COVID can more than triple the chance of being diagnosed with type 2 diabetes within a year of being infected, according to a new Canadian study.

Men who had even a mild case of COVID were significantly more likely than were noninfected men to be diagnosed with type 2 diabetes. Women didn’t have an increased risk unless they were severely ill.

Both men and women who had severe cases were at the highest risk. People who were hospitalized for COVID treatment had more than a doubled risk of being diagnosed with type 2 diabetes, and those who were admitted to intensive care units had more than a tripled risk.

“This is definitely a concern in terms of long-term outcomes,” researcher and University of British Columbia professor Naveed Z. Janjua, PhD, told The New York Times. “With a respiratory infection, you usually think, ‘Seven or eight days and I’m done with it, that’s it.’ [But] here we’re seeing lingering effects that are lifelong.”

The study was published in JAMA Network Open. Researchers analyzed health data from 2020 and 2021 for 629,935 people, 20% of whom were diagnosed with COVID during that time. Most people in the study had not been vaccinated because vaccines were not widely available then. The health information came from a registry maintained by public health officials in British Columbia. The follow-up period was 257 days.

The authors cautioned that their findings could not say that COVID causes type 2 diabetes; rather, in a commentary published along with the study, Pamela B. Davis, MD, PhD, said the link makes sense because COVID is known to impact the pancreas.

“Such a stress may move a patient from a prediabetic state into diabetes,” wrote Dr. Davis, former dean of Case Western Reserve University, Cleveland, where she is now a professor.

The researchers estimated that the increased pattern of diagnoses of diabetes following COVID infection could increase the rate of the disease occurring in the general population by 3%-5% overall.
 

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

COVID can more than triple the chance of being diagnosed with type 2 diabetes within a year of being infected, according to a new Canadian study.

Men who had even a mild case of COVID were significantly more likely than were noninfected men to be diagnosed with type 2 diabetes. Women didn’t have an increased risk unless they were severely ill.

Both men and women who had severe cases were at the highest risk. People who were hospitalized for COVID treatment had more than a doubled risk of being diagnosed with type 2 diabetes, and those who were admitted to intensive care units had more than a tripled risk.

“This is definitely a concern in terms of long-term outcomes,” researcher and University of British Columbia professor Naveed Z. Janjua, PhD, told The New York Times. “With a respiratory infection, you usually think, ‘Seven or eight days and I’m done with it, that’s it.’ [But] here we’re seeing lingering effects that are lifelong.”

The study was published in JAMA Network Open. Researchers analyzed health data from 2020 and 2021 for 629,935 people, 20% of whom were diagnosed with COVID during that time. Most people in the study had not been vaccinated because vaccines were not widely available then. The health information came from a registry maintained by public health officials in British Columbia. The follow-up period was 257 days.

The authors cautioned that their findings could not say that COVID causes type 2 diabetes; rather, in a commentary published along with the study, Pamela B. Davis, MD, PhD, said the link makes sense because COVID is known to impact the pancreas.

“Such a stress may move a patient from a prediabetic state into diabetes,” wrote Dr. Davis, former dean of Case Western Reserve University, Cleveland, where she is now a professor.

The researchers estimated that the increased pattern of diagnoses of diabetes following COVID infection could increase the rate of the disease occurring in the general population by 3%-5% overall.
 

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

COVID can more than triple the chance of being diagnosed with type 2 diabetes within a year of being infected, according to a new Canadian study.

Men who had even a mild case of COVID were significantly more likely than were noninfected men to be diagnosed with type 2 diabetes. Women didn’t have an increased risk unless they were severely ill.

Both men and women who had severe cases were at the highest risk. People who were hospitalized for COVID treatment had more than a doubled risk of being diagnosed with type 2 diabetes, and those who were admitted to intensive care units had more than a tripled risk.

“This is definitely a concern in terms of long-term outcomes,” researcher and University of British Columbia professor Naveed Z. Janjua, PhD, told The New York Times. “With a respiratory infection, you usually think, ‘Seven or eight days and I’m done with it, that’s it.’ [But] here we’re seeing lingering effects that are lifelong.”

The study was published in JAMA Network Open. Researchers analyzed health data from 2020 and 2021 for 629,935 people, 20% of whom were diagnosed with COVID during that time. Most people in the study had not been vaccinated because vaccines were not widely available then. The health information came from a registry maintained by public health officials in British Columbia. The follow-up period was 257 days.

The authors cautioned that their findings could not say that COVID causes type 2 diabetes; rather, in a commentary published along with the study, Pamela B. Davis, MD, PhD, said the link makes sense because COVID is known to impact the pancreas.

“Such a stress may move a patient from a prediabetic state into diabetes,” wrote Dr. Davis, former dean of Case Western Reserve University, Cleveland, where she is now a professor.

The researchers estimated that the increased pattern of diagnoses of diabetes following COVID infection could increase the rate of the disease occurring in the general population by 3%-5% overall.
 

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

WASHINGTON – A group therapy suicide prevention program for veterans delivered via telehealth is feasible and acceptable, new research shows.

Skeptics had worried that participating in the program through telehealth would exacerbate safety and other issues veterans had about discussing suicide in a group setting, study investigator Sarah Sullivan, PhD student, Health Psychology & Clinical Science, City University of New York, told this news organization.

“But that for us was not really true. People opened up about their suicidal thoughts and triggers even on this telehealth format, and that’s really important for providers to know,” she said.

The findings were presented as part of the Anxiety and Depression Association of America Anxiety & Depression conference.
 

Trial run

Suicide is a major public health issue, particularly for veterans. Recent data from the Veterans Administration show 17 veterans die by suicide every day.

The current study included 15 male and 2 female veterans (29.4% White, 70.6% Hispanic) from New York City and Philadelphia. Participants had an average age of 50 and all were either deemed by a clinician to be at extremely high risk for suicide or were hospitalized for this reason.

The individuals completed an online version of the Project Life Force (PLF) program, which uses dialectical behavioral therapy and psychoeducational approaches. The program includes the brief Safety Planning intervention (SPI), aimed at reducing short-term suicide risk.

Considered a best practice, the SPI includes a written list of personal suicide warning signs or triggers, internal coping strategies, social contacts who offer support and distraction from suicidal thoughts, contact information for professionals, a suicide crisis hotline, and nearby emergency services.

In addition to these steps, the PLF program focuses on sleep, exercise, and making the safety plan accessible.

The telehealth platform for the program was WebEx software. Participants were offered a “trial run” to orient them to the technology, said Ms. Sullivan.

Group sessions were held once weekly for 10 weeks, with optional “booster” sessions if needed. Each session included about five participants.

To ensure privacy, participants were provided with headphones and laptops. This was especially important for those sharing a living space, including spouses and children, said Ms. Sullivan.
 

High ratings

Participants completed the Acceptability of Intervention Measure (AIM), Intervention Appropriateness Measure (IAM), and Feasibility of Intervention Measure (FIM). Each of these yields scores from four items rated on a Likert scale of 1-5, for a total score ranging from 5 to 20, with higher scores indicating higher ratings.

Veterans rated PLF-T as highly acceptable (mean AIM, 17.50), appropriate (mean IAM, 17.25), and feasible (mean FIM, 18).

Study participants reported the program was convenient and noted that it decreased the burden of traveling to sessions, especially during the COVID-19 pandemic.

They also reported the program was less likely to compete with other demands such as childcare and other appointments, said Ms. Sullivan.

In addition, it helped those with comorbidities such as posttraumatic stress disorder, she added. She noted veterans with PTSD may be triggered on subways or buses when traveling to in-person treatment sessions.

“That can take away from addressing the suicidal triggers,” said Ms. Sullivan. “So, this program allows them to fully concentrate on the safety plan.”

Results showed that study participants “enjoyed the group and would recommend it to others,” said Ms. Sullivan. “I think that signifies the group was effective in its goal of mitigating loneliness, which was exacerbated during the COVID-19 pandemic, and creating a socially supportive environment, especially for the vets living alone.”

Veterans also reported that the program helped them understand the connection between depression or PTSD and suicidal thoughts, urges, and plans. In addition, they appreciated the group dynamics, where they felt connected to other veterans experiencing similar challenges.
 

Hopeful results

Commenting on the study, Paul E. Holtzheimer, MD, deputy director for research at the National Center for PTSD, praised the study for focusing on a very high-risk group.

“This gets you closer to the population you’re probably going to have an impact on in terms of preventing suicide,” said Dr. Holtzheimer, a  professor of psychiatry and surgery at Dartmouth College’s Geisel School of Medicine, Hanover, N.H.

The fact that many of the participants had attempted suicide in the last year underlines that this was a very high-risk population, said Dr. Holtzheimer. “Not only are they thinking about suicide, but almost two-thirds had actually attempted or tried something.”

This kind of program “would be great for rural environments where people may be living like four hours away from the VA or a clinic,” said Dr. Holtzheimer, noting that many veterans are often quite isolated.

“One of the very positive outcomes of the COVID-19 pandemic was helping us strengthen our ability to do telehealth,” he said.

However, Dr. Holtzheimer noted the study was small and qualitative. “The next step ideally would be a controlled trial looking at not just ideation but at risky behavior or clear suicide attempts or preparation, like buying a gun or hoarding medication, to help determine efficacy.”

The researchers and Dr. Holtzheimer report no relevant financial relationships.

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

WASHINGTON – A group therapy suicide prevention program for veterans delivered via telehealth is feasible and acceptable, new research shows.

Skeptics had worried that participating in the program through telehealth would exacerbate safety and other issues veterans had about discussing suicide in a group setting, study investigator Sarah Sullivan, PhD student, Health Psychology & Clinical Science, City University of New York, told this news organization.

“But that for us was not really true. People opened up about their suicidal thoughts and triggers even on this telehealth format, and that’s really important for providers to know,” she said.

The findings were presented as part of the Anxiety and Depression Association of America Anxiety & Depression conference.
 

Trial run

Suicide is a major public health issue, particularly for veterans. Recent data from the Veterans Administration show 17 veterans die by suicide every day.

The current study included 15 male and 2 female veterans (29.4% White, 70.6% Hispanic) from New York City and Philadelphia. Participants had an average age of 50 and all were either deemed by a clinician to be at extremely high risk for suicide or were hospitalized for this reason.

The individuals completed an online version of the Project Life Force (PLF) program, which uses dialectical behavioral therapy and psychoeducational approaches. The program includes the brief Safety Planning intervention (SPI), aimed at reducing short-term suicide risk.

Considered a best practice, the SPI includes a written list of personal suicide warning signs or triggers, internal coping strategies, social contacts who offer support and distraction from suicidal thoughts, contact information for professionals, a suicide crisis hotline, and nearby emergency services.

In addition to these steps, the PLF program focuses on sleep, exercise, and making the safety plan accessible.

The telehealth platform for the program was WebEx software. Participants were offered a “trial run” to orient them to the technology, said Ms. Sullivan.

Group sessions were held once weekly for 10 weeks, with optional “booster” sessions if needed. Each session included about five participants.

To ensure privacy, participants were provided with headphones and laptops. This was especially important for those sharing a living space, including spouses and children, said Ms. Sullivan.
 

High ratings

Participants completed the Acceptability of Intervention Measure (AIM), Intervention Appropriateness Measure (IAM), and Feasibility of Intervention Measure (FIM). Each of these yields scores from four items rated on a Likert scale of 1-5, for a total score ranging from 5 to 20, with higher scores indicating higher ratings.

Veterans rated PLF-T as highly acceptable (mean AIM, 17.50), appropriate (mean IAM, 17.25), and feasible (mean FIM, 18).

Study participants reported the program was convenient and noted that it decreased the burden of traveling to sessions, especially during the COVID-19 pandemic.

They also reported the program was less likely to compete with other demands such as childcare and other appointments, said Ms. Sullivan.

In addition, it helped those with comorbidities such as posttraumatic stress disorder, she added. She noted veterans with PTSD may be triggered on subways or buses when traveling to in-person treatment sessions.

“That can take away from addressing the suicidal triggers,” said Ms. Sullivan. “So, this program allows them to fully concentrate on the safety plan.”

Results showed that study participants “enjoyed the group and would recommend it to others,” said Ms. Sullivan. “I think that signifies the group was effective in its goal of mitigating loneliness, which was exacerbated during the COVID-19 pandemic, and creating a socially supportive environment, especially for the vets living alone.”

Veterans also reported that the program helped them understand the connection between depression or PTSD and suicidal thoughts, urges, and plans. In addition, they appreciated the group dynamics, where they felt connected to other veterans experiencing similar challenges.
 

Hopeful results

Commenting on the study, Paul E. Holtzheimer, MD, deputy director for research at the National Center for PTSD, praised the study for focusing on a very high-risk group.

“This gets you closer to the population you’re probably going to have an impact on in terms of preventing suicide,” said Dr. Holtzheimer, a  professor of psychiatry and surgery at Dartmouth College’s Geisel School of Medicine, Hanover, N.H.

The fact that many of the participants had attempted suicide in the last year underlines that this was a very high-risk population, said Dr. Holtzheimer. “Not only are they thinking about suicide, but almost two-thirds had actually attempted or tried something.”

This kind of program “would be great for rural environments where people may be living like four hours away from the VA or a clinic,” said Dr. Holtzheimer, noting that many veterans are often quite isolated.

“One of the very positive outcomes of the COVID-19 pandemic was helping us strengthen our ability to do telehealth,” he said.

However, Dr. Holtzheimer noted the study was small and qualitative. “The next step ideally would be a controlled trial looking at not just ideation but at risky behavior or clear suicide attempts or preparation, like buying a gun or hoarding medication, to help determine efficacy.”

The researchers and Dr. Holtzheimer report no relevant financial relationships.

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

WASHINGTON – A group therapy suicide prevention program for veterans delivered via telehealth is feasible and acceptable, new research shows.

Skeptics had worried that participating in the program through telehealth would exacerbate safety and other issues veterans had about discussing suicide in a group setting, study investigator Sarah Sullivan, PhD student, Health Psychology & Clinical Science, City University of New York, told this news organization.

“But that for us was not really true. People opened up about their suicidal thoughts and triggers even on this telehealth format, and that’s really important for providers to know,” she said.

The findings were presented as part of the Anxiety and Depression Association of America Anxiety & Depression conference.
 

Trial run

Suicide is a major public health issue, particularly for veterans. Recent data from the Veterans Administration show 17 veterans die by suicide every day.

The current study included 15 male and 2 female veterans (29.4% White, 70.6% Hispanic) from New York City and Philadelphia. Participants had an average age of 50 and all were either deemed by a clinician to be at extremely high risk for suicide or were hospitalized for this reason.

The individuals completed an online version of the Project Life Force (PLF) program, which uses dialectical behavioral therapy and psychoeducational approaches. The program includes the brief Safety Planning intervention (SPI), aimed at reducing short-term suicide risk.

Considered a best practice, the SPI includes a written list of personal suicide warning signs or triggers, internal coping strategies, social contacts who offer support and distraction from suicidal thoughts, contact information for professionals, a suicide crisis hotline, and nearby emergency services.

In addition to these steps, the PLF program focuses on sleep, exercise, and making the safety plan accessible.

The telehealth platform for the program was WebEx software. Participants were offered a “trial run” to orient them to the technology, said Ms. Sullivan.

Group sessions were held once weekly for 10 weeks, with optional “booster” sessions if needed. Each session included about five participants.

To ensure privacy, participants were provided with headphones and laptops. This was especially important for those sharing a living space, including spouses and children, said Ms. Sullivan.
 

High ratings

Participants completed the Acceptability of Intervention Measure (AIM), Intervention Appropriateness Measure (IAM), and Feasibility of Intervention Measure (FIM). Each of these yields scores from four items rated on a Likert scale of 1-5, for a total score ranging from 5 to 20, with higher scores indicating higher ratings.

Veterans rated PLF-T as highly acceptable (mean AIM, 17.50), appropriate (mean IAM, 17.25), and feasible (mean FIM, 18).

Study participants reported the program was convenient and noted that it decreased the burden of traveling to sessions, especially during the COVID-19 pandemic.

They also reported the program was less likely to compete with other demands such as childcare and other appointments, said Ms. Sullivan.

In addition, it helped those with comorbidities such as posttraumatic stress disorder, she added. She noted veterans with PTSD may be triggered on subways or buses when traveling to in-person treatment sessions.

“That can take away from addressing the suicidal triggers,” said Ms. Sullivan. “So, this program allows them to fully concentrate on the safety plan.”

Results showed that study participants “enjoyed the group and would recommend it to others,” said Ms. Sullivan. “I think that signifies the group was effective in its goal of mitigating loneliness, which was exacerbated during the COVID-19 pandemic, and creating a socially supportive environment, especially for the vets living alone.”

Veterans also reported that the program helped them understand the connection between depression or PTSD and suicidal thoughts, urges, and plans. In addition, they appreciated the group dynamics, where they felt connected to other veterans experiencing similar challenges.
 

Hopeful results

Commenting on the study, Paul E. Holtzheimer, MD, deputy director for research at the National Center for PTSD, praised the study for focusing on a very high-risk group.

“This gets you closer to the population you’re probably going to have an impact on in terms of preventing suicide,” said Dr. Holtzheimer, a  professor of psychiatry and surgery at Dartmouth College’s Geisel School of Medicine, Hanover, N.H.

The fact that many of the participants had attempted suicide in the last year underlines that this was a very high-risk population, said Dr. Holtzheimer. “Not only are they thinking about suicide, but almost two-thirds had actually attempted or tried something.”

This kind of program “would be great for rural environments where people may be living like four hours away from the VA or a clinic,” said Dr. Holtzheimer, noting that many veterans are often quite isolated.

“One of the very positive outcomes of the COVID-19 pandemic was helping us strengthen our ability to do telehealth,” he said.

However, Dr. Holtzheimer noted the study was small and qualitative. “The next step ideally would be a controlled trial looking at not just ideation but at risky behavior or clear suicide attempts or preparation, like buying a gun or hoarding medication, to help determine efficacy.”

The researchers and Dr. Holtzheimer report no relevant financial relationships.

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

Multiple sclerosis (MS) is a chronic, inflammatory demyelinating and neurodegenerative disease that affects the central nervous system. While there is no cure for MS, significant progress has been made during the last 2 decades, with over 25 medications developed, including disease modifying therapies (DMTs) that have shown benefit in reducing the number of acute events (relapses), curbing the development of new lesions seen on magnetic resonance imaging (MRI), and slowing disease progression/worsening. However, the benefit of available DMTs is seen primarily during the inflammatory stage of the disease (relapsing remitting) and is less clear in the later stages (secondary-progressive disease). Age was shown to be one of the most consistent contributing factors linked to disease worsening, and most studies suggest limited benefit of available DMTs in patients older than 50 years. 

Meanwhile, the aging MS population is increasing worldwide, with most patients being between ages 55 and 65 years—a trend considered related to a general extended life expectancy, better diagnosis, early initiation of efficient DMTs, and improved general medical care. As persons with MS (pwMS) age, there is a clear change in the clinical presentation, with reduced risk for relapses and/or development of new MRI lesions but increased risk for disease worsening, with physical and cognitive decline. Systematic analysis–gathered data from clinical trials suggest an inadequate benefit of available DMTs in patients over 50 years, although the data have limitations, as most studies in relapsing MS did not enroll patients over the age of 55 years. In progressive MS trials, the median age of participants is 47 years; therefore, available data on aging populations are currently limited and cannot fully justify whether the medication is actually beneficial.

Another challenge in treating aging pwMS besides the limited benefit of DMTs is concern regarding safety and tolerability, especially as the most potent medications, which are now considered the most efficacious interventions for MS, are immunosuppressive agents. Aging populations with known weaker immune systems (immunosenescence) that are exposed to immunosuppressive interventions can be more susceptible to infections, have a decreased response to vaccinations, and face an increased risk of cancer. 

The aging population is also known to have other health issues (comorbidities) and, therefore, may become more vulnerable to side effects from DMTs, making it necessary to consider a different management approach. Until more effective and safe therapeutic interventions become available for aging pwMS, discontinuation or de-escalation are the most frequently used approaches. Choosing between continuing, discontinuing, or de-escalating DMTs when treating aging MS patients is a complex process that requires careful consideration as well as active patient and patient family engagement in the final management decision. 

The 2022 DISCO-MS trial was the first randomized discontinuation trial of MS drugs in older pwMS. The trial was designed to investigate the effect of discontinuing DMTs in patients aged 55 years and older who had not had recent relapses for at least 5 years and had no recent or new MRI lesions for at least 3 years. This multicenter study was conducted by the University of Colorado (supported/funded by a Patient-Centered Outcomes Research Institute grant) and included 259 participants with a median age of 63 years. Participants were randomly assigned to either continue or discontinue treatment and were followed for up to 22 months. The results of the DISCO-MS trial showed that 1 of 128 participants who stayed on medication had a relapse, and 3 of 131 people who discontinued medication had a relapse. There were no significant differences between the groups in progression of disability, cognition, quality of life, or adverse events. However, more participants who discontinued DMTs had new MRI lesions (16 vs 6), although there was no relationship to relapses or disability progression. Based on a noninferiority study design, the primary outcome (combined relapses and/or new MRI lesions) was not reached in this study. Other retrospective studies, such as a large study conducted in 2018, showed that most patients over age 60 years who discontinued DMTs remained off DMTs. These studies provide preliminary data that may guide clinicians who are considering discontinuing DMTs in their aging patients.

The second approach is de-escalation, which aims primarily to minimize the risk of side effects and complications while maintaining efficacy. Therefore, de-escalating MS medication in aging pwMS should always be done with great care. Some factors that should be considered when de-escalating treatment include the patient's age, their overall health, and the severity of their MS symptoms. Some approaches to de-escalating MS medication include gradually reducing the dosage of the medication over time or increasing the interval between the administration of infusible medications. This can help minimize the risk of side effects and complications, while still monitoring for maintained efficacy. These changes require shared decision-making between practitioners and patients after discussing the potential risks of MS relapse, new MRI lesions, or disease progression, along with the potential benefits of reducing medication-related side effects. Another approach is to switch to a different type of medication that is less  immunosuppressive (ie, immunomodulatory) and that may be better suited to the patient's needs; these medications are less likely to cause side effects in older patients or may be better tolerated by patients with certain health conditions.

DMTs may cause side effects in patients of any age, but aging patients may be more susceptible to certain side effects due to changes in their physiology and increased vulnerability due to other health issues. Some side effects of DMTs in aging pwMS that should be considered include:

• Cardiovascular issues: some DMTs may increase the risk of cardiovascular complications such as hypertension, hyperlipidemia, and heart failure, which may be more concerning in aging patients who may already have cardiovascular risk factors.

• Infections: aging patients may be more vulnerable to more severe infections, which often require hospitalization. Such patients are also at higher risk for opportunistic infections, such as zoster infections, or progressive multifocal leukoencephalopathy due to changes in the weakening of their immune system function and higher prevalence of other health issues. 

• Skin reactions/change to skin pathology: sphingosine-1-phosphate receptor modulators are oral DMTs for MS that were associated with cases of basal cell carcinoma in clinical trials.

Ultimately, the decision to continue, discontinue, or de-escalate DMTs in aging pwMS should be based on the individual patient's needs and circumstances. It is important for clinicians to work closely with their patients to develop a personalized treatment plan that considers all the relevant benefits and risks. In the meantime, more research is needed on this topic to provide better outcomes for our growing population of aging patients who are living with MS.

Multiple sclerosis (MS) is a chronic, inflammatory demyelinating and neurodegenerative disease that affects the central nervous system. While there is no cure for MS, significant progress has been made during the last 2 decades, with over 25 medications developed, including disease modifying therapies (DMTs) that have shown benefit in reducing the number of acute events (relapses), curbing the development of new lesions seen on magnetic resonance imaging (MRI), and slowing disease progression/worsening. However, the benefit of available DMTs is seen primarily during the inflammatory stage of the disease (relapsing remitting) and is less clear in the later stages (secondary-progressive disease). Age was shown to be one of the most consistent contributing factors linked to disease worsening, and most studies suggest limited benefit of available DMTs in patients older than 50 years. 

Meanwhile, the aging MS population is increasing worldwide, with most patients being between ages 55 and 65 years—a trend considered related to a general extended life expectancy, better diagnosis, early initiation of efficient DMTs, and improved general medical care. As persons with MS (pwMS) age, there is a clear change in the clinical presentation, with reduced risk for relapses and/or development of new MRI lesions but increased risk for disease worsening, with physical and cognitive decline. Systematic analysis–gathered data from clinical trials suggest an inadequate benefit of available DMTs in patients over 50 years, although the data have limitations, as most studies in relapsing MS did not enroll patients over the age of 55 years. In progressive MS trials, the median age of participants is 47 years; therefore, available data on aging populations are currently limited and cannot fully justify whether the medication is actually beneficial.

Another challenge in treating aging pwMS besides the limited benefit of DMTs is concern regarding safety and tolerability, especially as the most potent medications, which are now considered the most efficacious interventions for MS, are immunosuppressive agents. Aging populations with known weaker immune systems (immunosenescence) that are exposed to immunosuppressive interventions can be more susceptible to infections, have a decreased response to vaccinations, and face an increased risk of cancer. 

The aging population is also known to have other health issues (comorbidities) and, therefore, may become more vulnerable to side effects from DMTs, making it necessary to consider a different management approach. Until more effective and safe therapeutic interventions become available for aging pwMS, discontinuation or de-escalation are the most frequently used approaches. Choosing between continuing, discontinuing, or de-escalating DMTs when treating aging MS patients is a complex process that requires careful consideration as well as active patient and patient family engagement in the final management decision. 

The 2022 DISCO-MS trial was the first randomized discontinuation trial of MS drugs in older pwMS. The trial was designed to investigate the effect of discontinuing DMTs in patients aged 55 years and older who had not had recent relapses for at least 5 years and had no recent or new MRI lesions for at least 3 years. This multicenter study was conducted by the University of Colorado (supported/funded by a Patient-Centered Outcomes Research Institute grant) and included 259 participants with a median age of 63 years. Participants were randomly assigned to either continue or discontinue treatment and were followed for up to 22 months. The results of the DISCO-MS trial showed that 1 of 128 participants who stayed on medication had a relapse, and 3 of 131 people who discontinued medication had a relapse. There were no significant differences between the groups in progression of disability, cognition, quality of life, or adverse events. However, more participants who discontinued DMTs had new MRI lesions (16 vs 6), although there was no relationship to relapses or disability progression. Based on a noninferiority study design, the primary outcome (combined relapses and/or new MRI lesions) was not reached in this study. Other retrospective studies, such as a large study conducted in 2018, showed that most patients over age 60 years who discontinued DMTs remained off DMTs. These studies provide preliminary data that may guide clinicians who are considering discontinuing DMTs in their aging patients.

The second approach is de-escalation, which aims primarily to minimize the risk of side effects and complications while maintaining efficacy. Therefore, de-escalating MS medication in aging pwMS should always be done with great care. Some factors that should be considered when de-escalating treatment include the patient's age, their overall health, and the severity of their MS symptoms. Some approaches to de-escalating MS medication include gradually reducing the dosage of the medication over time or increasing the interval between the administration of infusible medications. This can help minimize the risk of side effects and complications, while still monitoring for maintained efficacy. These changes require shared decision-making between practitioners and patients after discussing the potential risks of MS relapse, new MRI lesions, or disease progression, along with the potential benefits of reducing medication-related side effects. Another approach is to switch to a different type of medication that is less  immunosuppressive (ie, immunomodulatory) and that may be better suited to the patient's needs; these medications are less likely to cause side effects in older patients or may be better tolerated by patients with certain health conditions.

DMTs may cause side effects in patients of any age, but aging patients may be more susceptible to certain side effects due to changes in their physiology and increased vulnerability due to other health issues. Some side effects of DMTs in aging pwMS that should be considered include:

• Cardiovascular issues: some DMTs may increase the risk of cardiovascular complications such as hypertension, hyperlipidemia, and heart failure, which may be more concerning in aging patients who may already have cardiovascular risk factors.

• Infections: aging patients may be more vulnerable to more severe infections, which often require hospitalization. Such patients are also at higher risk for opportunistic infections, such as zoster infections, or progressive multifocal leukoencephalopathy due to changes in the weakening of their immune system function and higher prevalence of other health issues. 

• Skin reactions/change to skin pathology: sphingosine-1-phosphate receptor modulators are oral DMTs for MS that were associated with cases of basal cell carcinoma in clinical trials.

Ultimately, the decision to continue, discontinue, or de-escalate DMTs in aging pwMS should be based on the individual patient's needs and circumstances. It is important for clinicians to work closely with their patients to develop a personalized treatment plan that considers all the relevant benefits and risks. In the meantime, more research is needed on this topic to provide better outcomes for our growing population of aging patients who are living with MS.

Multiple sclerosis (MS) is a chronic, inflammatory demyelinating and neurodegenerative disease that affects the central nervous system. While there is no cure for MS, significant progress has been made during the last 2 decades, with over 25 medications developed, including disease modifying therapies (DMTs) that have shown benefit in reducing the number of acute events (relapses), curbing the development of new lesions seen on magnetic resonance imaging (MRI), and slowing disease progression/worsening. However, the benefit of available DMTs is seen primarily during the inflammatory stage of the disease (relapsing remitting) and is less clear in the later stages (secondary-progressive disease). Age was shown to be one of the most consistent contributing factors linked to disease worsening, and most studies suggest limited benefit of available DMTs in patients older than 50 years. 

Meanwhile, the aging MS population is increasing worldwide, with most patients being between ages 55 and 65 years—a trend considered related to a general extended life expectancy, better diagnosis, early initiation of efficient DMTs, and improved general medical care. As persons with MS (pwMS) age, there is a clear change in the clinical presentation, with reduced risk for relapses and/or development of new MRI lesions but increased risk for disease worsening, with physical and cognitive decline. Systematic analysis–gathered data from clinical trials suggest an inadequate benefit of available DMTs in patients over 50 years, although the data have limitations, as most studies in relapsing MS did not enroll patients over the age of 55 years. In progressive MS trials, the median age of participants is 47 years; therefore, available data on aging populations are currently limited and cannot fully justify whether the medication is actually beneficial.

Another challenge in treating aging pwMS besides the limited benefit of DMTs is concern regarding safety and tolerability, especially as the most potent medications, which are now considered the most efficacious interventions for MS, are immunosuppressive agents. Aging populations with known weaker immune systems (immunosenescence) that are exposed to immunosuppressive interventions can be more susceptible to infections, have a decreased response to vaccinations, and face an increased risk of cancer. 

The aging population is also known to have other health issues (comorbidities) and, therefore, may become more vulnerable to side effects from DMTs, making it necessary to consider a different management approach. Until more effective and safe therapeutic interventions become available for aging pwMS, discontinuation or de-escalation are the most frequently used approaches. Choosing between continuing, discontinuing, or de-escalating DMTs when treating aging MS patients is a complex process that requires careful consideration as well as active patient and patient family engagement in the final management decision. 

The 2022 DISCO-MS trial was the first randomized discontinuation trial of MS drugs in older pwMS. The trial was designed to investigate the effect of discontinuing DMTs in patients aged 55 years and older who had not had recent relapses for at least 5 years and had no recent or new MRI lesions for at least 3 years. This multicenter study was conducted by the University of Colorado (supported/funded by a Patient-Centered Outcomes Research Institute grant) and included 259 participants with a median age of 63 years. Participants were randomly assigned to either continue or discontinue treatment and were followed for up to 22 months. The results of the DISCO-MS trial showed that 1 of 128 participants who stayed on medication had a relapse, and 3 of 131 people who discontinued medication had a relapse. There were no significant differences between the groups in progression of disability, cognition, quality of life, or adverse events. However, more participants who discontinued DMTs had new MRI lesions (16 vs 6), although there was no relationship to relapses or disability progression. Based on a noninferiority study design, the primary outcome (combined relapses and/or new MRI lesions) was not reached in this study. Other retrospective studies, such as a large study conducted in 2018, showed that most patients over age 60 years who discontinued DMTs remained off DMTs. These studies provide preliminary data that may guide clinicians who are considering discontinuing DMTs in their aging patients.

The second approach is de-escalation, which aims primarily to minimize the risk of side effects and complications while maintaining efficacy. Therefore, de-escalating MS medication in aging pwMS should always be done with great care. Some factors that should be considered when de-escalating treatment include the patient's age, their overall health, and the severity of their MS symptoms. Some approaches to de-escalating MS medication include gradually reducing the dosage of the medication over time or increasing the interval between the administration of infusible medications. This can help minimize the risk of side effects and complications, while still monitoring for maintained efficacy. These changes require shared decision-making between practitioners and patients after discussing the potential risks of MS relapse, new MRI lesions, or disease progression, along with the potential benefits of reducing medication-related side effects. Another approach is to switch to a different type of medication that is less  immunosuppressive (ie, immunomodulatory) and that may be better suited to the patient's needs; these medications are less likely to cause side effects in older patients or may be better tolerated by patients with certain health conditions.

DMTs may cause side effects in patients of any age, but aging patients may be more susceptible to certain side effects due to changes in their physiology and increased vulnerability due to other health issues. Some side effects of DMTs in aging pwMS that should be considered include:

• Cardiovascular issues: some DMTs may increase the risk of cardiovascular complications such as hypertension, hyperlipidemia, and heart failure, which may be more concerning in aging patients who may already have cardiovascular risk factors.

• Infections: aging patients may be more vulnerable to more severe infections, which often require hospitalization. Such patients are also at higher risk for opportunistic infections, such as zoster infections, or progressive multifocal leukoencephalopathy due to changes in the weakening of their immune system function and higher prevalence of other health issues. 

• Skin reactions/change to skin pathology: sphingosine-1-phosphate receptor modulators are oral DMTs for MS that were associated with cases of basal cell carcinoma in clinical trials.

Ultimately, the decision to continue, discontinue, or de-escalate DMTs in aging pwMS should be based on the individual patient's needs and circumstances. It is important for clinicians to work closely with their patients to develop a personalized treatment plan that considers all the relevant benefits and risks. In the meantime, more research is needed on this topic to provide better outcomes for our growing population of aging patients who are living with MS.

A test that uses a single drop of dried blood to detect HIV, hepatitis B virus, and HCV has been validated and is now in use in some high-risk settings in Denmark, according to research presented at the annual European Congress of Clinical Microbiology & Infectious Diseases.

Molecular biologist Stephen Nilsson-Møller, MSc, and colleagues at the department of clinical microbiology, Copenhagen University Hospital, developed and validated the test, known as the Dried Blood Spot (DBS), for HIV, HBV, and HCV.

The “test that can detect low viral loads for all three viruses from a single drop of blood, and can be done using existing hospital equipment,” Mr. Nilsson-Møller said in an interview. “Importantly, it does not require venipuncture, but can be done from a drop of dried blood from the finger.”

He highlighted the utility of the new test in more challenging settings. “This method is particularly useful in high-risk settings such as homeless shelters, drug rehabilitation centers, and prisons, where needles might be misused, and it can be difficult to convince people to have the more invasive test.”

“Also, in some places – such as in low- and middle-income settings – there is a distinct risk of ruining blood samples before analysis due to limited refrigeration for transit and storage,” he added. “[Standard] blood samples need to be analyzed within 6 hours when kept at room temperature, while dried blood spots can last for 9 months at room temperature and can be mailed to a laboratory with the right equipment to analyze it.” 
 

Tiny amounts of virus detected

Mr. Nilsson-Møller was tasked with developing a test for use by the university’s department of infectious diseases to screen people in high-risk settings in the capital region of Copenhagen. The work forms part of a PhD project by Jonas Demant at the University of Copenhagen, for which he is screening for HIV, HBV, and HCV in drug rehabilitation centers, prisons, and homeless shelters. 

The study is the first to use the Hologic Panther system (a nucleic acid amplification test) combining all three viruses, Mr. Nilsson-Møller pointed out. “A tiny amount of virus can be detected because it is a very sensitive platform using transcription-mediated amplification.”

“If it detects low amounts of virus, it will create many copies very quickly, creating a signal that tells us that the sample is positive,” he explained.

The researchers collected whole blood from a finger prick, dried it out on a protein saver card (filter paper), and cut out a 1.2-cm diameter dry blood spot which was then prepared for analysis.

Twenty blood samples with known amounts of HIV, HBV, and HCV were analyzed via the DBS method (60 in total) and the viruses were detected in all of the samples.

To validate the method, the researchers used plasma with a known viral load, and a series of dilutions were performed to determine the lower limit for positive detection of all three viruses.

“Untreated patients typically have above 1 million IU/mL of viral loads in their plasma, and we found that we can detect much lower levels,” said Mr. Nilsson-Møller. “Ideally, 40 mcL of blood is good, but less should be sufficient if the test is on untreated patients.”
 

Early testing and treatment reduces morbidity and mortality

Elimination of HBV, HCV, and HIV by 2030 is a global health strategy set by the World Health Organization, but to meet this goal, new approaches for diagnostic testing are required. The DBS test for HIV, HBV, and HCV promises to make a significant contribution toward this goal.

“One in two people currently living with HIV is diagnosed late in the course of their infection, and an even larger proportion of the estimated 6 million Europeans living with chronic hepatitis B or C are not aware that they are infected,” said Anastasia Pharris, PhD, from the European Center for Disease Prevention and Control Principal Expert Infectious Diseases.

“Increasing testing coverage and uptake, especially for those most at risk, is an essential element of any strategy to eliminate HBV, HCV, and HIV in the European Union and European Economic Area,” she pointed out.

Dr. Pharris also highlighted that, while HIV, and often HBV infection, require lifelong treatment, HCV infection is now curable within a few weeks. “To maximize the benefits of individual treatment for all three infections, it is critical to test and diagnose people as soon as possible – in itself a challenge given that these infections can typically be asymptomatic for years.

“Early diagnosis of HBV, HCV, or HIV is vital as it allows people to access treatment, which significantly reduces associated long-term morbidity and mortality.

“In many cases, those most at risk of one of these infections are also more vulnerable to infection with one or both of the other viruses, making the argument for integrated testing even stronger,” she said in an interview.

Mr. Nilsson-Møller and Dr. Pharris reported no relevant financial relationships. Aptima kits for validation were provided by Hologic.

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

A test that uses a single drop of dried blood to detect HIV, hepatitis B virus, and HCV has been validated and is now in use in some high-risk settings in Denmark, according to research presented at the annual European Congress of Clinical Microbiology & Infectious Diseases.

Molecular biologist Stephen Nilsson-Møller, MSc, and colleagues at the department of clinical microbiology, Copenhagen University Hospital, developed and validated the test, known as the Dried Blood Spot (DBS), for HIV, HBV, and HCV.

The “test that can detect low viral loads for all three viruses from a single drop of blood, and can be done using existing hospital equipment,” Mr. Nilsson-Møller said in an interview. “Importantly, it does not require venipuncture, but can be done from a drop of dried blood from the finger.”

He highlighted the utility of the new test in more challenging settings. “This method is particularly useful in high-risk settings such as homeless shelters, drug rehabilitation centers, and prisons, where needles might be misused, and it can be difficult to convince people to have the more invasive test.”

“Also, in some places – such as in low- and middle-income settings – there is a distinct risk of ruining blood samples before analysis due to limited refrigeration for transit and storage,” he added. “[Standard] blood samples need to be analyzed within 6 hours when kept at room temperature, while dried blood spots can last for 9 months at room temperature and can be mailed to a laboratory with the right equipment to analyze it.” 
 

Tiny amounts of virus detected

Mr. Nilsson-Møller was tasked with developing a test for use by the university’s department of infectious diseases to screen people in high-risk settings in the capital region of Copenhagen. The work forms part of a PhD project by Jonas Demant at the University of Copenhagen, for which he is screening for HIV, HBV, and HCV in drug rehabilitation centers, prisons, and homeless shelters. 

The study is the first to use the Hologic Panther system (a nucleic acid amplification test) combining all three viruses, Mr. Nilsson-Møller pointed out. “A tiny amount of virus can be detected because it is a very sensitive platform using transcription-mediated amplification.”

“If it detects low amounts of virus, it will create many copies very quickly, creating a signal that tells us that the sample is positive,” he explained.

The researchers collected whole blood from a finger prick, dried it out on a protein saver card (filter paper), and cut out a 1.2-cm diameter dry blood spot which was then prepared for analysis.

Twenty blood samples with known amounts of HIV, HBV, and HCV were analyzed via the DBS method (60 in total) and the viruses were detected in all of the samples.

To validate the method, the researchers used plasma with a known viral load, and a series of dilutions were performed to determine the lower limit for positive detection of all three viruses.

“Untreated patients typically have above 1 million IU/mL of viral loads in their plasma, and we found that we can detect much lower levels,” said Mr. Nilsson-Møller. “Ideally, 40 mcL of blood is good, but less should be sufficient if the test is on untreated patients.”
 

Early testing and treatment reduces morbidity and mortality

Elimination of HBV, HCV, and HIV by 2030 is a global health strategy set by the World Health Organization, but to meet this goal, new approaches for diagnostic testing are required. The DBS test for HIV, HBV, and HCV promises to make a significant contribution toward this goal.

“One in two people currently living with HIV is diagnosed late in the course of their infection, and an even larger proportion of the estimated 6 million Europeans living with chronic hepatitis B or C are not aware that they are infected,” said Anastasia Pharris, PhD, from the European Center for Disease Prevention and Control Principal Expert Infectious Diseases.

“Increasing testing coverage and uptake, especially for those most at risk, is an essential element of any strategy to eliminate HBV, HCV, and HIV in the European Union and European Economic Area,” she pointed out.

Dr. Pharris also highlighted that, while HIV, and often HBV infection, require lifelong treatment, HCV infection is now curable within a few weeks. “To maximize the benefits of individual treatment for all three infections, it is critical to test and diagnose people as soon as possible – in itself a challenge given that these infections can typically be asymptomatic for years.

“Early diagnosis of HBV, HCV, or HIV is vital as it allows people to access treatment, which significantly reduces associated long-term morbidity and mortality.

“In many cases, those most at risk of one of these infections are also more vulnerable to infection with one or both of the other viruses, making the argument for integrated testing even stronger,” she said in an interview.

Mr. Nilsson-Møller and Dr. Pharris reported no relevant financial relationships. Aptima kits for validation were provided by Hologic.

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

A test that uses a single drop of dried blood to detect HIV, hepatitis B virus, and HCV has been validated and is now in use in some high-risk settings in Denmark, according to research presented at the annual European Congress of Clinical Microbiology & Infectious Diseases.

Molecular biologist Stephen Nilsson-Møller, MSc, and colleagues at the department of clinical microbiology, Copenhagen University Hospital, developed and validated the test, known as the Dried Blood Spot (DBS), for HIV, HBV, and HCV.

The “test that can detect low viral loads for all three viruses from a single drop of blood, and can be done using existing hospital equipment,” Mr. Nilsson-Møller said in an interview. “Importantly, it does not require venipuncture, but can be done from a drop of dried blood from the finger.”

He highlighted the utility of the new test in more challenging settings. “This method is particularly useful in high-risk settings such as homeless shelters, drug rehabilitation centers, and prisons, where needles might be misused, and it can be difficult to convince people to have the more invasive test.”

“Also, in some places – such as in low- and middle-income settings – there is a distinct risk of ruining blood samples before analysis due to limited refrigeration for transit and storage,” he added. “[Standard] blood samples need to be analyzed within 6 hours when kept at room temperature, while dried blood spots can last for 9 months at room temperature and can be mailed to a laboratory with the right equipment to analyze it.” 
 

Tiny amounts of virus detected

Mr. Nilsson-Møller was tasked with developing a test for use by the university’s department of infectious diseases to screen people in high-risk settings in the capital region of Copenhagen. The work forms part of a PhD project by Jonas Demant at the University of Copenhagen, for which he is screening for HIV, HBV, and HCV in drug rehabilitation centers, prisons, and homeless shelters. 

The study is the first to use the Hologic Panther system (a nucleic acid amplification test) combining all three viruses, Mr. Nilsson-Møller pointed out. “A tiny amount of virus can be detected because it is a very sensitive platform using transcription-mediated amplification.”

“If it detects low amounts of virus, it will create many copies very quickly, creating a signal that tells us that the sample is positive,” he explained.

The researchers collected whole blood from a finger prick, dried it out on a protein saver card (filter paper), and cut out a 1.2-cm diameter dry blood spot which was then prepared for analysis.

Twenty blood samples with known amounts of HIV, HBV, and HCV were analyzed via the DBS method (60 in total) and the viruses were detected in all of the samples.

To validate the method, the researchers used plasma with a known viral load, and a series of dilutions were performed to determine the lower limit for positive detection of all three viruses.

“Untreated patients typically have above 1 million IU/mL of viral loads in their plasma, and we found that we can detect much lower levels,” said Mr. Nilsson-Møller. “Ideally, 40 mcL of blood is good, but less should be sufficient if the test is on untreated patients.”
 

Early testing and treatment reduces morbidity and mortality

Elimination of HBV, HCV, and HIV by 2030 is a global health strategy set by the World Health Organization, but to meet this goal, new approaches for diagnostic testing are required. The DBS test for HIV, HBV, and HCV promises to make a significant contribution toward this goal.

“One in two people currently living with HIV is diagnosed late in the course of their infection, and an even larger proportion of the estimated 6 million Europeans living with chronic hepatitis B or C are not aware that they are infected,” said Anastasia Pharris, PhD, from the European Center for Disease Prevention and Control Principal Expert Infectious Diseases.

“Increasing testing coverage and uptake, especially for those most at risk, is an essential element of any strategy to eliminate HBV, HCV, and HIV in the European Union and European Economic Area,” she pointed out.

Dr. Pharris also highlighted that, while HIV, and often HBV infection, require lifelong treatment, HCV infection is now curable within a few weeks. “To maximize the benefits of individual treatment for all three infections, it is critical to test and diagnose people as soon as possible – in itself a challenge given that these infections can typically be asymptomatic for years.

“Early diagnosis of HBV, HCV, or HIV is vital as it allows people to access treatment, which significantly reduces associated long-term morbidity and mortality.

“In many cases, those most at risk of one of these infections are also more vulnerable to infection with one or both of the other viruses, making the argument for integrated testing even stronger,” she said in an interview.

Mr. Nilsson-Møller and Dr. Pharris reported no relevant financial relationships. Aptima kits for validation were provided by Hologic.

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

I recently posted a case about a smoker who became angry when I hesitated to prescribe antibiotics for his self-diagnosed bronchitis. He even threatened to retaliate by posting negative online reviews of my practice. In the end, I decided to use the strategy of a delayed prescription for antibiotics, instructing him to fill the prescription only if his symptoms worsened. I asked whether readers agreed with this approach. Thank you for the thoughtful comments regarding a case that certainly seemed familiar to many of you. I very much appreciate the chance to interact and share perspectives in a challenging clinical dilemma.
 

One theme that emerged through several comments was the perceived futility of the delayed prescriptions for antibiotics. To summarize, the collective logic stated that there is no point in delaying a prescription, because the patient will be very likely to fill that prescription right away despite counseling from the health care provider (HCP).

However, studies of delayed antibiotic prescriptions show that patients generally honor the advice to only fill the prescription if they are not improving clinically. In a study comparing immediate, delayed, or no antibiotic prescriptions among a cohort of children with uncomplicated respiratory infections, the overall rates of use of antibiotics in the three respective groups were 96%, 25.3%, and 12.0%. In another randomized trial exploring different strategies for delayed prescriptions among adults with upper respiratory infections, the rate of antibiotic use was 37% with delayed prescription strategies vs. 97% of patients prescribed antibiotics immediately. Neither of these prospective studies found a significant difference in clinical symptoms or complications in comparing the delayed and immediate antibiotic prescription groups.

Another common theme in the comments on this case focused on the challenge of online reviews of HCPs by patients. Multiple popular websites are devoted to patients’ unedited comments on HCPs and their practices, but there are still certain patterns to the comments. Some reviews describe the professionalism or empathy of the HCP, but others might focus more attention on the overall practice or office. These latter comments might emphasize issues such as timeliness of appointments, interactions with staff, or even parking and traffic. These are issues over which the HCP usually has little control.

HCPs are quite human, and therefore we might feel great about positive comments and dispirited or even angry with negative comments. So what is the best practice for HCPs in managing these online comments? A review by Dr Rebekah Bernard, which was published in the Sept. 25, 2018, issue of Medical Economics, offered some pragmatic advice:

Do not perseverate on one or two negative reviews. In fact, they might help! Dr. Bernard describes the psychological theory of the “pratfall effect,” in which people are more likely to prefer someone who is generally very good but not perfect to someone with nothing but exceptional reviews. HCPs with perfect reviews every time may be seen as intimidating or unapproachable.

Satisfied patients will frequently rally to support an HCP with an unfavorable review. This group may not be very motivated to complete online reviews until they see a comment which does at all match their own experience with the HCP.

Most importantly, HCPs can take an active role in minimizing the impact of negative online reviews while also enhancing their business model. Increasing your presence on the Internet and social media can help dilute negative reviews and push them down the list when someone performs a search on your name or practice. Creating a website for your practice is an effective means to be first on search engine lists, and HCPs should seek search-engine optimization features that promote this outcome. Adding social media contacts for yourself and/or your practice, as many as you can tolerate and maintain, allows HCPs to further control the narrative regarding their practice and central messaging to patients and the community.

In conclusion, delayed antibiotic prescriptions can reduce the use of unnecessary antibiotics for upper respiratory infections among children and adults, and they are not associated with worse clinical outcomes vs. immediate antibiotic prescriptions. They can also improve patient satisfaction for these visits, which can minimize the challenging issue of negative reviews of HCPs. HCPs should therefore consider delayed prescriptions as a strong option among patients without an indication for an antibiotic prescription.

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

I recently posted a case about a smoker who became angry when I hesitated to prescribe antibiotics for his self-diagnosed bronchitis. He even threatened to retaliate by posting negative online reviews of my practice. In the end, I decided to use the strategy of a delayed prescription for antibiotics, instructing him to fill the prescription only if his symptoms worsened. I asked whether readers agreed with this approach. Thank you for the thoughtful comments regarding a case that certainly seemed familiar to many of you. I very much appreciate the chance to interact and share perspectives in a challenging clinical dilemma.
 

One theme that emerged through several comments was the perceived futility of the delayed prescriptions for antibiotics. To summarize, the collective logic stated that there is no point in delaying a prescription, because the patient will be very likely to fill that prescription right away despite counseling from the health care provider (HCP).

However, studies of delayed antibiotic prescriptions show that patients generally honor the advice to only fill the prescription if they are not improving clinically. In a study comparing immediate, delayed, or no antibiotic prescriptions among a cohort of children with uncomplicated respiratory infections, the overall rates of use of antibiotics in the three respective groups were 96%, 25.3%, and 12.0%. In another randomized trial exploring different strategies for delayed prescriptions among adults with upper respiratory infections, the rate of antibiotic use was 37% with delayed prescription strategies vs. 97% of patients prescribed antibiotics immediately. Neither of these prospective studies found a significant difference in clinical symptoms or complications in comparing the delayed and immediate antibiotic prescription groups.

Another common theme in the comments on this case focused on the challenge of online reviews of HCPs by patients. Multiple popular websites are devoted to patients’ unedited comments on HCPs and their practices, but there are still certain patterns to the comments. Some reviews describe the professionalism or empathy of the HCP, but others might focus more attention on the overall practice or office. These latter comments might emphasize issues such as timeliness of appointments, interactions with staff, or even parking and traffic. These are issues over which the HCP usually has little control.

HCPs are quite human, and therefore we might feel great about positive comments and dispirited or even angry with negative comments. So what is the best practice for HCPs in managing these online comments? A review by Dr Rebekah Bernard, which was published in the Sept. 25, 2018, issue of Medical Economics, offered some pragmatic advice:

Do not perseverate on one or two negative reviews. In fact, they might help! Dr. Bernard describes the psychological theory of the “pratfall effect,” in which people are more likely to prefer someone who is generally very good but not perfect to someone with nothing but exceptional reviews. HCPs with perfect reviews every time may be seen as intimidating or unapproachable.

Satisfied patients will frequently rally to support an HCP with an unfavorable review. This group may not be very motivated to complete online reviews until they see a comment which does at all match their own experience with the HCP.

Most importantly, HCPs can take an active role in minimizing the impact of negative online reviews while also enhancing their business model. Increasing your presence on the Internet and social media can help dilute negative reviews and push them down the list when someone performs a search on your name or practice. Creating a website for your practice is an effective means to be first on search engine lists, and HCPs should seek search-engine optimization features that promote this outcome. Adding social media contacts for yourself and/or your practice, as many as you can tolerate and maintain, allows HCPs to further control the narrative regarding their practice and central messaging to patients and the community.

In conclusion, delayed antibiotic prescriptions can reduce the use of unnecessary antibiotics for upper respiratory infections among children and adults, and they are not associated with worse clinical outcomes vs. immediate antibiotic prescriptions. They can also improve patient satisfaction for these visits, which can minimize the challenging issue of negative reviews of HCPs. HCPs should therefore consider delayed prescriptions as a strong option among patients without an indication for an antibiotic prescription.

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

I recently posted a case about a smoker who became angry when I hesitated to prescribe antibiotics for his self-diagnosed bronchitis. He even threatened to retaliate by posting negative online reviews of my practice. In the end, I decided to use the strategy of a delayed prescription for antibiotics, instructing him to fill the prescription only if his symptoms worsened. I asked whether readers agreed with this approach. Thank you for the thoughtful comments regarding a case that certainly seemed familiar to many of you. I very much appreciate the chance to interact and share perspectives in a challenging clinical dilemma.
 

One theme that emerged through several comments was the perceived futility of the delayed prescriptions for antibiotics. To summarize, the collective logic stated that there is no point in delaying a prescription, because the patient will be very likely to fill that prescription right away despite counseling from the health care provider (HCP).

However, studies of delayed antibiotic prescriptions show that patients generally honor the advice to only fill the prescription if they are not improving clinically. In a study comparing immediate, delayed, or no antibiotic prescriptions among a cohort of children with uncomplicated respiratory infections, the overall rates of use of antibiotics in the three respective groups were 96%, 25.3%, and 12.0%. In another randomized trial exploring different strategies for delayed prescriptions among adults with upper respiratory infections, the rate of antibiotic use was 37% with delayed prescription strategies vs. 97% of patients prescribed antibiotics immediately. Neither of these prospective studies found a significant difference in clinical symptoms or complications in comparing the delayed and immediate antibiotic prescription groups.

Another common theme in the comments on this case focused on the challenge of online reviews of HCPs by patients. Multiple popular websites are devoted to patients’ unedited comments on HCPs and their practices, but there are still certain patterns to the comments. Some reviews describe the professionalism or empathy of the HCP, but others might focus more attention on the overall practice or office. These latter comments might emphasize issues such as timeliness of appointments, interactions with staff, or even parking and traffic. These are issues over which the HCP usually has little control.

HCPs are quite human, and therefore we might feel great about positive comments and dispirited or even angry with negative comments. So what is the best practice for HCPs in managing these online comments? A review by Dr Rebekah Bernard, which was published in the Sept. 25, 2018, issue of Medical Economics, offered some pragmatic advice:

Do not perseverate on one or two negative reviews. In fact, they might help! Dr. Bernard describes the psychological theory of the “pratfall effect,” in which people are more likely to prefer someone who is generally very good but not perfect to someone with nothing but exceptional reviews. HCPs with perfect reviews every time may be seen as intimidating or unapproachable.

Satisfied patients will frequently rally to support an HCP with an unfavorable review. This group may not be very motivated to complete online reviews until they see a comment which does at all match their own experience with the HCP.

Most importantly, HCPs can take an active role in minimizing the impact of negative online reviews while also enhancing their business model. Increasing your presence on the Internet and social media can help dilute negative reviews and push them down the list when someone performs a search on your name or practice. Creating a website for your practice is an effective means to be first on search engine lists, and HCPs should seek search-engine optimization features that promote this outcome. Adding social media contacts for yourself and/or your practice, as many as you can tolerate and maintain, allows HCPs to further control the narrative regarding their practice and central messaging to patients and the community.

In conclusion, delayed antibiotic prescriptions can reduce the use of unnecessary antibiotics for upper respiratory infections among children and adults, and they are not associated with worse clinical outcomes vs. immediate antibiotic prescriptions. They can also improve patient satisfaction for these visits, which can minimize the challenging issue of negative reviews of HCPs. HCPs should therefore consider delayed prescriptions as a strong option among patients without an indication for an antibiotic prescription.

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

Poor diets account for most newly diagnosed type 2 diabetes cases worldwide, a new analysis has found.

More specifically, the modeling study showed that roughly 14 million cases of type 2 diabetes – or 70% of total type 2 diabetes diagnoses in 2018 – were linked with a poor diet, found Meghan O’Hearn, a doctoral student at the Friedman School of Nutrition Science and Policy, Tufts University, Boston, and colleagues. The study was published online in Nature Medicine.

The results also indicate that the greatest burdens of type 2 diabetes were accounted for by excess wheat intake and refined rice (24.6%), excess processed meat consumption (20.3%), and inadequate whole-grain consumption (26.1%). Factors such as drinking too much fruit juice and not eating enough nonstarchy vegetables, nuts, or seeds, had less of an impact on new cases of the disease, the researchers determined.

“These findings can help inform nutritional priorities for clinicians, policymakers, and private sector actors as they encourage healthier dietary choices that address this global epidemic,” Ms. O’Hearn said in a press release.

Prior research has suggested that poor diet contributes to about 40% of type 2 diabetes cases worldwide, the researchers note.

The team attributes their finding of a 70% contribution to the new information in their analysis, such as the first-ever inclusion of refined grains, which was one of the top contributors to diabetes burden, and updated data on dietary habits based on national individual-level dietary surveys rather than agricultural estimates. 

“Our study suggests poor carbohydrate quality is a leading driver of diet-attributable type 2 diabetes globally and with important variation by nation and over time,” said senior author Dariush Mozaffarian, MD, DrPh, MPH, who is the Jean Mayer Professor of Nutrition at the Friedman School of Nutrition Science and Policy.

“These new findings reveal critical areas for national and global focus to improve nutrition and reduce devastating burdens of diabetes,” he noted.

“Left unchecked and with incidence only projected to rise, type 2 diabetes will continue to impact population health, economic productivity, [and] health care system capacity, [as well as] drive health inequities worldwide,” Ms. O’Hearn said.
 

It’s about reducing harmful dietary components

Ms. O’Hearn and colleagues set out to fill information gaps in knowledge about how the global burden of diet-associated type 2 diabetes is impacted by disparities and other factors known to influence risk, including dietary components.

They used information from the Global Dietary Database to study dietary intake in 184 nations from 1990 to 2018. They also studied demographics from multiple sources, estimates of type 2 diabetes incidence around the world, and data on food choices, including the effect of 11 dietary factors, from prior research.

They found that there were 8.6 million more cases of type 2 diabetes in 2018 than in 1990 because of poor diet. 

Regionally, Central and Eastern Europe and Central Asia had the greatest number of type 2 diabetes cases linked to diet, particularly Poland and Russia, where diets tend to be rich in red meat, processed meat, and potatoes. Incidence was also high in Latin America and the Caribbean, especially in Colombia and Mexico, which was attributed to high consumption of sugary drinks and processed meat and low intake of whole grains.

Regions where diet had less of an impact on type 2 diabetes cases included South Asia and sub-Saharan Africa, although the largest increases in type 2 diabetes due to poor diet between 1990 and 2018 were observed in sub-Saharan Africa.

Diet-attributable type 2 diabetes was generally larger among urban versus rural residents and higher versus lower educated individuals, except in high-income countries, Central and Eastern Europe, and Central Asia, where burdens were larger in rural residents and in lower educated individuals.

Notably, women had lower proportions of diet-related type 2 diabetes, compared with men, and these proportions were inversely related to age.

Excess intake of harmful dietary factors contributed a greater percentage of the burden of type 2 diabetes globally (60.8%) than did insufficient intake of protective dietary factors (39.2%).

“Future research should address whether more complex diet–type 2 diabetes dose–response relationships exist,” the authors conclude.

Ms. O’Hearn has reported receiving research funding from the Gates Foundation, as well as the National Institutes of Health and Vail Innovative Global Research and employment with Food Systems for the Future. Dr. Mozaffarian has reported receiving funding from the National Institutes of Health, the Gates Foundation, the Rockefeller Foundation, Vail Innovative Global Research, and the Kaiser Permanente Fund at East Bay Community Foundation; personal fees from Acasti Pharma, Barilla, Danone, and Motif FoodWorks; is on the scientific advisory board for Beren Therapeutics, Brightseed, Calibrate, DiscernDx, Elysium Health, Filtricine, HumanCo, January, Perfect Day, Tiny Organics and (ended) Day Two and Season Health; has stock ownership in Calibrate and HumanCo; and receives chapter royalties from UpToDate.

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

Poor diets account for most newly diagnosed type 2 diabetes cases worldwide, a new analysis has found.

More specifically, the modeling study showed that roughly 14 million cases of type 2 diabetes – or 70% of total type 2 diabetes diagnoses in 2018 – were linked with a poor diet, found Meghan O’Hearn, a doctoral student at the Friedman School of Nutrition Science and Policy, Tufts University, Boston, and colleagues. The study was published online in Nature Medicine.

The results also indicate that the greatest burdens of type 2 diabetes were accounted for by excess wheat intake and refined rice (24.6%), excess processed meat consumption (20.3%), and inadequate whole-grain consumption (26.1%). Factors such as drinking too much fruit juice and not eating enough nonstarchy vegetables, nuts, or seeds, had less of an impact on new cases of the disease, the researchers determined.

“These findings can help inform nutritional priorities for clinicians, policymakers, and private sector actors as they encourage healthier dietary choices that address this global epidemic,” Ms. O’Hearn said in a press release.

Prior research has suggested that poor diet contributes to about 40% of type 2 diabetes cases worldwide, the researchers note.

The team attributes their finding of a 70% contribution to the new information in their analysis, such as the first-ever inclusion of refined grains, which was one of the top contributors to diabetes burden, and updated data on dietary habits based on national individual-level dietary surveys rather than agricultural estimates. 

“Our study suggests poor carbohydrate quality is a leading driver of diet-attributable type 2 diabetes globally and with important variation by nation and over time,” said senior author Dariush Mozaffarian, MD, DrPh, MPH, who is the Jean Mayer Professor of Nutrition at the Friedman School of Nutrition Science and Policy.

“These new findings reveal critical areas for national and global focus to improve nutrition and reduce devastating burdens of diabetes,” he noted.

“Left unchecked and with incidence only projected to rise, type 2 diabetes will continue to impact population health, economic productivity, [and] health care system capacity, [as well as] drive health inequities worldwide,” Ms. O’Hearn said.
 

It’s about reducing harmful dietary components

Ms. O’Hearn and colleagues set out to fill information gaps in knowledge about how the global burden of diet-associated type 2 diabetes is impacted by disparities and other factors known to influence risk, including dietary components.

They used information from the Global Dietary Database to study dietary intake in 184 nations from 1990 to 2018. They also studied demographics from multiple sources, estimates of type 2 diabetes incidence around the world, and data on food choices, including the effect of 11 dietary factors, from prior research.

They found that there were 8.6 million more cases of type 2 diabetes in 2018 than in 1990 because of poor diet. 

Regionally, Central and Eastern Europe and Central Asia had the greatest number of type 2 diabetes cases linked to diet, particularly Poland and Russia, where diets tend to be rich in red meat, processed meat, and potatoes. Incidence was also high in Latin America and the Caribbean, especially in Colombia and Mexico, which was attributed to high consumption of sugary drinks and processed meat and low intake of whole grains.

Regions where diet had less of an impact on type 2 diabetes cases included South Asia and sub-Saharan Africa, although the largest increases in type 2 diabetes due to poor diet between 1990 and 2018 were observed in sub-Saharan Africa.

Diet-attributable type 2 diabetes was generally larger among urban versus rural residents and higher versus lower educated individuals, except in high-income countries, Central and Eastern Europe, and Central Asia, where burdens were larger in rural residents and in lower educated individuals.

Notably, women had lower proportions of diet-related type 2 diabetes, compared with men, and these proportions were inversely related to age.

Excess intake of harmful dietary factors contributed a greater percentage of the burden of type 2 diabetes globally (60.8%) than did insufficient intake of protective dietary factors (39.2%).

“Future research should address whether more complex diet–type 2 diabetes dose–response relationships exist,” the authors conclude.

Ms. O’Hearn has reported receiving research funding from the Gates Foundation, as well as the National Institutes of Health and Vail Innovative Global Research and employment with Food Systems for the Future. Dr. Mozaffarian has reported receiving funding from the National Institutes of Health, the Gates Foundation, the Rockefeller Foundation, Vail Innovative Global Research, and the Kaiser Permanente Fund at East Bay Community Foundation; personal fees from Acasti Pharma, Barilla, Danone, and Motif FoodWorks; is on the scientific advisory board for Beren Therapeutics, Brightseed, Calibrate, DiscernDx, Elysium Health, Filtricine, HumanCo, January, Perfect Day, Tiny Organics and (ended) Day Two and Season Health; has stock ownership in Calibrate and HumanCo; and receives chapter royalties from UpToDate.

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

Poor diets account for most newly diagnosed type 2 diabetes cases worldwide, a new analysis has found.

More specifically, the modeling study showed that roughly 14 million cases of type 2 diabetes – or 70% of total type 2 diabetes diagnoses in 2018 – were linked with a poor diet, found Meghan O’Hearn, a doctoral student at the Friedman School of Nutrition Science and Policy, Tufts University, Boston, and colleagues. The study was published online in Nature Medicine.

The results also indicate that the greatest burdens of type 2 diabetes were accounted for by excess wheat intake and refined rice (24.6%), excess processed meat consumption (20.3%), and inadequate whole-grain consumption (26.1%). Factors such as drinking too much fruit juice and not eating enough nonstarchy vegetables, nuts, or seeds, had less of an impact on new cases of the disease, the researchers determined.

“These findings can help inform nutritional priorities for clinicians, policymakers, and private sector actors as they encourage healthier dietary choices that address this global epidemic,” Ms. O’Hearn said in a press release.

Prior research has suggested that poor diet contributes to about 40% of type 2 diabetes cases worldwide, the researchers note.

The team attributes their finding of a 70% contribution to the new information in their analysis, such as the first-ever inclusion of refined grains, which was one of the top contributors to diabetes burden, and updated data on dietary habits based on national individual-level dietary surveys rather than agricultural estimates. 

“Our study suggests poor carbohydrate quality is a leading driver of diet-attributable type 2 diabetes globally and with important variation by nation and over time,” said senior author Dariush Mozaffarian, MD, DrPh, MPH, who is the Jean Mayer Professor of Nutrition at the Friedman School of Nutrition Science and Policy.

“These new findings reveal critical areas for national and global focus to improve nutrition and reduce devastating burdens of diabetes,” he noted.

“Left unchecked and with incidence only projected to rise, type 2 diabetes will continue to impact population health, economic productivity, [and] health care system capacity, [as well as] drive health inequities worldwide,” Ms. O’Hearn said.
 

It’s about reducing harmful dietary components

Ms. O’Hearn and colleagues set out to fill information gaps in knowledge about how the global burden of diet-associated type 2 diabetes is impacted by disparities and other factors known to influence risk, including dietary components.

They used information from the Global Dietary Database to study dietary intake in 184 nations from 1990 to 2018. They also studied demographics from multiple sources, estimates of type 2 diabetes incidence around the world, and data on food choices, including the effect of 11 dietary factors, from prior research.

They found that there were 8.6 million more cases of type 2 diabetes in 2018 than in 1990 because of poor diet. 

Regionally, Central and Eastern Europe and Central Asia had the greatest number of type 2 diabetes cases linked to diet, particularly Poland and Russia, where diets tend to be rich in red meat, processed meat, and potatoes. Incidence was also high in Latin America and the Caribbean, especially in Colombia and Mexico, which was attributed to high consumption of sugary drinks and processed meat and low intake of whole grains.

Regions where diet had less of an impact on type 2 diabetes cases included South Asia and sub-Saharan Africa, although the largest increases in type 2 diabetes due to poor diet between 1990 and 2018 were observed in sub-Saharan Africa.

Diet-attributable type 2 diabetes was generally larger among urban versus rural residents and higher versus lower educated individuals, except in high-income countries, Central and Eastern Europe, and Central Asia, where burdens were larger in rural residents and in lower educated individuals.

Notably, women had lower proportions of diet-related type 2 diabetes, compared with men, and these proportions were inversely related to age.

Excess intake of harmful dietary factors contributed a greater percentage of the burden of type 2 diabetes globally (60.8%) than did insufficient intake of protective dietary factors (39.2%).

“Future research should address whether more complex diet–type 2 diabetes dose–response relationships exist,” the authors conclude.

Ms. O’Hearn has reported receiving research funding from the Gates Foundation, as well as the National Institutes of Health and Vail Innovative Global Research and employment with Food Systems for the Future. Dr. Mozaffarian has reported receiving funding from the National Institutes of Health, the Gates Foundation, the Rockefeller Foundation, Vail Innovative Global Research, and the Kaiser Permanente Fund at East Bay Community Foundation; personal fees from Acasti Pharma, Barilla, Danone, and Motif FoodWorks; is on the scientific advisory board for Beren Therapeutics, Brightseed, Calibrate, DiscernDx, Elysium Health, Filtricine, HumanCo, January, Perfect Day, Tiny Organics and (ended) Day Two and Season Health; has stock ownership in Calibrate and HumanCo; and receives chapter royalties from UpToDate.

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

The Centers for Medicare & Medicaid Services (CMS) released its annual update to the inpatient prospective payment system (IPPS) and long-term care hospital (LTCH) PPS on April 10, with many changes centered around improving health equity and quality as well as alleviating rural clinician shortages.

“This proposed rule reflects our person-centric approach to better measure health care quality and safety in hospitals to reduce preventable harm and our commitment to ensure that people with Medicare in rural and underserved areas have improved access to high-quality health care,” said CMS Administrator Chiquita Brooks-LaSure said in a statement.

Here are 14 things to know about the fiscal year (FY) 2024 proposal:

1. New payment rate: Acute-care hospitals that report inpatient quality data and participate in the EHR Meaningful Use program will receive a 2.8% net increase in payment rates. The rate adjustment will send approximately $3.3 billion more funding to hospitals compared with 2023.

2. LTCH payments: CMS projects that the LTCH standard payment rate will increase by 2.9%, whereas discharge payments will decrease by 2.5% or $59 million.

3. Disproportionate share hospital payments: Medicare disproportionate share hospital payments and Medicare uncompensated care payments will decrease by about $115 million for FY 2024.

4. Health equity categories: CMS proposes adding 15 new health equity hospital categorizations for IPPS payments to advance the goals of its Framework for Health Equity initiative.   

5. Social determinants of health codes: To reflect increased resource utilization, the severity designation for the three International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) diagnosis codes describing homelessness will change from noncomplication or comorbidity to complication or comorbidity.

6. Rural emergency hospitals: The proposed rule will allow designated rural emergency hospitals to serve as training sites and receive Medicare graduate medical education payments to address concerns over rural hospital closures.

7. COVID treatment add-on payments: If the public health emergency ends in May, add-on payments for discharges involving eligible products like convalescent plasma and nirmatrelvir-ritonavir will expire on Sept. 30.

8. Technology add-on payments: Requests for new technology add-on payments must include a complete, active Food and Drug Administration market authorization application. Beginning with FY 2025 applications, the FDA approval deadline will move from July 1 to May 1.

9. Physician-owned hospitals: To receive Medicare payment for services referred by a physician owner or investor, the hospital must satisfy all requirements of the whole hospital exception or the rural provider exception to the Stark Law. In either case, a hospital may not increase the aggregate number of operating rooms, procedure rooms, or beds above the level it was licensed for on March 23, 2010, unless CMS grants an exception.

10. Electronic clinical quality measures: The new rule will remove and modify several existing electronic clinical quality measures and add three new ones: hospital harm, pressure injury; hospital harm, acute kidney injury; and excessive radiation dose or inadequate image quality for diagnostic CT in adult inpatients.

11. HCAHPS survey: Beginning Jan. 1, 2025, modifications to the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey will extend the data collection period from 42 to 49 days, limit supplemental survey items to 12, and require an official Spanish translation for patients.

12. Safety-net hospitals request for information: CMS seeks public input about the unique challenges faced by safety-net hospitals and potential solutions to ensure that uninsured, underinsured, and other vulnerable populations have access to essential services.

13. LTCH quality reporting: CMS proposes several quality-measure updates, including a functional discharge score measure beginning in FY 2025 and reporting the percentage of patients current with Centers for Disease Control and Prevention–recommended COVID vaccinations starting in FY 2026.

14. Commenting period: CMS will accept comments on the proposed rule through June 9.
 

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

The Centers for Medicare & Medicaid Services (CMS) released its annual update to the inpatient prospective payment system (IPPS) and long-term care hospital (LTCH) PPS on April 10, with many changes centered around improving health equity and quality as well as alleviating rural clinician shortages.

“This proposed rule reflects our person-centric approach to better measure health care quality and safety in hospitals to reduce preventable harm and our commitment to ensure that people with Medicare in rural and underserved areas have improved access to high-quality health care,” said CMS Administrator Chiquita Brooks-LaSure said in a statement.

Here are 14 things to know about the fiscal year (FY) 2024 proposal:

1. New payment rate: Acute-care hospitals that report inpatient quality data and participate in the EHR Meaningful Use program will receive a 2.8% net increase in payment rates. The rate adjustment will send approximately $3.3 billion more funding to hospitals compared with 2023.

2. LTCH payments: CMS projects that the LTCH standard payment rate will increase by 2.9%, whereas discharge payments will decrease by 2.5% or $59 million.

3. Disproportionate share hospital payments: Medicare disproportionate share hospital payments and Medicare uncompensated care payments will decrease by about $115 million for FY 2024.

4. Health equity categories: CMS proposes adding 15 new health equity hospital categorizations for IPPS payments to advance the goals of its Framework for Health Equity initiative.   

5. Social determinants of health codes: To reflect increased resource utilization, the severity designation for the three International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) diagnosis codes describing homelessness will change from noncomplication or comorbidity to complication or comorbidity.

6. Rural emergency hospitals: The proposed rule will allow designated rural emergency hospitals to serve as training sites and receive Medicare graduate medical education payments to address concerns over rural hospital closures.

7. COVID treatment add-on payments: If the public health emergency ends in May, add-on payments for discharges involving eligible products like convalescent plasma and nirmatrelvir-ritonavir will expire on Sept. 30.

8. Technology add-on payments: Requests for new technology add-on payments must include a complete, active Food and Drug Administration market authorization application. Beginning with FY 2025 applications, the FDA approval deadline will move from July 1 to May 1.

9. Physician-owned hospitals: To receive Medicare payment for services referred by a physician owner or investor, the hospital must satisfy all requirements of the whole hospital exception or the rural provider exception to the Stark Law. In either case, a hospital may not increase the aggregate number of operating rooms, procedure rooms, or beds above the level it was licensed for on March 23, 2010, unless CMS grants an exception.

10. Electronic clinical quality measures: The new rule will remove and modify several existing electronic clinical quality measures and add three new ones: hospital harm, pressure injury; hospital harm, acute kidney injury; and excessive radiation dose or inadequate image quality for diagnostic CT in adult inpatients.

11. HCAHPS survey: Beginning Jan. 1, 2025, modifications to the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey will extend the data collection period from 42 to 49 days, limit supplemental survey items to 12, and require an official Spanish translation for patients.

12. Safety-net hospitals request for information: CMS seeks public input about the unique challenges faced by safety-net hospitals and potential solutions to ensure that uninsured, underinsured, and other vulnerable populations have access to essential services.

13. LTCH quality reporting: CMS proposes several quality-measure updates, including a functional discharge score measure beginning in FY 2025 and reporting the percentage of patients current with Centers for Disease Control and Prevention–recommended COVID vaccinations starting in FY 2026.

14. Commenting period: CMS will accept comments on the proposed rule through June 9.
 

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

The Centers for Medicare & Medicaid Services (CMS) released its annual update to the inpatient prospective payment system (IPPS) and long-term care hospital (LTCH) PPS on April 10, with many changes centered around improving health equity and quality as well as alleviating rural clinician shortages.

“This proposed rule reflects our person-centric approach to better measure health care quality and safety in hospitals to reduce preventable harm and our commitment to ensure that people with Medicare in rural and underserved areas have improved access to high-quality health care,” said CMS Administrator Chiquita Brooks-LaSure said in a statement.

Here are 14 things to know about the fiscal year (FY) 2024 proposal:

1. New payment rate: Acute-care hospitals that report inpatient quality data and participate in the EHR Meaningful Use program will receive a 2.8% net increase in payment rates. The rate adjustment will send approximately $3.3 billion more funding to hospitals compared with 2023.

2. LTCH payments: CMS projects that the LTCH standard payment rate will increase by 2.9%, whereas discharge payments will decrease by 2.5% or $59 million.

3. Disproportionate share hospital payments: Medicare disproportionate share hospital payments and Medicare uncompensated care payments will decrease by about $115 million for FY 2024.

4. Health equity categories: CMS proposes adding 15 new health equity hospital categorizations for IPPS payments to advance the goals of its Framework for Health Equity initiative.   

5. Social determinants of health codes: To reflect increased resource utilization, the severity designation for the three International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) diagnosis codes describing homelessness will change from noncomplication or comorbidity to complication or comorbidity.

6. Rural emergency hospitals: The proposed rule will allow designated rural emergency hospitals to serve as training sites and receive Medicare graduate medical education payments to address concerns over rural hospital closures.

7. COVID treatment add-on payments: If the public health emergency ends in May, add-on payments for discharges involving eligible products like convalescent plasma and nirmatrelvir-ritonavir will expire on Sept. 30.

8. Technology add-on payments: Requests for new technology add-on payments must include a complete, active Food and Drug Administration market authorization application. Beginning with FY 2025 applications, the FDA approval deadline will move from July 1 to May 1.

9. Physician-owned hospitals: To receive Medicare payment for services referred by a physician owner or investor, the hospital must satisfy all requirements of the whole hospital exception or the rural provider exception to the Stark Law. In either case, a hospital may not increase the aggregate number of operating rooms, procedure rooms, or beds above the level it was licensed for on March 23, 2010, unless CMS grants an exception.

10. Electronic clinical quality measures: The new rule will remove and modify several existing electronic clinical quality measures and add three new ones: hospital harm, pressure injury; hospital harm, acute kidney injury; and excessive radiation dose or inadequate image quality for diagnostic CT in adult inpatients.

11. HCAHPS survey: Beginning Jan. 1, 2025, modifications to the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey will extend the data collection period from 42 to 49 days, limit supplemental survey items to 12, and require an official Spanish translation for patients.

12. Safety-net hospitals request for information: CMS seeks public input about the unique challenges faced by safety-net hospitals and potential solutions to ensure that uninsured, underinsured, and other vulnerable populations have access to essential services.

13. LTCH quality reporting: CMS proposes several quality-measure updates, including a functional discharge score measure beginning in FY 2025 and reporting the percentage of patients current with Centers for Disease Control and Prevention–recommended COVID vaccinations starting in FY 2026.

14. Commenting period: CMS will accept comments on the proposed rule through June 9.
 

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

We have long recognized that our environment has a significant impact on our general health. Air pollution is known to contribute to respiratory conditions, poor cardiovascular outcomes, and certain kinds of cancer. Less well-known (or studied) is the potential impact of such fumes on bone health.

It’s increasingly important to identify factors that might contribute to suboptimal bone density and associated fracture risk in the population as a whole, and particularly in older adults. Aging is associated with a higher risk for osteoporosis and fractures, with their attendant morbidity, but individuals differ in their extent of bone loss and risk for fractures.

Known factors affecting bone health include genetics, age, sex, nutrition, physical activity, and hormonal factors. Certain medications, diseases, and lifestyle choices – such as smoking and alcohol intake – can also have deleterious effects on bone.

More recently, researchers have started examining the impact of air pollution on bone health.

As we know, the degree of pollution varies greatly from one region to another and can potentially significantly affect life in many parts of the world. In fact, the World Health Organization indicates that 99% of the world’s population breathes air exceeding the WHO guideline limits for pollutants.

Air pollutants include particulate matter (PM) as well as gases, such as nitric oxide, nitrogen dioxide, ammonia, carbon monoxide, sulfur dioxide, ozone, and certain volatile organic compounds. Particulate pollutants include a variety of substances produced from mostly human activities (such as vehicle emissions, biofuel combustion, mining, agriculture, and manufacturing, and also forest fires). They are classified not by their composition, but by their size (for example, PM1.0, PM2.5, and PM10 indicate PM with a diameter < 1.0, 2.5, and 10 microns, respectively). The finer the particle, the more likely it is to cross into the systemic circulation from the respiratory tract, with the potential to induce oxidative, inflammatory, and other changes in the body.

Many studies report that air pollution is a risk factor for osteoporosis. Some have found associations of lower bone density, osteoporosis, and fracture risk with higher concentrations of PM1.0, PM2.5, or PM10, even after controlling for other factors that could affect bone health. Some researchers have reported that although they didn’t find a significant association between PM and bone health, they did find an association between distance from the freeway and bone health – thus, exposure to polycyclic aromatic hydrocarbons and black carbon from vehicle emissions needs to be studied as a contributor to fracture risk.

Importantly, a prospective, observational study from the Women’s Health Initiative (which included more than 9,000 ethnically diverse women from three sites in the United States) reported a significant negative impact of PM10, nitric oxide, nitrogen dioxide, and sulfur dioxide over 1, 3, and 5 years on bone density at multiple sites, and particularly at the lumbar spine, in both cross-sectional and longitudinal analyses after controlling for demographic and socioeconomic factors. This study reported that nitrogen dioxide exposure may be a key determinant of bone density at the lumbar spine and in the whole body. Similarly, other studies have reported associations between atmospheric nitrogen dioxide or sulfur dioxide and risk for osteoporotic fractures.
 

Why the impact on bones?

The potential negative impact of pollution on bone has been attributed to many factors. PM induces systemic inflammation and an increase in cytokines that stimulate bone cells (osteoclasts) that cause bone loss. Other pollutants (gases and metal compounds) can cause oxidative damage to bone cells, whereas others act as endocrine disrupters and affect the functioning of these cells.

Pollution might also affect the synthesis and metabolism of vitamin D, which is necessary for absorption of calcium from the gut. High rates of pollution can reduce the amount of ultraviolet radiation reaching the earth which is important because certain wavelengths of ultraviolet radiation are necessary for vitamin D synthesis in our skin. Reduced vitamin D synthesis in skin can lead to poorly mineralized bone unless there is sufficient intake of vitamin D in diet or as supplements. Also, the conversion of vitamin D to its active form happens in the kidneys, and PM can be harmful to renal function. PM is also believed to cause increased breakdown of vitamin D into its inactive form.

Conversely, some studies have reported no association between pollution and bone density or osteoporosis risk, and two meta-analyses indicated that the association between the two is inconsistent. Some factors explaining variances in results include the number of individuals included in the study (larger studies are generally considered to be more reproducible), the fact that most studies are cross-sectional and not prospective, many do not control for other factors that might be deleterious to bone, and prediction models for the extent of PM or other exposure may not be completely accurate.

However, another recent meta-analysis reported an increased risk for lower total-body bone density and hip fracture after exposure to air pollution, particularly PM2.5 and nitrogen dioxide, but not to PM10, nitric oxide, or ozone. More studies are needed to confirm, or refute, the association between air pollution and impaired bone health. But accumulating evidence suggests that air pollution very likely has a deleterious effect on bone.

When feasible, it’s important to avoid living or working in areas with poor air quality and high pollution rates. However, this isn’t always possible based on one’s occupation, geography, circumstances, or economic status. Therefore, attention to a cleaner environment is critical at both the individual and the macro level.

As an example of the latter, the city of London extended its ultralow emission zone (ULEZ) farther out of the city in October 2021, and a further expansion is planned to include all of the city’s boroughs in August 2023.

We can do our bit by driving less and walking, biking, or using public transportation more often. We can also turn off the car engine when it’s not running, maintain our vehicles, switch to electric or hand-powered yard equipment, and not burn household garbage and limit backyard fires. We can also switch from gas to solar energy or wind, use efficient appliances and heating, and avoid unnecessary energy use. And we can choose sustainable products when possible.

For optimal bone health, we should remind patients to eat a healthy diet with the requisite amount of protein, calcium, and vitamin D. Vitamin D and calcium supplementation may be necessary for people whose intake of dairy and dairy products is low. Other important strategies to optimize bone health include engaging in healthy physical activity; avoiding smoking or excessive alcohol intake; and treating underlying gastrointestinal, endocrine, or other conditions that can reduce bone density.

Madhusmita Misra, MD, MPH, is the chief of the division of pediatric endocrinology, Mass General for Children; the associate director of the Harvard Catalyst Translation and Clinical Research Center; and the director of the Pediatric Endocrine-Sports Endocrine-Neuroendocrine Lab, Mass General Hospital, Boston.

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

We have long recognized that our environment has a significant impact on our general health. Air pollution is known to contribute to respiratory conditions, poor cardiovascular outcomes, and certain kinds of cancer. Less well-known (or studied) is the potential impact of such fumes on bone health.

It’s increasingly important to identify factors that might contribute to suboptimal bone density and associated fracture risk in the population as a whole, and particularly in older adults. Aging is associated with a higher risk for osteoporosis and fractures, with their attendant morbidity, but individuals differ in their extent of bone loss and risk for fractures.

Known factors affecting bone health include genetics, age, sex, nutrition, physical activity, and hormonal factors. Certain medications, diseases, and lifestyle choices – such as smoking and alcohol intake – can also have deleterious effects on bone.

More recently, researchers have started examining the impact of air pollution on bone health.

As we know, the degree of pollution varies greatly from one region to another and can potentially significantly affect life in many parts of the world. In fact, the World Health Organization indicates that 99% of the world’s population breathes air exceeding the WHO guideline limits for pollutants.

Air pollutants include particulate matter (PM) as well as gases, such as nitric oxide, nitrogen dioxide, ammonia, carbon monoxide, sulfur dioxide, ozone, and certain volatile organic compounds. Particulate pollutants include a variety of substances produced from mostly human activities (such as vehicle emissions, biofuel combustion, mining, agriculture, and manufacturing, and also forest fires). They are classified not by their composition, but by their size (for example, PM1.0, PM2.5, and PM10 indicate PM with a diameter < 1.0, 2.5, and 10 microns, respectively). The finer the particle, the more likely it is to cross into the systemic circulation from the respiratory tract, with the potential to induce oxidative, inflammatory, and other changes in the body.

Many studies report that air pollution is a risk factor for osteoporosis. Some have found associations of lower bone density, osteoporosis, and fracture risk with higher concentrations of PM1.0, PM2.5, or PM10, even after controlling for other factors that could affect bone health. Some researchers have reported that although they didn’t find a significant association between PM and bone health, they did find an association between distance from the freeway and bone health – thus, exposure to polycyclic aromatic hydrocarbons and black carbon from vehicle emissions needs to be studied as a contributor to fracture risk.

Importantly, a prospective, observational study from the Women’s Health Initiative (which included more than 9,000 ethnically diverse women from three sites in the United States) reported a significant negative impact of PM10, nitric oxide, nitrogen dioxide, and sulfur dioxide over 1, 3, and 5 years on bone density at multiple sites, and particularly at the lumbar spine, in both cross-sectional and longitudinal analyses after controlling for demographic and socioeconomic factors. This study reported that nitrogen dioxide exposure may be a key determinant of bone density at the lumbar spine and in the whole body. Similarly, other studies have reported associations between atmospheric nitrogen dioxide or sulfur dioxide and risk for osteoporotic fractures.
 

Why the impact on bones?

The potential negative impact of pollution on bone has been attributed to many factors. PM induces systemic inflammation and an increase in cytokines that stimulate bone cells (osteoclasts) that cause bone loss. Other pollutants (gases and metal compounds) can cause oxidative damage to bone cells, whereas others act as endocrine disrupters and affect the functioning of these cells.

Pollution might also affect the synthesis and metabolism of vitamin D, which is necessary for absorption of calcium from the gut. High rates of pollution can reduce the amount of ultraviolet radiation reaching the earth which is important because certain wavelengths of ultraviolet radiation are necessary for vitamin D synthesis in our skin. Reduced vitamin D synthesis in skin can lead to poorly mineralized bone unless there is sufficient intake of vitamin D in diet or as supplements. Also, the conversion of vitamin D to its active form happens in the kidneys, and PM can be harmful to renal function. PM is also believed to cause increased breakdown of vitamin D into its inactive form.

Conversely, some studies have reported no association between pollution and bone density or osteoporosis risk, and two meta-analyses indicated that the association between the two is inconsistent. Some factors explaining variances in results include the number of individuals included in the study (larger studies are generally considered to be more reproducible), the fact that most studies are cross-sectional and not prospective, many do not control for other factors that might be deleterious to bone, and prediction models for the extent of PM or other exposure may not be completely accurate.

However, another recent meta-analysis reported an increased risk for lower total-body bone density and hip fracture after exposure to air pollution, particularly PM2.5 and nitrogen dioxide, but not to PM10, nitric oxide, or ozone. More studies are needed to confirm, or refute, the association between air pollution and impaired bone health. But accumulating evidence suggests that air pollution very likely has a deleterious effect on bone.

When feasible, it’s important to avoid living or working in areas with poor air quality and high pollution rates. However, this isn’t always possible based on one’s occupation, geography, circumstances, or economic status. Therefore, attention to a cleaner environment is critical at both the individual and the macro level.

As an example of the latter, the city of London extended its ultralow emission zone (ULEZ) farther out of the city in October 2021, and a further expansion is planned to include all of the city’s boroughs in August 2023.

We can do our bit by driving less and walking, biking, or using public transportation more often. We can also turn off the car engine when it’s not running, maintain our vehicles, switch to electric or hand-powered yard equipment, and not burn household garbage and limit backyard fires. We can also switch from gas to solar energy or wind, use efficient appliances and heating, and avoid unnecessary energy use. And we can choose sustainable products when possible.

For optimal bone health, we should remind patients to eat a healthy diet with the requisite amount of protein, calcium, and vitamin D. Vitamin D and calcium supplementation may be necessary for people whose intake of dairy and dairy products is low. Other important strategies to optimize bone health include engaging in healthy physical activity; avoiding smoking or excessive alcohol intake; and treating underlying gastrointestinal, endocrine, or other conditions that can reduce bone density.

Madhusmita Misra, MD, MPH, is the chief of the division of pediatric endocrinology, Mass General for Children; the associate director of the Harvard Catalyst Translation and Clinical Research Center; and the director of the Pediatric Endocrine-Sports Endocrine-Neuroendocrine Lab, Mass General Hospital, Boston.

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

We have long recognized that our environment has a significant impact on our general health. Air pollution is known to contribute to respiratory conditions, poor cardiovascular outcomes, and certain kinds of cancer. Less well-known (or studied) is the potential impact of such fumes on bone health.

It’s increasingly important to identify factors that might contribute to suboptimal bone density and associated fracture risk in the population as a whole, and particularly in older adults. Aging is associated with a higher risk for osteoporosis and fractures, with their attendant morbidity, but individuals differ in their extent of bone loss and risk for fractures.

Known factors affecting bone health include genetics, age, sex, nutrition, physical activity, and hormonal factors. Certain medications, diseases, and lifestyle choices – such as smoking and alcohol intake – can also have deleterious effects on bone.

More recently, researchers have started examining the impact of air pollution on bone health.

As we know, the degree of pollution varies greatly from one region to another and can potentially significantly affect life in many parts of the world. In fact, the World Health Organization indicates that 99% of the world’s population breathes air exceeding the WHO guideline limits for pollutants.

Air pollutants include particulate matter (PM) as well as gases, such as nitric oxide, nitrogen dioxide, ammonia, carbon monoxide, sulfur dioxide, ozone, and certain volatile organic compounds. Particulate pollutants include a variety of substances produced from mostly human activities (such as vehicle emissions, biofuel combustion, mining, agriculture, and manufacturing, and also forest fires). They are classified not by their composition, but by their size (for example, PM1.0, PM2.5, and PM10 indicate PM with a diameter < 1.0, 2.5, and 10 microns, respectively). The finer the particle, the more likely it is to cross into the systemic circulation from the respiratory tract, with the potential to induce oxidative, inflammatory, and other changes in the body.

Many studies report that air pollution is a risk factor for osteoporosis. Some have found associations of lower bone density, osteoporosis, and fracture risk with higher concentrations of PM1.0, PM2.5, or PM10, even after controlling for other factors that could affect bone health. Some researchers have reported that although they didn’t find a significant association between PM and bone health, they did find an association between distance from the freeway and bone health – thus, exposure to polycyclic aromatic hydrocarbons and black carbon from vehicle emissions needs to be studied as a contributor to fracture risk.

Importantly, a prospective, observational study from the Women’s Health Initiative (which included more than 9,000 ethnically diverse women from three sites in the United States) reported a significant negative impact of PM10, nitric oxide, nitrogen dioxide, and sulfur dioxide over 1, 3, and 5 years on bone density at multiple sites, and particularly at the lumbar spine, in both cross-sectional and longitudinal analyses after controlling for demographic and socioeconomic factors. This study reported that nitrogen dioxide exposure may be a key determinant of bone density at the lumbar spine and in the whole body. Similarly, other studies have reported associations between atmospheric nitrogen dioxide or sulfur dioxide and risk for osteoporotic fractures.
 

Why the impact on bones?

The potential negative impact of pollution on bone has been attributed to many factors. PM induces systemic inflammation and an increase in cytokines that stimulate bone cells (osteoclasts) that cause bone loss. Other pollutants (gases and metal compounds) can cause oxidative damage to bone cells, whereas others act as endocrine disrupters and affect the functioning of these cells.

Pollution might also affect the synthesis and metabolism of vitamin D, which is necessary for absorption of calcium from the gut. High rates of pollution can reduce the amount of ultraviolet radiation reaching the earth which is important because certain wavelengths of ultraviolet radiation are necessary for vitamin D synthesis in our skin. Reduced vitamin D synthesis in skin can lead to poorly mineralized bone unless there is sufficient intake of vitamin D in diet or as supplements. Also, the conversion of vitamin D to its active form happens in the kidneys, and PM can be harmful to renal function. PM is also believed to cause increased breakdown of vitamin D into its inactive form.

Conversely, some studies have reported no association between pollution and bone density or osteoporosis risk, and two meta-analyses indicated that the association between the two is inconsistent. Some factors explaining variances in results include the number of individuals included in the study (larger studies are generally considered to be more reproducible), the fact that most studies are cross-sectional and not prospective, many do not control for other factors that might be deleterious to bone, and prediction models for the extent of PM or other exposure may not be completely accurate.

However, another recent meta-analysis reported an increased risk for lower total-body bone density and hip fracture after exposure to air pollution, particularly PM2.5 and nitrogen dioxide, but not to PM10, nitric oxide, or ozone. More studies are needed to confirm, or refute, the association between air pollution and impaired bone health. But accumulating evidence suggests that air pollution very likely has a deleterious effect on bone.

When feasible, it’s important to avoid living or working in areas with poor air quality and high pollution rates. However, this isn’t always possible based on one’s occupation, geography, circumstances, or economic status. Therefore, attention to a cleaner environment is critical at both the individual and the macro level.

As an example of the latter, the city of London extended its ultralow emission zone (ULEZ) farther out of the city in October 2021, and a further expansion is planned to include all of the city’s boroughs in August 2023.

We can do our bit by driving less and walking, biking, or using public transportation more often. We can also turn off the car engine when it’s not running, maintain our vehicles, switch to electric or hand-powered yard equipment, and not burn household garbage and limit backyard fires. We can also switch from gas to solar energy or wind, use efficient appliances and heating, and avoid unnecessary energy use. And we can choose sustainable products when possible.

For optimal bone health, we should remind patients to eat a healthy diet with the requisite amount of protein, calcium, and vitamin D. Vitamin D and calcium supplementation may be necessary for people whose intake of dairy and dairy products is low. Other important strategies to optimize bone health include engaging in healthy physical activity; avoiding smoking or excessive alcohol intake; and treating underlying gastrointestinal, endocrine, or other conditions that can reduce bone density.

Madhusmita Misra, MD, MPH, is the chief of the division of pediatric endocrinology, Mass General for Children; the associate director of the Harvard Catalyst Translation and Clinical Research Center; and the director of the Pediatric Endocrine-Sports Endocrine-Neuroendocrine Lab, Mass General Hospital, Boston.

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

The history and findings in this case are suggestive of axial psoriatic arthritis (PsA).

Psoriasis is a complex, chronic, inflammatory, immune-mediated disease that is associated with significant morbidity, reduced quality of life, and increased mortality. Approximately 7.4 million adults in the United States have psoriasis; worldwide, approximately 2%-3% of the population is affected. Patients with psoriasis frequently have comorbidities; PsA, an inflammatory, seronegative musculoskeletal disease, is among the most common. It is estimated that 25%-30% of patients with psoriasis develop PsA. 

PsA is a heterogeneous disease. Patients may present with nail and skin changes, peripheral arthritis, enthesitis, dactylitis, and axial spondyloarthritis (SpA), either alone or in combination. Men and women are equally affected by PsA, which typically develops when patients are age 30-50 years. Like psoriasis, PsA is associated with numerous comorbidities, including cardiovascular disease, metabolic syndrome, obesity, diabetes, depression, uveitis, and anxiety.

PsA is a potentially erosive disease. Structural damage and functional impairment occurs within 2 years of initial assessment in approximately 50% of patients; as the disease progresses, patients may experience irreversible joint damage and disability. Axial involvement occurs in 25%-70% of patients with PsA; exclusive axial involvement is uncommon, occurring in 5% of patients. Common symptoms of axial PsA include inflammatory back pain (eg, pain that improves with activity but worsens with rest, morning stiffness lasting longer than 30 minutes). Some patients with axial involvement may be asymptomatic. If untreated, cervical spinal mobility and lateral flexion significantly decline within 5 years in patients with axial PsA. In addition, sacroiliitis worsens over time; 37% and 52% of patients develop grade 2 or higher sacroiliitis within 5 and 10 years, respectively. This highlights the importance of early identification and treatment of patients with axial PsA.

The diagnosis of axial PsA is confirmed by physical examination and imaging. Axial PsA characteristics, including sacroiliitis and spondylitis, are distinguished by the development of syndesmophytes (ie, ossification of the annulus fibrosis). PsA can be differentiated from ankylosing spondylitis by the asymmetric and frequently unilateral presentation of sacroiliitis and syndesmophytes, which frequently presents as nonmarginal, bulky, asymmetric, and discontinuous skipping vertebral levels.

Plain radiography, CT, ultrasound, and MRI are all useful tools for evaluating patients with PsA. MRI and ultrasound may be more sensitive than plain radiography is for detecting early joint inflammation and damage as well as axial changes, including sacroiliitis; however, they are not required for a diagnosis of PsA.

The treatment of axial PsA is based on international guidelines developed by the American College of Rheumatology/Spondylitis Association of America/Spondyloarthritis Research and Treatment Network, the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis and the Assessment of SpondyloArthritis International Society–European League Against Rheumatism. Treatment focuses on minimizing pain, stiffness, and fatigue; improving and preserving spinal flexibility and posture; enhancing functional capacity; and maintaining the ability to work, with a target of remission or minimal/low disease activity.

Medications for symptomatic relief include nonsteroidal anti-inflammatory drugs (NSAIDs), glucocorticoids, and sacroiliac joint injections with glucocorticoids for mild disease; however, long-term treatment with systemic glucocorticoids is not recommended. If patients remain symptomatic or if erosive disease or other indications of high disease activity is observed, guidelines recommend initiation of a TNF inhibitor. Disease-modifying antirheumatic drugs, such as methotrexate, are not routinely prescribed for patients with axial disease because they have not been shown to be effective.

If symptoms of axial PsA are not controlled by NSAIDs, tumor necrosis factor (TNF) inhibitors are recommended. However, interleukin 17A inhibitors may be used in preference to TNF inhibitors in patients with significant skin involvement. In the United States, adalimumab, certolizumab pegol, golimumab, and infliximab are recommended over etanercept for patients with axial SpA in the presence of concomitant inflammatory bowel disease (IBD) or recurrent uveitis (although there is no evidence for golimumab) because etanercept has contradictory results for uveitis and has not been shown to have efficacy in IBD.

If patients fail to respond to a first trial of a TNF inhibitor, trying a second TNF inhibitor before switching to a different class of biologic is recommended by US guidelines. A Janus kinase inhibitor (tofacitinib) may be considered for patients who do not respond to TNF inhibitors. 

Nonpharmacologic therapies (ie, exercise, physical therapy, massage therapy, occupational therapy, acupuncture) are recommended for all patients with active PsA.

Herbert S. Diamond, MD, Professor of Medicine (retired), Temple University School of Medicine, University of Pittsburgh; Chairman, Department of Medicine Emeritus, Western Pennsylvania Hospital, Pittsburgh, PA.

Herbert S. Diamond, MD, has disclosed no relevant financial relationships.

Image Quizzes are fictional or fictionalized clinical scenarios intended to provide evidence-based educational takeaways.

The history and findings in this case are suggestive of axial psoriatic arthritis (PsA).

Psoriasis is a complex, chronic, inflammatory, immune-mediated disease that is associated with significant morbidity, reduced quality of life, and increased mortality. Approximately 7.4 million adults in the United States have psoriasis; worldwide, approximately 2%-3% of the population is affected. Patients with psoriasis frequently have comorbidities; PsA, an inflammatory, seronegative musculoskeletal disease, is among the most common. It is estimated that 25%-30% of patients with psoriasis develop PsA. 

PsA is a heterogeneous disease. Patients may present with nail and skin changes, peripheral arthritis, enthesitis, dactylitis, and axial spondyloarthritis (SpA), either alone or in combination. Men and women are equally affected by PsA, which typically develops when patients are age 30-50 years. Like psoriasis, PsA is associated with numerous comorbidities, including cardiovascular disease, metabolic syndrome, obesity, diabetes, depression, uveitis, and anxiety.

PsA is a potentially erosive disease. Structural damage and functional impairment occurs within 2 years of initial assessment in approximately 50% of patients; as the disease progresses, patients may experience irreversible joint damage and disability. Axial involvement occurs in 25%-70% of patients with PsA; exclusive axial involvement is uncommon, occurring in 5% of patients. Common symptoms of axial PsA include inflammatory back pain (eg, pain that improves with activity but worsens with rest, morning stiffness lasting longer than 30 minutes). Some patients with axial involvement may be asymptomatic. If untreated, cervical spinal mobility and lateral flexion significantly decline within 5 years in patients with axial PsA. In addition, sacroiliitis worsens over time; 37% and 52% of patients develop grade 2 or higher sacroiliitis within 5 and 10 years, respectively. This highlights the importance of early identification and treatment of patients with axial PsA.

The diagnosis of axial PsA is confirmed by physical examination and imaging. Axial PsA characteristics, including sacroiliitis and spondylitis, are distinguished by the development of syndesmophytes (ie, ossification of the annulus fibrosis). PsA can be differentiated from ankylosing spondylitis by the asymmetric and frequently unilateral presentation of sacroiliitis and syndesmophytes, which frequently presents as nonmarginal, bulky, asymmetric, and discontinuous skipping vertebral levels.

Plain radiography, CT, ultrasound, and MRI are all useful tools for evaluating patients with PsA. MRI and ultrasound may be more sensitive than plain radiography is for detecting early joint inflammation and damage as well as axial changes, including sacroiliitis; however, they are not required for a diagnosis of PsA.

The treatment of axial PsA is based on international guidelines developed by the American College of Rheumatology/Spondylitis Association of America/Spondyloarthritis Research and Treatment Network, the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis and the Assessment of SpondyloArthritis International Society–European League Against Rheumatism. Treatment focuses on minimizing pain, stiffness, and fatigue; improving and preserving spinal flexibility and posture; enhancing functional capacity; and maintaining the ability to work, with a target of remission or minimal/low disease activity.

Medications for symptomatic relief include nonsteroidal anti-inflammatory drugs (NSAIDs), glucocorticoids, and sacroiliac joint injections with glucocorticoids for mild disease; however, long-term treatment with systemic glucocorticoids is not recommended. If patients remain symptomatic or if erosive disease or other indications of high disease activity is observed, guidelines recommend initiation of a TNF inhibitor. Disease-modifying antirheumatic drugs, such as methotrexate, are not routinely prescribed for patients with axial disease because they have not been shown to be effective.

If symptoms of axial PsA are not controlled by NSAIDs, tumor necrosis factor (TNF) inhibitors are recommended. However, interleukin 17A inhibitors may be used in preference to TNF inhibitors in patients with significant skin involvement. In the United States, adalimumab, certolizumab pegol, golimumab, and infliximab are recommended over etanercept for patients with axial SpA in the presence of concomitant inflammatory bowel disease (IBD) or recurrent uveitis (although there is no evidence for golimumab) because etanercept has contradictory results for uveitis and has not been shown to have efficacy in IBD.

If patients fail to respond to a first trial of a TNF inhibitor, trying a second TNF inhibitor before switching to a different class of biologic is recommended by US guidelines. A Janus kinase inhibitor (tofacitinib) may be considered for patients who do not respond to TNF inhibitors. 

Nonpharmacologic therapies (ie, exercise, physical therapy, massage therapy, occupational therapy, acupuncture) are recommended for all patients with active PsA.

Herbert S. Diamond, MD, Professor of Medicine (retired), Temple University School of Medicine, University of Pittsburgh; Chairman, Department of Medicine Emeritus, Western Pennsylvania Hospital, Pittsburgh, PA.

Herbert S. Diamond, MD, has disclosed no relevant financial relationships.

Image Quizzes are fictional or fictionalized clinical scenarios intended to provide evidence-based educational takeaways.

The history and findings in this case are suggestive of axial psoriatic arthritis (PsA).

Psoriasis is a complex, chronic, inflammatory, immune-mediated disease that is associated with significant morbidity, reduced quality of life, and increased mortality. Approximately 7.4 million adults in the United States have psoriasis; worldwide, approximately 2%-3% of the population is affected. Patients with psoriasis frequently have comorbidities; PsA, an inflammatory, seronegative musculoskeletal disease, is among the most common. It is estimated that 25%-30% of patients with psoriasis develop PsA. 

PsA is a heterogeneous disease. Patients may present with nail and skin changes, peripheral arthritis, enthesitis, dactylitis, and axial spondyloarthritis (SpA), either alone or in combination. Men and women are equally affected by PsA, which typically develops when patients are age 30-50 years. Like psoriasis, PsA is associated with numerous comorbidities, including cardiovascular disease, metabolic syndrome, obesity, diabetes, depression, uveitis, and anxiety.

PsA is a potentially erosive disease. Structural damage and functional impairment occurs within 2 years of initial assessment in approximately 50% of patients; as the disease progresses, patients may experience irreversible joint damage and disability. Axial involvement occurs in 25%-70% of patients with PsA; exclusive axial involvement is uncommon, occurring in 5% of patients. Common symptoms of axial PsA include inflammatory back pain (eg, pain that improves with activity but worsens with rest, morning stiffness lasting longer than 30 minutes). Some patients with axial involvement may be asymptomatic. If untreated, cervical spinal mobility and lateral flexion significantly decline within 5 years in patients with axial PsA. In addition, sacroiliitis worsens over time; 37% and 52% of patients develop grade 2 or higher sacroiliitis within 5 and 10 years, respectively. This highlights the importance of early identification and treatment of patients with axial PsA.

The diagnosis of axial PsA is confirmed by physical examination and imaging. Axial PsA characteristics, including sacroiliitis and spondylitis, are distinguished by the development of syndesmophytes (ie, ossification of the annulus fibrosis). PsA can be differentiated from ankylosing spondylitis by the asymmetric and frequently unilateral presentation of sacroiliitis and syndesmophytes, which frequently presents as nonmarginal, bulky, asymmetric, and discontinuous skipping vertebral levels.

Plain radiography, CT, ultrasound, and MRI are all useful tools for evaluating patients with PsA. MRI and ultrasound may be more sensitive than plain radiography is for detecting early joint inflammation and damage as well as axial changes, including sacroiliitis; however, they are not required for a diagnosis of PsA.

The treatment of axial PsA is based on international guidelines developed by the American College of Rheumatology/Spondylitis Association of America/Spondyloarthritis Research and Treatment Network, the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis and the Assessment of SpondyloArthritis International Society–European League Against Rheumatism. Treatment focuses on minimizing pain, stiffness, and fatigue; improving and preserving spinal flexibility and posture; enhancing functional capacity; and maintaining the ability to work, with a target of remission or minimal/low disease activity.

Medications for symptomatic relief include nonsteroidal anti-inflammatory drugs (NSAIDs), glucocorticoids, and sacroiliac joint injections with glucocorticoids for mild disease; however, long-term treatment with systemic glucocorticoids is not recommended. If patients remain symptomatic or if erosive disease or other indications of high disease activity is observed, guidelines recommend initiation of a TNF inhibitor. Disease-modifying antirheumatic drugs, such as methotrexate, are not routinely prescribed for patients with axial disease because they have not been shown to be effective.

If symptoms of axial PsA are not controlled by NSAIDs, tumor necrosis factor (TNF) inhibitors are recommended. However, interleukin 17A inhibitors may be used in preference to TNF inhibitors in patients with significant skin involvement. In the United States, adalimumab, certolizumab pegol, golimumab, and infliximab are recommended over etanercept for patients with axial SpA in the presence of concomitant inflammatory bowel disease (IBD) or recurrent uveitis (although there is no evidence for golimumab) because etanercept has contradictory results for uveitis and has not been shown to have efficacy in IBD.

If patients fail to respond to a first trial of a TNF inhibitor, trying a second TNF inhibitor before switching to a different class of biologic is recommended by US guidelines. A Janus kinase inhibitor (tofacitinib) may be considered for patients who do not respond to TNF inhibitors. 

Nonpharmacologic therapies (ie, exercise, physical therapy, massage therapy, occupational therapy, acupuncture) are recommended for all patients with active PsA.

Herbert S. Diamond, MD, Professor of Medicine (retired), Temple University School of Medicine, University of Pittsburgh; Chairman, Department of Medicine Emeritus, Western Pennsylvania Hospital, Pittsburgh, PA.

Herbert S. Diamond, MD, has disclosed no relevant financial relationships.

Image Quizzes are fictional or fictionalized clinical scenarios intended to provide evidence-based educational takeaways.

A deep learning artificial intelligence (AI) model that used only a single histopathological slide predicted the risk of distant recurrence among endometrial cancer patients in a new study.

Endometrial cancer is the most frequently occurring uterine cancer. Early-stage patients have about a 95% 5-year survival, but distant recurrence is associated with very poor survival, according to Sarah Fremond, MSc, an author of the research (Abstract 5695), which she presented at the annual meeting of the American Association for Cancer Research.

“Most patients with endometrial cancer have a good prognosis and would not require any adjuvant treatment, but there is a proportion that will develop distant recurrence. For those you want to recommend adjuvant chemotherapy, because currently in the adjuvant setting, that’s the only treatment that is known to lower the risk of distant recurrence. But that also causes morbidity. Therefore, our clinical question was how to accurately identify patients at low and high risk of distant recurrence to reduce under- and overtreatment,” said Ms. Fremond, a PhD candidate at Leiden (the Netherlands) University Medical Center.

Pathologists can attempt such predictions, but Ms. Fremond noted that there are challenges. “There is a lot of variability between pathologists, and we don’t even use the entire visual information present in the H&E [hematoxylin and eosin] tumor slide. When it comes to molecular testing, it is hampered by cost, turnaround time, and sometimes interpretation. It’s quite complex to combine those data to specifically target risk of distant recurrence for patients with endometrial cancer.”

In her presentation, Ms. Fremond described how she and her colleagues used digitized histopathological slides in their research. She and her coauthors developed the AI model as part of a collaboration that included the AIRMEC Consortium, Leiden University Medical Center, the TransPORTEC Consortium, and the University of Zürich.

The researchers used long-term follow-up data from 1,408 patients drawn from three clinical cohorts and participants in the PORTEC-1, PORTEC-2, and PORTEC-3 studies, which tested radiotherapy and adjuvant therapy outcomes in endometrial cancer. Patients who had received prior adjuvant chemotherapy were excluded. In the model development phase, the system analyzed a single representative histopathological slide image from each patient and compared it with the known time to distant recurrence to identify patterns.

Once the system had been trained, the researchers applied it to a novel group of 353 patients. It ranked 89 patients as having a low risk of recurrence, 175 at intermediate risk, and 89 at high risk of recurrence. The system performed well: 3.37% of low-risk patients experienced a distant recurrence, as did 15.43% of the intermediate-risk group and 36% of the high-risk group.

The researchers also employed an external validation group with 152 patients and three slides per patient, with a 2.8-year follow-up. The model performed with a C index of 0.805 (±0.0136) when a random slide was selected for each patient, and the median predicted risk score per patient was associated with differences in distant recurrence-free survival between the three risk groups with a C index of 0.816 (P < .0001).
 

Questions about research and their answers

Session moderator Kristin Swanson, PhD, asked if the AI could be used with the pathology slide’s visible features to learn more about the underlying biology and pathophysiology of tumors.

“Overlying the HECTOR on to the tissue seems like a logical opportunity to go and then explore the biology and what’s attributed as a high-risk region,” said Dr. Swanson, who is director of the Mathematical NeuroOncology Lab and codirector of the Precision NeuroTherapeutics Innovation Program at Mayo Clinic Arizona, Phoenix.

Ms. Fremond agreed that the AI has the potential to be used that way.”

During the Q&A, an audience member asked how likely the model is to perform in populations that differ significantly from the populations used in her study.

Ms. Fremond responded that the populations used to develop and test the models were in or close to the Netherlands, and little information was available regarding patient ethnicity. “There is a possibility that perhaps we would have a different performance on a population that includes more minorities. That needs to be checked,” said Ms. Fremond.

The study is limited by its retrospective nature.

Ms. Fremond and Dr. Swanson have no relevant financial disclosures.

A deep learning artificial intelligence (AI) model that used only a single histopathological slide predicted the risk of distant recurrence among endometrial cancer patients in a new study.

Endometrial cancer is the most frequently occurring uterine cancer. Early-stage patients have about a 95% 5-year survival, but distant recurrence is associated with very poor survival, according to Sarah Fremond, MSc, an author of the research (Abstract 5695), which she presented at the annual meeting of the American Association for Cancer Research.

“Most patients with endometrial cancer have a good prognosis and would not require any adjuvant treatment, but there is a proportion that will develop distant recurrence. For those you want to recommend adjuvant chemotherapy, because currently in the adjuvant setting, that’s the only treatment that is known to lower the risk of distant recurrence. But that also causes morbidity. Therefore, our clinical question was how to accurately identify patients at low and high risk of distant recurrence to reduce under- and overtreatment,” said Ms. Fremond, a PhD candidate at Leiden (the Netherlands) University Medical Center.

Pathologists can attempt such predictions, but Ms. Fremond noted that there are challenges. “There is a lot of variability between pathologists, and we don’t even use the entire visual information present in the H&E [hematoxylin and eosin] tumor slide. When it comes to molecular testing, it is hampered by cost, turnaround time, and sometimes interpretation. It’s quite complex to combine those data to specifically target risk of distant recurrence for patients with endometrial cancer.”

In her presentation, Ms. Fremond described how she and her colleagues used digitized histopathological slides in their research. She and her coauthors developed the AI model as part of a collaboration that included the AIRMEC Consortium, Leiden University Medical Center, the TransPORTEC Consortium, and the University of Zürich.

The researchers used long-term follow-up data from 1,408 patients drawn from three clinical cohorts and participants in the PORTEC-1, PORTEC-2, and PORTEC-3 studies, which tested radiotherapy and adjuvant therapy outcomes in endometrial cancer. Patients who had received prior adjuvant chemotherapy were excluded. In the model development phase, the system analyzed a single representative histopathological slide image from each patient and compared it with the known time to distant recurrence to identify patterns.

Once the system had been trained, the researchers applied it to a novel group of 353 patients. It ranked 89 patients as having a low risk of recurrence, 175 at intermediate risk, and 89 at high risk of recurrence. The system performed well: 3.37% of low-risk patients experienced a distant recurrence, as did 15.43% of the intermediate-risk group and 36% of the high-risk group.

The researchers also employed an external validation group with 152 patients and three slides per patient, with a 2.8-year follow-up. The model performed with a C index of 0.805 (±0.0136) when a random slide was selected for each patient, and the median predicted risk score per patient was associated with differences in distant recurrence-free survival between the three risk groups with a C index of 0.816 (P < .0001).
 

Questions about research and their answers

Session moderator Kristin Swanson, PhD, asked if the AI could be used with the pathology slide’s visible features to learn more about the underlying biology and pathophysiology of tumors.

“Overlying the HECTOR on to the tissue seems like a logical opportunity to go and then explore the biology and what’s attributed as a high-risk region,” said Dr. Swanson, who is director of the Mathematical NeuroOncology Lab and codirector of the Precision NeuroTherapeutics Innovation Program at Mayo Clinic Arizona, Phoenix.

Ms. Fremond agreed that the AI has the potential to be used that way.”

During the Q&A, an audience member asked how likely the model is to perform in populations that differ significantly from the populations used in her study.

Ms. Fremond responded that the populations used to develop and test the models were in or close to the Netherlands, and little information was available regarding patient ethnicity. “There is a possibility that perhaps we would have a different performance on a population that includes more minorities. That needs to be checked,” said Ms. Fremond.

The study is limited by its retrospective nature.

Ms. Fremond and Dr. Swanson have no relevant financial disclosures.

A deep learning artificial intelligence (AI) model that used only a single histopathological slide predicted the risk of distant recurrence among endometrial cancer patients in a new study.

Endometrial cancer is the most frequently occurring uterine cancer. Early-stage patients have about a 95% 5-year survival, but distant recurrence is associated with very poor survival, according to Sarah Fremond, MSc, an author of the research (Abstract 5695), which she presented at the annual meeting of the American Association for Cancer Research.

“Most patients with endometrial cancer have a good prognosis and would not require any adjuvant treatment, but there is a proportion that will develop distant recurrence. For those you want to recommend adjuvant chemotherapy, because currently in the adjuvant setting, that’s the only treatment that is known to lower the risk of distant recurrence. But that also causes morbidity. Therefore, our clinical question was how to accurately identify patients at low and high risk of distant recurrence to reduce under- and overtreatment,” said Ms. Fremond, a PhD candidate at Leiden (the Netherlands) University Medical Center.

Pathologists can attempt such predictions, but Ms. Fremond noted that there are challenges. “There is a lot of variability between pathologists, and we don’t even use the entire visual information present in the H&E [hematoxylin and eosin] tumor slide. When it comes to molecular testing, it is hampered by cost, turnaround time, and sometimes interpretation. It’s quite complex to combine those data to specifically target risk of distant recurrence for patients with endometrial cancer.”

In her presentation, Ms. Fremond described how she and her colleagues used digitized histopathological slides in their research. She and her coauthors developed the AI model as part of a collaboration that included the AIRMEC Consortium, Leiden University Medical Center, the TransPORTEC Consortium, and the University of Zürich.

The researchers used long-term follow-up data from 1,408 patients drawn from three clinical cohorts and participants in the PORTEC-1, PORTEC-2, and PORTEC-3 studies, which tested radiotherapy and adjuvant therapy outcomes in endometrial cancer. Patients who had received prior adjuvant chemotherapy were excluded. In the model development phase, the system analyzed a single representative histopathological slide image from each patient and compared it with the known time to distant recurrence to identify patterns.

Once the system had been trained, the researchers applied it to a novel group of 353 patients. It ranked 89 patients as having a low risk of recurrence, 175 at intermediate risk, and 89 at high risk of recurrence. The system performed well: 3.37% of low-risk patients experienced a distant recurrence, as did 15.43% of the intermediate-risk group and 36% of the high-risk group.

The researchers also employed an external validation group with 152 patients and three slides per patient, with a 2.8-year follow-up. The model performed with a C index of 0.805 (±0.0136) when a random slide was selected for each patient, and the median predicted risk score per patient was associated with differences in distant recurrence-free survival between the three risk groups with a C index of 0.816 (P < .0001).
 

Questions about research and their answers

Session moderator Kristin Swanson, PhD, asked if the AI could be used with the pathology slide’s visible features to learn more about the underlying biology and pathophysiology of tumors.

“Overlying the HECTOR on to the tissue seems like a logical opportunity to go and then explore the biology and what’s attributed as a high-risk region,” said Dr. Swanson, who is director of the Mathematical NeuroOncology Lab and codirector of the Precision NeuroTherapeutics Innovation Program at Mayo Clinic Arizona, Phoenix.

Ms. Fremond agreed that the AI has the potential to be used that way.”

During the Q&A, an audience member asked how likely the model is to perform in populations that differ significantly from the populations used in her study.

Ms. Fremond responded that the populations used to develop and test the models were in or close to the Netherlands, and little information was available regarding patient ethnicity. “There is a possibility that perhaps we would have a different performance on a population that includes more minorities. That needs to be checked,” said Ms. Fremond.

The study is limited by its retrospective nature.

Ms. Fremond and Dr. Swanson have no relevant financial disclosures.