia but that it is difficult to establish a maximum timeframe to be adhered to strictly. 

Given that excess oxygen is harmful to patients in intensive care, “it would be better, when in doubt, to focus on physiological levels” and simply stop treatment when target saturation levels are reached. 

This article was translated from the Medscape French Edition. A version appeared on Medscape.com.

PARIS – Oxygen therapy is used too often in patients with respiratory difficulties, says one expert, and should be given only when oxygen saturation levels (SpO₂) drop below 93%, as per the current guidelines. Florian Negrello, MD, an emergency medicine specialist at University Hospital of Martinique in Fort-de-France, reiterated this message at the 2023 conference held by France’s emergency medicine society (Urgences 2023). The recommendation is intended to prevent hyperoxia; increasing evidence indicates the harmful effects of such a state on the body. 

“This is a real problem. Oxygen therapy is given all too readily despite studies now showing that excess oxygen is harmful, especially in patients with head trauma, ischemic stroke, or cardiac arrest,” stated the session’s moderator, Patrick Plaisance, MD, PhD, a doctor at Lariboisière Hospital in Paris. 
 

No proven hypoxia

Described as difficulty breathing or shortness of breath, dyspnea is common in the emergency department, occurring in 5%-9% of patients. Close to 20% of intensive care unit admissions involve patients with dyspnea. “Since this is a very subjective symptom, it’s possible it’s being underdiagnosed,” said Dr. Negrello.

Lower respiratory tract infection, acute heart failure, chronic obstructive pulmonary disease, and exacerbation of asthma are the four main diagnoses linked to dyspnea, but this symptom is also seen in several medical conditions (gastrointestinal, metabolic, neurologic, etc.), he noted. 

Often seen as a harmless treatment option, oxygen therapy is commonly administered to patients with breathing difficulties even when no hypoxemia is documented. This is particularly the case for patients brought into hospital via ambulance who are treated with oxygen without even having had their blood oxygen levels, SpO₂, and partial pressure of oxygen checked. 

In the United States, one of the few studies published on the topic showed that one-third of patients transported via ambulance are put on oxygen, with SpO₂ being measured in just 5% of these cases. Finally, just 17% of patients receiving oxygen were experiencing hypoxia, defined as SpO₂ < 94%. 
 

Oxidative stress 

Recently, several research studies have revealed the potential dangers of unjustified use of oxygen, which can lead to hyperoxia and increased mortality in hospitalized patients. 

A meta-analysis reported a linear relationship between severe hyperoxia, in-hospital mortality, and length of stay in intensive care. Another study revealed a greater mortality rate in patients with acute respiratory distress syndrome (ARDS) experiencing an episode of hyperoxia, regardless of the severity of ARDS. 

Oxygen toxicity in intensive care is said to be linked to oxidative stress caused by increased growth of reactive oxygen species but also to the systemic inflammation caused by hyperoxia, explained Dr. Negrello. Excess oxygen may also cause lung lesions with necrosis, the severity of which is proportional to the fraction of inspired oxygen and the length of exposure. 

According to the most up-to-date international recommendations published in 2018 on the use of oxygen therapy in treating acute conditions, oxygen should not be used when SpO₂ ≥ 93%. When treatment has been started, it must be stopped when SpO₂ reaches 96%. SpO₂ cannot be maintained above 96%, according to experts. 

These threshold values can be found in the COVID-19 treatment guidelines produced by the French-Language Society of Respiratory Medicine, with oxygen therapy being recommended when SpO₂ < 92%, added Dr. Negrello. The aim is to maintain normal oxygen levels, with SpO₂ between 92% and 96%. 
 

Use sparingly 

For patients with COPD, the target levels are lower, due to the risk of hypercapnia (higher than normal carbon dioxide levels in the blood). Oxygen saturation levels should then be kept between 88% and 92%, “by using the minimum amount of oxygen necessary,” per the guidelines. 

“Oxygen should be used sparingly,” concluded Dr. Negrello. “To treat our patients without harming them, we must be able to use it at the right time, meaning when a patient really has low blood oxygen, by focusing on normal saturation levels as the end goal.”

SpO₂ measurement is the first step to be taken to determine oxygen requirements, followed by, if necessary, blood gas analysis once the patient has been admitted, he explained. 

Questioned at the end of his session on how long oxygen therapy can be given for, Dr. Negrello reiterated that the risk for death is correlated with the length of time spent in a state of hyperoxia but that it is difficult to establish a maximum timeframe to be adhered to strictly. 

Given that excess oxygen is harmful to patients in intensive care, “it would be better, when in doubt, to focus on physiological levels” and simply stop treatment when target saturation levels are reached. 

This article was translated from the Medscape French Edition. A version appeared on Medscape.com.

The Food and Drug Administration has granted clearance for Roche’s Accu-Chek Solo micropump system, a tubing-free “patch” pump for people with diabetes who use insulin.

Olivier Le Moal/Getty Images

The product received CE Mark in Europe in 2018 and is now available in 19 markets worldwide. It offers users a choice of bolusing directly from the pump or from a handheld remote-control device. The pump can be detached and reattached without wasting insulin.

The remote-control device also incorporates blood glucose monitoring and bolus advice, although it currently does not integrate with continuous glucose monitoring (CGM) devices.

A Roche spokesperson said in an interview, “For future product generations, we are exploring possibilities to integrate CGM data into the system. Already today, the diabetes manager allows users to manually enter a glucose value that can be used to calculate a bolus. To do so, people with diabetes could use their CGM device of choice in conjunction with the Accu-Chek Solo micropump system.”

Roche will provide an update on next steps for further developments and time lines for launch “in due course,” according to a company statement.

A version of this article appeared on Medscape.com.

The Food and Drug Administration has granted clearance for Roche’s Accu-Chek Solo micropump system, a tubing-free “patch” pump for people with diabetes who use insulin.

Olivier Le Moal/Getty Images

The product received CE Mark in Europe in 2018 and is now available in 19 markets worldwide. It offers users a choice of bolusing directly from the pump or from a handheld remote-control device. The pump can be detached and reattached without wasting insulin.

The remote-control device also incorporates blood glucose monitoring and bolus advice, although it currently does not integrate with continuous glucose monitoring (CGM) devices.

A Roche spokesperson said in an interview, “For future product generations, we are exploring possibilities to integrate CGM data into the system. Already today, the diabetes manager allows users to manually enter a glucose value that can be used to calculate a bolus. To do so, people with diabetes could use their CGM device of choice in conjunction with the Accu-Chek Solo micropump system.”

Roche will provide an update on next steps for further developments and time lines for launch “in due course,” according to a company statement.

A version of this article appeared on Medscape.com.

The Food and Drug Administration has granted clearance for Roche’s Accu-Chek Solo micropump system, a tubing-free “patch” pump for people with diabetes who use insulin.

Olivier Le Moal/Getty Images

The product received CE Mark in Europe in 2018 and is now available in 19 markets worldwide. It offers users a choice of bolusing directly from the pump or from a handheld remote-control device. The pump can be detached and reattached without wasting insulin.

The remote-control device also incorporates blood glucose monitoring and bolus advice, although it currently does not integrate with continuous glucose monitoring (CGM) devices.

A Roche spokesperson said in an interview, “For future product generations, we are exploring possibilities to integrate CGM data into the system. Already today, the diabetes manager allows users to manually enter a glucose value that can be used to calculate a bolus. To do so, people with diabetes could use their CGM device of choice in conjunction with the Accu-Chek Solo micropump system.”

Roche will provide an update on next steps for further developments and time lines for launch “in due course,” according to a company statement.

A version of this article appeared on Medscape.com.

One in five women in the United States undergoing maternity care experiences mistreatment from health care providers, based on survey data from more than 2,000 individuals.

“We have to do better at providing respectful and unbiased care to all mothers,” Debra E. Houry, MD, chief medical officer of the Centers for Disease Control and Prevention, said in a press briefing announcing the findings, which were published as a Vital Signs report in the CDC’s Morbidity and Mortality Weekly Report.

Previous research showed an increase in maternal deaths in the United States from 17.4 to 32.9 per 100,000 live births between 2018 and 2021, but approximately 80% of these deaths are preventable, wrote Yousra A. Mohamoud, PhD, of the CDC’s division of reproductive health, and colleagues.

Dr. Mohamoud

“Maternal mortality review committees have identified discrimination as one factor contributing to pregnancy-related deaths,” the researchers wrote. Respectful care must be part of a larger strategy to prevent these deaths, they emphasized.

In the report, researchers reviewed data from 2,402 women who responded to an opt-in survey. The survey was conducted for the CDC through Porter Novelli, and no personally identifying information was included. Nearly 70% of the participants were White, 10.7% were Black, 10.2% were Hispanic, 4.8% were Asian, 1.5% were American Indian, Alaska Native, Pacific Islander, or Native Hawaiian, 2.8% were multiracial, and 0.5% were another race.

The survey included questions about maternity care experiences during pregnancy and delivery of the youngest child. For 65.5% of respondents, their youngest child was 5 years or older at the time of the survey.

Mistreatment during maternity care was defined using seven validated questions, including questions about violations of physical privacy, verbal abuse, and inattention to requests for help. Satisfaction with maternity care was defined as “very satisfied” or “somewhat satisfied.”

Participants also responded to questions about discrimination during maternity care based on factors such as race, ethnicity, skin color, age, and weight. Finally, participants were asked whether they refrained from asking questions about their health or raising concerns with health care providers.

Overall, 20.4% of respondents reported experiencing one of the defined forms of mistreatment during maternity care. The most common mistreatment reported by the women was being ignored by providers when they requested help (9.7%), followed by being shouted at or scolded (6.7%), having physical privacy violated (5.1%), and being forced to accept unwanted treatment or threatened with withholding of treatment (4.6%).

However, approximately 90% of women overall and 75% of those who reported any mistreatment were very or somewhat satisfied with their maternity care.

When stratified by race, mistreatment was reported most frequently by Black, Hispanic, and multiracial women (30%, 29%, and 27%, respectively).

Overall, 29% of women reported experiencing some type of discrimination; the most frequently reported reasons were age, weight, and income. Black women reported the highest rates of discrimination (40%) followed by multiracial women (39%) and Hispanic women (37%).

With regard to self-advocacy, 45% of women reported holding back from asking questions of health care providers; the most common reasons were thinking their health concerns were normal for pregnancy, being embarrassed, and being concerned that health care providers would consider them difficult.

In addition, more women with no insurance or public insurance at the time of delivery reported mistreatment during their maternity care than did women with private insurance (28%, 26%, and 16%, respectively).

The findings were limited by several factors, including the opt-in nature of the survey, which means that the data are likely not representative of the birthing population in the United States, the researchers noted. Other limitations included the reliance on self-reports, potential recall bias, use of English language only, and use of a combined category for respondents of American Indian, Alaska Native, Native Hawaiian, and Pacific Islander ethnicity.

However, the results highlight the need for improving respectful care as part of a larger strategy to reduce pregnancy-related deaths, the researchers said. At the system level, quality improvement programs are needed to standardize care and support providers in recognizing and reducing biases and increasing cultural awareness and communication. At the provider level, clinicians at all points in the maternity care process can improve patient experiences by providing equitable and respectful care, and by listening to and addressing patients’ concerns.

In addition, communication campaigns and community engagement can include perspectives of patients, families, and communities to support women and encourage them to ask questions and express concerns, the researchers said.

Improving respectful care can be part of actions to reduce mortality at all levels, the researchers noted. The Hear Her campaign, developed by the CDC Foundation with funding from Merck, provides resources for pregnant and postpartum women and their support networks to help reduce pregnancy-related deaths and complications by encouraging women to share concerns with providers and to recognize urgent maternal warning signs.

The study received no outside funding. The researchers had no financial conflicts to disclose.

One in five women in the United States undergoing maternity care experiences mistreatment from health care providers, based on survey data from more than 2,000 individuals.

“We have to do better at providing respectful and unbiased care to all mothers,” Debra E. Houry, MD, chief medical officer of the Centers for Disease Control and Prevention, said in a press briefing announcing the findings, which were published as a Vital Signs report in the CDC’s Morbidity and Mortality Weekly Report.

Previous research showed an increase in maternal deaths in the United States from 17.4 to 32.9 per 100,000 live births between 2018 and 2021, but approximately 80% of these deaths are preventable, wrote Yousra A. Mohamoud, PhD, of the CDC’s division of reproductive health, and colleagues.

Dr. Mohamoud

“Maternal mortality review committees have identified discrimination as one factor contributing to pregnancy-related deaths,” the researchers wrote. Respectful care must be part of a larger strategy to prevent these deaths, they emphasized.

In the report, researchers reviewed data from 2,402 women who responded to an opt-in survey. The survey was conducted for the CDC through Porter Novelli, and no personally identifying information was included. Nearly 70% of the participants were White, 10.7% were Black, 10.2% were Hispanic, 4.8% were Asian, 1.5% were American Indian, Alaska Native, Pacific Islander, or Native Hawaiian, 2.8% were multiracial, and 0.5% were another race.

The survey included questions about maternity care experiences during pregnancy and delivery of the youngest child. For 65.5% of respondents, their youngest child was 5 years or older at the time of the survey.

Mistreatment during maternity care was defined using seven validated questions, including questions about violations of physical privacy, verbal abuse, and inattention to requests for help. Satisfaction with maternity care was defined as “very satisfied” or “somewhat satisfied.”

Participants also responded to questions about discrimination during maternity care based on factors such as race, ethnicity, skin color, age, and weight. Finally, participants were asked whether they refrained from asking questions about their health or raising concerns with health care providers.

Overall, 20.4% of respondents reported experiencing one of the defined forms of mistreatment during maternity care. The most common mistreatment reported by the women was being ignored by providers when they requested help (9.7%), followed by being shouted at or scolded (6.7%), having physical privacy violated (5.1%), and being forced to accept unwanted treatment or threatened with withholding of treatment (4.6%).

However, approximately 90% of women overall and 75% of those who reported any mistreatment were very or somewhat satisfied with their maternity care.

When stratified by race, mistreatment was reported most frequently by Black, Hispanic, and multiracial women (30%, 29%, and 27%, respectively).

Overall, 29% of women reported experiencing some type of discrimination; the most frequently reported reasons were age, weight, and income. Black women reported the highest rates of discrimination (40%) followed by multiracial women (39%) and Hispanic women (37%).

With regard to self-advocacy, 45% of women reported holding back from asking questions of health care providers; the most common reasons were thinking their health concerns were normal for pregnancy, being embarrassed, and being concerned that health care providers would consider them difficult.

In addition, more women with no insurance or public insurance at the time of delivery reported mistreatment during their maternity care than did women with private insurance (28%, 26%, and 16%, respectively).

The findings were limited by several factors, including the opt-in nature of the survey, which means that the data are likely not representative of the birthing population in the United States, the researchers noted. Other limitations included the reliance on self-reports, potential recall bias, use of English language only, and use of a combined category for respondents of American Indian, Alaska Native, Native Hawaiian, and Pacific Islander ethnicity.

However, the results highlight the need for improving respectful care as part of a larger strategy to reduce pregnancy-related deaths, the researchers said. At the system level, quality improvement programs are needed to standardize care and support providers in recognizing and reducing biases and increasing cultural awareness and communication. At the provider level, clinicians at all points in the maternity care process can improve patient experiences by providing equitable and respectful care, and by listening to and addressing patients’ concerns.

In addition, communication campaigns and community engagement can include perspectives of patients, families, and communities to support women and encourage them to ask questions and express concerns, the researchers said.

Improving respectful care can be part of actions to reduce mortality at all levels, the researchers noted. The Hear Her campaign, developed by the CDC Foundation with funding from Merck, provides resources for pregnant and postpartum women and their support networks to help reduce pregnancy-related deaths and complications by encouraging women to share concerns with providers and to recognize urgent maternal warning signs.

The study received no outside funding. The researchers had no financial conflicts to disclose.

One in five women in the United States undergoing maternity care experiences mistreatment from health care providers, based on survey data from more than 2,000 individuals.

“We have to do better at providing respectful and unbiased care to all mothers,” Debra E. Houry, MD, chief medical officer of the Centers for Disease Control and Prevention, said in a press briefing announcing the findings, which were published as a Vital Signs report in the CDC’s Morbidity and Mortality Weekly Report.

Previous research showed an increase in maternal deaths in the United States from 17.4 to 32.9 per 100,000 live births between 2018 and 2021, but approximately 80% of these deaths are preventable, wrote Yousra A. Mohamoud, PhD, of the CDC’s division of reproductive health, and colleagues.

Dr. Mohamoud

“Maternal mortality review committees have identified discrimination as one factor contributing to pregnancy-related deaths,” the researchers wrote. Respectful care must be part of a larger strategy to prevent these deaths, they emphasized.

In the report, researchers reviewed data from 2,402 women who responded to an opt-in survey. The survey was conducted for the CDC through Porter Novelli, and no personally identifying information was included. Nearly 70% of the participants were White, 10.7% were Black, 10.2% were Hispanic, 4.8% were Asian, 1.5% were American Indian, Alaska Native, Pacific Islander, or Native Hawaiian, 2.8% were multiracial, and 0.5% were another race.

The survey included questions about maternity care experiences during pregnancy and delivery of the youngest child. For 65.5% of respondents, their youngest child was 5 years or older at the time of the survey.

Mistreatment during maternity care was defined using seven validated questions, including questions about violations of physical privacy, verbal abuse, and inattention to requests for help. Satisfaction with maternity care was defined as “very satisfied” or “somewhat satisfied.”

Participants also responded to questions about discrimination during maternity care based on factors such as race, ethnicity, skin color, age, and weight. Finally, participants were asked whether they refrained from asking questions about their health or raising concerns with health care providers.

Overall, 20.4% of respondents reported experiencing one of the defined forms of mistreatment during maternity care. The most common mistreatment reported by the women was being ignored by providers when they requested help (9.7%), followed by being shouted at or scolded (6.7%), having physical privacy violated (5.1%), and being forced to accept unwanted treatment or threatened with withholding of treatment (4.6%).

However, approximately 90% of women overall and 75% of those who reported any mistreatment were very or somewhat satisfied with their maternity care.

When stratified by race, mistreatment was reported most frequently by Black, Hispanic, and multiracial women (30%, 29%, and 27%, respectively).

Overall, 29% of women reported experiencing some type of discrimination; the most frequently reported reasons were age, weight, and income. Black women reported the highest rates of discrimination (40%) followed by multiracial women (39%) and Hispanic women (37%).

With regard to self-advocacy, 45% of women reported holding back from asking questions of health care providers; the most common reasons were thinking their health concerns were normal for pregnancy, being embarrassed, and being concerned that health care providers would consider them difficult.

In addition, more women with no insurance or public insurance at the time of delivery reported mistreatment during their maternity care than did women with private insurance (28%, 26%, and 16%, respectively).

The findings were limited by several factors, including the opt-in nature of the survey, which means that the data are likely not representative of the birthing population in the United States, the researchers noted. Other limitations included the reliance on self-reports, potential recall bias, use of English language only, and use of a combined category for respondents of American Indian, Alaska Native, Native Hawaiian, and Pacific Islander ethnicity.

However, the results highlight the need for improving respectful care as part of a larger strategy to reduce pregnancy-related deaths, the researchers said. At the system level, quality improvement programs are needed to standardize care and support providers in recognizing and reducing biases and increasing cultural awareness and communication. At the provider level, clinicians at all points in the maternity care process can improve patient experiences by providing equitable and respectful care, and by listening to and addressing patients’ concerns.

In addition, communication campaigns and community engagement can include perspectives of patients, families, and communities to support women and encourage them to ask questions and express concerns, the researchers said.

Improving respectful care can be part of actions to reduce mortality at all levels, the researchers noted. The Hear Her campaign, developed by the CDC Foundation with funding from Merck, provides resources for pregnant and postpartum women and their support networks to help reduce pregnancy-related deaths and complications by encouraging women to share concerns with providers and to recognize urgent maternal warning signs.

The study received no outside funding. The researchers had no financial conflicts to disclose.

Studies have shown that breast cancer survivors have increased rates of age-related conditions, including cardiovascular disease and osteoporosis among others, therefore postulating that the biological aging process may be accelerated in this population.² Among 417 women enrolled in the prospective Sister Study cohort, paired blood samples collected an average of 7.7 years apart compared three epigenetic metrics of biological aging (calculated on the basis of DNA methylation data) between women who were diagnosed and treated for breast cancer (n = 190) vs those who remained breast cancer–free (n = 227) (Kresovich et al). Women diagnosed and treated for breast cancer had higher biological aging metrics than women who were cancer-free at the time of follow-up: PhenoAgeAccel³ (standardized mean difference [β] = 0.13; P = .04), GrimAgeAccel⁴ (β = 0.14; P = .01), and DunedinPACE⁵ (β = 0.37; P < .001). Regarding breast cancer therapies received, the increases in biological aging were most striking for those women who underwent radiation. The effect of cancer treatments, specifically chemotherapy and radiation, on DNA methylation profiles and accelerating the aging process has been demonstrated in prior studies as well.⁶ Future research should strive to improve our understanding of the specific mechanisms underlying these age-related changes, identify ways to affect those which are modifiable, and positively influence long-term cognitive and functional consequences.

The association between cardiometabolic abnormalities, including obesity, hyperinsulinemia, diabetes, hypertension, and dyslipidemia, and an elevated breast cancer risk has been demonstrated in various studies.⁷ Furthermore, dysregulation of obesity-related proteins plays a role in breast cancer development and progression. A study by Xu and colleagues evaluated the temporal relationships and longitudinal associations of body mass index (BMI), cardiometabolic risk score (CRS), and obesity-related protein score (OPS) among 444 healthy women in a breast cancer screening cohort. After adjustment for demographics, lifestyle, and reproductive factors, a 1-kg/m² increase in BMI per year increased CRS in both premenopausal (0.057 unit; P = .025) and postmenopausal women (0.054 unit; P = .033) and increased OPS by 0.588 unit (P = .001) in postmenopausal women. A significant association was also observed between CRS and OPS in postmenopausal women (β = 0.281; P = .034). These results support the importance of weight management and its effect on cardiometabolic and obesity-related parameters in breast cancer prevention. Research focused on lifestyle interventions to modify risk factors and effective implementation of these techniques will contribute to further reducing breast cancer risk.

Additional References

1. García-Albéniz X, Hernán MA, Logan RW, et al. Continuation of annual screening mammography and breast cancer mortality in women older than 70 years. Ann Intern Med. 2020;172(6):381-389. doi: 10.7326/M18-1199
2. Greenlee H, Iribarren C, Rana JS, et al. Risk of cardiovascular disease in women with and without breast cancer: The Pathways Heart Study. J Clin Oncol. 2022;40(15):1647-1658. doi: 10.1200/JCO.21.01736
3. Levine ME, Lu AT, Quach A, et al. An epigenetic biomarker of aging for lifespan and healthspan. Aging (Albany NY). 2018;10(4):573-591. doi: 10.18632/aging.101414
4. Lu AT, Quach A, Wilson JG, et al. DNA methylation GrimAge strongly predicts lifespan and healthspan. Aging (Albany NY). 2019;11(2):303-327. doi: 10.18632/aging.101684
5. Belsky DW, Caspi A, Corcoran DL, et al. DunedinPACE, a DNA methylation biomarker of the pace of aging. eLife. 2022:11:e73420. doi: 10.7554/eLife.73420
6. Sehl ME, Carroll JE, Horvath S, Bower JE. The acute effects of adjuvant radiation and chemotherapy on peripheral blood epigenetic age in early stage breast cancer patients. NPJ Breast Cancer. 2020;6:23. doi: 10.1038/s41523-020-0161-3
7. Nouri M, Mohsenpour MA, Katsiki N, et al. Effect of serum lipid profile on the risk of breast cancer: Systematic review and meta-analysis of 1,628,871 women. J Clin Med. 2022;11(15):4503. doi: 10.3390/jcm11154503

Studies have shown that breast cancer survivors have increased rates of age-related conditions, including cardiovascular disease and osteoporosis among others, therefore postulating that the biological aging process may be accelerated in this population.² Among 417 women enrolled in the prospective Sister Study cohort, paired blood samples collected an average of 7.7 years apart compared three epigenetic metrics of biological aging (calculated on the basis of DNA methylation data) between women who were diagnosed and treated for breast cancer (n = 190) vs those who remained breast cancer–free (n = 227) (Kresovich et al). Women diagnosed and treated for breast cancer had higher biological aging metrics than women who were cancer-free at the time of follow-up: PhenoAgeAccel³ (standardized mean difference [β] = 0.13; P = .04), GrimAgeAccel⁴ (β = 0.14; P = .01), and DunedinPACE⁵ (β = 0.37; P < .001). Regarding breast cancer therapies received, the increases in biological aging were most striking for those women who underwent radiation. The effect of cancer treatments, specifically chemotherapy and radiation, on DNA methylation profiles and accelerating the aging process has been demonstrated in prior studies as well.⁶ Future research should strive to improve our understanding of the specific mechanisms underlying these age-related changes, identify ways to affect those which are modifiable, and positively influence long-term cognitive and functional consequences.

The association between cardiometabolic abnormalities, including obesity, hyperinsulinemia, diabetes, hypertension, and dyslipidemia, and an elevated breast cancer risk has been demonstrated in various studies.⁷ Furthermore, dysregulation of obesity-related proteins plays a role in breast cancer development and progression. A study by Xu and colleagues evaluated the temporal relationships and longitudinal associations of body mass index (BMI), cardiometabolic risk score (CRS), and obesity-related protein score (OPS) among 444 healthy women in a breast cancer screening cohort. After adjustment for demographics, lifestyle, and reproductive factors, a 1-kg/m² increase in BMI per year increased CRS in both premenopausal (0.057 unit; P = .025) and postmenopausal women (0.054 unit; P = .033) and increased OPS by 0.588 unit (P = .001) in postmenopausal women. A significant association was also observed between CRS and OPS in postmenopausal women (β = 0.281; P = .034). These results support the importance of weight management and its effect on cardiometabolic and obesity-related parameters in breast cancer prevention. Research focused on lifestyle interventions to modify risk factors and effective implementation of these techniques will contribute to further reducing breast cancer risk.

Additional References

1. García-Albéniz X, Hernán MA, Logan RW, et al. Continuation of annual screening mammography and breast cancer mortality in women older than 70 years. Ann Intern Med. 2020;172(6):381-389. doi: 10.7326/M18-1199
2. Greenlee H, Iribarren C, Rana JS, et al. Risk of cardiovascular disease in women with and without breast cancer: The Pathways Heart Study. J Clin Oncol. 2022;40(15):1647-1658. doi: 10.1200/JCO.21.01736
3. Levine ME, Lu AT, Quach A, et al. An epigenetic biomarker of aging for lifespan and healthspan. Aging (Albany NY). 2018;10(4):573-591. doi: 10.18632/aging.101414
4. Lu AT, Quach A, Wilson JG, et al. DNA methylation GrimAge strongly predicts lifespan and healthspan. Aging (Albany NY). 2019;11(2):303-327. doi: 10.18632/aging.101684
5. Belsky DW, Caspi A, Corcoran DL, et al. DunedinPACE, a DNA methylation biomarker of the pace of aging. eLife. 2022:11:e73420. doi: 10.7554/eLife.73420
6. Sehl ME, Carroll JE, Horvath S, Bower JE. The acute effects of adjuvant radiation and chemotherapy on peripheral blood epigenetic age in early stage breast cancer patients. NPJ Breast Cancer. 2020;6:23. doi: 10.1038/s41523-020-0161-3
7. Nouri M, Mohsenpour MA, Katsiki N, et al. Effect of serum lipid profile on the risk of breast cancer: Systematic review and meta-analysis of 1,628,871 women. J Clin Med. 2022;11(15):4503. doi: 10.3390/jcm11154503

Studies have shown that breast cancer survivors have increased rates of age-related conditions, including cardiovascular disease and osteoporosis among others, therefore postulating that the biological aging process may be accelerated in this population.² Among 417 women enrolled in the prospective Sister Study cohort, paired blood samples collected an average of 7.7 years apart compared three epigenetic metrics of biological aging (calculated on the basis of DNA methylation data) between women who were diagnosed and treated for breast cancer (n = 190) vs those who remained breast cancer–free (n = 227) (Kresovich et al). Women diagnosed and treated for breast cancer had higher biological aging metrics than women who were cancer-free at the time of follow-up: PhenoAgeAccel³ (standardized mean difference [β] = 0.13; P = .04), GrimAgeAccel⁴ (β = 0.14; P = .01), and DunedinPACE⁵ (β = 0.37; P < .001). Regarding breast cancer therapies received, the increases in biological aging were most striking for those women who underwent radiation. The effect of cancer treatments, specifically chemotherapy and radiation, on DNA methylation profiles and accelerating the aging process has been demonstrated in prior studies as well.⁶ Future research should strive to improve our understanding of the specific mechanisms underlying these age-related changes, identify ways to affect those which are modifiable, and positively influence long-term cognitive and functional consequences.

The association between cardiometabolic abnormalities, including obesity, hyperinsulinemia, diabetes, hypertension, and dyslipidemia, and an elevated breast cancer risk has been demonstrated in various studies.⁷ Furthermore, dysregulation of obesity-related proteins plays a role in breast cancer development and progression. A study by Xu and colleagues evaluated the temporal relationships and longitudinal associations of body mass index (BMI), cardiometabolic risk score (CRS), and obesity-related protein score (OPS) among 444 healthy women in a breast cancer screening cohort. After adjustment for demographics, lifestyle, and reproductive factors, a 1-kg/m² increase in BMI per year increased CRS in both premenopausal (0.057 unit; P = .025) and postmenopausal women (0.054 unit; P = .033) and increased OPS by 0.588 unit (P = .001) in postmenopausal women. A significant association was also observed between CRS and OPS in postmenopausal women (β = 0.281; P = .034). These results support the importance of weight management and its effect on cardiometabolic and obesity-related parameters in breast cancer prevention. Research focused on lifestyle interventions to modify risk factors and effective implementation of these techniques will contribute to further reducing breast cancer risk.

Additional References

1. García-Albéniz X, Hernán MA, Logan RW, et al. Continuation of annual screening mammography and breast cancer mortality in women older than 70 years. Ann Intern Med. 2020;172(6):381-389. doi: 10.7326/M18-1199
2. Greenlee H, Iribarren C, Rana JS, et al. Risk of cardiovascular disease in women with and without breast cancer: The Pathways Heart Study. J Clin Oncol. 2022;40(15):1647-1658. doi: 10.1200/JCO.21.01736
3. Levine ME, Lu AT, Quach A, et al. An epigenetic biomarker of aging for lifespan and healthspan. Aging (Albany NY). 2018;10(4):573-591. doi: 10.18632/aging.101414
4. Lu AT, Quach A, Wilson JG, et al. DNA methylation GrimAge strongly predicts lifespan and healthspan. Aging (Albany NY). 2019;11(2):303-327. doi: 10.18632/aging.101684
5. Belsky DW, Caspi A, Corcoran DL, et al. DunedinPACE, a DNA methylation biomarker of the pace of aging. eLife. 2022:11:e73420. doi: 10.7554/eLife.73420
6. Sehl ME, Carroll JE, Horvath S, Bower JE. The acute effects of adjuvant radiation and chemotherapy on peripheral blood epigenetic age in early stage breast cancer patients. NPJ Breast Cancer. 2020;6:23. doi: 10.1038/s41523-020-0161-3
7. Nouri M, Mohsenpour MA, Katsiki N, et al. Effect of serum lipid profile on the risk of breast cancer: Systematic review and meta-analysis of 1,628,871 women. J Clin Med. 2022;11(15):4503. doi: 10.3390/jcm11154503

Across all industries, studies by the U.S. Department of Labor have shown that women, on average, earn 83.7 percent of what their male peers earn. While a lot has been written about the struggles women face in medicine, there have been decidedly fewer analyses that focus on women who choose to become mothers while working in medicine.

Elina Maymind

I’ve been privileged to work with medical students and residents for the last 8 years as the director of graduate and medical student mental health at Rowan-Virtua School of Osteopathic Medicine in Mt. Laurel, N.J. Often, the women I see as patients speak about their struggles with the elusive goal of “having it all.” While both men and women in medicine have difficulty maintaining a work-life balance, I’ve learned, both personally and professionally, that many women face a unique set of challenges.

No matter what their professional status, our society often views a woman as the default parent. For example, the teacher often calls the mothers first. The camp nurse calls me first, not my husband, when our child scrapes a knee. After-school play dates are arranged by the mothers, not fathers.

But mothers also bring to medicine a wealth of unique experiences, ideas, and viewpoints. They learn firsthand how to foster affect regulation and frustration tolerance in their kids and become efficient at managing the constant, conflicting tug of war of demands.

Some may argue that, over time, women end up earning significantly less than their male counterparts because they leave the workforce while on maternity leave, ultimately delaying their upward career progression. It’s likely a much more complex problem. Many of my patients believe that, in our male-dominated society (and workforce), women are punished for being aggressive or stating bold opinions, while men are rewarded for the same actions. While a man may sound forceful and in charge, a women will likely be thought of as brusque and unappreciative.

Outside of work, many women may have more on their plate. A 2020 Gallup poll of more than 3,000 heterosexual couples found that women are responsible for the majority of household chores. Women continue to handle more of the emotional labor within their families, regardless of income, age, or professional status. This is sometimes called the “Mental Load’ or “Second Shift.” As our society continues to view women as the default parent for childcare, medical issues, and overarching social and emotional tasks vital to raising happy, healthy children, the struggle a female medical professional feels is palpable.

Despite the very real and difficult challenges in finding a perfect balance and having it all, both at home and at work, the role of mother and physician must be intimately intertwined. Raising kids requires a parent to consistently dole out control, predictability, and reassurance for a child to thrive. Good limit and boundary setting leads to healthy development from a young age.

Psychiatric patients (and perhaps all patients) also require control, predictability, and reassurance from their doctor. The lessons learned in being a good mother can be directly applied in patient care, and vice versa. The cross-pollination of this relationship continues to grow more powerful as a woman’s children grow and her career matures.

Pediatrician and psychoanalyst Donald Winnicott’s idea of a “good enough” mother cannot be a one-size-fits-all approach. Women who self-select into the world of medicine often hold themselves to a higher standard than “good enough.” Acknowledging that the demands from both home and work will fluctuate is key to achieving success both personally and professionally, and lessons from home can and should be utilized to become a more effective physician. The notion of having it all, and the definition of success, must evolve over time.

Dr. Maymind is director of medical and graduate student mental health at Rowan-Virtua School of Osteopathic Medicine in Mt. Laurel, N.J. She has no relevant disclosures.

Across all industries, studies by the U.S. Department of Labor have shown that women, on average, earn 83.7 percent of what their male peers earn. While a lot has been written about the struggles women face in medicine, there have been decidedly fewer analyses that focus on women who choose to become mothers while working in medicine.

Elina Maymind

I’ve been privileged to work with medical students and residents for the last 8 years as the director of graduate and medical student mental health at Rowan-Virtua School of Osteopathic Medicine in Mt. Laurel, N.J. Often, the women I see as patients speak about their struggles with the elusive goal of “having it all.” While both men and women in medicine have difficulty maintaining a work-life balance, I’ve learned, both personally and professionally, that many women face a unique set of challenges.

No matter what their professional status, our society often views a woman as the default parent. For example, the teacher often calls the mothers first. The camp nurse calls me first, not my husband, when our child scrapes a knee. After-school play dates are arranged by the mothers, not fathers.

But mothers also bring to medicine a wealth of unique experiences, ideas, and viewpoints. They learn firsthand how to foster affect regulation and frustration tolerance in their kids and become efficient at managing the constant, conflicting tug of war of demands.

Some may argue that, over time, women end up earning significantly less than their male counterparts because they leave the workforce while on maternity leave, ultimately delaying their upward career progression. It’s likely a much more complex problem. Many of my patients believe that, in our male-dominated society (and workforce), women are punished for being aggressive or stating bold opinions, while men are rewarded for the same actions. While a man may sound forceful and in charge, a women will likely be thought of as brusque and unappreciative.

Outside of work, many women may have more on their plate. A 2020 Gallup poll of more than 3,000 heterosexual couples found that women are responsible for the majority of household chores. Women continue to handle more of the emotional labor within their families, regardless of income, age, or professional status. This is sometimes called the “Mental Load’ or “Second Shift.” As our society continues to view women as the default parent for childcare, medical issues, and overarching social and emotional tasks vital to raising happy, healthy children, the struggle a female medical professional feels is palpable.

Despite the very real and difficult challenges in finding a perfect balance and having it all, both at home and at work, the role of mother and physician must be intimately intertwined. Raising kids requires a parent to consistently dole out control, predictability, and reassurance for a child to thrive. Good limit and boundary setting leads to healthy development from a young age.

Psychiatric patients (and perhaps all patients) also require control, predictability, and reassurance from their doctor. The lessons learned in being a good mother can be directly applied in patient care, and vice versa. The cross-pollination of this relationship continues to grow more powerful as a woman’s children grow and her career matures.

Pediatrician and psychoanalyst Donald Winnicott’s idea of a “good enough” mother cannot be a one-size-fits-all approach. Women who self-select into the world of medicine often hold themselves to a higher standard than “good enough.” Acknowledging that the demands from both home and work will fluctuate is key to achieving success both personally and professionally, and lessons from home can and should be utilized to become a more effective physician. The notion of having it all, and the definition of success, must evolve over time.

Dr. Maymind is director of medical and graduate student mental health at Rowan-Virtua School of Osteopathic Medicine in Mt. Laurel, N.J. She has no relevant disclosures.

Across all industries, studies by the U.S. Department of Labor have shown that women, on average, earn 83.7 percent of what their male peers earn. While a lot has been written about the struggles women face in medicine, there have been decidedly fewer analyses that focus on women who choose to become mothers while working in medicine.

Elina Maymind

I’ve been privileged to work with medical students and residents for the last 8 years as the director of graduate and medical student mental health at Rowan-Virtua School of Osteopathic Medicine in Mt. Laurel, N.J. Often, the women I see as patients speak about their struggles with the elusive goal of “having it all.” While both men and women in medicine have difficulty maintaining a work-life balance, I’ve learned, both personally and professionally, that many women face a unique set of challenges.

No matter what their professional status, our society often views a woman as the default parent. For example, the teacher often calls the mothers first. The camp nurse calls me first, not my husband, when our child scrapes a knee. After-school play dates are arranged by the mothers, not fathers.

But mothers also bring to medicine a wealth of unique experiences, ideas, and viewpoints. They learn firsthand how to foster affect regulation and frustration tolerance in their kids and become efficient at managing the constant, conflicting tug of war of demands.

Some may argue that, over time, women end up earning significantly less than their male counterparts because they leave the workforce while on maternity leave, ultimately delaying their upward career progression. It’s likely a much more complex problem. Many of my patients believe that, in our male-dominated society (and workforce), women are punished for being aggressive or stating bold opinions, while men are rewarded for the same actions. While a man may sound forceful and in charge, a women will likely be thought of as brusque and unappreciative.

Outside of work, many women may have more on their plate. A 2020 Gallup poll of more than 3,000 heterosexual couples found that women are responsible for the majority of household chores. Women continue to handle more of the emotional labor within their families, regardless of income, age, or professional status. This is sometimes called the “Mental Load’ or “Second Shift.” As our society continues to view women as the default parent for childcare, medical issues, and overarching social and emotional tasks vital to raising happy, healthy children, the struggle a female medical professional feels is palpable.

Despite the very real and difficult challenges in finding a perfect balance and having it all, both at home and at work, the role of mother and physician must be intimately intertwined. Raising kids requires a parent to consistently dole out control, predictability, and reassurance for a child to thrive. Good limit and boundary setting leads to healthy development from a young age.

Psychiatric patients (and perhaps all patients) also require control, predictability, and reassurance from their doctor. The lessons learned in being a good mother can be directly applied in patient care, and vice versa. The cross-pollination of this relationship continues to grow more powerful as a woman’s children grow and her career matures.

Pediatrician and psychoanalyst Donald Winnicott’s idea of a “good enough” mother cannot be a one-size-fits-all approach. Women who self-select into the world of medicine often hold themselves to a higher standard than “good enough.” Acknowledging that the demands from both home and work will fluctuate is key to achieving success both personally and professionally, and lessons from home can and should be utilized to become a more effective physician. The notion of having it all, and the definition of success, must evolve over time.

Dr. Maymind is director of medical and graduate student mental health at Rowan-Virtua School of Osteopathic Medicine in Mt. Laurel, N.J. She has no relevant disclosures.

Aspirin has long been recommended for secondary prevention of cardiovascular disease (CVD), but a new global study highlights considerable underuse for that purpose, especially in lower-income countries.

Nationally representative survey data from 51 countries showed that fewer than half of eligible people overall, including less than one-quarter in low-income and lower-middle–income countries, were taking aspirin for secondary CVD prevention.

“Our findings were not surprising but rather disappointing,” first author Sang Gune Yoo, MD, fellow in cardiovascular disease at Washington University in St Louis, said in an interview.

“We had hoped that the rates of aspirin use for secondary prevention would have increased after decades of effort to promote cardiovascular health worldwide,” Dr. Yoo said.

In high-income countries, such as the United States, rates of aspirin use for secondary CVD prevention were higher – at around 65% – but that’s also “really low and not particularly good or anything to be proud of,” Deepak Bhatt, MD, MPH, director of Mount Sinai Heart, New York, who wasn’t involved in the study, said in an interview.

The study was published online in JAMA. It provides the most extensive and up-to-date estimates of the worldwide use of aspirin for secondary prevention of CVD.

The researchers did a cross-sectional analysis using pooled, individual participant data from nationally representative health surveys conducted from 2013 to 2020 in 51 low-, middle-, and high-income countries.

The overall pooled sample included 124,505 nonpregnant adults (mean age, 52 years; 51% women). A total of 10,589 (8.1%) had a self-reported history of CVD and about 40% of these individuals were taking aspirin.

However, rates differed markedly by country, with use rates lowest in low-income and lower-middle–income countries and highest in upper-middle–income and high-income countries.

Medscape

Primary vs. secondary prevention

The study did not explore the factors or reasons behind suboptimal aspirin use for secondary CVD prevention. 

For example, it did not investigate whether data demonstrating that aspirin is not helpful in primary prevention is having a negative effect on use rates for secondary prevention. However, “rates of aspirin use for secondary prevention were low previously and remain suboptimal,” Dr. Yoo said.

Dr. Bhatt said that the “suboptimal” use of aspirin for secondary prevention is “a bit perplexing because this is a medicine that’s familiar, the data in secondary prevention are broadly known to physicians and it’s a cheap medicine so we can’t, in this case, blame high cost.”

Dr. Bhatt said it’s possible that coverage in the lay media of “negative” aspirin trials that may not distinguish between a primary and secondary prevention trial may contribute to confusion about aspirin. “In some cases, the doctor may think the patient is taking aspirin, but self discontinues it based on something they read or saw on the Internet.”

Dr. Yoo and colleagues said that, to meet the goal of reducing premature mortality from noncommunicable diseases, including CVD, “national health policies and health systems must develop, implement and evaluate strategies to promote evidence-based use of aspirin.”

“Strategies to boost appropriate aspirin use must be contextualized to the country and its health system,” Dr. Yoo added.

The study had no commercial funding. Dr. Yoo has disclosed no relevant financial relationships. Dr. Bhatt disclosed receiving grants and/or personal fees from many companies, publications, and organizations.

A version of this article appeared on Medscape.com.

Aspirin has long been recommended for secondary prevention of cardiovascular disease (CVD), but a new global study highlights considerable underuse for that purpose, especially in lower-income countries.

Nationally representative survey data from 51 countries showed that fewer than half of eligible people overall, including less than one-quarter in low-income and lower-middle–income countries, were taking aspirin for secondary CVD prevention.

“Our findings were not surprising but rather disappointing,” first author Sang Gune Yoo, MD, fellow in cardiovascular disease at Washington University in St Louis, said in an interview.

“We had hoped that the rates of aspirin use for secondary prevention would have increased after decades of effort to promote cardiovascular health worldwide,” Dr. Yoo said.

In high-income countries, such as the United States, rates of aspirin use for secondary CVD prevention were higher – at around 65% – but that’s also “really low and not particularly good or anything to be proud of,” Deepak Bhatt, MD, MPH, director of Mount Sinai Heart, New York, who wasn’t involved in the study, said in an interview.

The study was published online in JAMA. It provides the most extensive and up-to-date estimates of the worldwide use of aspirin for secondary prevention of CVD.

The researchers did a cross-sectional analysis using pooled, individual participant data from nationally representative health surveys conducted from 2013 to 2020 in 51 low-, middle-, and high-income countries.

The overall pooled sample included 124,505 nonpregnant adults (mean age, 52 years; 51% women). A total of 10,589 (8.1%) had a self-reported history of CVD and about 40% of these individuals were taking aspirin.

However, rates differed markedly by country, with use rates lowest in low-income and lower-middle–income countries and highest in upper-middle–income and high-income countries.

Medscape

Primary vs. secondary prevention

The study did not explore the factors or reasons behind suboptimal aspirin use for secondary CVD prevention. 

For example, it did not investigate whether data demonstrating that aspirin is not helpful in primary prevention is having a negative effect on use rates for secondary prevention. However, “rates of aspirin use for secondary prevention were low previously and remain suboptimal,” Dr. Yoo said.

Dr. Bhatt said that the “suboptimal” use of aspirin for secondary prevention is “a bit perplexing because this is a medicine that’s familiar, the data in secondary prevention are broadly known to physicians and it’s a cheap medicine so we can’t, in this case, blame high cost.”

Dr. Bhatt said it’s possible that coverage in the lay media of “negative” aspirin trials that may not distinguish between a primary and secondary prevention trial may contribute to confusion about aspirin. “In some cases, the doctor may think the patient is taking aspirin, but self discontinues it based on something they read or saw on the Internet.”

Dr. Yoo and colleagues said that, to meet the goal of reducing premature mortality from noncommunicable diseases, including CVD, “national health policies and health systems must develop, implement and evaluate strategies to promote evidence-based use of aspirin.”

“Strategies to boost appropriate aspirin use must be contextualized to the country and its health system,” Dr. Yoo added.

The study had no commercial funding. Dr. Yoo has disclosed no relevant financial relationships. Dr. Bhatt disclosed receiving grants and/or personal fees from many companies, publications, and organizations.

A version of this article appeared on Medscape.com.

Aspirin has long been recommended for secondary prevention of cardiovascular disease (CVD), but a new global study highlights considerable underuse for that purpose, especially in lower-income countries.

Nationally representative survey data from 51 countries showed that fewer than half of eligible people overall, including less than one-quarter in low-income and lower-middle–income countries, were taking aspirin for secondary CVD prevention.

“Our findings were not surprising but rather disappointing,” first author Sang Gune Yoo, MD, fellow in cardiovascular disease at Washington University in St Louis, said in an interview.

“We had hoped that the rates of aspirin use for secondary prevention would have increased after decades of effort to promote cardiovascular health worldwide,” Dr. Yoo said.

In high-income countries, such as the United States, rates of aspirin use for secondary CVD prevention were higher – at around 65% – but that’s also “really low and not particularly good or anything to be proud of,” Deepak Bhatt, MD, MPH, director of Mount Sinai Heart, New York, who wasn’t involved in the study, said in an interview.

The study was published online in JAMA. It provides the most extensive and up-to-date estimates of the worldwide use of aspirin for secondary prevention of CVD.

The researchers did a cross-sectional analysis using pooled, individual participant data from nationally representative health surveys conducted from 2013 to 2020 in 51 low-, middle-, and high-income countries.

The overall pooled sample included 124,505 nonpregnant adults (mean age, 52 years; 51% women). A total of 10,589 (8.1%) had a self-reported history of CVD and about 40% of these individuals were taking aspirin.

However, rates differed markedly by country, with use rates lowest in low-income and lower-middle–income countries and highest in upper-middle–income and high-income countries.

Medscape

Primary vs. secondary prevention

The study did not explore the factors or reasons behind suboptimal aspirin use for secondary CVD prevention. 

For example, it did not investigate whether data demonstrating that aspirin is not helpful in primary prevention is having a negative effect on use rates for secondary prevention. However, “rates of aspirin use for secondary prevention were low previously and remain suboptimal,” Dr. Yoo said.

Dr. Bhatt said that the “suboptimal” use of aspirin for secondary prevention is “a bit perplexing because this is a medicine that’s familiar, the data in secondary prevention are broadly known to physicians and it’s a cheap medicine so we can’t, in this case, blame high cost.”

Dr. Bhatt said it’s possible that coverage in the lay media of “negative” aspirin trials that may not distinguish between a primary and secondary prevention trial may contribute to confusion about aspirin. “In some cases, the doctor may think the patient is taking aspirin, but self discontinues it based on something they read or saw on the Internet.”

Dr. Yoo and colleagues said that, to meet the goal of reducing premature mortality from noncommunicable diseases, including CVD, “national health policies and health systems must develop, implement and evaluate strategies to promote evidence-based use of aspirin.”

“Strategies to boost appropriate aspirin use must be contextualized to the country and its health system,” Dr. Yoo added.

The study had no commercial funding. Dr. Yoo has disclosed no relevant financial relationships. Dr. Bhatt disclosed receiving grants and/or personal fees from many companies, publications, and organizations.

A version of this article appeared on Medscape.com.

To the Editor:

The term ectopic breast tissue serves as an umbrella term that encompasses breast tissue positioned in anatomically incorrect locations, including the subtypes of supernumerary and aberrant breasts.¹ However, the more frequently used term is accessory breast tissue (ABT).¹ Supernumerary breasts have diverse variations of a nipple, areola, and/or ductal tissue and can span in size from a small mole to a fully functioning breast. This breast type maintains structured ductal systems connected to the overlying skin and experiences regular changes during the reproductive cycle. In contrast, an aberrant breast is isolated breast tissue that does not contain organized ductal systems.¹ Accessory breast tissue is prevalent in up to 6.0% of the world population, with Japanese individuals being the most affected and White individuals being the least affected.¹

Accessory breasts typically are located along the milk line—the embryologic precursor to mammary glands and nipples, which extend from the axillae to the groin and regress from the caudal end spanning to the groin.² For this reason, incomplete regression of the mammary ridge results in ABT, most commonly in the axillary region.³ Accessory breast tissue usually is benign and is considered an anatomical variant; however, because the histomorphology is similar to mammary gland tissue, accessory breasts have the same proliferative potential as anatomically correct breasts and therefore can form fibroadenomas, cysts, abscesses, mastitis, or breast cancer.⁴ Accessory breast carcinomas comprise 0.3% to 0.6% of all breast malignancies.⁵ Certain genodermatoses (ie, Cowden syndrome) also may predispose patients to benign or malignant pathology in ABT.⁶ We present a rare case of accessory breast cancer in the inframammary region masquerading as a cyst. These findings were further supported by ultrasonography and mammography.

A 45-year-old White woman presented to our clinic for removal of a dermal mass underlying a supernumerary nipple at the left inframammary fold. Her medical history was noncontributory and was only remarkable for uterine fibroids. She developed pain and swelling in the left breast 1 year prior, which prompted her to seek medical attention from her primary care physician. Diagnostic mammography was negative for any concerning malignant nodules, and subsequent BRCA genetic testing also was negative. Six months after the diagnostic mammography, she continued to experience pain and swelling in the left breast and was then referred for diagnostic ultrasonography; 2 masses in the left breast suspected as infected cysts with rupture were identified (Figure 1). She was then referred to our dermatology clinic for evaluation and surgical extirpation of the suspected cyst underlying the accessory breast. The area subsequently was excised under local anesthesia, and a second similar but smaller mass also was identified adjacent to the initial growth. Dermatopathologic examination revealed an estrogen receptor– (Figure 2A) and progesterone receptor–positive (Figure 2B), ERBB2 (HER2/neu)–negative, nuclear grade III ductal carcinoma in situ (Figure 3).

Various ABT classification methods have been proposed with Brightmore⁷ categorizing polymastia into 8 subtypes: (1) complete breast; (2) glandular tissue and nipple; (3) glandular tissue and areola; (4) glandular tissue only; (5) nipple, areola, and fat; (6) nipple only; (7) areola only; and (8) patch of hair only. De Cholnokey⁸ focused on axillary polymastia, dividing it into 4 classes: (1) axillary tumor in milk line without nipple or areola; (2) axillary tumor with areola with or without pigmentation; (3) nipple or areola without underlying breast tissue; and (4) complete breast with nipple, areola, and glandular tissue. Fenench’s⁹ method is preferred and simply describes ABT as 2 subtypes: supernumerary and aberrant.^1,2,10 One study observed 6% of ABT cancers were the supernumerary type and 94% were the aberrant type.¹ Ductal lumen stagnation increases the risk for accessory breast carcinoma development.¹⁰ Men have a higher prevalence of cancer in ABT compared to anatomically correct breast tissue.¹¹

There currently is no standardized guideline for ABT cancer treatment. The initial clinical impression of cancer of ABT may be misdiagnosed as lymphadenopathy, abscesses, or lipomas.¹² The risk for misdiagnosis is higher for cancer of ABT compared to normal breast tissue and is associated with a poorer prognosis.¹ Despite multiple screening modalities, our patient’s initial breast cancer screenings proved unreliable. A mammogram failed to detect malignancy, likely secondary to the area of concern being out of the standard imaging field. Ultrasonography also was unreliable and led to misdiagnosis as an infected sebaceous cyst with rupture in our patient. Upon review of the ultrasound, concerns were raised by dermatology that the mass was more likely an epidermal inclusion cyst with rupture given the more superficial and sac-free nature of sebaceous cysts, which commonly are associated with steatocystoma multiplex.¹³ Definitive diagnosis of ductal carcinoma in situ was made with dermatopathologic examination.

Prophylactic surgical excision of ABT has been recommended, suggesting that excisional biopsy and histopathologic examination is the more appropriate method to rule out malignancy. Surgical treatment of ABT may omit any risk for malignant transformation and may provide psychological relief to patients for aesthetic reasons.^10,12,14 The risk and benefits of prophylactic excision of ABT has been compared to prophylactic mastectomy of anatomically correct breasts,¹⁵ with some clinicians considering this definitive procedure unnecessary except in high-risk patients with a strong genetic predisposition.^16,17

Accessory breast tissue should be viewed as an anatomical variant with the option of surgical removal for symptomatic concerns, such as firm nodules, discharge, and pain. Although ABT is rare and cancer in ABT is even more uncommon (<1% of all breast cancers),^5,11 clinicians should be suspicious of benign diagnostic reports when the clinical situation does not fit the proposed narrative.

To the Editor:

The term ectopic breast tissue serves as an umbrella term that encompasses breast tissue positioned in anatomically incorrect locations, including the subtypes of supernumerary and aberrant breasts.¹ However, the more frequently used term is accessory breast tissue (ABT).¹ Supernumerary breasts have diverse variations of a nipple, areola, and/or ductal tissue and can span in size from a small mole to a fully functioning breast. This breast type maintains structured ductal systems connected to the overlying skin and experiences regular changes during the reproductive cycle. In contrast, an aberrant breast is isolated breast tissue that does not contain organized ductal systems.¹ Accessory breast tissue is prevalent in up to 6.0% of the world population, with Japanese individuals being the most affected and White individuals being the least affected.¹

Accessory breasts typically are located along the milk line—the embryologic precursor to mammary glands and nipples, which extend from the axillae to the groin and regress from the caudal end spanning to the groin.² For this reason, incomplete regression of the mammary ridge results in ABT, most commonly in the axillary region.³ Accessory breast tissue usually is benign and is considered an anatomical variant; however, because the histomorphology is similar to mammary gland tissue, accessory breasts have the same proliferative potential as anatomically correct breasts and therefore can form fibroadenomas, cysts, abscesses, mastitis, or breast cancer.⁴ Accessory breast carcinomas comprise 0.3% to 0.6% of all breast malignancies.⁵ Certain genodermatoses (ie, Cowden syndrome) also may predispose patients to benign or malignant pathology in ABT.⁶ We present a rare case of accessory breast cancer in the inframammary region masquerading as a cyst. These findings were further supported by ultrasonography and mammography.

A 45-year-old White woman presented to our clinic for removal of a dermal mass underlying a supernumerary nipple at the left inframammary fold. Her medical history was noncontributory and was only remarkable for uterine fibroids. She developed pain and swelling in the left breast 1 year prior, which prompted her to seek medical attention from her primary care physician. Diagnostic mammography was negative for any concerning malignant nodules, and subsequent BRCA genetic testing also was negative. Six months after the diagnostic mammography, she continued to experience pain and swelling in the left breast and was then referred for diagnostic ultrasonography; 2 masses in the left breast suspected as infected cysts with rupture were identified (Figure 1). She was then referred to our dermatology clinic for evaluation and surgical extirpation of the suspected cyst underlying the accessory breast. The area subsequently was excised under local anesthesia, and a second similar but smaller mass also was identified adjacent to the initial growth. Dermatopathologic examination revealed an estrogen receptor– (Figure 2A) and progesterone receptor–positive (Figure 2B), ERBB2 (HER2/neu)–negative, nuclear grade III ductal carcinoma in situ (Figure 3).

Various ABT classification methods have been proposed with Brightmore⁷ categorizing polymastia into 8 subtypes: (1) complete breast; (2) glandular tissue and nipple; (3) glandular tissue and areola; (4) glandular tissue only; (5) nipple, areola, and fat; (6) nipple only; (7) areola only; and (8) patch of hair only. De Cholnokey⁸ focused on axillary polymastia, dividing it into 4 classes: (1) axillary tumor in milk line without nipple or areola; (2) axillary tumor with areola with or without pigmentation; (3) nipple or areola without underlying breast tissue; and (4) complete breast with nipple, areola, and glandular tissue. Fenench’s⁹ method is preferred and simply describes ABT as 2 subtypes: supernumerary and aberrant.^1,2,10 One study observed 6% of ABT cancers were the supernumerary type and 94% were the aberrant type.¹ Ductal lumen stagnation increases the risk for accessory breast carcinoma development.¹⁰ Men have a higher prevalence of cancer in ABT compared to anatomically correct breast tissue.¹¹

There currently is no standardized guideline for ABT cancer treatment. The initial clinical impression of cancer of ABT may be misdiagnosed as lymphadenopathy, abscesses, or lipomas.¹² The risk for misdiagnosis is higher for cancer of ABT compared to normal breast tissue and is associated with a poorer prognosis.¹ Despite multiple screening modalities, our patient’s initial breast cancer screenings proved unreliable. A mammogram failed to detect malignancy, likely secondary to the area of concern being out of the standard imaging field. Ultrasonography also was unreliable and led to misdiagnosis as an infected sebaceous cyst with rupture in our patient. Upon review of the ultrasound, concerns were raised by dermatology that the mass was more likely an epidermal inclusion cyst with rupture given the more superficial and sac-free nature of sebaceous cysts, which commonly are associated with steatocystoma multiplex.¹³ Definitive diagnosis of ductal carcinoma in situ was made with dermatopathologic examination.

Prophylactic surgical excision of ABT has been recommended, suggesting that excisional biopsy and histopathologic examination is the more appropriate method to rule out malignancy. Surgical treatment of ABT may omit any risk for malignant transformation and may provide psychological relief to patients for aesthetic reasons.^10,12,14 The risk and benefits of prophylactic excision of ABT has been compared to prophylactic mastectomy of anatomically correct breasts,¹⁵ with some clinicians considering this definitive procedure unnecessary except in high-risk patients with a strong genetic predisposition.^16,17

Accessory breast tissue should be viewed as an anatomical variant with the option of surgical removal for symptomatic concerns, such as firm nodules, discharge, and pain. Although ABT is rare and cancer in ABT is even more uncommon (<1% of all breast cancers),^5,11 clinicians should be suspicious of benign diagnostic reports when the clinical situation does not fit the proposed narrative.

To the Editor:

The term ectopic breast tissue serves as an umbrella term that encompasses breast tissue positioned in anatomically incorrect locations, including the subtypes of supernumerary and aberrant breasts.¹ However, the more frequently used term is accessory breast tissue (ABT).¹ Supernumerary breasts have diverse variations of a nipple, areola, and/or ductal tissue and can span in size from a small mole to a fully functioning breast. This breast type maintains structured ductal systems connected to the overlying skin and experiences regular changes during the reproductive cycle. In contrast, an aberrant breast is isolated breast tissue that does not contain organized ductal systems.¹ Accessory breast tissue is prevalent in up to 6.0% of the world population, with Japanese individuals being the most affected and White individuals being the least affected.¹

Accessory breasts typically are located along the milk line—the embryologic precursor to mammary glands and nipples, which extend from the axillae to the groin and regress from the caudal end spanning to the groin.² For this reason, incomplete regression of the mammary ridge results in ABT, most commonly in the axillary region.³ Accessory breast tissue usually is benign and is considered an anatomical variant; however, because the histomorphology is similar to mammary gland tissue, accessory breasts have the same proliferative potential as anatomically correct breasts and therefore can form fibroadenomas, cysts, abscesses, mastitis, or breast cancer.⁴ Accessory breast carcinomas comprise 0.3% to 0.6% of all breast malignancies.⁵ Certain genodermatoses (ie, Cowden syndrome) also may predispose patients to benign or malignant pathology in ABT.⁶ We present a rare case of accessory breast cancer in the inframammary region masquerading as a cyst. These findings were further supported by ultrasonography and mammography.

A 45-year-old White woman presented to our clinic for removal of a dermal mass underlying a supernumerary nipple at the left inframammary fold. Her medical history was noncontributory and was only remarkable for uterine fibroids. She developed pain and swelling in the left breast 1 year prior, which prompted her to seek medical attention from her primary care physician. Diagnostic mammography was negative for any concerning malignant nodules, and subsequent BRCA genetic testing also was negative. Six months after the diagnostic mammography, she continued to experience pain and swelling in the left breast and was then referred for diagnostic ultrasonography; 2 masses in the left breast suspected as infected cysts with rupture were identified (Figure 1). She was then referred to our dermatology clinic for evaluation and surgical extirpation of the suspected cyst underlying the accessory breast. The area subsequently was excised under local anesthesia, and a second similar but smaller mass also was identified adjacent to the initial growth. Dermatopathologic examination revealed an estrogen receptor– (Figure 2A) and progesterone receptor–positive (Figure 2B), ERBB2 (HER2/neu)–negative, nuclear grade III ductal carcinoma in situ (Figure 3).

Various ABT classification methods have been proposed with Brightmore⁷ categorizing polymastia into 8 subtypes: (1) complete breast; (2) glandular tissue and nipple; (3) glandular tissue and areola; (4) glandular tissue only; (5) nipple, areola, and fat; (6) nipple only; (7) areola only; and (8) patch of hair only. De Cholnokey⁸ focused on axillary polymastia, dividing it into 4 classes: (1) axillary tumor in milk line without nipple or areola; (2) axillary tumor with areola with or without pigmentation; (3) nipple or areola without underlying breast tissue; and (4) complete breast with nipple, areola, and glandular tissue. Fenench’s⁹ method is preferred and simply describes ABT as 2 subtypes: supernumerary and aberrant.^1,2,10 One study observed 6% of ABT cancers were the supernumerary type and 94% were the aberrant type.¹ Ductal lumen stagnation increases the risk for accessory breast carcinoma development.¹⁰ Men have a higher prevalence of cancer in ABT compared to anatomically correct breast tissue.¹¹

There currently is no standardized guideline for ABT cancer treatment. The initial clinical impression of cancer of ABT may be misdiagnosed as lymphadenopathy, abscesses, or lipomas.¹² The risk for misdiagnosis is higher for cancer of ABT compared to normal breast tissue and is associated with a poorer prognosis.¹ Despite multiple screening modalities, our patient’s initial breast cancer screenings proved unreliable. A mammogram failed to detect malignancy, likely secondary to the area of concern being out of the standard imaging field. Ultrasonography also was unreliable and led to misdiagnosis as an infected sebaceous cyst with rupture in our patient. Upon review of the ultrasound, concerns were raised by dermatology that the mass was more likely an epidermal inclusion cyst with rupture given the more superficial and sac-free nature of sebaceous cysts, which commonly are associated with steatocystoma multiplex.¹³ Definitive diagnosis of ductal carcinoma in situ was made with dermatopathologic examination.

Prophylactic surgical excision of ABT has been recommended, suggesting that excisional biopsy and histopathologic examination is the more appropriate method to rule out malignancy. Surgical treatment of ABT may omit any risk for malignant transformation and may provide psychological relief to patients for aesthetic reasons.^10,12,14 The risk and benefits of prophylactic excision of ABT has been compared to prophylactic mastectomy of anatomically correct breasts,¹⁵ with some clinicians considering this definitive procedure unnecessary except in high-risk patients with a strong genetic predisposition.^16,17

Accessory breast tissue should be viewed as an anatomical variant with the option of surgical removal for symptomatic concerns, such as firm nodules, discharge, and pain. Although ABT is rare and cancer in ABT is even more uncommon (<1% of all breast cancers),^5,11 clinicians should be suspicious of benign diagnostic reports when the clinical situation does not fit the proposed narrative.