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Demographic Characteristics of Veterans Diagnosed With Breast and Gynecologic Cancers: A Comparative Analysis With the General Population
PURPOSE
This project aims to describe the demographics of Veterans diagnosed with breast and gynecologic cancers and assess differences compared to the general population.
BACKGROUND
With an increasing number of women Veterans enrolling in the VA, it is crucial for oncologists to be prepared to provide care for VeterS32 • SEPTEMBER 2023 www.mdedge.com/fedprac/avaho NOTES ans diagnosed with breast and gynecologic cancers. Despite the rising incidence of these cancers among Veterans, there is limited characterization of the demographic profile of this population. Understanding the unique characteristics of Veterans with these malignancies, distinct from the general population, is essential for the Veterans Administration (VA) to develop programs and enhance care for these patients.
METHODS/DATA ANALYSIS
Consult records from the VA Corporate Data Warehouse between January 1, 2021, and December 31, 2022, were analyzed to identify Veterans with newly diagnosed breast, uterine, ovarian, cervical, and vulvovaginal cancer. Demographic were evaluated. Data on the general population were obtained data from SEER (Surveillance, Epidemiology, and End Results) 19 database for 2020.
RESULTS
A total of 3,304 Veterans diagnosed with breast cancer and 918 Veterans with gynecologic cancers were identified (uterine, n = 365; cervical, n = 344, ovarian, n = 177; vulvovaginal, n = 32). Veterans were found to be younger than the general population, with a mean age at diagnosis of 59 for Veterans with breast cancer to 63 for non-veterans. Among those with gynecologic cancers, the mean age at diagnosis for Veterans was 55 compared to 61 for non-veterans. Male breast cancer cases were more prevalent among Veterans, accounting for 11% in the VA compared to 1% in SEER. The Veteran cohort also displayed a higher proportion of Black patients, with 30% of breast cancer cases in the VA being Black compared to 12% in SEER.
CONCLUSIONS/IMPLICATIONS
Veterans diagnosed with breast and gynecologic cancers exhibit unique demographic characteristics compared to the general population. They tend to be younger and have a higher representation of Black patients. The incidence of male breast cancer is notably higher among Veterans. As the prevalence of these cancer types continue to rise among Veterans, it is vital for oncologists to be aware of and adequately address the unique health needs of this population. These findings emphasize the importance of tailored strategies and programs to provide optimal care for Veterans with breast and gynecologic cancers.
PURPOSE
This project aims to describe the demographics of Veterans diagnosed with breast and gynecologic cancers and assess differences compared to the general population.
BACKGROUND
With an increasing number of women Veterans enrolling in the VA, it is crucial for oncologists to be prepared to provide care for VeterS32 • SEPTEMBER 2023 www.mdedge.com/fedprac/avaho NOTES ans diagnosed with breast and gynecologic cancers. Despite the rising incidence of these cancers among Veterans, there is limited characterization of the demographic profile of this population. Understanding the unique characteristics of Veterans with these malignancies, distinct from the general population, is essential for the Veterans Administration (VA) to develop programs and enhance care for these patients.
METHODS/DATA ANALYSIS
Consult records from the VA Corporate Data Warehouse between January 1, 2021, and December 31, 2022, were analyzed to identify Veterans with newly diagnosed breast, uterine, ovarian, cervical, and vulvovaginal cancer. Demographic were evaluated. Data on the general population were obtained data from SEER (Surveillance, Epidemiology, and End Results) 19 database for 2020.
RESULTS
A total of 3,304 Veterans diagnosed with breast cancer and 918 Veterans with gynecologic cancers were identified (uterine, n = 365; cervical, n = 344, ovarian, n = 177; vulvovaginal, n = 32). Veterans were found to be younger than the general population, with a mean age at diagnosis of 59 for Veterans with breast cancer to 63 for non-veterans. Among those with gynecologic cancers, the mean age at diagnosis for Veterans was 55 compared to 61 for non-veterans. Male breast cancer cases were more prevalent among Veterans, accounting for 11% in the VA compared to 1% in SEER. The Veteran cohort also displayed a higher proportion of Black patients, with 30% of breast cancer cases in the VA being Black compared to 12% in SEER.
CONCLUSIONS/IMPLICATIONS
Veterans diagnosed with breast and gynecologic cancers exhibit unique demographic characteristics compared to the general population. They tend to be younger and have a higher representation of Black patients. The incidence of male breast cancer is notably higher among Veterans. As the prevalence of these cancer types continue to rise among Veterans, it is vital for oncologists to be aware of and adequately address the unique health needs of this population. These findings emphasize the importance of tailored strategies and programs to provide optimal care for Veterans with breast and gynecologic cancers.
PURPOSE
This project aims to describe the demographics of Veterans diagnosed with breast and gynecologic cancers and assess differences compared to the general population.
BACKGROUND
With an increasing number of women Veterans enrolling in the VA, it is crucial for oncologists to be prepared to provide care for VeterS32 • SEPTEMBER 2023 www.mdedge.com/fedprac/avaho NOTES ans diagnosed with breast and gynecologic cancers. Despite the rising incidence of these cancers among Veterans, there is limited characterization of the demographic profile of this population. Understanding the unique characteristics of Veterans with these malignancies, distinct from the general population, is essential for the Veterans Administration (VA) to develop programs and enhance care for these patients.
METHODS/DATA ANALYSIS
Consult records from the VA Corporate Data Warehouse between January 1, 2021, and December 31, 2022, were analyzed to identify Veterans with newly diagnosed breast, uterine, ovarian, cervical, and vulvovaginal cancer. Demographic were evaluated. Data on the general population were obtained data from SEER (Surveillance, Epidemiology, and End Results) 19 database for 2020.
RESULTS
A total of 3,304 Veterans diagnosed with breast cancer and 918 Veterans with gynecologic cancers were identified (uterine, n = 365; cervical, n = 344, ovarian, n = 177; vulvovaginal, n = 32). Veterans were found to be younger than the general population, with a mean age at diagnosis of 59 for Veterans with breast cancer to 63 for non-veterans. Among those with gynecologic cancers, the mean age at diagnosis for Veterans was 55 compared to 61 for non-veterans. Male breast cancer cases were more prevalent among Veterans, accounting for 11% in the VA compared to 1% in SEER. The Veteran cohort also displayed a higher proportion of Black patients, with 30% of breast cancer cases in the VA being Black compared to 12% in SEER.
CONCLUSIONS/IMPLICATIONS
Veterans diagnosed with breast and gynecologic cancers exhibit unique demographic characteristics compared to the general population. They tend to be younger and have a higher representation of Black patients. The incidence of male breast cancer is notably higher among Veterans. As the prevalence of these cancer types continue to rise among Veterans, it is vital for oncologists to be aware of and adequately address the unique health needs of this population. These findings emphasize the importance of tailored strategies and programs to provide optimal care for Veterans with breast and gynecologic cancers.
Enhancing Usability of Health Information Technology: Comparative Evaluation of Workflow Support Tools
BACKGROUND
The Breast and Gynecologic System of Excellence (BGSOE) program has developed a workflow support tool using health information technology to assist clinicians, coordinators and stakeholders in identifying, tracking and supporting Veterans with breast and gynecological cancers. This tool was designed and implemented through a novel process that involved clarifying program aims, defining workflows in process delivery diagrams, and identifying data, analytic products, and user needs. To determine the optimal tool for the program, a comparative usability evaluation was conducted, comparing the new workflow support tool with a previous tool that shared identical aims but utilized a different approach.
METHODS
Usability evaluation employed the System Usability Scale (SUS) and measured acceptance using modified items from a validated instrument used in a national survey of electronic health records. Task efficiency was evaluated based on time taken and the number of clicks required to complete tasks.
RESULTS
Eight healthcare professionals with experience in the BGSOE program or similar programs in the VA participated in the usability evaluation. This group comprised physicians (38%), clinical pharmacist (25%), health care coordinators (25%), and registered nurse (12%). The workflow support tool achieved an impressive SUS score of 89.06, with acceptance scores of 93% (positive statements) and 6% (negative statements), outperforming the standard tool, which scored score of 57.5 on the SUS and had acceptance scores of 53% (positive statements) and 50% (negative statements). In the comparative ranking, 100% of the users preferred the workflow support tool, citing its userfriendliness, intuitiveness, and ease of use. On average, users completed all tasks using the workflow support tool in 8 minutes with 31 clicks, while the standard tool required 18 minutes and 124 clicks.
CONCLUSIONS
The adoption of a workflow support tool in the design of health information technology interventions leads to improved usability, efficiency, and adoption. Based on the positive results from the usability evaluation, the BGSOE program has chosen to adopt the workflow support tool as its preferred health information technology solution.
BACKGROUND
The Breast and Gynecologic System of Excellence (BGSOE) program has developed a workflow support tool using health information technology to assist clinicians, coordinators and stakeholders in identifying, tracking and supporting Veterans with breast and gynecological cancers. This tool was designed and implemented through a novel process that involved clarifying program aims, defining workflows in process delivery diagrams, and identifying data, analytic products, and user needs. To determine the optimal tool for the program, a comparative usability evaluation was conducted, comparing the new workflow support tool with a previous tool that shared identical aims but utilized a different approach.
METHODS
Usability evaluation employed the System Usability Scale (SUS) and measured acceptance using modified items from a validated instrument used in a national survey of electronic health records. Task efficiency was evaluated based on time taken and the number of clicks required to complete tasks.
RESULTS
Eight healthcare professionals with experience in the BGSOE program or similar programs in the VA participated in the usability evaluation. This group comprised physicians (38%), clinical pharmacist (25%), health care coordinators (25%), and registered nurse (12%). The workflow support tool achieved an impressive SUS score of 89.06, with acceptance scores of 93% (positive statements) and 6% (negative statements), outperforming the standard tool, which scored score of 57.5 on the SUS and had acceptance scores of 53% (positive statements) and 50% (negative statements). In the comparative ranking, 100% of the users preferred the workflow support tool, citing its userfriendliness, intuitiveness, and ease of use. On average, users completed all tasks using the workflow support tool in 8 minutes with 31 clicks, while the standard tool required 18 minutes and 124 clicks.
CONCLUSIONS
The adoption of a workflow support tool in the design of health information technology interventions leads to improved usability, efficiency, and adoption. Based on the positive results from the usability evaluation, the BGSOE program has chosen to adopt the workflow support tool as its preferred health information technology solution.
BACKGROUND
The Breast and Gynecologic System of Excellence (BGSOE) program has developed a workflow support tool using health information technology to assist clinicians, coordinators and stakeholders in identifying, tracking and supporting Veterans with breast and gynecological cancers. This tool was designed and implemented through a novel process that involved clarifying program aims, defining workflows in process delivery diagrams, and identifying data, analytic products, and user needs. To determine the optimal tool for the program, a comparative usability evaluation was conducted, comparing the new workflow support tool with a previous tool that shared identical aims but utilized a different approach.
METHODS
Usability evaluation employed the System Usability Scale (SUS) and measured acceptance using modified items from a validated instrument used in a national survey of electronic health records. Task efficiency was evaluated based on time taken and the number of clicks required to complete tasks.
RESULTS
Eight healthcare professionals with experience in the BGSOE program or similar programs in the VA participated in the usability evaluation. This group comprised physicians (38%), clinical pharmacist (25%), health care coordinators (25%), and registered nurse (12%). The workflow support tool achieved an impressive SUS score of 89.06, with acceptance scores of 93% (positive statements) and 6% (negative statements), outperforming the standard tool, which scored score of 57.5 on the SUS and had acceptance scores of 53% (positive statements) and 50% (negative statements). In the comparative ranking, 100% of the users preferred the workflow support tool, citing its userfriendliness, intuitiveness, and ease of use. On average, users completed all tasks using the workflow support tool in 8 minutes with 31 clicks, while the standard tool required 18 minutes and 124 clicks.
CONCLUSIONS
The adoption of a workflow support tool in the design of health information technology interventions leads to improved usability, efficiency, and adoption. Based on the positive results from the usability evaluation, the BGSOE program has chosen to adopt the workflow support tool as its preferred health information technology solution.
Nurses maintain more stigma toward pregnant women with OUD
Opioid use disorder among pregnant women continues to rise, and untreated opioid use is associated with complications including preterm delivery, placental abruption, and stillbirth, wrote Alexis Braverman, MD, of the University of Illinois, Chicago, and colleagues. However, many perinatal women who seek care and medications for opioid use disorder (OUD) report stigma that limits their ability to reduce these risks.
In a study published in the American Journal on Addictions , the researchers conducted an anonymous survey of 132 health care workers at six outpatient locations and a main hospital of an urban medical center. The survey was designed to assess attitudes toward pregnant women who were using opioids. The 119 complete responses in the final analysis included 40 nurses and 79 clinicians across ob.gyn., family medicine, and pediatrics. A total of 19 respondents were waivered to prescribe outpatient buprenorphine for OUD.
Nurses were significantly less likely than clinicians to agree that OUD is a chronic illness, to feel sympathy for women who use opioids during pregnancy, and to see pregnancy as an opportunity for behavior change (P = .000, P = .003, and P = .001, respectively).
Overall, family medicine providers and clinicians with 11-20 years of practice experience were significantly more sympathetic to pregnant women who used opioids, compared with providers from other departments and with fewer years of practice (P = .025 and P = .039, respectively).
Providers in pediatrics departments were significantly more likely than those from other departments to agree strongly with feeling anger at pregnant women who use opioids (P = .009), and that these women should not be allowed to parent (P = .013). However, providers in pediatrics were significantly more comfortable than those in other departments with discussing the involvement of social services in patient care (P = .020) and with counseling patients on neonatal opioid withdrawal syndrome, known as NOWS (P = .027).
“We hypothesize that nurses who perform more acute, inpatient work rather than outpatient work may not be exposed as frequently to a patient’s personal progress on their journey with OUD,” and therefore might not be exposed to the rewarding experiences and progress made by patients, the researchers wrote in their discussion.
However, the overall low level of comfort in discussing NOWS and social service involvement across provider groups (one-quarter for pediatrics, one-fifth for ob.gyn, and one-sixth for family medicine) highlights the need for further training in this area, they said.
The findings were limited by several factors, including the potential for responder bias; however, the results identify a need for greater training in stigma reduction and in counseling families on issues related to OUD, the researchers said. More studies are needed to examine attitude changes after the implementation of stigma reduction strategies, they concluded.
The study received no outside funding. The researchers had no financial conflicts to disclose.
Opioid use disorder among pregnant women continues to rise, and untreated opioid use is associated with complications including preterm delivery, placental abruption, and stillbirth, wrote Alexis Braverman, MD, of the University of Illinois, Chicago, and colleagues. However, many perinatal women who seek care and medications for opioid use disorder (OUD) report stigma that limits their ability to reduce these risks.
In a study published in the American Journal on Addictions , the researchers conducted an anonymous survey of 132 health care workers at six outpatient locations and a main hospital of an urban medical center. The survey was designed to assess attitudes toward pregnant women who were using opioids. The 119 complete responses in the final analysis included 40 nurses and 79 clinicians across ob.gyn., family medicine, and pediatrics. A total of 19 respondents were waivered to prescribe outpatient buprenorphine for OUD.
Nurses were significantly less likely than clinicians to agree that OUD is a chronic illness, to feel sympathy for women who use opioids during pregnancy, and to see pregnancy as an opportunity for behavior change (P = .000, P = .003, and P = .001, respectively).
Overall, family medicine providers and clinicians with 11-20 years of practice experience were significantly more sympathetic to pregnant women who used opioids, compared with providers from other departments and with fewer years of practice (P = .025 and P = .039, respectively).
Providers in pediatrics departments were significantly more likely than those from other departments to agree strongly with feeling anger at pregnant women who use opioids (P = .009), and that these women should not be allowed to parent (P = .013). However, providers in pediatrics were significantly more comfortable than those in other departments with discussing the involvement of social services in patient care (P = .020) and with counseling patients on neonatal opioid withdrawal syndrome, known as NOWS (P = .027).
“We hypothesize that nurses who perform more acute, inpatient work rather than outpatient work may not be exposed as frequently to a patient’s personal progress on their journey with OUD,” and therefore might not be exposed to the rewarding experiences and progress made by patients, the researchers wrote in their discussion.
However, the overall low level of comfort in discussing NOWS and social service involvement across provider groups (one-quarter for pediatrics, one-fifth for ob.gyn, and one-sixth for family medicine) highlights the need for further training in this area, they said.
The findings were limited by several factors, including the potential for responder bias; however, the results identify a need for greater training in stigma reduction and in counseling families on issues related to OUD, the researchers said. More studies are needed to examine attitude changes after the implementation of stigma reduction strategies, they concluded.
The study received no outside funding. The researchers had no financial conflicts to disclose.
Opioid use disorder among pregnant women continues to rise, and untreated opioid use is associated with complications including preterm delivery, placental abruption, and stillbirth, wrote Alexis Braverman, MD, of the University of Illinois, Chicago, and colleagues. However, many perinatal women who seek care and medications for opioid use disorder (OUD) report stigma that limits their ability to reduce these risks.
In a study published in the American Journal on Addictions , the researchers conducted an anonymous survey of 132 health care workers at six outpatient locations and a main hospital of an urban medical center. The survey was designed to assess attitudes toward pregnant women who were using opioids. The 119 complete responses in the final analysis included 40 nurses and 79 clinicians across ob.gyn., family medicine, and pediatrics. A total of 19 respondents were waivered to prescribe outpatient buprenorphine for OUD.
Nurses were significantly less likely than clinicians to agree that OUD is a chronic illness, to feel sympathy for women who use opioids during pregnancy, and to see pregnancy as an opportunity for behavior change (P = .000, P = .003, and P = .001, respectively).
Overall, family medicine providers and clinicians with 11-20 years of practice experience were significantly more sympathetic to pregnant women who used opioids, compared with providers from other departments and with fewer years of practice (P = .025 and P = .039, respectively).
Providers in pediatrics departments were significantly more likely than those from other departments to agree strongly with feeling anger at pregnant women who use opioids (P = .009), and that these women should not be allowed to parent (P = .013). However, providers in pediatrics were significantly more comfortable than those in other departments with discussing the involvement of social services in patient care (P = .020) and with counseling patients on neonatal opioid withdrawal syndrome, known as NOWS (P = .027).
“We hypothesize that nurses who perform more acute, inpatient work rather than outpatient work may not be exposed as frequently to a patient’s personal progress on their journey with OUD,” and therefore might not be exposed to the rewarding experiences and progress made by patients, the researchers wrote in their discussion.
However, the overall low level of comfort in discussing NOWS and social service involvement across provider groups (one-quarter for pediatrics, one-fifth for ob.gyn, and one-sixth for family medicine) highlights the need for further training in this area, they said.
The findings were limited by several factors, including the potential for responder bias; however, the results identify a need for greater training in stigma reduction and in counseling families on issues related to OUD, the researchers said. More studies are needed to examine attitude changes after the implementation of stigma reduction strategies, they concluded.
The study received no outside funding. The researchers had no financial conflicts to disclose.
FROM THE AMERICAN JOURNAL ON ADDICTIONS
New European restrictions on topiramate in pregnancy
While it’s well known that topiramate can cause major congenital malformations and fetal growth restriction when used during pregnancy, recent data also suggest a possibly increased risk for neurodevelopmental disorders when topiramate is used during pregnancy, the EMA said in a statement.
The data include two observational studies that showed children born to mothers with epilepsy and who were exposed to topiramate in the womb may have a two- to threefold higher risk for neurodevelopmental disorders, in particular autism spectrum disorders (ASD), intellectual disability, or attention deficit hyperactivity disorder (ADHD), compared with children born to mothers with epilepsy not taking antiepileptic medication.
For patients using topiramate for the treatment of epilepsy, the PRAC now recommends that the medicine not be used during pregnancy unless no other suitable treatment is available.
The PRAC had also recommended a pregnancy prevention program to avoid exposure of the developing fetus to topiramate. “These measures will inform any woman or girl who is able to have children of the risks of taking topiramate during pregnancy and the need to avoid becoming pregnant while taking topiramate,” the EMA said.
Regardless of indication, the agency said topiramate should be used in women of childbearing age only when the following conditions of the pregnancy prevention program are met:
- A pregnancy test before starting treatment.
- Counseling about the risks of topiramate treatment and the need for highly effective contraception throughout treatment.
- A review of ongoing treatment at least annually by completion of a risk awareness form.
The PRAC recommends that health care professionals ensure women of childbearing age are fully aware of the risks of taking topiramate during pregnancy. The committee noted that alternative treatment options should be considered and the need for topiramate treatment should be reassessed at least annually.
The product information for topiramate-containing medicines will be updated to further highlight the risks for neurodevelopmental disorders and the additional safety measures to be taken.
Patients and health care professionals will be provided with educational materials regarding the risks of using topiramate during pregnancy, and a patient card will be provided to the patient with each medicine package. A visible warning will also be added to the outer packaging of the medicine.
The new PRAC recommendations will be sent to the Coordination Group for Mutual Recognition and Decentralised Procedures – Human (CMDh), which will adopt a position.
A version of this article first appeared on Medscape.com.
While it’s well known that topiramate can cause major congenital malformations and fetal growth restriction when used during pregnancy, recent data also suggest a possibly increased risk for neurodevelopmental disorders when topiramate is used during pregnancy, the EMA said in a statement.
The data include two observational studies that showed children born to mothers with epilepsy and who were exposed to topiramate in the womb may have a two- to threefold higher risk for neurodevelopmental disorders, in particular autism spectrum disorders (ASD), intellectual disability, or attention deficit hyperactivity disorder (ADHD), compared with children born to mothers with epilepsy not taking antiepileptic medication.
For patients using topiramate for the treatment of epilepsy, the PRAC now recommends that the medicine not be used during pregnancy unless no other suitable treatment is available.
The PRAC had also recommended a pregnancy prevention program to avoid exposure of the developing fetus to topiramate. “These measures will inform any woman or girl who is able to have children of the risks of taking topiramate during pregnancy and the need to avoid becoming pregnant while taking topiramate,” the EMA said.
Regardless of indication, the agency said topiramate should be used in women of childbearing age only when the following conditions of the pregnancy prevention program are met:
- A pregnancy test before starting treatment.
- Counseling about the risks of topiramate treatment and the need for highly effective contraception throughout treatment.
- A review of ongoing treatment at least annually by completion of a risk awareness form.
The PRAC recommends that health care professionals ensure women of childbearing age are fully aware of the risks of taking topiramate during pregnancy. The committee noted that alternative treatment options should be considered and the need for topiramate treatment should be reassessed at least annually.
The product information for topiramate-containing medicines will be updated to further highlight the risks for neurodevelopmental disorders and the additional safety measures to be taken.
Patients and health care professionals will be provided with educational materials regarding the risks of using topiramate during pregnancy, and a patient card will be provided to the patient with each medicine package. A visible warning will also be added to the outer packaging of the medicine.
The new PRAC recommendations will be sent to the Coordination Group for Mutual Recognition and Decentralised Procedures – Human (CMDh), which will adopt a position.
A version of this article first appeared on Medscape.com.
While it’s well known that topiramate can cause major congenital malformations and fetal growth restriction when used during pregnancy, recent data also suggest a possibly increased risk for neurodevelopmental disorders when topiramate is used during pregnancy, the EMA said in a statement.
The data include two observational studies that showed children born to mothers with epilepsy and who were exposed to topiramate in the womb may have a two- to threefold higher risk for neurodevelopmental disorders, in particular autism spectrum disorders (ASD), intellectual disability, or attention deficit hyperactivity disorder (ADHD), compared with children born to mothers with epilepsy not taking antiepileptic medication.
For patients using topiramate for the treatment of epilepsy, the PRAC now recommends that the medicine not be used during pregnancy unless no other suitable treatment is available.
The PRAC had also recommended a pregnancy prevention program to avoid exposure of the developing fetus to topiramate. “These measures will inform any woman or girl who is able to have children of the risks of taking topiramate during pregnancy and the need to avoid becoming pregnant while taking topiramate,” the EMA said.
Regardless of indication, the agency said topiramate should be used in women of childbearing age only when the following conditions of the pregnancy prevention program are met:
- A pregnancy test before starting treatment.
- Counseling about the risks of topiramate treatment and the need for highly effective contraception throughout treatment.
- A review of ongoing treatment at least annually by completion of a risk awareness form.
The PRAC recommends that health care professionals ensure women of childbearing age are fully aware of the risks of taking topiramate during pregnancy. The committee noted that alternative treatment options should be considered and the need for topiramate treatment should be reassessed at least annually.
The product information for topiramate-containing medicines will be updated to further highlight the risks for neurodevelopmental disorders and the additional safety measures to be taken.
Patients and health care professionals will be provided with educational materials regarding the risks of using topiramate during pregnancy, and a patient card will be provided to the patient with each medicine package. A visible warning will also be added to the outer packaging of the medicine.
The new PRAC recommendations will be sent to the Coordination Group for Mutual Recognition and Decentralised Procedures – Human (CMDh), which will adopt a position.
A version of this article first appeared on Medscape.com.
Treating fractures in elderly patients: Beyond the broken bone
While half the fracture-prevention battle is getting people diagnosed with low bone density, nearly 80% of older Americans who suffer bone breaks are not tested or treated for osteoporosis. Fractures associated with aging and diminished bone mineral density exact an enormous toll on patients’ lives and cost the health care system billions of dollars annually according to Bone Health and Osteoporosis: A Report of the Surgeon General. But current gaps in patient education and bone density screening are huge.
“It’s concerning that older patients at risk for fracture are often not screened to determine their risk factors contributing to osteoporosis and patients are not educated about fracture prevention,” said Meryl S. LeBoff, MD, an endocrinologist at Brigham and Women’s Hospital, and chief of calcium and bone section, and professor of medicine, at Harvard Medical School, Boston. “Furthermore, the majority of highest-risk women and men who do have fractures are not screened and they do not receive effective, [Food and Drug Administration]–approved therapies.”
Recent guidelines
Screening with dual-energy x-ray absorptiometry (DEXA) is recommended for all women at age 65 and all men at age 70. But the occasion of a fracture in an older person who has not yet met these age thresholds should prompt a bone density assessment.
“Doctors need to stress that one in two women and one in four men over age 50 will have a fracture in their remaining lifetimes,” Dr. LeBoff said. ”Primary care doctors play a critical role in ordering timely bone densitometry for both sexes.
If an older patient has been treated for a fracture, the main goal going forward is to prevent another one, for which the risk is highest in the 2 years after the incident fracture.”
According to Kendall F. Moseley, MD, clinical director of the division of endocrinology, diabetes & metabolism at Johns Hopkins Medicine in Baltimore, “Elderly patients need to understand that a fracture at their age is like a heart attack of the bone,” she said, adding that just as cardiovascular risk factors such as high blood pressure and blood lipids are silent before a stroke or infarction, the bone thinning of old age is also silent.
Endocrinologist Jennifer J. Kelly, DO, director of the metabolic bone program and an associate professor at the University of Vermont Medical Center in Burlington, said a fracture in anyone over age 50 that appears not to have resulted from a traumatic blow, is a compelling reason to order a DEXA exam.
Nahid J. Rianon, MBBS/MD, DrPH, assistant professor of the division of geriatric medicine at the UTHealth McGovern Medical School, Houston, goes further: “Any fracture in someone age 50 and older warrants screening for osteoporosis. And if the fracture is nontraumatic, that is by definition a clinical diagnosis of osteoporosis regardless of normal results on bone density tests and they should be treated medically. There are aspects of bone that we still can’t measure in the clinical setting.”
If DEXA is not accessible, fracture risk over the next 10 years can be evaluated based on multiple patient characteristics and medical history using the online FRAX calculator.
Just a 3% risk of hip fracture on FRAX is considered an indication to begin medical osteoporosis treatment in the United States regardless of bone density test results, Dr. Rianon said.
Fracture management
Whether a senior suffers a traumatic fracture or an osteoporosis-related fragility fracture, older age can impede the healing process in some. Senescence may also increase systemic proinflammatory status, according to Clark and colleagues, writing in Current Osteoporosis Reports.
They called for research to develop more directed treatment options for the elderly population.
Dr. Rianon noted that healing may also be affected by a decrease in muscle mass, which plays a role in holding the bone in place. “But it is still controversial how changing metabolic factors affect bone healing in the elderly.”
However, countered Dr. Kelly, fractures in elderly patients are not necessarily less likely to mend – if osteoporosis is not present. “Many heal very well – it really depends more upon their overall health and medical history. Whether or not a person requires surgery depends more upon the extent of the fracture and if the bone is able to align and heal appropriately without surgery.”
Fracture sites
Spine. According to the American Academy of Orthopedic Surgeons the earliest and most frequent site of fragility fractures in the elderly is the spine. Most vertebral fracture pain improves within 3 months without specific treatment. A short period of rest, limited analgesic use, and possible back bracing may help as the fractures heal on their own. But if pain is severe and persistent, vertebral augmentation with percutaneous kyphoplasty or vertebroplasty may be an option. These procedures, however, can destabilize surrounding discs because of the greater thickness of the injected cement.
Hip. The most dangerous fractures occur in the hip. These carry at least a 20% risk of death in the first postoperative year and must be treated surgically. Those in the proximal femur, the head, or the femoral neck will usually need hip replacement, but if the break is farther down, it may be repaired with cement, screws, plates, and rods.
Distal radius. Outcomes of wrist fractures may be positive without surgical intervention, according to a recent retrospective analysis from Turkey by Yalin and colleagues. In a comparison of clinical outcomes in seniors aged 70-89 and assigned to cast immobilization or various surgical treatments for distal radius fractures, no statistically significant difference was found in patient-reported disability scores and range of motion values between casting and surgery in the first postoperative year.
Other sites. Fractures in the elderly are not uncommon in the shoulder, distal radius, cubitus, proximal humerus, and humerus. These fractures are often treated without surgery, but nevertheless signal a high risk for additional fractures.
Bone-enhancing medications
Even in the absence of diagnosed low bone density or osteoporosis, anabolic agents such as the synthetic human parathyroid hormones abaloparatide (Tymlos) and teriparatide (Forteo) may be used to help in some cases with a bad healing prognosis and may also be used for people undergoing surgeries such as a spinal fusion, but there are not clinical guidelines. “We receive referrals regularly for this treatment from our orthopedics colleagues, but it is considered an off-label use,” Dr. Kelly said.
The anabolics teriparatide and romosozumab (Evenity) have proved effective in lowering fractures in high-risk older women.
Post fracture
After recovering from a fracture, elderly people are strongly advised to make lifestyle changes to boost bone health and reduce risk of further fractures, said Willy M. Valencia, MD, a geriatrician-endocrinologist at the Cleveland Clinic. Apart from active daily living, he recommends several types of formal exercise to promote bone formation; increase muscle mass, strength, and flexibility; and improve endurance, balance, and gait. The National Institute on Aging outlines suitable exercise programs for seniors.
“These exercises will help reduce the risk of falling and to avoid more fractures,” he said. “Whether a patient has been exercising before the fracture or not, they may feel some reticence or reluctance to take up exercise afterwards because they’re afraid of having another fracture, but they should understand that their fracture risk increases if they remain sedentary. They should start slowly but they can’t be sitting all day.”
Even before it’s possible to exercise at the healing fracture site, added Dr. Rianon, its advisable to work other areas of the body. “Overall mobility is important, and exercising other parts of the body can stimulate strength and help prevent falling.”
In other postsurgical measures, a bone-friendly diet rich in calcium and vitamin D, as well as supplementation with these vital nutrients, is essential to lower the risk of falling.
Fall prevention is paramount, said Dr. Valencia. While exercise can improve, gait, balance, and endurance, logistical measures may also be necessary. Seniors may have to move to a one-floor domicile with no stairs to negotiate. At the very least, they need to fall-proof their daily lives by upgrading their eyeglasses and home lighting, eliminating obstacles and loose carpets, fixing bannisters, and installing bathroom handrails. Some may need assistive devices for walking, especially outdoors in slippery conditions.
At the end of the day, the role of the primary physician in screening for bone problems before fracture and postsurgical care is key. “Risk factors for osteoporosis and fracture risk must be added to the patient’s chart,” said Dr. Rianon. Added Dr. Moseley. “No matter how busy they are, my hope is that primary care physicians will not put patients’ bone health at the bottom of the clinical agenda.”
While half the fracture-prevention battle is getting people diagnosed with low bone density, nearly 80% of older Americans who suffer bone breaks are not tested or treated for osteoporosis. Fractures associated with aging and diminished bone mineral density exact an enormous toll on patients’ lives and cost the health care system billions of dollars annually according to Bone Health and Osteoporosis: A Report of the Surgeon General. But current gaps in patient education and bone density screening are huge.
“It’s concerning that older patients at risk for fracture are often not screened to determine their risk factors contributing to osteoporosis and patients are not educated about fracture prevention,” said Meryl S. LeBoff, MD, an endocrinologist at Brigham and Women’s Hospital, and chief of calcium and bone section, and professor of medicine, at Harvard Medical School, Boston. “Furthermore, the majority of highest-risk women and men who do have fractures are not screened and they do not receive effective, [Food and Drug Administration]–approved therapies.”
Recent guidelines
Screening with dual-energy x-ray absorptiometry (DEXA) is recommended for all women at age 65 and all men at age 70. But the occasion of a fracture in an older person who has not yet met these age thresholds should prompt a bone density assessment.
“Doctors need to stress that one in two women and one in four men over age 50 will have a fracture in their remaining lifetimes,” Dr. LeBoff said. ”Primary care doctors play a critical role in ordering timely bone densitometry for both sexes.
If an older patient has been treated for a fracture, the main goal going forward is to prevent another one, for which the risk is highest in the 2 years after the incident fracture.”
According to Kendall F. Moseley, MD, clinical director of the division of endocrinology, diabetes & metabolism at Johns Hopkins Medicine in Baltimore, “Elderly patients need to understand that a fracture at their age is like a heart attack of the bone,” she said, adding that just as cardiovascular risk factors such as high blood pressure and blood lipids are silent before a stroke or infarction, the bone thinning of old age is also silent.
Endocrinologist Jennifer J. Kelly, DO, director of the metabolic bone program and an associate professor at the University of Vermont Medical Center in Burlington, said a fracture in anyone over age 50 that appears not to have resulted from a traumatic blow, is a compelling reason to order a DEXA exam.
Nahid J. Rianon, MBBS/MD, DrPH, assistant professor of the division of geriatric medicine at the UTHealth McGovern Medical School, Houston, goes further: “Any fracture in someone age 50 and older warrants screening for osteoporosis. And if the fracture is nontraumatic, that is by definition a clinical diagnosis of osteoporosis regardless of normal results on bone density tests and they should be treated medically. There are aspects of bone that we still can’t measure in the clinical setting.”
If DEXA is not accessible, fracture risk over the next 10 years can be evaluated based on multiple patient characteristics and medical history using the online FRAX calculator.
Just a 3% risk of hip fracture on FRAX is considered an indication to begin medical osteoporosis treatment in the United States regardless of bone density test results, Dr. Rianon said.
Fracture management
Whether a senior suffers a traumatic fracture or an osteoporosis-related fragility fracture, older age can impede the healing process in some. Senescence may also increase systemic proinflammatory status, according to Clark and colleagues, writing in Current Osteoporosis Reports.
They called for research to develop more directed treatment options for the elderly population.
Dr. Rianon noted that healing may also be affected by a decrease in muscle mass, which plays a role in holding the bone in place. “But it is still controversial how changing metabolic factors affect bone healing in the elderly.”
However, countered Dr. Kelly, fractures in elderly patients are not necessarily less likely to mend – if osteoporosis is not present. “Many heal very well – it really depends more upon their overall health and medical history. Whether or not a person requires surgery depends more upon the extent of the fracture and if the bone is able to align and heal appropriately without surgery.”
Fracture sites
Spine. According to the American Academy of Orthopedic Surgeons the earliest and most frequent site of fragility fractures in the elderly is the spine. Most vertebral fracture pain improves within 3 months without specific treatment. A short period of rest, limited analgesic use, and possible back bracing may help as the fractures heal on their own. But if pain is severe and persistent, vertebral augmentation with percutaneous kyphoplasty or vertebroplasty may be an option. These procedures, however, can destabilize surrounding discs because of the greater thickness of the injected cement.
Hip. The most dangerous fractures occur in the hip. These carry at least a 20% risk of death in the first postoperative year and must be treated surgically. Those in the proximal femur, the head, or the femoral neck will usually need hip replacement, but if the break is farther down, it may be repaired with cement, screws, plates, and rods.
Distal radius. Outcomes of wrist fractures may be positive without surgical intervention, according to a recent retrospective analysis from Turkey by Yalin and colleagues. In a comparison of clinical outcomes in seniors aged 70-89 and assigned to cast immobilization or various surgical treatments for distal radius fractures, no statistically significant difference was found in patient-reported disability scores and range of motion values between casting and surgery in the first postoperative year.
Other sites. Fractures in the elderly are not uncommon in the shoulder, distal radius, cubitus, proximal humerus, and humerus. These fractures are often treated without surgery, but nevertheless signal a high risk for additional fractures.
Bone-enhancing medications
Even in the absence of diagnosed low bone density or osteoporosis, anabolic agents such as the synthetic human parathyroid hormones abaloparatide (Tymlos) and teriparatide (Forteo) may be used to help in some cases with a bad healing prognosis and may also be used for people undergoing surgeries such as a spinal fusion, but there are not clinical guidelines. “We receive referrals regularly for this treatment from our orthopedics colleagues, but it is considered an off-label use,” Dr. Kelly said.
The anabolics teriparatide and romosozumab (Evenity) have proved effective in lowering fractures in high-risk older women.
Post fracture
After recovering from a fracture, elderly people are strongly advised to make lifestyle changes to boost bone health and reduce risk of further fractures, said Willy M. Valencia, MD, a geriatrician-endocrinologist at the Cleveland Clinic. Apart from active daily living, he recommends several types of formal exercise to promote bone formation; increase muscle mass, strength, and flexibility; and improve endurance, balance, and gait. The National Institute on Aging outlines suitable exercise programs for seniors.
“These exercises will help reduce the risk of falling and to avoid more fractures,” he said. “Whether a patient has been exercising before the fracture or not, they may feel some reticence or reluctance to take up exercise afterwards because they’re afraid of having another fracture, but they should understand that their fracture risk increases if they remain sedentary. They should start slowly but they can’t be sitting all day.”
Even before it’s possible to exercise at the healing fracture site, added Dr. Rianon, its advisable to work other areas of the body. “Overall mobility is important, and exercising other parts of the body can stimulate strength and help prevent falling.”
In other postsurgical measures, a bone-friendly diet rich in calcium and vitamin D, as well as supplementation with these vital nutrients, is essential to lower the risk of falling.
Fall prevention is paramount, said Dr. Valencia. While exercise can improve, gait, balance, and endurance, logistical measures may also be necessary. Seniors may have to move to a one-floor domicile with no stairs to negotiate. At the very least, they need to fall-proof their daily lives by upgrading their eyeglasses and home lighting, eliminating obstacles and loose carpets, fixing bannisters, and installing bathroom handrails. Some may need assistive devices for walking, especially outdoors in slippery conditions.
At the end of the day, the role of the primary physician in screening for bone problems before fracture and postsurgical care is key. “Risk factors for osteoporosis and fracture risk must be added to the patient’s chart,” said Dr. Rianon. Added Dr. Moseley. “No matter how busy they are, my hope is that primary care physicians will not put patients’ bone health at the bottom of the clinical agenda.”
While half the fracture-prevention battle is getting people diagnosed with low bone density, nearly 80% of older Americans who suffer bone breaks are not tested or treated for osteoporosis. Fractures associated with aging and diminished bone mineral density exact an enormous toll on patients’ lives and cost the health care system billions of dollars annually according to Bone Health and Osteoporosis: A Report of the Surgeon General. But current gaps in patient education and bone density screening are huge.
“It’s concerning that older patients at risk for fracture are often not screened to determine their risk factors contributing to osteoporosis and patients are not educated about fracture prevention,” said Meryl S. LeBoff, MD, an endocrinologist at Brigham and Women’s Hospital, and chief of calcium and bone section, and professor of medicine, at Harvard Medical School, Boston. “Furthermore, the majority of highest-risk women and men who do have fractures are not screened and they do not receive effective, [Food and Drug Administration]–approved therapies.”
Recent guidelines
Screening with dual-energy x-ray absorptiometry (DEXA) is recommended for all women at age 65 and all men at age 70. But the occasion of a fracture in an older person who has not yet met these age thresholds should prompt a bone density assessment.
“Doctors need to stress that one in two women and one in four men over age 50 will have a fracture in their remaining lifetimes,” Dr. LeBoff said. ”Primary care doctors play a critical role in ordering timely bone densitometry for both sexes.
If an older patient has been treated for a fracture, the main goal going forward is to prevent another one, for which the risk is highest in the 2 years after the incident fracture.”
According to Kendall F. Moseley, MD, clinical director of the division of endocrinology, diabetes & metabolism at Johns Hopkins Medicine in Baltimore, “Elderly patients need to understand that a fracture at their age is like a heart attack of the bone,” she said, adding that just as cardiovascular risk factors such as high blood pressure and blood lipids are silent before a stroke or infarction, the bone thinning of old age is also silent.
Endocrinologist Jennifer J. Kelly, DO, director of the metabolic bone program and an associate professor at the University of Vermont Medical Center in Burlington, said a fracture in anyone over age 50 that appears not to have resulted from a traumatic blow, is a compelling reason to order a DEXA exam.
Nahid J. Rianon, MBBS/MD, DrPH, assistant professor of the division of geriatric medicine at the UTHealth McGovern Medical School, Houston, goes further: “Any fracture in someone age 50 and older warrants screening for osteoporosis. And if the fracture is nontraumatic, that is by definition a clinical diagnosis of osteoporosis regardless of normal results on bone density tests and they should be treated medically. There are aspects of bone that we still can’t measure in the clinical setting.”
If DEXA is not accessible, fracture risk over the next 10 years can be evaluated based on multiple patient characteristics and medical history using the online FRAX calculator.
Just a 3% risk of hip fracture on FRAX is considered an indication to begin medical osteoporosis treatment in the United States regardless of bone density test results, Dr. Rianon said.
Fracture management
Whether a senior suffers a traumatic fracture or an osteoporosis-related fragility fracture, older age can impede the healing process in some. Senescence may also increase systemic proinflammatory status, according to Clark and colleagues, writing in Current Osteoporosis Reports.
They called for research to develop more directed treatment options for the elderly population.
Dr. Rianon noted that healing may also be affected by a decrease in muscle mass, which plays a role in holding the bone in place. “But it is still controversial how changing metabolic factors affect bone healing in the elderly.”
However, countered Dr. Kelly, fractures in elderly patients are not necessarily less likely to mend – if osteoporosis is not present. “Many heal very well – it really depends more upon their overall health and medical history. Whether or not a person requires surgery depends more upon the extent of the fracture and if the bone is able to align and heal appropriately without surgery.”
Fracture sites
Spine. According to the American Academy of Orthopedic Surgeons the earliest and most frequent site of fragility fractures in the elderly is the spine. Most vertebral fracture pain improves within 3 months without specific treatment. A short period of rest, limited analgesic use, and possible back bracing may help as the fractures heal on their own. But if pain is severe and persistent, vertebral augmentation with percutaneous kyphoplasty or vertebroplasty may be an option. These procedures, however, can destabilize surrounding discs because of the greater thickness of the injected cement.
Hip. The most dangerous fractures occur in the hip. These carry at least a 20% risk of death in the first postoperative year and must be treated surgically. Those in the proximal femur, the head, or the femoral neck will usually need hip replacement, but if the break is farther down, it may be repaired with cement, screws, plates, and rods.
Distal radius. Outcomes of wrist fractures may be positive without surgical intervention, according to a recent retrospective analysis from Turkey by Yalin and colleagues. In a comparison of clinical outcomes in seniors aged 70-89 and assigned to cast immobilization or various surgical treatments for distal radius fractures, no statistically significant difference was found in patient-reported disability scores and range of motion values between casting and surgery in the first postoperative year.
Other sites. Fractures in the elderly are not uncommon in the shoulder, distal radius, cubitus, proximal humerus, and humerus. These fractures are often treated without surgery, but nevertheless signal a high risk for additional fractures.
Bone-enhancing medications
Even in the absence of diagnosed low bone density or osteoporosis, anabolic agents such as the synthetic human parathyroid hormones abaloparatide (Tymlos) and teriparatide (Forteo) may be used to help in some cases with a bad healing prognosis and may also be used for people undergoing surgeries such as a spinal fusion, but there are not clinical guidelines. “We receive referrals regularly for this treatment from our orthopedics colleagues, but it is considered an off-label use,” Dr. Kelly said.
The anabolics teriparatide and romosozumab (Evenity) have proved effective in lowering fractures in high-risk older women.
Post fracture
After recovering from a fracture, elderly people are strongly advised to make lifestyle changes to boost bone health and reduce risk of further fractures, said Willy M. Valencia, MD, a geriatrician-endocrinologist at the Cleveland Clinic. Apart from active daily living, he recommends several types of formal exercise to promote bone formation; increase muscle mass, strength, and flexibility; and improve endurance, balance, and gait. The National Institute on Aging outlines suitable exercise programs for seniors.
“These exercises will help reduce the risk of falling and to avoid more fractures,” he said. “Whether a patient has been exercising before the fracture or not, they may feel some reticence or reluctance to take up exercise afterwards because they’re afraid of having another fracture, but they should understand that their fracture risk increases if they remain sedentary. They should start slowly but they can’t be sitting all day.”
Even before it’s possible to exercise at the healing fracture site, added Dr. Rianon, its advisable to work other areas of the body. “Overall mobility is important, and exercising other parts of the body can stimulate strength and help prevent falling.”
In other postsurgical measures, a bone-friendly diet rich in calcium and vitamin D, as well as supplementation with these vital nutrients, is essential to lower the risk of falling.
Fall prevention is paramount, said Dr. Valencia. While exercise can improve, gait, balance, and endurance, logistical measures may also be necessary. Seniors may have to move to a one-floor domicile with no stairs to negotiate. At the very least, they need to fall-proof their daily lives by upgrading their eyeglasses and home lighting, eliminating obstacles and loose carpets, fixing bannisters, and installing bathroom handrails. Some may need assistive devices for walking, especially outdoors in slippery conditions.
At the end of the day, the role of the primary physician in screening for bone problems before fracture and postsurgical care is key. “Risk factors for osteoporosis and fracture risk must be added to the patient’s chart,” said Dr. Rianon. Added Dr. Moseley. “No matter how busy they are, my hope is that primary care physicians will not put patients’ bone health at the bottom of the clinical agenda.”
‘Missed opportunities’ for accurate diagnosing of women with vaginitis
Although the standard of care of diagnosing vaginitis is clinical evaluation, many practices do not perform accurate and comprehensive clinical examinations for a variety for reasons, and the Centers for Disease Control and Prevention currently recommends molecular testing, wrote Casey N. Pinto, PhD, of Penn State University, Hershey, and colleagues. The CDC also recommends testing women with vaginitis for Chlamydia trachomatis (CT) and Neissaria gonorrhoeae (NG) given the high rate of coinfections between vaginitis and these sexually transmitted infections, but data on cotesting in clinical practice are limited, they said.
In a study published in Sexually Transmitted Diseases, the researchers reviewed data from a commercial administrative claims database for 1,359,289 women aged 18-50 years who were diagnosed with vaginitis between 2012 and 2017.
The women were categorized into groups based on type of vaginitis diagnosis: nucleic amplification test (NAAT), DNA probe test, traditional lab test, and those diagnosed clinically at an index visit but with no CPT code for further testing.
Overall, nearly half of the women (49.2%) had no CPT code for further vaginitis testing beyond clinical diagnosis. Of those with CPT codes for testing, 50.9% underwent traditional point-of-care testing, wet mount, or culture, 23.5% had a DNA probe, and 20.6% had NAAT testing.
Approximately one-third (34%) of women were cotested for CT/NG. Testing rates varied widely across the type of vaginitis test, from 70.8% of women who received NAAT to 22.8% of women with no CPT code. In multivariate analysis including age, region, and the Charlson Comorbidity Index (CCI), those tested with NAAT were eight times more likely to be cotested for CT/NG than those with no CPT code (odds ratio, 8.77; P < .0001).
Women who received a traditional test or DNA probe test for vaginitis also were more likely to have CT/NG testing than women with no CPT code, but only 1.8-2.5 times as likely.
“Our data suggest that most clinicians are not engaging the standard of care for testing and diagnosing vaginitis, or not engaging in comprehensive care by cotesting for vaginitis and CT/NG when patients may be at risk, resulting in missed opportunities for accurate diagnosis and potential associated coinfections,” the researchers wrote in their discussion. The higher rates for CT/NG testing among women receiving either NAAT or DNA probe vaginitis testing could be attributed to bundled testing, they noted, and the lower rate of CT/NG testing for patients with no CPT code could stem from limited access to microscopy or clinician preference for clinical diagnosis only, they said.
The findings were limited by several factors, including the lack of data on testing and diagnoses prior to the study period and not billed to insurance, and by the inability to account for variables including race, ethnicity, and socioeconomic status, the researchers noted.
However, the results highlight the need for more comprehensive care in vaginitis testing to take advantage of opportunities to identify CT or NG in women diagnosed with vaginitis, they concluded.
The study was supported by Becton, Dickinson and Company. Lead author Dr. Pinto disclosed consulting for Becton, Dickinson and Company, and receiving an honorarium from Roche.
Although the standard of care of diagnosing vaginitis is clinical evaluation, many practices do not perform accurate and comprehensive clinical examinations for a variety for reasons, and the Centers for Disease Control and Prevention currently recommends molecular testing, wrote Casey N. Pinto, PhD, of Penn State University, Hershey, and colleagues. The CDC also recommends testing women with vaginitis for Chlamydia trachomatis (CT) and Neissaria gonorrhoeae (NG) given the high rate of coinfections between vaginitis and these sexually transmitted infections, but data on cotesting in clinical practice are limited, they said.
In a study published in Sexually Transmitted Diseases, the researchers reviewed data from a commercial administrative claims database for 1,359,289 women aged 18-50 years who were diagnosed with vaginitis between 2012 and 2017.
The women were categorized into groups based on type of vaginitis diagnosis: nucleic amplification test (NAAT), DNA probe test, traditional lab test, and those diagnosed clinically at an index visit but with no CPT code for further testing.
Overall, nearly half of the women (49.2%) had no CPT code for further vaginitis testing beyond clinical diagnosis. Of those with CPT codes for testing, 50.9% underwent traditional point-of-care testing, wet mount, or culture, 23.5% had a DNA probe, and 20.6% had NAAT testing.
Approximately one-third (34%) of women were cotested for CT/NG. Testing rates varied widely across the type of vaginitis test, from 70.8% of women who received NAAT to 22.8% of women with no CPT code. In multivariate analysis including age, region, and the Charlson Comorbidity Index (CCI), those tested with NAAT were eight times more likely to be cotested for CT/NG than those with no CPT code (odds ratio, 8.77; P < .0001).
Women who received a traditional test or DNA probe test for vaginitis also were more likely to have CT/NG testing than women with no CPT code, but only 1.8-2.5 times as likely.
“Our data suggest that most clinicians are not engaging the standard of care for testing and diagnosing vaginitis, or not engaging in comprehensive care by cotesting for vaginitis and CT/NG when patients may be at risk, resulting in missed opportunities for accurate diagnosis and potential associated coinfections,” the researchers wrote in their discussion. The higher rates for CT/NG testing among women receiving either NAAT or DNA probe vaginitis testing could be attributed to bundled testing, they noted, and the lower rate of CT/NG testing for patients with no CPT code could stem from limited access to microscopy or clinician preference for clinical diagnosis only, they said.
The findings were limited by several factors, including the lack of data on testing and diagnoses prior to the study period and not billed to insurance, and by the inability to account for variables including race, ethnicity, and socioeconomic status, the researchers noted.
However, the results highlight the need for more comprehensive care in vaginitis testing to take advantage of opportunities to identify CT or NG in women diagnosed with vaginitis, they concluded.
The study was supported by Becton, Dickinson and Company. Lead author Dr. Pinto disclosed consulting for Becton, Dickinson and Company, and receiving an honorarium from Roche.
Although the standard of care of diagnosing vaginitis is clinical evaluation, many practices do not perform accurate and comprehensive clinical examinations for a variety for reasons, and the Centers for Disease Control and Prevention currently recommends molecular testing, wrote Casey N. Pinto, PhD, of Penn State University, Hershey, and colleagues. The CDC also recommends testing women with vaginitis for Chlamydia trachomatis (CT) and Neissaria gonorrhoeae (NG) given the high rate of coinfections between vaginitis and these sexually transmitted infections, but data on cotesting in clinical practice are limited, they said.
In a study published in Sexually Transmitted Diseases, the researchers reviewed data from a commercial administrative claims database for 1,359,289 women aged 18-50 years who were diagnosed with vaginitis between 2012 and 2017.
The women were categorized into groups based on type of vaginitis diagnosis: nucleic amplification test (NAAT), DNA probe test, traditional lab test, and those diagnosed clinically at an index visit but with no CPT code for further testing.
Overall, nearly half of the women (49.2%) had no CPT code for further vaginitis testing beyond clinical diagnosis. Of those with CPT codes for testing, 50.9% underwent traditional point-of-care testing, wet mount, or culture, 23.5% had a DNA probe, and 20.6% had NAAT testing.
Approximately one-third (34%) of women were cotested for CT/NG. Testing rates varied widely across the type of vaginitis test, from 70.8% of women who received NAAT to 22.8% of women with no CPT code. In multivariate analysis including age, region, and the Charlson Comorbidity Index (CCI), those tested with NAAT were eight times more likely to be cotested for CT/NG than those with no CPT code (odds ratio, 8.77; P < .0001).
Women who received a traditional test or DNA probe test for vaginitis also were more likely to have CT/NG testing than women with no CPT code, but only 1.8-2.5 times as likely.
“Our data suggest that most clinicians are not engaging the standard of care for testing and diagnosing vaginitis, or not engaging in comprehensive care by cotesting for vaginitis and CT/NG when patients may be at risk, resulting in missed opportunities for accurate diagnosis and potential associated coinfections,” the researchers wrote in their discussion. The higher rates for CT/NG testing among women receiving either NAAT or DNA probe vaginitis testing could be attributed to bundled testing, they noted, and the lower rate of CT/NG testing for patients with no CPT code could stem from limited access to microscopy or clinician preference for clinical diagnosis only, they said.
The findings were limited by several factors, including the lack of data on testing and diagnoses prior to the study period and not billed to insurance, and by the inability to account for variables including race, ethnicity, and socioeconomic status, the researchers noted.
However, the results highlight the need for more comprehensive care in vaginitis testing to take advantage of opportunities to identify CT or NG in women diagnosed with vaginitis, they concluded.
The study was supported by Becton, Dickinson and Company. Lead author Dr. Pinto disclosed consulting for Becton, Dickinson and Company, and receiving an honorarium from Roche.
FROM SEXUALLY TRANSMITTED DISEASES
Underprescribed menopause relief: Women suffer needlessly
The result: Countless women grapple with the physical and emotional toll of this life transition.
These shortcomings have led to an influx of doctors moving from traditional practice to virtual startups that focus on women’s health issues, treating patients who come to them desperate and frustrated after years of unresolved issues.
The solution is often so simple it is almost maddening, specialists say: vaginal creams containing low-dose estrogen which can address the symptoms of menopause, from vaginal dryness to recurrent urinary tract infections.
“Hands down, this is one of the most meaningful interventions I’ve ever offered to a patient and yet it is underutilized,” said Ashley Winter, MD, chief medical officer and urologist at Odela Health, a digital women’s health clinic. “A lot of companies are blossoming in this menopause space because it is underserved by traditional health care – your gynecologist typically deals with reproduction, and typically when women are done with child-bearing, they’re kind of discharged from the care of their gynecologist.”
More than 1 million women in the United States go through menopause each year. According to a 2022 survey, 4 in 10 women report menopause symptoms that have been disruptive enough to interfere with their work performance on at least a weekly basis.
And yet, many women are not getting appropriate treatment.
Partially to blame is the harmful legacy of faulty data, doctors say. The early results of the federally funded Women’s Health Initiative, released in 2002, showed that hormone therapy (HT) led to increased risk for heart attacks, strokes, and breast cancer. But further analysis showed the opposite: Hormonal therapies have a helpful effect on cardiovascular and bone health and generally reduce risk of death in younger women or those in the early postmenopausal period.
Hormone therapy delivers estrogen, sometimes with progesterone, to the body through gels, creams, patches, pills, suppositories, or a device fitted inside the uterus. Systemic HT sends hormones into the bloodstream, while local HT – like vaginal estrogen cream – specifically treats vaginal symptoms of menopause.
Myths about the health risks linked to systemic and topical HT have long been debunked, and research on topical HT in particular shows it poses no risk for cancer or other chronic diseases.
Yet while 2 decades have passed since the misinformation first started to spread, people remain woefully uninformed about hormone treatments.
The FDA still requires that estrogen products carry a black-box warning on the early data, even though it has since been proven false.
“This is one of the most damaging PR misadventures of modern medicine in my opinion,” Dr. Winter said. “It has literally killed women, and it’s made them miserable.”
The public has a glaring lack of knowledge about menopause management, said Stephanie Faubion, MD, medical director for the North American Menopause Society and director of Mayo Clinic’s Center for Women’s Health.
Treating with low-dose estrogen isn’t a radical approach – in fact, it is the standard of care for women experiencing many menopause symptoms, Dr. Faubion said. But the topic does have nuance, and some people get lost in the specifics.
“I don’t think there’s a lot of knowledge on the risk-benefits of hormone therapy in general,” Dr. Faubion said. “New information comes out so frequently it’s difficult to keep track of. The answer is complicated and depends on dose, duration of treatment, what formulation you’re on. It’s difficult for a lot of people to understand.”
But Dr. Winter said the lack of public knowledge reflects a bigger problem: Knowledge gaps exist among doctors, too, stemming from insufficient training on menopause-related issues.
During her 6-year urology residency, she never learned the role of vaginal estrogen on urinary problems, Dr. Winter said. Only during a 1-year fellowship on sexual dysfunction did she hear about the treatment.
“Despite dealing with urinary issues, incontinence, blood in the urine – training to manage all those concerns – the role of local hormones in the vagina for managing all them was never taught, never discussed,” Dr. Winter said. “I never prescribed any of it.”
A year ago, Dr. Winter left her job at Kaiser Permanente to join Odela. After years of prescribing medications for overactive bladder with little to no results, she said, she now uses the knowledge she gained during her fellowship by helping women who have spent years battling debilitating symptoms.
Urologists are not the only clinicians who lack appropriate training. Obstetrics and gynecology residencies offer little knowledge on menopause treatments, said Ghazaleh Moayedi, DO, an ob.gyn. and complex family planning specialist for Texas-based Pegasus Health Justice Center.
The problem is partly a systems-based one, she said. Training programs often direct patients who are uninsured, or covered through public insurance, to medical residents. Patients who qualify for Medicaid or Medicare are often either pregnant or over 65, Dr. Moayedi said, so women actively going through the transition can slip through the cracks.
“What that means in a state like Texas where I’m based, where it is difficult to qualify for Medicaid, is that the people we see who do qualify are pregnant,” she said. “And you’re not on Medicare until you’re 65. So most ob.gyn. residents don’t graduate with expansive experience in menopause.”
According to Medicaid.gov, 80% of the national population covered by Medicaid is age 45 and younger.
When doctors have proper training and prescribe local hormones, patients don’t always follow the treatment plan, said Andrea Rapkin, MD, professor of obstetrics and gynecology at David Geffen School of Medicine at UCLA.
That failure to follow treatment is yet another example of remaining doubts from the misinformation spread through early research, Dr. Rapkin said.
“I’ll prescribe an estrogen product, and I’ll find out they didn’t take it even though I’ll reassure them,” she said. “I do think there are some lingering concerns, but I’m glad to see there is a growing interest in vaginal hormones.”
A version of this article first appeared on WebMD.com.
The result: Countless women grapple with the physical and emotional toll of this life transition.
These shortcomings have led to an influx of doctors moving from traditional practice to virtual startups that focus on women’s health issues, treating patients who come to them desperate and frustrated after years of unresolved issues.
The solution is often so simple it is almost maddening, specialists say: vaginal creams containing low-dose estrogen which can address the symptoms of menopause, from vaginal dryness to recurrent urinary tract infections.
“Hands down, this is one of the most meaningful interventions I’ve ever offered to a patient and yet it is underutilized,” said Ashley Winter, MD, chief medical officer and urologist at Odela Health, a digital women’s health clinic. “A lot of companies are blossoming in this menopause space because it is underserved by traditional health care – your gynecologist typically deals with reproduction, and typically when women are done with child-bearing, they’re kind of discharged from the care of their gynecologist.”
More than 1 million women in the United States go through menopause each year. According to a 2022 survey, 4 in 10 women report menopause symptoms that have been disruptive enough to interfere with their work performance on at least a weekly basis.
And yet, many women are not getting appropriate treatment.
Partially to blame is the harmful legacy of faulty data, doctors say. The early results of the federally funded Women’s Health Initiative, released in 2002, showed that hormone therapy (HT) led to increased risk for heart attacks, strokes, and breast cancer. But further analysis showed the opposite: Hormonal therapies have a helpful effect on cardiovascular and bone health and generally reduce risk of death in younger women or those in the early postmenopausal period.
Hormone therapy delivers estrogen, sometimes with progesterone, to the body through gels, creams, patches, pills, suppositories, or a device fitted inside the uterus. Systemic HT sends hormones into the bloodstream, while local HT – like vaginal estrogen cream – specifically treats vaginal symptoms of menopause.
Myths about the health risks linked to systemic and topical HT have long been debunked, and research on topical HT in particular shows it poses no risk for cancer or other chronic diseases.
Yet while 2 decades have passed since the misinformation first started to spread, people remain woefully uninformed about hormone treatments.
The FDA still requires that estrogen products carry a black-box warning on the early data, even though it has since been proven false.
“This is one of the most damaging PR misadventures of modern medicine in my opinion,” Dr. Winter said. “It has literally killed women, and it’s made them miserable.”
The public has a glaring lack of knowledge about menopause management, said Stephanie Faubion, MD, medical director for the North American Menopause Society and director of Mayo Clinic’s Center for Women’s Health.
Treating with low-dose estrogen isn’t a radical approach – in fact, it is the standard of care for women experiencing many menopause symptoms, Dr. Faubion said. But the topic does have nuance, and some people get lost in the specifics.
“I don’t think there’s a lot of knowledge on the risk-benefits of hormone therapy in general,” Dr. Faubion said. “New information comes out so frequently it’s difficult to keep track of. The answer is complicated and depends on dose, duration of treatment, what formulation you’re on. It’s difficult for a lot of people to understand.”
But Dr. Winter said the lack of public knowledge reflects a bigger problem: Knowledge gaps exist among doctors, too, stemming from insufficient training on menopause-related issues.
During her 6-year urology residency, she never learned the role of vaginal estrogen on urinary problems, Dr. Winter said. Only during a 1-year fellowship on sexual dysfunction did she hear about the treatment.
“Despite dealing with urinary issues, incontinence, blood in the urine – training to manage all those concerns – the role of local hormones in the vagina for managing all them was never taught, never discussed,” Dr. Winter said. “I never prescribed any of it.”
A year ago, Dr. Winter left her job at Kaiser Permanente to join Odela. After years of prescribing medications for overactive bladder with little to no results, she said, she now uses the knowledge she gained during her fellowship by helping women who have spent years battling debilitating symptoms.
Urologists are not the only clinicians who lack appropriate training. Obstetrics and gynecology residencies offer little knowledge on menopause treatments, said Ghazaleh Moayedi, DO, an ob.gyn. and complex family planning specialist for Texas-based Pegasus Health Justice Center.
The problem is partly a systems-based one, she said. Training programs often direct patients who are uninsured, or covered through public insurance, to medical residents. Patients who qualify for Medicaid or Medicare are often either pregnant or over 65, Dr. Moayedi said, so women actively going through the transition can slip through the cracks.
“What that means in a state like Texas where I’m based, where it is difficult to qualify for Medicaid, is that the people we see who do qualify are pregnant,” she said. “And you’re not on Medicare until you’re 65. So most ob.gyn. residents don’t graduate with expansive experience in menopause.”
According to Medicaid.gov, 80% of the national population covered by Medicaid is age 45 and younger.
When doctors have proper training and prescribe local hormones, patients don’t always follow the treatment plan, said Andrea Rapkin, MD, professor of obstetrics and gynecology at David Geffen School of Medicine at UCLA.
That failure to follow treatment is yet another example of remaining doubts from the misinformation spread through early research, Dr. Rapkin said.
“I’ll prescribe an estrogen product, and I’ll find out they didn’t take it even though I’ll reassure them,” she said. “I do think there are some lingering concerns, but I’m glad to see there is a growing interest in vaginal hormones.”
A version of this article first appeared on WebMD.com.
The result: Countless women grapple with the physical and emotional toll of this life transition.
These shortcomings have led to an influx of doctors moving from traditional practice to virtual startups that focus on women’s health issues, treating patients who come to them desperate and frustrated after years of unresolved issues.
The solution is often so simple it is almost maddening, specialists say: vaginal creams containing low-dose estrogen which can address the symptoms of menopause, from vaginal dryness to recurrent urinary tract infections.
“Hands down, this is one of the most meaningful interventions I’ve ever offered to a patient and yet it is underutilized,” said Ashley Winter, MD, chief medical officer and urologist at Odela Health, a digital women’s health clinic. “A lot of companies are blossoming in this menopause space because it is underserved by traditional health care – your gynecologist typically deals with reproduction, and typically when women are done with child-bearing, they’re kind of discharged from the care of their gynecologist.”
More than 1 million women in the United States go through menopause each year. According to a 2022 survey, 4 in 10 women report menopause symptoms that have been disruptive enough to interfere with their work performance on at least a weekly basis.
And yet, many women are not getting appropriate treatment.
Partially to blame is the harmful legacy of faulty data, doctors say. The early results of the federally funded Women’s Health Initiative, released in 2002, showed that hormone therapy (HT) led to increased risk for heart attacks, strokes, and breast cancer. But further analysis showed the opposite: Hormonal therapies have a helpful effect on cardiovascular and bone health and generally reduce risk of death in younger women or those in the early postmenopausal period.
Hormone therapy delivers estrogen, sometimes with progesterone, to the body through gels, creams, patches, pills, suppositories, or a device fitted inside the uterus. Systemic HT sends hormones into the bloodstream, while local HT – like vaginal estrogen cream – specifically treats vaginal symptoms of menopause.
Myths about the health risks linked to systemic and topical HT have long been debunked, and research on topical HT in particular shows it poses no risk for cancer or other chronic diseases.
Yet while 2 decades have passed since the misinformation first started to spread, people remain woefully uninformed about hormone treatments.
The FDA still requires that estrogen products carry a black-box warning on the early data, even though it has since been proven false.
“This is one of the most damaging PR misadventures of modern medicine in my opinion,” Dr. Winter said. “It has literally killed women, and it’s made them miserable.”
The public has a glaring lack of knowledge about menopause management, said Stephanie Faubion, MD, medical director for the North American Menopause Society and director of Mayo Clinic’s Center for Women’s Health.
Treating with low-dose estrogen isn’t a radical approach – in fact, it is the standard of care for women experiencing many menopause symptoms, Dr. Faubion said. But the topic does have nuance, and some people get lost in the specifics.
“I don’t think there’s a lot of knowledge on the risk-benefits of hormone therapy in general,” Dr. Faubion said. “New information comes out so frequently it’s difficult to keep track of. The answer is complicated and depends on dose, duration of treatment, what formulation you’re on. It’s difficult for a lot of people to understand.”
But Dr. Winter said the lack of public knowledge reflects a bigger problem: Knowledge gaps exist among doctors, too, stemming from insufficient training on menopause-related issues.
During her 6-year urology residency, she never learned the role of vaginal estrogen on urinary problems, Dr. Winter said. Only during a 1-year fellowship on sexual dysfunction did she hear about the treatment.
“Despite dealing with urinary issues, incontinence, blood in the urine – training to manage all those concerns – the role of local hormones in the vagina for managing all them was never taught, never discussed,” Dr. Winter said. “I never prescribed any of it.”
A year ago, Dr. Winter left her job at Kaiser Permanente to join Odela. After years of prescribing medications for overactive bladder with little to no results, she said, she now uses the knowledge she gained during her fellowship by helping women who have spent years battling debilitating symptoms.
Urologists are not the only clinicians who lack appropriate training. Obstetrics and gynecology residencies offer little knowledge on menopause treatments, said Ghazaleh Moayedi, DO, an ob.gyn. and complex family planning specialist for Texas-based Pegasus Health Justice Center.
The problem is partly a systems-based one, she said. Training programs often direct patients who are uninsured, or covered through public insurance, to medical residents. Patients who qualify for Medicaid or Medicare are often either pregnant or over 65, Dr. Moayedi said, so women actively going through the transition can slip through the cracks.
“What that means in a state like Texas where I’m based, where it is difficult to qualify for Medicaid, is that the people we see who do qualify are pregnant,” she said. “And you’re not on Medicare until you’re 65. So most ob.gyn. residents don’t graduate with expansive experience in menopause.”
According to Medicaid.gov, 80% of the national population covered by Medicaid is age 45 and younger.
When doctors have proper training and prescribe local hormones, patients don’t always follow the treatment plan, said Andrea Rapkin, MD, professor of obstetrics and gynecology at David Geffen School of Medicine at UCLA.
That failure to follow treatment is yet another example of remaining doubts from the misinformation spread through early research, Dr. Rapkin said.
“I’ll prescribe an estrogen product, and I’ll find out they didn’t take it even though I’ll reassure them,” she said. “I do think there are some lingering concerns, but I’m glad to see there is a growing interest in vaginal hormones.”
A version of this article first appeared on WebMD.com.
Mammography breast density reporting: What it means for clinicians
This transcript has been edited for clarity.
Today, I’m going to talk about the 2023 Food and Drug Administration regulation that requires breast density to be reported on all mammogram results nationwide, and for that report to go to both clinicians and patients. Previously this was the rule in some states, but not in others. This is important because 40%-50% of women have dense breasts. I’m going to discuss what that means for you, and for our patients.
First
Breast density describes the appearance of the breast on mammography. Appearance varies on the basis of breast tissue composition, with fibroglandular tissue being more dense than fatty tissue. Breast density is important because it relates to both the risk for cancer and the ability of mammography to detect cancer.
Breast density is defined and classified according to the American College of Radiology’s BI-RADS four-category scale. Categories 1 and 2 refer to breast tissue that is not dense, accounting for about 50% of the population. Categories 3 and 4 describe heterogeneously dense and extremely dense breast tissue, which occur in approximately 40% and 50% of women, respectively. When speaking about dense breast tissue readings on mammography, we are referring to categories 3 and 4.
Women with dense breast tissue have an increased risk of developing breast cancer and are less likely to have early breast cancer detected on mammography.
Let’s go over the details by category:
For women in categories 1 and 2 (considered not dense breast tissue), the sensitivity of mammography for detecting early breast cancer is 80%-90%. In categories 3 and 4, the sensitivity of mammography drops to 60%-70%.
Compared with women with average breast density, the risk of developing breast cancer is 20% higher in women with BI-RADS category 3 breasts, and more than twice as high (relative risk, 2.1) in those with BI-RADS category 4 breasts. Thus, the risk of developing breast cancer is higher, but the sensitivity of the test is lower.
The clinical question is, what should we do about this? For women who have a normal mammogram with dense breasts, should follow-up testing be done, and if so, what test? The main follow-up testing options are either ultrasound or MRI, usually ultrasound. Additional testing will detect additional cancers that were not picked up on the initial mammogram and will also lead to additional biopsies for false-positive tests from the additional testing.
An American College of Gynecology and Obstetrics practice advisory nicely summarizes the evidence and clarifies that this decision is made in the context of a lack of published evidence demonstrating improved outcomes, specifically no reduction in breast cancer mortality, with supplemental testing. The official ACOG stance is that they “do not recommend routine use of alternative or adjunctive tests to screening mammography in women with dense breasts who are asymptomatic and have no additional risk factors.”
This is an area where it is important to understand the data. We are all going to be getting test results back that indicate level of breast density, and those test results will also be sent to our patients, so we are going to be asked about this by interested patients. Should this be something that we talk to patients about, utilizing shared decision-making to decide about whether follow-up testing is necessary in women with dense breasts? That is something each clinician will need to decide, and knowing the data is a critically important step in that decision.
Neil Skolnik, MD, is a professor, department of family medicine, at Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, and associate director, department of family medicine, Abington (Pennsylvania) Jefferson Health.
A version of this article first appeared on Medscape.com.
This transcript has been edited for clarity.
Today, I’m going to talk about the 2023 Food and Drug Administration regulation that requires breast density to be reported on all mammogram results nationwide, and for that report to go to both clinicians and patients. Previously this was the rule in some states, but not in others. This is important because 40%-50% of women have dense breasts. I’m going to discuss what that means for you, and for our patients.
First
Breast density describes the appearance of the breast on mammography. Appearance varies on the basis of breast tissue composition, with fibroglandular tissue being more dense than fatty tissue. Breast density is important because it relates to both the risk for cancer and the ability of mammography to detect cancer.
Breast density is defined and classified according to the American College of Radiology’s BI-RADS four-category scale. Categories 1 and 2 refer to breast tissue that is not dense, accounting for about 50% of the population. Categories 3 and 4 describe heterogeneously dense and extremely dense breast tissue, which occur in approximately 40% and 50% of women, respectively. When speaking about dense breast tissue readings on mammography, we are referring to categories 3 and 4.
Women with dense breast tissue have an increased risk of developing breast cancer and are less likely to have early breast cancer detected on mammography.
Let’s go over the details by category:
For women in categories 1 and 2 (considered not dense breast tissue), the sensitivity of mammography for detecting early breast cancer is 80%-90%. In categories 3 and 4, the sensitivity of mammography drops to 60%-70%.
Compared with women with average breast density, the risk of developing breast cancer is 20% higher in women with BI-RADS category 3 breasts, and more than twice as high (relative risk, 2.1) in those with BI-RADS category 4 breasts. Thus, the risk of developing breast cancer is higher, but the sensitivity of the test is lower.
The clinical question is, what should we do about this? For women who have a normal mammogram with dense breasts, should follow-up testing be done, and if so, what test? The main follow-up testing options are either ultrasound or MRI, usually ultrasound. Additional testing will detect additional cancers that were not picked up on the initial mammogram and will also lead to additional biopsies for false-positive tests from the additional testing.
An American College of Gynecology and Obstetrics practice advisory nicely summarizes the evidence and clarifies that this decision is made in the context of a lack of published evidence demonstrating improved outcomes, specifically no reduction in breast cancer mortality, with supplemental testing. The official ACOG stance is that they “do not recommend routine use of alternative or adjunctive tests to screening mammography in women with dense breasts who are asymptomatic and have no additional risk factors.”
This is an area where it is important to understand the data. We are all going to be getting test results back that indicate level of breast density, and those test results will also be sent to our patients, so we are going to be asked about this by interested patients. Should this be something that we talk to patients about, utilizing shared decision-making to decide about whether follow-up testing is necessary in women with dense breasts? That is something each clinician will need to decide, and knowing the data is a critically important step in that decision.
Neil Skolnik, MD, is a professor, department of family medicine, at Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, and associate director, department of family medicine, Abington (Pennsylvania) Jefferson Health.
A version of this article first appeared on Medscape.com.
This transcript has been edited for clarity.
Today, I’m going to talk about the 2023 Food and Drug Administration regulation that requires breast density to be reported on all mammogram results nationwide, and for that report to go to both clinicians and patients. Previously this was the rule in some states, but not in others. This is important because 40%-50% of women have dense breasts. I’m going to discuss what that means for you, and for our patients.
First
Breast density describes the appearance of the breast on mammography. Appearance varies on the basis of breast tissue composition, with fibroglandular tissue being more dense than fatty tissue. Breast density is important because it relates to both the risk for cancer and the ability of mammography to detect cancer.
Breast density is defined and classified according to the American College of Radiology’s BI-RADS four-category scale. Categories 1 and 2 refer to breast tissue that is not dense, accounting for about 50% of the population. Categories 3 and 4 describe heterogeneously dense and extremely dense breast tissue, which occur in approximately 40% and 50% of women, respectively. When speaking about dense breast tissue readings on mammography, we are referring to categories 3 and 4.
Women with dense breast tissue have an increased risk of developing breast cancer and are less likely to have early breast cancer detected on mammography.
Let’s go over the details by category:
For women in categories 1 and 2 (considered not dense breast tissue), the sensitivity of mammography for detecting early breast cancer is 80%-90%. In categories 3 and 4, the sensitivity of mammography drops to 60%-70%.
Compared with women with average breast density, the risk of developing breast cancer is 20% higher in women with BI-RADS category 3 breasts, and more than twice as high (relative risk, 2.1) in those with BI-RADS category 4 breasts. Thus, the risk of developing breast cancer is higher, but the sensitivity of the test is lower.
The clinical question is, what should we do about this? For women who have a normal mammogram with dense breasts, should follow-up testing be done, and if so, what test? The main follow-up testing options are either ultrasound or MRI, usually ultrasound. Additional testing will detect additional cancers that were not picked up on the initial mammogram and will also lead to additional biopsies for false-positive tests from the additional testing.
An American College of Gynecology and Obstetrics practice advisory nicely summarizes the evidence and clarifies that this decision is made in the context of a lack of published evidence demonstrating improved outcomes, specifically no reduction in breast cancer mortality, with supplemental testing. The official ACOG stance is that they “do not recommend routine use of alternative or adjunctive tests to screening mammography in women with dense breasts who are asymptomatic and have no additional risk factors.”
This is an area where it is important to understand the data. We are all going to be getting test results back that indicate level of breast density, and those test results will also be sent to our patients, so we are going to be asked about this by interested patients. Should this be something that we talk to patients about, utilizing shared decision-making to decide about whether follow-up testing is necessary in women with dense breasts? That is something each clinician will need to decide, and knowing the data is a critically important step in that decision.
Neil Skolnik, MD, is a professor, department of family medicine, at Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, and associate director, department of family medicine, Abington (Pennsylvania) Jefferson Health.
A version of this article first appeared on Medscape.com.
Weight loss linked to mortality risk in older women
Weight loss of at least 5% over a 3-year period was associated with significantly increased mortality in women at age 90, 95, and 100 years compared with those whose weight remained stable, based on data from more than 50,000 individuals.
Previous studies of later-life weight changes and mortality have yielded inconsistent results driven by considerations of weight loss intentionality, and data on older adults in particular are limited, wrote Aladdin H. Shadyab, PhD, of the University of California, San Diego, and colleagues.
In a study published in the Journals of Gerontology: Medical Sciences, the researchers reviewed data from the Women’s Health Initiative, a prospective study of factors affecting chronic disease development in postmenopausal women. The study population included 54,437 women who entered the WHI between 1993 and 1998 at ages 50-79 years. The mean baseline age was 69.8 years; 89.5% of the participants were White, 5.7% were Black, 2.7% were Asian, 2.5% were Hispanic/Latino, and the remaining 1.0% were multiracial, American Indian/Alaskan Native, Native Hawaiian/Other Pacific Islander, or unknown.
The primary outcomes were the associations of short-term (3-year) and long-term (10-year) weight changes with survival to ages 90, 95, and 100 years.
A total of 30,647 women survived to at least 90 years (56.3%).
Overall, women with a short-term weight loss of 5% or more of body weight were 33% less likely to survive to age 90 years, 35% less likely to survive to age 95 years, and 38% less likely to survive to age 100 years than were those whose weight remained stable (odds ratios, 0.67, 0.65, and 0.62, respectively).
The associations were stronger in cases of unintentional short-term weight loss. Intentional weight loss from baseline to year 3 was associated with 17% lower odds of survival to age 90 compared to stable weight (OR, 0.83), but unintentional weight loss was associated with 51% lower odds of survival to age 90 (OR, 0.49).
Similarly, women with 10-year weight loss of at least 5% were 40% less likely to survive to 90 years and 49% less likely to survive to 95 years (OR, 0.60 and OR, 0.51, respectively). The sample size was too small to assess the relation of 10-year weight loss with survival to 100 years, and intentionality was not assessed for 10-year weight changes.
By contrast, weight gain of at least 5% had no significant effect on survival to ages 90, 95, or 100 years, but stable weight over time increased the odds of living to ages 90 to 100 years by 1.2-fold to 2-fold compared to either intentional or unintentional weight loss of at least 5%.
The trends in results were similar across body weight categories (normal weight, overweight, and obese as defined by body mass index). Baseline age and smoking status had no significant effect on the results.
Some of the proportion of self-reported intentional weight loss in the study population may have been unintentional, the researchers wrote in their discussion.
“It is important to note that perceived intentionality of weight loss may be influenced by the many societal pressures to lose weight, especially among women, and therefore overestimate the behavioral changes underlying experienced weight loss in older adults,” they said.
The findings were limited by several factors including the potential for inaccurate self-reported weight loss intention, and the likelihood that the mean older age of the population at baseline (older than 60 years) meant that they were more likely to live longer regardless of weight changes, the researchers noted. Other limitations included the primarily White study population, and other residual confounding factors such as ill health that might drive weight loss, the researchers noted.
However, the results were strengthened by the large sample size and long follow-up period, and suggest that “blanket recommendations for weight loss in older women are unlikely to lead to better survival at advanced ages,” they concluded.
Data support weight monitoring
The investigators acknowledged that their data do not affect clinical recommendations for moderate weight loss in older women to improve health outcomes, especially in those with overweight or obesity, but instead “support close monitoring of the amount and speed of weight loss, particularly when unintentional, as an indicator of underlying poor health and predictor of decreased lifespan in older women.”
Neil Skolnik, MD, professor of family and community medicine at the Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, agreed with this conclusion. The current study suggests that when older women lose a significant amount of weight unintentionally, it could be a sign of failing health, he said.
Weight gain or loss in old age is very different from weight issues in younger people, where clinicians may be encouraging weight loss to improve health outcomes, Dr. Skolnik said in an interview.
A key take-home message for clinicians, in addition to monitoring weight in older patients, is to emphasize nutrition for individuals in their 80s, 90s, and beyond, he said.
The study was supported by the National Heart, Lung, and Blood Institute. Dr. Shadyab had no financial conflicts to disclose. Dr. Skolnik had no financial conflicts to disclose and serves on the editorial advisory board of Family Practice News.
Weight loss of at least 5% over a 3-year period was associated with significantly increased mortality in women at age 90, 95, and 100 years compared with those whose weight remained stable, based on data from more than 50,000 individuals.
Previous studies of later-life weight changes and mortality have yielded inconsistent results driven by considerations of weight loss intentionality, and data on older adults in particular are limited, wrote Aladdin H. Shadyab, PhD, of the University of California, San Diego, and colleagues.
In a study published in the Journals of Gerontology: Medical Sciences, the researchers reviewed data from the Women’s Health Initiative, a prospective study of factors affecting chronic disease development in postmenopausal women. The study population included 54,437 women who entered the WHI between 1993 and 1998 at ages 50-79 years. The mean baseline age was 69.8 years; 89.5% of the participants were White, 5.7% were Black, 2.7% were Asian, 2.5% were Hispanic/Latino, and the remaining 1.0% were multiracial, American Indian/Alaskan Native, Native Hawaiian/Other Pacific Islander, or unknown.
The primary outcomes were the associations of short-term (3-year) and long-term (10-year) weight changes with survival to ages 90, 95, and 100 years.
A total of 30,647 women survived to at least 90 years (56.3%).
Overall, women with a short-term weight loss of 5% or more of body weight were 33% less likely to survive to age 90 years, 35% less likely to survive to age 95 years, and 38% less likely to survive to age 100 years than were those whose weight remained stable (odds ratios, 0.67, 0.65, and 0.62, respectively).
The associations were stronger in cases of unintentional short-term weight loss. Intentional weight loss from baseline to year 3 was associated with 17% lower odds of survival to age 90 compared to stable weight (OR, 0.83), but unintentional weight loss was associated with 51% lower odds of survival to age 90 (OR, 0.49).
Similarly, women with 10-year weight loss of at least 5% were 40% less likely to survive to 90 years and 49% less likely to survive to 95 years (OR, 0.60 and OR, 0.51, respectively). The sample size was too small to assess the relation of 10-year weight loss with survival to 100 years, and intentionality was not assessed for 10-year weight changes.
By contrast, weight gain of at least 5% had no significant effect on survival to ages 90, 95, or 100 years, but stable weight over time increased the odds of living to ages 90 to 100 years by 1.2-fold to 2-fold compared to either intentional or unintentional weight loss of at least 5%.
The trends in results were similar across body weight categories (normal weight, overweight, and obese as defined by body mass index). Baseline age and smoking status had no significant effect on the results.
Some of the proportion of self-reported intentional weight loss in the study population may have been unintentional, the researchers wrote in their discussion.
“It is important to note that perceived intentionality of weight loss may be influenced by the many societal pressures to lose weight, especially among women, and therefore overestimate the behavioral changes underlying experienced weight loss in older adults,” they said.
The findings were limited by several factors including the potential for inaccurate self-reported weight loss intention, and the likelihood that the mean older age of the population at baseline (older than 60 years) meant that they were more likely to live longer regardless of weight changes, the researchers noted. Other limitations included the primarily White study population, and other residual confounding factors such as ill health that might drive weight loss, the researchers noted.
However, the results were strengthened by the large sample size and long follow-up period, and suggest that “blanket recommendations for weight loss in older women are unlikely to lead to better survival at advanced ages,” they concluded.
Data support weight monitoring
The investigators acknowledged that their data do not affect clinical recommendations for moderate weight loss in older women to improve health outcomes, especially in those with overweight or obesity, but instead “support close monitoring of the amount and speed of weight loss, particularly when unintentional, as an indicator of underlying poor health and predictor of decreased lifespan in older women.”
Neil Skolnik, MD, professor of family and community medicine at the Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, agreed with this conclusion. The current study suggests that when older women lose a significant amount of weight unintentionally, it could be a sign of failing health, he said.
Weight gain or loss in old age is very different from weight issues in younger people, where clinicians may be encouraging weight loss to improve health outcomes, Dr. Skolnik said in an interview.
A key take-home message for clinicians, in addition to monitoring weight in older patients, is to emphasize nutrition for individuals in their 80s, 90s, and beyond, he said.
The study was supported by the National Heart, Lung, and Blood Institute. Dr. Shadyab had no financial conflicts to disclose. Dr. Skolnik had no financial conflicts to disclose and serves on the editorial advisory board of Family Practice News.
Weight loss of at least 5% over a 3-year period was associated with significantly increased mortality in women at age 90, 95, and 100 years compared with those whose weight remained stable, based on data from more than 50,000 individuals.
Previous studies of later-life weight changes and mortality have yielded inconsistent results driven by considerations of weight loss intentionality, and data on older adults in particular are limited, wrote Aladdin H. Shadyab, PhD, of the University of California, San Diego, and colleagues.
In a study published in the Journals of Gerontology: Medical Sciences, the researchers reviewed data from the Women’s Health Initiative, a prospective study of factors affecting chronic disease development in postmenopausal women. The study population included 54,437 women who entered the WHI between 1993 and 1998 at ages 50-79 years. The mean baseline age was 69.8 years; 89.5% of the participants were White, 5.7% were Black, 2.7% were Asian, 2.5% were Hispanic/Latino, and the remaining 1.0% were multiracial, American Indian/Alaskan Native, Native Hawaiian/Other Pacific Islander, or unknown.
The primary outcomes were the associations of short-term (3-year) and long-term (10-year) weight changes with survival to ages 90, 95, and 100 years.
A total of 30,647 women survived to at least 90 years (56.3%).
Overall, women with a short-term weight loss of 5% or more of body weight were 33% less likely to survive to age 90 years, 35% less likely to survive to age 95 years, and 38% less likely to survive to age 100 years than were those whose weight remained stable (odds ratios, 0.67, 0.65, and 0.62, respectively).
The associations were stronger in cases of unintentional short-term weight loss. Intentional weight loss from baseline to year 3 was associated with 17% lower odds of survival to age 90 compared to stable weight (OR, 0.83), but unintentional weight loss was associated with 51% lower odds of survival to age 90 (OR, 0.49).
Similarly, women with 10-year weight loss of at least 5% were 40% less likely to survive to 90 years and 49% less likely to survive to 95 years (OR, 0.60 and OR, 0.51, respectively). The sample size was too small to assess the relation of 10-year weight loss with survival to 100 years, and intentionality was not assessed for 10-year weight changes.
By contrast, weight gain of at least 5% had no significant effect on survival to ages 90, 95, or 100 years, but stable weight over time increased the odds of living to ages 90 to 100 years by 1.2-fold to 2-fold compared to either intentional or unintentional weight loss of at least 5%.
The trends in results were similar across body weight categories (normal weight, overweight, and obese as defined by body mass index). Baseline age and smoking status had no significant effect on the results.
Some of the proportion of self-reported intentional weight loss in the study population may have been unintentional, the researchers wrote in their discussion.
“It is important to note that perceived intentionality of weight loss may be influenced by the many societal pressures to lose weight, especially among women, and therefore overestimate the behavioral changes underlying experienced weight loss in older adults,” they said.
The findings were limited by several factors including the potential for inaccurate self-reported weight loss intention, and the likelihood that the mean older age of the population at baseline (older than 60 years) meant that they were more likely to live longer regardless of weight changes, the researchers noted. Other limitations included the primarily White study population, and other residual confounding factors such as ill health that might drive weight loss, the researchers noted.
However, the results were strengthened by the large sample size and long follow-up period, and suggest that “blanket recommendations for weight loss in older women are unlikely to lead to better survival at advanced ages,” they concluded.
Data support weight monitoring
The investigators acknowledged that their data do not affect clinical recommendations for moderate weight loss in older women to improve health outcomes, especially in those with overweight or obesity, but instead “support close monitoring of the amount and speed of weight loss, particularly when unintentional, as an indicator of underlying poor health and predictor of decreased lifespan in older women.”
Neil Skolnik, MD, professor of family and community medicine at the Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, agreed with this conclusion. The current study suggests that when older women lose a significant amount of weight unintentionally, it could be a sign of failing health, he said.
Weight gain or loss in old age is very different from weight issues in younger people, where clinicians may be encouraging weight loss to improve health outcomes, Dr. Skolnik said in an interview.
A key take-home message for clinicians, in addition to monitoring weight in older patients, is to emphasize nutrition for individuals in their 80s, 90s, and beyond, he said.
The study was supported by the National Heart, Lung, and Blood Institute. Dr. Shadyab had no financial conflicts to disclose. Dr. Skolnik had no financial conflicts to disclose and serves on the editorial advisory board of Family Practice News.
FROM THE JOURNALS OF GERONTOLOGY: MEDICAL SCIENCES
A nurse’s view: Blood test for severe preeclampsia will save lives
There is amazing news for the world of obstetrics and for all pregnant women. Severe preeclampsia is a critical obstetrical condition that can have serious outcomes for a mother and baby. It can lead to eclampsia, an obstetrical emergency, which often results in death of the mother and/or baby.
Based on research published in the Journal of the American Heart Association, the incidence of new‐onset hypertensive disorders of pregnancy (gestational hypertension and preeclampsia/eclampsia) have nearly doubled in the United States from 2007 to 2019. And they continue to climb.
According to the Preeclampsia Foundation, 5%-8% of all pregnancies in the United States will result in preeclampsia. Black women are at a 60% higher risk than white women, and according to various sources, other risk groups include those who became pregnant via in vitro fertilization, mothers of multiples (twins and triplets), women with gestational diabetes, women over age 35, women with chronic hypertension, obesity, polycystic ovary syndrome, sickle cell disease, rheumatoid arthritis, lupus, migraines, antiphospholipid syndrome, previous pregnancy with preeclampsia, family history, and scleroderma.
Screening and treatment
Preeclampsia is a multiorgan disease of pregnancy, and can be mild, but may quickly progress to severe, which can be life-threatening for mother and baby. It was previously referred to as toxemia or the high blood pressure disease of pregnancy. It primarily involves the cardiovascular, neurologic and renal systems, and the liver. Patients typically present with elevated blood pressures, but other symptoms may include headache, swelling of hands and feet, blurry/double vision or seeing spots, nausea/vomiting, and epigastric pain. It is diagnosed with elevated blood pressures, blood work, and protein in the urine.
Early screening for preeclampsia is done in the first trimester. Presently, a combination of prenatal blood work, blood pressure monitoring, and recognition of high-risk groups is used to determine a treatment plan going forward. The American Congress of Obstetricians and Gynecologists recommends women that fall into this group for potentially developing preeclampsia take daily aspirin as a preventative measure.
In its milder form, a pregnant woman can be observed as an outpatient – monitored with antepartum testing, lab work, and patient education to report significant symptoms as listed above. Teaching patients about fetal kick counts to monitor their baby’s movements is equally important. Women with mild preeclampsia usually can safely deliver at term, being induced between 37-39 weeks’ gestation.
On the other hand, if mild preeclampsia progresses to severe preeclampsia, delivery may be preterm for the safety of mother and baby. Severe preeclampsia can lead to maternal organ damage, seizures, and even death of mother and/or baby.
About 20% of women with severe preeclampsia will develop HELLP (Hemolysis, Elevated Liver enzymes, and Low Platelets) syndrome, a life-threatening disease that often warrants immediate delivery. According to the National Library of Medicine, the mortality rate of women with HELLP syndrome is up to 24% and the perinatal death rate is up as high as 37%. These serious conditions can cause ineffective maternal clotting, liver rupture, placental abruption, and postpartum hemorrhage. It is most prevalent in the third trimester but can occur within 48 hours of delivery.
The only cure for preeclampsia in any form is delivery.
Patients with severe preeclampsia are hospitalized until delivery – sometimes a few days to a couple of weeks. Mother and baby are closely watched for further progression, including signs of organ damage in the mother and changes to the well-being of the baby. If the mother’s health is severely compromised, then the baby will be compromised as well. A preterm delivery may be necessary.
Impact of the new test
The National Institute of Health states that preterm babies born from preeclamptic mothers can suffer many health problems including cerebral palsy, deafness, blindness, epilepsy, and a host of other respiratory, cardiovascular, and endocrine issues. But the biggest issue is preterm birth, defined as birth before 37 weeks gestation. Being born preterm can require a long stay in the intensive care nursery.
This is where the first-of-its-kind prognostic blood test comes into play. The test’s ability to predict severe preeclampsia within 2 weeks can help save lives. The test can offer health care providers the ability to administer steroids for fetal lung maturity before delivery and be more prepared to care for what could be a very compromised newborn.
The blood test, which is recommended between 23-35 weeks gestation, involves analyzing a ratio between two proteins from the placenta, sFlt1 and PIGF. The higher the ratio, the higher the risk that severe preeclampsia will develop. Results can be available within 30 minutes, which is critical when contemplating treatment.
An example of the use of this ratio is illustrated with chronic hypertension in pregnancy, which is defined as elevated blood pressure before 20 weeks or even before conception. Since chronic hypertension can be a primary precursor to preeclampsia, patients with this condition are at higher risk. The FDA-approved blood test would be helpful in determining the plan of care; that is, delivery versus hospitalization versus monitor as an outpatient.
With a positive test result, a pregnant woman can be immediately hospitalized where she can get the care she and baby need as they await delivery. Since health care providers already know the high-risk groups, surveillance can begin early, utilizing this blood test to predict the progression to severe preeclampsia. Conversely, if the test is negative, a treatment plan can be made as an outpatient and the pregnancy continues.
Not all hospitals are equipped to care for premature babies. If delivery is not imminent, providers can use this blood test to identify those that should be transferred to a tertiary center for observation and monitoring. Mother and baby would then not be separated after birth.
We really don’t know who will develop severe preeclampsia and who won’t. This new blood test will be a critical tool as pregnant patients go through their second and third trimesters. It will be especially pivotal for these women, but important for all pregnant women in reducing maternal and fetal mortality and morbidity.
Ms. Barnett is a registered nurse in the department of obstetrics, Mills-Peninsula Medical Center, Burlingame, Calif. She has disclosed no relevant financial relationships.
There is amazing news for the world of obstetrics and for all pregnant women. Severe preeclampsia is a critical obstetrical condition that can have serious outcomes for a mother and baby. It can lead to eclampsia, an obstetrical emergency, which often results in death of the mother and/or baby.
Based on research published in the Journal of the American Heart Association, the incidence of new‐onset hypertensive disorders of pregnancy (gestational hypertension and preeclampsia/eclampsia) have nearly doubled in the United States from 2007 to 2019. And they continue to climb.
According to the Preeclampsia Foundation, 5%-8% of all pregnancies in the United States will result in preeclampsia. Black women are at a 60% higher risk than white women, and according to various sources, other risk groups include those who became pregnant via in vitro fertilization, mothers of multiples (twins and triplets), women with gestational diabetes, women over age 35, women with chronic hypertension, obesity, polycystic ovary syndrome, sickle cell disease, rheumatoid arthritis, lupus, migraines, antiphospholipid syndrome, previous pregnancy with preeclampsia, family history, and scleroderma.
Screening and treatment
Preeclampsia is a multiorgan disease of pregnancy, and can be mild, but may quickly progress to severe, which can be life-threatening for mother and baby. It was previously referred to as toxemia or the high blood pressure disease of pregnancy. It primarily involves the cardiovascular, neurologic and renal systems, and the liver. Patients typically present with elevated blood pressures, but other symptoms may include headache, swelling of hands and feet, blurry/double vision or seeing spots, nausea/vomiting, and epigastric pain. It is diagnosed with elevated blood pressures, blood work, and protein in the urine.
Early screening for preeclampsia is done in the first trimester. Presently, a combination of prenatal blood work, blood pressure monitoring, and recognition of high-risk groups is used to determine a treatment plan going forward. The American Congress of Obstetricians and Gynecologists recommends women that fall into this group for potentially developing preeclampsia take daily aspirin as a preventative measure.
In its milder form, a pregnant woman can be observed as an outpatient – monitored with antepartum testing, lab work, and patient education to report significant symptoms as listed above. Teaching patients about fetal kick counts to monitor their baby’s movements is equally important. Women with mild preeclampsia usually can safely deliver at term, being induced between 37-39 weeks’ gestation.
On the other hand, if mild preeclampsia progresses to severe preeclampsia, delivery may be preterm for the safety of mother and baby. Severe preeclampsia can lead to maternal organ damage, seizures, and even death of mother and/or baby.
About 20% of women with severe preeclampsia will develop HELLP (Hemolysis, Elevated Liver enzymes, and Low Platelets) syndrome, a life-threatening disease that often warrants immediate delivery. According to the National Library of Medicine, the mortality rate of women with HELLP syndrome is up to 24% and the perinatal death rate is up as high as 37%. These serious conditions can cause ineffective maternal clotting, liver rupture, placental abruption, and postpartum hemorrhage. It is most prevalent in the third trimester but can occur within 48 hours of delivery.
The only cure for preeclampsia in any form is delivery.
Patients with severe preeclampsia are hospitalized until delivery – sometimes a few days to a couple of weeks. Mother and baby are closely watched for further progression, including signs of organ damage in the mother and changes to the well-being of the baby. If the mother’s health is severely compromised, then the baby will be compromised as well. A preterm delivery may be necessary.
Impact of the new test
The National Institute of Health states that preterm babies born from preeclamptic mothers can suffer many health problems including cerebral palsy, deafness, blindness, epilepsy, and a host of other respiratory, cardiovascular, and endocrine issues. But the biggest issue is preterm birth, defined as birth before 37 weeks gestation. Being born preterm can require a long stay in the intensive care nursery.
This is where the first-of-its-kind prognostic blood test comes into play. The test’s ability to predict severe preeclampsia within 2 weeks can help save lives. The test can offer health care providers the ability to administer steroids for fetal lung maturity before delivery and be more prepared to care for what could be a very compromised newborn.
The blood test, which is recommended between 23-35 weeks gestation, involves analyzing a ratio between two proteins from the placenta, sFlt1 and PIGF. The higher the ratio, the higher the risk that severe preeclampsia will develop. Results can be available within 30 minutes, which is critical when contemplating treatment.
An example of the use of this ratio is illustrated with chronic hypertension in pregnancy, which is defined as elevated blood pressure before 20 weeks or even before conception. Since chronic hypertension can be a primary precursor to preeclampsia, patients with this condition are at higher risk. The FDA-approved blood test would be helpful in determining the plan of care; that is, delivery versus hospitalization versus monitor as an outpatient.
With a positive test result, a pregnant woman can be immediately hospitalized where she can get the care she and baby need as they await delivery. Since health care providers already know the high-risk groups, surveillance can begin early, utilizing this blood test to predict the progression to severe preeclampsia. Conversely, if the test is negative, a treatment plan can be made as an outpatient and the pregnancy continues.
Not all hospitals are equipped to care for premature babies. If delivery is not imminent, providers can use this blood test to identify those that should be transferred to a tertiary center for observation and monitoring. Mother and baby would then not be separated after birth.
We really don’t know who will develop severe preeclampsia and who won’t. This new blood test will be a critical tool as pregnant patients go through their second and third trimesters. It will be especially pivotal for these women, but important for all pregnant women in reducing maternal and fetal mortality and morbidity.
Ms. Barnett is a registered nurse in the department of obstetrics, Mills-Peninsula Medical Center, Burlingame, Calif. She has disclosed no relevant financial relationships.
There is amazing news for the world of obstetrics and for all pregnant women. Severe preeclampsia is a critical obstetrical condition that can have serious outcomes for a mother and baby. It can lead to eclampsia, an obstetrical emergency, which often results in death of the mother and/or baby.
Based on research published in the Journal of the American Heart Association, the incidence of new‐onset hypertensive disorders of pregnancy (gestational hypertension and preeclampsia/eclampsia) have nearly doubled in the United States from 2007 to 2019. And they continue to climb.
According to the Preeclampsia Foundation, 5%-8% of all pregnancies in the United States will result in preeclampsia. Black women are at a 60% higher risk than white women, and according to various sources, other risk groups include those who became pregnant via in vitro fertilization, mothers of multiples (twins and triplets), women with gestational diabetes, women over age 35, women with chronic hypertension, obesity, polycystic ovary syndrome, sickle cell disease, rheumatoid arthritis, lupus, migraines, antiphospholipid syndrome, previous pregnancy with preeclampsia, family history, and scleroderma.
Screening and treatment
Preeclampsia is a multiorgan disease of pregnancy, and can be mild, but may quickly progress to severe, which can be life-threatening for mother and baby. It was previously referred to as toxemia or the high blood pressure disease of pregnancy. It primarily involves the cardiovascular, neurologic and renal systems, and the liver. Patients typically present with elevated blood pressures, but other symptoms may include headache, swelling of hands and feet, blurry/double vision or seeing spots, nausea/vomiting, and epigastric pain. It is diagnosed with elevated blood pressures, blood work, and protein in the urine.
Early screening for preeclampsia is done in the first trimester. Presently, a combination of prenatal blood work, blood pressure monitoring, and recognition of high-risk groups is used to determine a treatment plan going forward. The American Congress of Obstetricians and Gynecologists recommends women that fall into this group for potentially developing preeclampsia take daily aspirin as a preventative measure.
In its milder form, a pregnant woman can be observed as an outpatient – monitored with antepartum testing, lab work, and patient education to report significant symptoms as listed above. Teaching patients about fetal kick counts to monitor their baby’s movements is equally important. Women with mild preeclampsia usually can safely deliver at term, being induced between 37-39 weeks’ gestation.
On the other hand, if mild preeclampsia progresses to severe preeclampsia, delivery may be preterm for the safety of mother and baby. Severe preeclampsia can lead to maternal organ damage, seizures, and even death of mother and/or baby.
About 20% of women with severe preeclampsia will develop HELLP (Hemolysis, Elevated Liver enzymes, and Low Platelets) syndrome, a life-threatening disease that often warrants immediate delivery. According to the National Library of Medicine, the mortality rate of women with HELLP syndrome is up to 24% and the perinatal death rate is up as high as 37%. These serious conditions can cause ineffective maternal clotting, liver rupture, placental abruption, and postpartum hemorrhage. It is most prevalent in the third trimester but can occur within 48 hours of delivery.
The only cure for preeclampsia in any form is delivery.
Patients with severe preeclampsia are hospitalized until delivery – sometimes a few days to a couple of weeks. Mother and baby are closely watched for further progression, including signs of organ damage in the mother and changes to the well-being of the baby. If the mother’s health is severely compromised, then the baby will be compromised as well. A preterm delivery may be necessary.
Impact of the new test
The National Institute of Health states that preterm babies born from preeclamptic mothers can suffer many health problems including cerebral palsy, deafness, blindness, epilepsy, and a host of other respiratory, cardiovascular, and endocrine issues. But the biggest issue is preterm birth, defined as birth before 37 weeks gestation. Being born preterm can require a long stay in the intensive care nursery.
This is where the first-of-its-kind prognostic blood test comes into play. The test’s ability to predict severe preeclampsia within 2 weeks can help save lives. The test can offer health care providers the ability to administer steroids for fetal lung maturity before delivery and be more prepared to care for what could be a very compromised newborn.
The blood test, which is recommended between 23-35 weeks gestation, involves analyzing a ratio between two proteins from the placenta, sFlt1 and PIGF. The higher the ratio, the higher the risk that severe preeclampsia will develop. Results can be available within 30 minutes, which is critical when contemplating treatment.
An example of the use of this ratio is illustrated with chronic hypertension in pregnancy, which is defined as elevated blood pressure before 20 weeks or even before conception. Since chronic hypertension can be a primary precursor to preeclampsia, patients with this condition are at higher risk. The FDA-approved blood test would be helpful in determining the plan of care; that is, delivery versus hospitalization versus monitor as an outpatient.
With a positive test result, a pregnant woman can be immediately hospitalized where she can get the care she and baby need as they await delivery. Since health care providers already know the high-risk groups, surveillance can begin early, utilizing this blood test to predict the progression to severe preeclampsia. Conversely, if the test is negative, a treatment plan can be made as an outpatient and the pregnancy continues.
Not all hospitals are equipped to care for premature babies. If delivery is not imminent, providers can use this blood test to identify those that should be transferred to a tertiary center for observation and monitoring. Mother and baby would then not be separated after birth.
We really don’t know who will develop severe preeclampsia and who won’t. This new blood test will be a critical tool as pregnant patients go through their second and third trimesters. It will be especially pivotal for these women, but important for all pregnant women in reducing maternal and fetal mortality and morbidity.
Ms. Barnett is a registered nurse in the department of obstetrics, Mills-Peninsula Medical Center, Burlingame, Calif. She has disclosed no relevant financial relationships.