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Family Doctors Can Intervene to Treat and Prevent STIs
VANCOUVER, BRITISH COLUMBIA — Family physicians should familiarize themselves with doxycycline post-exposure prophylaxis (doxy PEP) as a prescription for patients who frequently have unprotected sex (including oral, anal, and vaginal) with multiple partners, according to a presentation at the Family Medicine Forum (FMF) 2024. Doxy PEP decreases the risk for bacterial sexually transmitted infections (STIs).
Many family physicians may be unaware of doxy PEP as a means of avoiding STIs. “Doxy PEP is an incredible tool that can be used within 72 hours of unprotected sex to reduce bacterial STI risk,” said James Owen, MD, assistant professor of family and community medicine at the University of Toronto in Ontario, Canada.
The US Centers for Disease Control and Prevention point to data from three randomized, controlled trials that demonstrate the ability of doxy PEP to decrease syphilis and chlamydia infections by more than 70% and decrease gonococcal infections by about 50%, said Jordan Goodridge, MD, assistant professor of family and community medicine at the University of Toronto.
Optimizing Doxy PEP
Doxy PEP (200 mg) is most effective when administered in the first 24 hours after unprotected sex, explained Goodridge. It is recommended that patients repeat the 200-mg dose if they are sexually active again within 24 hours.
To ensure optimal absorption of doxy PEP, the drug should not be taken with antacids or multivitamins, said Goodridge. Antacids “can bind to doxycycline and prevent it from being absorbed,” he said.
A key concern about doxy PEP is the development of antimicrobial resistance, noted Goodridge. “We don’t have long-term studies to give us an idea about what this risk is, to quantify it. The studies we have are relatively short, generally less than a year, and didn’t suggest that there was a huge risk [for antimicrobial resistance].”
Moreover, doxycycline is teratogenic, and its use is contraindicated in pregnancy, said Goodridge. If a pregnant patient is being treated for syphilis, then penicillin is the treatment of choice. For pregnant patients with penicillin allergy, Public Health Agency of Canada guidelines call for penicillin desensitization followed by penicillin.
The rate of syphilis has been rising in Canadian women of reproductive age, thus increasing the potential for congenital syphilis, noted Goodridge.
Benefits of HPV Vaccine
The 9-valent HPV vaccine is recommended in Canada for patients aged 9-26 years, but those aged 27 years or older at ongoing risk for HPV exposure may receive the 9-valent HPV vaccine after discussion with their healthcare providers, noted Owen.
High-risk patients can benefit from the vaccine even though they have likely had exposure to HPV, he added. “If someone has multiple sexual partners, they have probably been exposed to HPV at some point,” said Owen. “You still could reduce a patient’s risk for being exposed to certain oncogenic strains [of HPV]. Certainly, within our practices, we’re often giving it [that is, the HPV vaccine] to higher-risk individuals, including men having sex with men.”
HIV Prevention
“Condoms are still a mainstay of HIV and STI prevention, but condom use is going down,” said Owen.
In a national survey commissioned by the Toronto-based organization LetsStopAIDS and including more than 1100 Canadians aged 18-24 years, 24% of respondents said they use condoms “all the time.” In 2020, by contrast, more than half (53%) of respondents reported that they use condoms all the time.
Updated Canadian guidelines on the use of HIV pre-exposure prophylaxis (PrEP) are expected to be released in 2025 and will address questions about how frequently individuals taking HIV PrEP should be tested to ensure a negative HIV result. The guidelines will also provide guidance as to whether HIV serology or HIV viral load should be captured, said Owen. Patients in Canada who take HIV PrEP are now generally screened for HIV every 3 months.
A new HIV PrEP tool that has become available to Canadian clinicians is the injectable drug cabotegravir, which is dosed every 2 months.
Owen and Goodridge reported having no relevant financial relationships.
A version of this article appeared on Medscape.com.
VANCOUVER, BRITISH COLUMBIA — Family physicians should familiarize themselves with doxycycline post-exposure prophylaxis (doxy PEP) as a prescription for patients who frequently have unprotected sex (including oral, anal, and vaginal) with multiple partners, according to a presentation at the Family Medicine Forum (FMF) 2024. Doxy PEP decreases the risk for bacterial sexually transmitted infections (STIs).
Many family physicians may be unaware of doxy PEP as a means of avoiding STIs. “Doxy PEP is an incredible tool that can be used within 72 hours of unprotected sex to reduce bacterial STI risk,” said James Owen, MD, assistant professor of family and community medicine at the University of Toronto in Ontario, Canada.
The US Centers for Disease Control and Prevention point to data from three randomized, controlled trials that demonstrate the ability of doxy PEP to decrease syphilis and chlamydia infections by more than 70% and decrease gonococcal infections by about 50%, said Jordan Goodridge, MD, assistant professor of family and community medicine at the University of Toronto.
Optimizing Doxy PEP
Doxy PEP (200 mg) is most effective when administered in the first 24 hours after unprotected sex, explained Goodridge. It is recommended that patients repeat the 200-mg dose if they are sexually active again within 24 hours.
To ensure optimal absorption of doxy PEP, the drug should not be taken with antacids or multivitamins, said Goodridge. Antacids “can bind to doxycycline and prevent it from being absorbed,” he said.
A key concern about doxy PEP is the development of antimicrobial resistance, noted Goodridge. “We don’t have long-term studies to give us an idea about what this risk is, to quantify it. The studies we have are relatively short, generally less than a year, and didn’t suggest that there was a huge risk [for antimicrobial resistance].”
Moreover, doxycycline is teratogenic, and its use is contraindicated in pregnancy, said Goodridge. If a pregnant patient is being treated for syphilis, then penicillin is the treatment of choice. For pregnant patients with penicillin allergy, Public Health Agency of Canada guidelines call for penicillin desensitization followed by penicillin.
The rate of syphilis has been rising in Canadian women of reproductive age, thus increasing the potential for congenital syphilis, noted Goodridge.
Benefits of HPV Vaccine
The 9-valent HPV vaccine is recommended in Canada for patients aged 9-26 years, but those aged 27 years or older at ongoing risk for HPV exposure may receive the 9-valent HPV vaccine after discussion with their healthcare providers, noted Owen.
High-risk patients can benefit from the vaccine even though they have likely had exposure to HPV, he added. “If someone has multiple sexual partners, they have probably been exposed to HPV at some point,” said Owen. “You still could reduce a patient’s risk for being exposed to certain oncogenic strains [of HPV]. Certainly, within our practices, we’re often giving it [that is, the HPV vaccine] to higher-risk individuals, including men having sex with men.”
HIV Prevention
“Condoms are still a mainstay of HIV and STI prevention, but condom use is going down,” said Owen.
In a national survey commissioned by the Toronto-based organization LetsStopAIDS and including more than 1100 Canadians aged 18-24 years, 24% of respondents said they use condoms “all the time.” In 2020, by contrast, more than half (53%) of respondents reported that they use condoms all the time.
Updated Canadian guidelines on the use of HIV pre-exposure prophylaxis (PrEP) are expected to be released in 2025 and will address questions about how frequently individuals taking HIV PrEP should be tested to ensure a negative HIV result. The guidelines will also provide guidance as to whether HIV serology or HIV viral load should be captured, said Owen. Patients in Canada who take HIV PrEP are now generally screened for HIV every 3 months.
A new HIV PrEP tool that has become available to Canadian clinicians is the injectable drug cabotegravir, which is dosed every 2 months.
Owen and Goodridge reported having no relevant financial relationships.
A version of this article appeared on Medscape.com.
VANCOUVER, BRITISH COLUMBIA — Family physicians should familiarize themselves with doxycycline post-exposure prophylaxis (doxy PEP) as a prescription for patients who frequently have unprotected sex (including oral, anal, and vaginal) with multiple partners, according to a presentation at the Family Medicine Forum (FMF) 2024. Doxy PEP decreases the risk for bacterial sexually transmitted infections (STIs).
Many family physicians may be unaware of doxy PEP as a means of avoiding STIs. “Doxy PEP is an incredible tool that can be used within 72 hours of unprotected sex to reduce bacterial STI risk,” said James Owen, MD, assistant professor of family and community medicine at the University of Toronto in Ontario, Canada.
The US Centers for Disease Control and Prevention point to data from three randomized, controlled trials that demonstrate the ability of doxy PEP to decrease syphilis and chlamydia infections by more than 70% and decrease gonococcal infections by about 50%, said Jordan Goodridge, MD, assistant professor of family and community medicine at the University of Toronto.
Optimizing Doxy PEP
Doxy PEP (200 mg) is most effective when administered in the first 24 hours after unprotected sex, explained Goodridge. It is recommended that patients repeat the 200-mg dose if they are sexually active again within 24 hours.
To ensure optimal absorption of doxy PEP, the drug should not be taken with antacids or multivitamins, said Goodridge. Antacids “can bind to doxycycline and prevent it from being absorbed,” he said.
A key concern about doxy PEP is the development of antimicrobial resistance, noted Goodridge. “We don’t have long-term studies to give us an idea about what this risk is, to quantify it. The studies we have are relatively short, generally less than a year, and didn’t suggest that there was a huge risk [for antimicrobial resistance].”
Moreover, doxycycline is teratogenic, and its use is contraindicated in pregnancy, said Goodridge. If a pregnant patient is being treated for syphilis, then penicillin is the treatment of choice. For pregnant patients with penicillin allergy, Public Health Agency of Canada guidelines call for penicillin desensitization followed by penicillin.
The rate of syphilis has been rising in Canadian women of reproductive age, thus increasing the potential for congenital syphilis, noted Goodridge.
Benefits of HPV Vaccine
The 9-valent HPV vaccine is recommended in Canada for patients aged 9-26 years, but those aged 27 years or older at ongoing risk for HPV exposure may receive the 9-valent HPV vaccine after discussion with their healthcare providers, noted Owen.
High-risk patients can benefit from the vaccine even though they have likely had exposure to HPV, he added. “If someone has multiple sexual partners, they have probably been exposed to HPV at some point,” said Owen. “You still could reduce a patient’s risk for being exposed to certain oncogenic strains [of HPV]. Certainly, within our practices, we’re often giving it [that is, the HPV vaccine] to higher-risk individuals, including men having sex with men.”
HIV Prevention
“Condoms are still a mainstay of HIV and STI prevention, but condom use is going down,” said Owen.
In a national survey commissioned by the Toronto-based organization LetsStopAIDS and including more than 1100 Canadians aged 18-24 years, 24% of respondents said they use condoms “all the time.” In 2020, by contrast, more than half (53%) of respondents reported that they use condoms all the time.
Updated Canadian guidelines on the use of HIV pre-exposure prophylaxis (PrEP) are expected to be released in 2025 and will address questions about how frequently individuals taking HIV PrEP should be tested to ensure a negative HIV result. The guidelines will also provide guidance as to whether HIV serology or HIV viral load should be captured, said Owen. Patients in Canada who take HIV PrEP are now generally screened for HIV every 3 months.
A new HIV PrEP tool that has become available to Canadian clinicians is the injectable drug cabotegravir, which is dosed every 2 months.
Owen and Goodridge reported having no relevant financial relationships.
A version of this article appeared on Medscape.com.
FROM FMF 2024
Deprescribe Low-Value Meds to Reduce Polypharmacy Harms
VANCOUVER, BRITISH COLUMBIA — While polypharmacy is inevitable for patients with multiple chronic diseases, not all medications improve patient-oriented outcomes, members of the Patients, Experience, Evidence, Research (PEER) team, a group of Canadian primary care professionals who develop evidence-based guidelines, told attendees at the Family Medicine Forum (FMF) 2024.
In a thought-provoking presentation called “Axe the Rx: Deprescribing Chronic Medications with PEER,” the panelists gave examples of medications that may be safely stopped or tapered, particularly for older adults “whose pill bag is heavier than their lunch bag.”
Curbing Cardiovascular Drugs
The 2021 Canadian Cardiovascular Society Guidelines for the Management of Dyslipidemia for the Prevention of Cardiovascular Disease in Adults call for reaching an LDL-C < 1.8 mmol/L in secondary cardiovascular prevention by potentially adding on medical therapies such as proprotein convertase subtilisin/kexin type 9 inhibitors or ezetimibe or both if that target is not reached with the maximal dosage of a statin.
But family physicians do not need to follow this guidance for their patients who have had a myocardial infarction, said Ontario family physician Jennifer Young, MD, a physician advisor in the Canadian College of Family Physicians’ Knowledge Experts and Tools Program.
Treating to below 1.8 mmol/L “means lab testing for the patients,” Young told this news organization. “It means increasing doses [of a statin] to try and get to that level.” If the patient is already on the highest dose of a statin, it means adding other medications that lower cholesterol.
“If that was translating into better outcomes like [preventing] death and another heart attack, then all of that extra effort would be worth it,” said Young. “But we don’t have evidence that it actually does have a benefit for outcomes like death and repeated heart attacks,” compared with putting them on a high dose of a potent statin.
Tapering Opioids
Before placing patients on an opioid taper, clinicians should first assess them for opioid use disorder (OUD), said Jessica Kirkwood, MD, assistant professor of family medicine at the University of Alberta in Edmonton, Canada. She suggested using the Prescription Opioid Misuse Index questionnaire to do so.
Clinicians should be much more careful in initiating a taper with patients with OUD, said Kirkwood. They must ensure that these patients are motivated to discontinue their opioids. “We’re losing 21 Canadians a day to the opioid crisis. We all know that cutting someone off their opioids and potentially having them seek opioids elsewhere through illicit means can be fatal.”
In addition, clinicians should spend more time counseling patients with OUD than those without, Kirkwood continued. They must explain to these patients how they are being tapered (eg, the intervals and doses) and highlight the benefits of a taper, such as reduced constipation. Opioid agonist therapy (such as methadone or buprenorphine) can be considered in these patients.
Some research has pointed to the importance of patient motivation as a factor in the success of opioid tapers, noted Kirkwood.
Deprescribing Benzodiazepines
Benzodiazepine receptor agonists, too, often can be deprescribed. These drugs should not be prescribed to promote sleep on a long-term basis. Yet clinicians commonly encounter patients who have been taking them for more than a year, said pharmacist Betsy Thomas, assistant adjunct professor of family medicine at the University of Alberta.
The medications “are usually fairly effective for the first couple of weeks to about a month, and then the benefits start to decrease, and we start to see more harms,” she said.
Some of the harms that have been associated with continued use of benzodiazepine receptor agonists include delayed reaction time and impaired cognition, which can affect the ability to drive, the risk for falls, and the risk for hip fractures, she noted. Some research suggests that these drugs are not an option for treating insomnia in patients aged 65 years or older.
Clinicians should encourage tapering the use of benzodiazepine receptor agonists to minimize dependence and transition patients to nonpharmacologic approaches such as cognitive behavioral therapy to manage insomnia, she said. A recent study demonstrated the efficacy of the intervention, and Thomas suggested that family physicians visit the mysleepwell.ca website for more information.
Young, Kirkwood, and Thomas reported no relevant financial relationships.
A version of this article first appeared on Medscape.com.
VANCOUVER, BRITISH COLUMBIA — While polypharmacy is inevitable for patients with multiple chronic diseases, not all medications improve patient-oriented outcomes, members of the Patients, Experience, Evidence, Research (PEER) team, a group of Canadian primary care professionals who develop evidence-based guidelines, told attendees at the Family Medicine Forum (FMF) 2024.
In a thought-provoking presentation called “Axe the Rx: Deprescribing Chronic Medications with PEER,” the panelists gave examples of medications that may be safely stopped or tapered, particularly for older adults “whose pill bag is heavier than their lunch bag.”
Curbing Cardiovascular Drugs
The 2021 Canadian Cardiovascular Society Guidelines for the Management of Dyslipidemia for the Prevention of Cardiovascular Disease in Adults call for reaching an LDL-C < 1.8 mmol/L in secondary cardiovascular prevention by potentially adding on medical therapies such as proprotein convertase subtilisin/kexin type 9 inhibitors or ezetimibe or both if that target is not reached with the maximal dosage of a statin.
But family physicians do not need to follow this guidance for their patients who have had a myocardial infarction, said Ontario family physician Jennifer Young, MD, a physician advisor in the Canadian College of Family Physicians’ Knowledge Experts and Tools Program.
Treating to below 1.8 mmol/L “means lab testing for the patients,” Young told this news organization. “It means increasing doses [of a statin] to try and get to that level.” If the patient is already on the highest dose of a statin, it means adding other medications that lower cholesterol.
“If that was translating into better outcomes like [preventing] death and another heart attack, then all of that extra effort would be worth it,” said Young. “But we don’t have evidence that it actually does have a benefit for outcomes like death and repeated heart attacks,” compared with putting them on a high dose of a potent statin.
Tapering Opioids
Before placing patients on an opioid taper, clinicians should first assess them for opioid use disorder (OUD), said Jessica Kirkwood, MD, assistant professor of family medicine at the University of Alberta in Edmonton, Canada. She suggested using the Prescription Opioid Misuse Index questionnaire to do so.
Clinicians should be much more careful in initiating a taper with patients with OUD, said Kirkwood. They must ensure that these patients are motivated to discontinue their opioids. “We’re losing 21 Canadians a day to the opioid crisis. We all know that cutting someone off their opioids and potentially having them seek opioids elsewhere through illicit means can be fatal.”
In addition, clinicians should spend more time counseling patients with OUD than those without, Kirkwood continued. They must explain to these patients how they are being tapered (eg, the intervals and doses) and highlight the benefits of a taper, such as reduced constipation. Opioid agonist therapy (such as methadone or buprenorphine) can be considered in these patients.
Some research has pointed to the importance of patient motivation as a factor in the success of opioid tapers, noted Kirkwood.
Deprescribing Benzodiazepines
Benzodiazepine receptor agonists, too, often can be deprescribed. These drugs should not be prescribed to promote sleep on a long-term basis. Yet clinicians commonly encounter patients who have been taking them for more than a year, said pharmacist Betsy Thomas, assistant adjunct professor of family medicine at the University of Alberta.
The medications “are usually fairly effective for the first couple of weeks to about a month, and then the benefits start to decrease, and we start to see more harms,” she said.
Some of the harms that have been associated with continued use of benzodiazepine receptor agonists include delayed reaction time and impaired cognition, which can affect the ability to drive, the risk for falls, and the risk for hip fractures, she noted. Some research suggests that these drugs are not an option for treating insomnia in patients aged 65 years or older.
Clinicians should encourage tapering the use of benzodiazepine receptor agonists to minimize dependence and transition patients to nonpharmacologic approaches such as cognitive behavioral therapy to manage insomnia, she said. A recent study demonstrated the efficacy of the intervention, and Thomas suggested that family physicians visit the mysleepwell.ca website for more information.
Young, Kirkwood, and Thomas reported no relevant financial relationships.
A version of this article first appeared on Medscape.com.
VANCOUVER, BRITISH COLUMBIA — While polypharmacy is inevitable for patients with multiple chronic diseases, not all medications improve patient-oriented outcomes, members of the Patients, Experience, Evidence, Research (PEER) team, a group of Canadian primary care professionals who develop evidence-based guidelines, told attendees at the Family Medicine Forum (FMF) 2024.
In a thought-provoking presentation called “Axe the Rx: Deprescribing Chronic Medications with PEER,” the panelists gave examples of medications that may be safely stopped or tapered, particularly for older adults “whose pill bag is heavier than their lunch bag.”
Curbing Cardiovascular Drugs
The 2021 Canadian Cardiovascular Society Guidelines for the Management of Dyslipidemia for the Prevention of Cardiovascular Disease in Adults call for reaching an LDL-C < 1.8 mmol/L in secondary cardiovascular prevention by potentially adding on medical therapies such as proprotein convertase subtilisin/kexin type 9 inhibitors or ezetimibe or both if that target is not reached with the maximal dosage of a statin.
But family physicians do not need to follow this guidance for their patients who have had a myocardial infarction, said Ontario family physician Jennifer Young, MD, a physician advisor in the Canadian College of Family Physicians’ Knowledge Experts and Tools Program.
Treating to below 1.8 mmol/L “means lab testing for the patients,” Young told this news organization. “It means increasing doses [of a statin] to try and get to that level.” If the patient is already on the highest dose of a statin, it means adding other medications that lower cholesterol.
“If that was translating into better outcomes like [preventing] death and another heart attack, then all of that extra effort would be worth it,” said Young. “But we don’t have evidence that it actually does have a benefit for outcomes like death and repeated heart attacks,” compared with putting them on a high dose of a potent statin.
Tapering Opioids
Before placing patients on an opioid taper, clinicians should first assess them for opioid use disorder (OUD), said Jessica Kirkwood, MD, assistant professor of family medicine at the University of Alberta in Edmonton, Canada. She suggested using the Prescription Opioid Misuse Index questionnaire to do so.
Clinicians should be much more careful in initiating a taper with patients with OUD, said Kirkwood. They must ensure that these patients are motivated to discontinue their opioids. “We’re losing 21 Canadians a day to the opioid crisis. We all know that cutting someone off their opioids and potentially having them seek opioids elsewhere through illicit means can be fatal.”
In addition, clinicians should spend more time counseling patients with OUD than those without, Kirkwood continued. They must explain to these patients how they are being tapered (eg, the intervals and doses) and highlight the benefits of a taper, such as reduced constipation. Opioid agonist therapy (such as methadone or buprenorphine) can be considered in these patients.
Some research has pointed to the importance of patient motivation as a factor in the success of opioid tapers, noted Kirkwood.
Deprescribing Benzodiazepines
Benzodiazepine receptor agonists, too, often can be deprescribed. These drugs should not be prescribed to promote sleep on a long-term basis. Yet clinicians commonly encounter patients who have been taking them for more than a year, said pharmacist Betsy Thomas, assistant adjunct professor of family medicine at the University of Alberta.
The medications “are usually fairly effective for the first couple of weeks to about a month, and then the benefits start to decrease, and we start to see more harms,” she said.
Some of the harms that have been associated with continued use of benzodiazepine receptor agonists include delayed reaction time and impaired cognition, which can affect the ability to drive, the risk for falls, and the risk for hip fractures, she noted. Some research suggests that these drugs are not an option for treating insomnia in patients aged 65 years or older.
Clinicians should encourage tapering the use of benzodiazepine receptor agonists to minimize dependence and transition patients to nonpharmacologic approaches such as cognitive behavioral therapy to manage insomnia, she said. A recent study demonstrated the efficacy of the intervention, and Thomas suggested that family physicians visit the mysleepwell.ca website for more information.
Young, Kirkwood, and Thomas reported no relevant financial relationships.
A version of this article first appeared on Medscape.com.
FROM FMF 2024
Managing Diabetes and Dementia in Long-Term Care
VANCOUVER, BRITISH COLUMBIA — Conditions like diabetes and dementia are common in patients who are admitted to long-term care facilities, but aggressive management of these conditions in long-term care residents is not recommended, according to a presentation given at the Family Medicine Forum (FMF) 2024.
Hospitalizations for hypoglycemia are risky for patients with diabetes who are residents of long-term care facilities, particularly those aged 75 years or older, said Adam Gurau, MD, a family physician in Toronto. Gurau completed a fellowship in care of the elderly at the University of Toronto, in Ontario, Canada.
“A lot of studies have shown diabetes-related hospitalizations,” said Gurau. He cited a 2014 study that found that hypoglycemia hospitalization rates were twice as high in older patients (age, 75 years or older) as in younger patients (age, 65-74 years).
“It is important to keep in mind that our residents in long-term care are at increasing risk for hypoglycemia, and we really should try to reduce [this risk] and not use dangerous medications or potentially dangerous [means of] diabetes management,” said Gurau.
A Canadian study that examined the composite risk for emergency department visits, hospitalizations, or death within 30 days of reaching intensive glycemic control with high-risk agents (such as insulin or sulfonylureas) suggested little benefit and possible harm in using these agents in adults aged 75 years or older.
In addition, current guidelines on diabetes management encourage a different approach. “Looking at some of the more recent North American guidelines, many of them actually now recommend relaxing glycemic targets to reduce overtreatment and prevent hypoglycemia,” said Gurau.
Deprescribing Medications
Medication reviews present opportunities for taking a global view of a patient’s treatments and determining whether any drug can be removed from the list. “What we want to do is optimize medications,” said Gurau. “We’re not talking about adding medications. We’re talking about removing medications, which is, I think, what we should be doing.”
Some research suggests that patients are open to deprescribing. One survey examined older adults (mean age, 79.1 years) with three or more chronic conditions who had been prescribed at least five medications. The researchers found that most participants (77%) were willing to deprescribe one or more medicines if a doctor advised that it was possible. “General practitioners may be able to increase deprescribing by building trust with their patients and communicating evidence about the risks of medication use,” the researchers wrote.
About 62% of seniors living in a residential care home have a diagnosis of Alzheimer’s disease or another dementia, according to the Alzheimer Society of Canada. Evidence suggests that nonpharmacologic approaches, such as massage and touch therapy and music, can manage neuropsychiatric symptoms, such as aggression and agitation, that are associated with dementia in older adults, noted Gurau.
“We want to focus on nonpharmacologic approaches for many of these [long-term care] residents,” said Gurau. “We have to do as much as we can to exhaust all the nonpharmacologic approaches.”
Preventing Hospitalizations
Another challenge to tackle in long-term care is the unnecessary transfer of residents to hospital emergency departments, according to Gurau. “In many situations, it’s worth trying as hard as we can to treat them in the nursing home, as opposed to having them go to hospital.”
Researchers estimated that 25% of the transfers from long-term care facilities in Canada to hospital emergency departments in 2014 were potentially preventable.
Urinary tract infections accounted for 30% of hospital emergency department visits for potentially preventable conditions by older patients who are residents in long-term care, according to 2013-2014 data from the Canadian Institute for Health Information.
“There are lots of downsides to going to the hospital [from long-term care],” Gurau told this news organization. “There are risks for infections, risks for increasing delirium and agitation [in patients with dementia], and risks for other behavior that can really impact somebody’s life.”
Gurau reported having no relevant financial relationships.
A version of this article first appeared on Medscape.com.
VANCOUVER, BRITISH COLUMBIA — Conditions like diabetes and dementia are common in patients who are admitted to long-term care facilities, but aggressive management of these conditions in long-term care residents is not recommended, according to a presentation given at the Family Medicine Forum (FMF) 2024.
Hospitalizations for hypoglycemia are risky for patients with diabetes who are residents of long-term care facilities, particularly those aged 75 years or older, said Adam Gurau, MD, a family physician in Toronto. Gurau completed a fellowship in care of the elderly at the University of Toronto, in Ontario, Canada.
“A lot of studies have shown diabetes-related hospitalizations,” said Gurau. He cited a 2014 study that found that hypoglycemia hospitalization rates were twice as high in older patients (age, 75 years or older) as in younger patients (age, 65-74 years).
“It is important to keep in mind that our residents in long-term care are at increasing risk for hypoglycemia, and we really should try to reduce [this risk] and not use dangerous medications or potentially dangerous [means of] diabetes management,” said Gurau.
A Canadian study that examined the composite risk for emergency department visits, hospitalizations, or death within 30 days of reaching intensive glycemic control with high-risk agents (such as insulin or sulfonylureas) suggested little benefit and possible harm in using these agents in adults aged 75 years or older.
In addition, current guidelines on diabetes management encourage a different approach. “Looking at some of the more recent North American guidelines, many of them actually now recommend relaxing glycemic targets to reduce overtreatment and prevent hypoglycemia,” said Gurau.
Deprescribing Medications
Medication reviews present opportunities for taking a global view of a patient’s treatments and determining whether any drug can be removed from the list. “What we want to do is optimize medications,” said Gurau. “We’re not talking about adding medications. We’re talking about removing medications, which is, I think, what we should be doing.”
Some research suggests that patients are open to deprescribing. One survey examined older adults (mean age, 79.1 years) with three or more chronic conditions who had been prescribed at least five medications. The researchers found that most participants (77%) were willing to deprescribe one or more medicines if a doctor advised that it was possible. “General practitioners may be able to increase deprescribing by building trust with their patients and communicating evidence about the risks of medication use,” the researchers wrote.
About 62% of seniors living in a residential care home have a diagnosis of Alzheimer’s disease or another dementia, according to the Alzheimer Society of Canada. Evidence suggests that nonpharmacologic approaches, such as massage and touch therapy and music, can manage neuropsychiatric symptoms, such as aggression and agitation, that are associated with dementia in older adults, noted Gurau.
“We want to focus on nonpharmacologic approaches for many of these [long-term care] residents,” said Gurau. “We have to do as much as we can to exhaust all the nonpharmacologic approaches.”
Preventing Hospitalizations
Another challenge to tackle in long-term care is the unnecessary transfer of residents to hospital emergency departments, according to Gurau. “In many situations, it’s worth trying as hard as we can to treat them in the nursing home, as opposed to having them go to hospital.”
Researchers estimated that 25% of the transfers from long-term care facilities in Canada to hospital emergency departments in 2014 were potentially preventable.
Urinary tract infections accounted for 30% of hospital emergency department visits for potentially preventable conditions by older patients who are residents in long-term care, according to 2013-2014 data from the Canadian Institute for Health Information.
“There are lots of downsides to going to the hospital [from long-term care],” Gurau told this news organization. “There are risks for infections, risks for increasing delirium and agitation [in patients with dementia], and risks for other behavior that can really impact somebody’s life.”
Gurau reported having no relevant financial relationships.
A version of this article first appeared on Medscape.com.
VANCOUVER, BRITISH COLUMBIA — Conditions like diabetes and dementia are common in patients who are admitted to long-term care facilities, but aggressive management of these conditions in long-term care residents is not recommended, according to a presentation given at the Family Medicine Forum (FMF) 2024.
Hospitalizations for hypoglycemia are risky for patients with diabetes who are residents of long-term care facilities, particularly those aged 75 years or older, said Adam Gurau, MD, a family physician in Toronto. Gurau completed a fellowship in care of the elderly at the University of Toronto, in Ontario, Canada.
“A lot of studies have shown diabetes-related hospitalizations,” said Gurau. He cited a 2014 study that found that hypoglycemia hospitalization rates were twice as high in older patients (age, 75 years or older) as in younger patients (age, 65-74 years).
“It is important to keep in mind that our residents in long-term care are at increasing risk for hypoglycemia, and we really should try to reduce [this risk] and not use dangerous medications or potentially dangerous [means of] diabetes management,” said Gurau.
A Canadian study that examined the composite risk for emergency department visits, hospitalizations, or death within 30 days of reaching intensive glycemic control with high-risk agents (such as insulin or sulfonylureas) suggested little benefit and possible harm in using these agents in adults aged 75 years or older.
In addition, current guidelines on diabetes management encourage a different approach. “Looking at some of the more recent North American guidelines, many of them actually now recommend relaxing glycemic targets to reduce overtreatment and prevent hypoglycemia,” said Gurau.
Deprescribing Medications
Medication reviews present opportunities for taking a global view of a patient’s treatments and determining whether any drug can be removed from the list. “What we want to do is optimize medications,” said Gurau. “We’re not talking about adding medications. We’re talking about removing medications, which is, I think, what we should be doing.”
Some research suggests that patients are open to deprescribing. One survey examined older adults (mean age, 79.1 years) with three or more chronic conditions who had been prescribed at least five medications. The researchers found that most participants (77%) were willing to deprescribe one or more medicines if a doctor advised that it was possible. “General practitioners may be able to increase deprescribing by building trust with their patients and communicating evidence about the risks of medication use,” the researchers wrote.
About 62% of seniors living in a residential care home have a diagnosis of Alzheimer’s disease or another dementia, according to the Alzheimer Society of Canada. Evidence suggests that nonpharmacologic approaches, such as massage and touch therapy and music, can manage neuropsychiatric symptoms, such as aggression and agitation, that are associated with dementia in older adults, noted Gurau.
“We want to focus on nonpharmacologic approaches for many of these [long-term care] residents,” said Gurau. “We have to do as much as we can to exhaust all the nonpharmacologic approaches.”
Preventing Hospitalizations
Another challenge to tackle in long-term care is the unnecessary transfer of residents to hospital emergency departments, according to Gurau. “In many situations, it’s worth trying as hard as we can to treat them in the nursing home, as opposed to having them go to hospital.”
Researchers estimated that 25% of the transfers from long-term care facilities in Canada to hospital emergency departments in 2014 were potentially preventable.
Urinary tract infections accounted for 30% of hospital emergency department visits for potentially preventable conditions by older patients who are residents in long-term care, according to 2013-2014 data from the Canadian Institute for Health Information.
“There are lots of downsides to going to the hospital [from long-term care],” Gurau told this news organization. “There are risks for infections, risks for increasing delirium and agitation [in patients with dementia], and risks for other behavior that can really impact somebody’s life.”
Gurau reported having no relevant financial relationships.
A version of this article first appeared on Medscape.com.
FROM FMF 2024
What Is the Clinical Course of Low Back Pain?
Patients with back pain that has persisted for less than 12 weeks have a high probability of substantial pain reduction over time, but patients with back pain that has persisted for 12 or more weeks have a lower chance of improvement, new data suggest.
Patients with persistent pain (ie, pain lasting for more than 12 weeks but less than 52 weeks) had smaller improvements at 52 weeks, however.
“The outcomes for acute pain are better than we thought they were,” study author Lorimer Moseley, AO, DSc, PhD, professor of clinical neurosciences and chair of physiotherapy at the University of South Australia in Adelaide, told this news organization.
The study was published in the Canadian Medical Association Journal.
Good Prognoses
The current analysis represents an update to and advance on a 2012 systematic review and meta-analysis, said Moseley. That study found that patients with subacute low back pain and those with persistent low back pain had similar decreases in pain over 6 weeks. The previous analysis “may have resulted in improved outcomes in the persistent group,” the investigators wrote in the current analysis.
For the current study, the researchers examined 95 studies to understand the clinical course of acute, subacute (ie, lasting for 6 to less than 12 weeks), and persistent low back pain. They excluded retrospective cohorts and interventional studies, as well as studies of patients with low back pain for more than 12 months. The researchers also conducted meta-analyses on aggregate data, where possible, using pain and disability outcome data.
In patients with acute pain, the mean pain score improved from 56 at baseline to 26 at 6 weeks and 21 at 52 weeks. Patients with subacute pain had a mean pain score of 63 at baseline that improved to 29 at 6 weeks and was maintained at 31 at 52 weeks. Patients with persistent pain had a mean pain score of 56 at baseline that improved to 48 at six weeks and 40 at 52 weeks.
“I don’t think we need to do any more studies to clarify recovery from acute back pain,” said Dr. Moseley. “For subacute back pain, I think there is a moderate to high level of certainty, so the prognosis is pretty good there. The bad news is that the data suggest that if someone’s got back pain 3 months after onset, the likelihood of recovery is much less, but those data are the ones we can’t be certain of on the basis of this meta-analysis.”
Dr. Moseley noted that the current analysis is not highly detailed, because individual patient data are absent. This is “the biggest limitation from a methodological perspective,” he said. “Individual patient analysis is a lot more powerful.”
Comprehensive Literature Search
Commenting on the findings for this news organization, David Borenstein, MD, clinical professor of rheumatology at the George Washington University Medical Center and partner at Arthritis and Rheumatism Associates in Washington, DC, described the literature search as comprehensive. Dr. Borenstein did not participate in the study. The assessment of low back pain as either short-lived or lasting is worth investigating, he added, given that low back pain impairs a patient’s function and carries a hefty price tag at a societal level.
The study results suggest “that people with acute low back pain do pretty well, and people with subacute low back pain will do less well but still have a chance of healing,” said Dr. Borenstein. “People who have chronic low back pain do not do as well, and they have some increase in disability.” It would be important to develop ways to identify patients whose low back pain will persist beyond 3 months, as well as ways to identify the criteria or characteristics that might prevent those patients from having prolonged difficulties and persistent low back pain, he added.
Dr. Borenstein noted that the authors failed to mention specific approaches that could decrease progression from subacute to persistent low back pain. “They really don’t point anyone in a direction to what would make a difference,” he said. “It would have really improved the impact of the paper if they had seen anything along the way in their review of these articles that might have suggested how someone or a group might have been able to impact this progression.”
The study was funded by supported by a National Health and Medical Research Council Leadership Investigator Grant to Dr. Moseley. Dr. Moseley and Dr. Borenstein reported no relevant disclosures.
A version of this article appeared on Medscape.com.
Patients with back pain that has persisted for less than 12 weeks have a high probability of substantial pain reduction over time, but patients with back pain that has persisted for 12 or more weeks have a lower chance of improvement, new data suggest.
Patients with persistent pain (ie, pain lasting for more than 12 weeks but less than 52 weeks) had smaller improvements at 52 weeks, however.
“The outcomes for acute pain are better than we thought they were,” study author Lorimer Moseley, AO, DSc, PhD, professor of clinical neurosciences and chair of physiotherapy at the University of South Australia in Adelaide, told this news organization.
The study was published in the Canadian Medical Association Journal.
Good Prognoses
The current analysis represents an update to and advance on a 2012 systematic review and meta-analysis, said Moseley. That study found that patients with subacute low back pain and those with persistent low back pain had similar decreases in pain over 6 weeks. The previous analysis “may have resulted in improved outcomes in the persistent group,” the investigators wrote in the current analysis.
For the current study, the researchers examined 95 studies to understand the clinical course of acute, subacute (ie, lasting for 6 to less than 12 weeks), and persistent low back pain. They excluded retrospective cohorts and interventional studies, as well as studies of patients with low back pain for more than 12 months. The researchers also conducted meta-analyses on aggregate data, where possible, using pain and disability outcome data.
In patients with acute pain, the mean pain score improved from 56 at baseline to 26 at 6 weeks and 21 at 52 weeks. Patients with subacute pain had a mean pain score of 63 at baseline that improved to 29 at 6 weeks and was maintained at 31 at 52 weeks. Patients with persistent pain had a mean pain score of 56 at baseline that improved to 48 at six weeks and 40 at 52 weeks.
“I don’t think we need to do any more studies to clarify recovery from acute back pain,” said Dr. Moseley. “For subacute back pain, I think there is a moderate to high level of certainty, so the prognosis is pretty good there. The bad news is that the data suggest that if someone’s got back pain 3 months after onset, the likelihood of recovery is much less, but those data are the ones we can’t be certain of on the basis of this meta-analysis.”
Dr. Moseley noted that the current analysis is not highly detailed, because individual patient data are absent. This is “the biggest limitation from a methodological perspective,” he said. “Individual patient analysis is a lot more powerful.”
Comprehensive Literature Search
Commenting on the findings for this news organization, David Borenstein, MD, clinical professor of rheumatology at the George Washington University Medical Center and partner at Arthritis and Rheumatism Associates in Washington, DC, described the literature search as comprehensive. Dr. Borenstein did not participate in the study. The assessment of low back pain as either short-lived or lasting is worth investigating, he added, given that low back pain impairs a patient’s function and carries a hefty price tag at a societal level.
The study results suggest “that people with acute low back pain do pretty well, and people with subacute low back pain will do less well but still have a chance of healing,” said Dr. Borenstein. “People who have chronic low back pain do not do as well, and they have some increase in disability.” It would be important to develop ways to identify patients whose low back pain will persist beyond 3 months, as well as ways to identify the criteria or characteristics that might prevent those patients from having prolonged difficulties and persistent low back pain, he added.
Dr. Borenstein noted that the authors failed to mention specific approaches that could decrease progression from subacute to persistent low back pain. “They really don’t point anyone in a direction to what would make a difference,” he said. “It would have really improved the impact of the paper if they had seen anything along the way in their review of these articles that might have suggested how someone or a group might have been able to impact this progression.”
The study was funded by supported by a National Health and Medical Research Council Leadership Investigator Grant to Dr. Moseley. Dr. Moseley and Dr. Borenstein reported no relevant disclosures.
A version of this article appeared on Medscape.com.
Patients with back pain that has persisted for less than 12 weeks have a high probability of substantial pain reduction over time, but patients with back pain that has persisted for 12 or more weeks have a lower chance of improvement, new data suggest.
Patients with persistent pain (ie, pain lasting for more than 12 weeks but less than 52 weeks) had smaller improvements at 52 weeks, however.
“The outcomes for acute pain are better than we thought they were,” study author Lorimer Moseley, AO, DSc, PhD, professor of clinical neurosciences and chair of physiotherapy at the University of South Australia in Adelaide, told this news organization.
The study was published in the Canadian Medical Association Journal.
Good Prognoses
The current analysis represents an update to and advance on a 2012 systematic review and meta-analysis, said Moseley. That study found that patients with subacute low back pain and those with persistent low back pain had similar decreases in pain over 6 weeks. The previous analysis “may have resulted in improved outcomes in the persistent group,” the investigators wrote in the current analysis.
For the current study, the researchers examined 95 studies to understand the clinical course of acute, subacute (ie, lasting for 6 to less than 12 weeks), and persistent low back pain. They excluded retrospective cohorts and interventional studies, as well as studies of patients with low back pain for more than 12 months. The researchers also conducted meta-analyses on aggregate data, where possible, using pain and disability outcome data.
In patients with acute pain, the mean pain score improved from 56 at baseline to 26 at 6 weeks and 21 at 52 weeks. Patients with subacute pain had a mean pain score of 63 at baseline that improved to 29 at 6 weeks and was maintained at 31 at 52 weeks. Patients with persistent pain had a mean pain score of 56 at baseline that improved to 48 at six weeks and 40 at 52 weeks.
“I don’t think we need to do any more studies to clarify recovery from acute back pain,” said Dr. Moseley. “For subacute back pain, I think there is a moderate to high level of certainty, so the prognosis is pretty good there. The bad news is that the data suggest that if someone’s got back pain 3 months after onset, the likelihood of recovery is much less, but those data are the ones we can’t be certain of on the basis of this meta-analysis.”
Dr. Moseley noted that the current analysis is not highly detailed, because individual patient data are absent. This is “the biggest limitation from a methodological perspective,” he said. “Individual patient analysis is a lot more powerful.”
Comprehensive Literature Search
Commenting on the findings for this news organization, David Borenstein, MD, clinical professor of rheumatology at the George Washington University Medical Center and partner at Arthritis and Rheumatism Associates in Washington, DC, described the literature search as comprehensive. Dr. Borenstein did not participate in the study. The assessment of low back pain as either short-lived or lasting is worth investigating, he added, given that low back pain impairs a patient’s function and carries a hefty price tag at a societal level.
The study results suggest “that people with acute low back pain do pretty well, and people with subacute low back pain will do less well but still have a chance of healing,” said Dr. Borenstein. “People who have chronic low back pain do not do as well, and they have some increase in disability.” It would be important to develop ways to identify patients whose low back pain will persist beyond 3 months, as well as ways to identify the criteria or characteristics that might prevent those patients from having prolonged difficulties and persistent low back pain, he added.
Dr. Borenstein noted that the authors failed to mention specific approaches that could decrease progression from subacute to persistent low back pain. “They really don’t point anyone in a direction to what would make a difference,” he said. “It would have really improved the impact of the paper if they had seen anything along the way in their review of these articles that might have suggested how someone or a group might have been able to impact this progression.”
The study was funded by supported by a National Health and Medical Research Council Leadership Investigator Grant to Dr. Moseley. Dr. Moseley and Dr. Borenstein reported no relevant disclosures.
A version of this article appeared on Medscape.com.
FROM THE CANADIAN MEDICAL ASSOCIATION JOURNAL
Prehospital COVID therapy effective in rheumatic disease patients
Outpatient COVID-19 treatment with monoclonal antibodies or antiretroviral medications such as nirmatrelvir-ritonavir (Paxlovid) administered to patients with systemic autoimmune rheumatic disease led to lower odds of having severe outcomes when compared with similar patients who received no outpatient treatment in a real-world, retrospective analysis of cases.
The investigators found that there were nine hospitalizations or deaths (2.1%) among 426 patients who received outpatient treatment, compared with 49 (17.6%) among 278 who did not receive outpatient treatment, yielding an odds ratio of 0.12 (95% confidence interval, 0.05-0.25), after adjusting for age, sex, race, comorbidities, and kidney function. The study was published in Lancet Rheumatology.
“Across the board, there was a really strong association with receiving outpatient treatment and lower risk of severe COVID-19,” senior author Jeffrey A. Sparks, MD, MMSc, assistant professor of medicine, Harvard Medical School and Brigham and Women’s Hospital, Boston, said in an interview. “It is pretty powerful evidence that, in this high-risk group, that treatment still matters related to preventing severe COVID. We found almost all patients who had severe COVID-19, either hospitalized or who had died, were in the untreated group.”
Early outpatient treatment an important tool in patients with rheumatic disease
Dr. Sparks noted that he and his coinvestigators conducted the study because the benefit of outpatient COVID-19 treatments in individuals with systemic autoimmune rheumatic disease was not adequately determined in clinical trials because they had infrequent enrollment of such patients.
The analysis included 704 patients with a mean age of 58.4 years who were seen at Mass General Brigham Integrated Health Care System, a multicenter health care system that includes 14 hospitals and primary care or specialty outpatient centers in the Boston area. A majority were female (76%) and White (84%). Nearly half had rheumatoid arthritis. Of the 704, 426 (61%) received outpatient treatment, which included nirmatrelvir-ritonavir (n = 307), monoclonal antibodies (n = 105), molnupiravir (n = 5), remdesivir (n = 3), and combination treatment (n = 6).
The findings underline the need to individualize approaches to outpatient treatment in those who test positive for SARS-CoV-2 to fend off severe COVID-19, according to Dr. Sparks. “It seems if you are vaccinated and in the general population that you are way less likely to have severe COVID-19 in the current environment, but that doesn’t necessarily apply to some high-risk groups like patients on immunosuppression. There are still patients at risk of severe COVID-19, and some of them are in this group of rheumatic patients. This should be part of the discussion related to deciding whether or not to treat.”
Dr. Sparks noted that vaccination against COVID-19 confers protection against developing severe COVID-19 in patients with rheumatic disease as it does in the general population, but patients with rheumatic diseases remain at increased risk for severe presentation. “Certainly, the vaccines really help our patients too, but there’s still a bit of a gap between the risk for our patients with rheumatic diseases and the general population” in developing severe COVID-19.
Dr. Sparks said he hopes the results represent a “call to action” that even among vaccinated patients there are still some who have poor outcomes, and that early outpatient treatment appears to be an important tool in the fight against poor outcomes from SARS-CoV-2 infection.
COVID-19 rebound
The study also reported on the phenomenon of COVID-19 rebound (recurrence of symptoms and test positivity after regimen completion) after oral outpatient SARS-CoV-2 treatment. “This [COVID-19 rebound] is a downside to treatment,” he said. COVID rebound was not infrequent: A total of 25 (8%) of 318 patients who received oral outpatient treatment had documented COVID-19 rebound.
“It was reassuring because we found no one who had rebound progressed to have severe COVID-19,” Dr. Sparks said. “On the other hand, [rebound] happened pretty frequently in our data, as 8% of patients are documented to have it.”
Dr. Sparks said he and coinvestigators speculate that more patients in the cohort may have experienced COVID-19 rebound but did not communicate this to their health care providers, and, as such, it was not documented in the medical record. The potential development of COVID-19 rebound “is something to counsel your patients about.” COVID-19 rebound is a phenomenon that is being most commonly observed with nirmatrelvir-ritonavir as outpatient treatment.
Possible confounding factors in study
Katie Bechman, MBChB, clinical lecturer in rheumatology at King’s College London, who coauthored an accompanying editorial about the study and its findings, pointed out that the study is limited by its observational design.
“With any study that looks at the efficacy of treatment, especially in an observational cohort, you’re going to have to consider the unmeasured confounding and the difference between these two groups,” Dr. Bechman said. “I know that they did try to adjust for that in this study, but there’s always going to be factors that we can’t [control for]. That is something that needs to be considered. I think that’s always something we need to consider when we’re looking at observational data.”
In lieu of a randomized, controlled trial, Dr. Bechman noted that the study and its associated findings serve as “the best data we have,” and she described the results as “very informative and positive.”
She added that the large number of patients represents a strength of the study, as does the robust method employed for identifying which patients had COVID-19.
The learnings from this study with respect to outpatient treatment can be applied to more common illnesses that patients with rheumatic disease may develop, such as the flu, according to Dr. Bechman.
“One of the positive aspects from this pandemic is that we’ve learned a huge amount about how best to treat certain viruses and prevent them in patients,” she said. “It would be worth thinking towards the future, what we can do for illnesses that we see very commonly in these populations. There may be treatment regimens that we haven’t really considered until now. You could hypothesize that in the next couple of years, if we have an influenza breakout, that we should be providing some prehospital antiviral treatment to patients, especially the ones that are at high risk.”
The study was conducted without outside funding. Dr. Sparks has received research support from Bristol-Myers Squibb and consulted for AbbVie, Amgen, Boehringer Ingelheim, Bristol-Myers Squibb, Gilead, Inova Diagnostics, Janssen, Optum, and Pfizer unrelated to this work. Dr. Bechman reported no relevant financial relationships.
A version of this article first appeared on Medscape.com.
Outpatient COVID-19 treatment with monoclonal antibodies or antiretroviral medications such as nirmatrelvir-ritonavir (Paxlovid) administered to patients with systemic autoimmune rheumatic disease led to lower odds of having severe outcomes when compared with similar patients who received no outpatient treatment in a real-world, retrospective analysis of cases.
The investigators found that there were nine hospitalizations or deaths (2.1%) among 426 patients who received outpatient treatment, compared with 49 (17.6%) among 278 who did not receive outpatient treatment, yielding an odds ratio of 0.12 (95% confidence interval, 0.05-0.25), after adjusting for age, sex, race, comorbidities, and kidney function. The study was published in Lancet Rheumatology.
“Across the board, there was a really strong association with receiving outpatient treatment and lower risk of severe COVID-19,” senior author Jeffrey A. Sparks, MD, MMSc, assistant professor of medicine, Harvard Medical School and Brigham and Women’s Hospital, Boston, said in an interview. “It is pretty powerful evidence that, in this high-risk group, that treatment still matters related to preventing severe COVID. We found almost all patients who had severe COVID-19, either hospitalized or who had died, were in the untreated group.”
Early outpatient treatment an important tool in patients with rheumatic disease
Dr. Sparks noted that he and his coinvestigators conducted the study because the benefit of outpatient COVID-19 treatments in individuals with systemic autoimmune rheumatic disease was not adequately determined in clinical trials because they had infrequent enrollment of such patients.
The analysis included 704 patients with a mean age of 58.4 years who were seen at Mass General Brigham Integrated Health Care System, a multicenter health care system that includes 14 hospitals and primary care or specialty outpatient centers in the Boston area. A majority were female (76%) and White (84%). Nearly half had rheumatoid arthritis. Of the 704, 426 (61%) received outpatient treatment, which included nirmatrelvir-ritonavir (n = 307), monoclonal antibodies (n = 105), molnupiravir (n = 5), remdesivir (n = 3), and combination treatment (n = 6).
The findings underline the need to individualize approaches to outpatient treatment in those who test positive for SARS-CoV-2 to fend off severe COVID-19, according to Dr. Sparks. “It seems if you are vaccinated and in the general population that you are way less likely to have severe COVID-19 in the current environment, but that doesn’t necessarily apply to some high-risk groups like patients on immunosuppression. There are still patients at risk of severe COVID-19, and some of them are in this group of rheumatic patients. This should be part of the discussion related to deciding whether or not to treat.”
Dr. Sparks noted that vaccination against COVID-19 confers protection against developing severe COVID-19 in patients with rheumatic disease as it does in the general population, but patients with rheumatic diseases remain at increased risk for severe presentation. “Certainly, the vaccines really help our patients too, but there’s still a bit of a gap between the risk for our patients with rheumatic diseases and the general population” in developing severe COVID-19.
Dr. Sparks said he hopes the results represent a “call to action” that even among vaccinated patients there are still some who have poor outcomes, and that early outpatient treatment appears to be an important tool in the fight against poor outcomes from SARS-CoV-2 infection.
COVID-19 rebound
The study also reported on the phenomenon of COVID-19 rebound (recurrence of symptoms and test positivity after regimen completion) after oral outpatient SARS-CoV-2 treatment. “This [COVID-19 rebound] is a downside to treatment,” he said. COVID rebound was not infrequent: A total of 25 (8%) of 318 patients who received oral outpatient treatment had documented COVID-19 rebound.
“It was reassuring because we found no one who had rebound progressed to have severe COVID-19,” Dr. Sparks said. “On the other hand, [rebound] happened pretty frequently in our data, as 8% of patients are documented to have it.”
Dr. Sparks said he and coinvestigators speculate that more patients in the cohort may have experienced COVID-19 rebound but did not communicate this to their health care providers, and, as such, it was not documented in the medical record. The potential development of COVID-19 rebound “is something to counsel your patients about.” COVID-19 rebound is a phenomenon that is being most commonly observed with nirmatrelvir-ritonavir as outpatient treatment.
Possible confounding factors in study
Katie Bechman, MBChB, clinical lecturer in rheumatology at King’s College London, who coauthored an accompanying editorial about the study and its findings, pointed out that the study is limited by its observational design.
“With any study that looks at the efficacy of treatment, especially in an observational cohort, you’re going to have to consider the unmeasured confounding and the difference between these two groups,” Dr. Bechman said. “I know that they did try to adjust for that in this study, but there’s always going to be factors that we can’t [control for]. That is something that needs to be considered. I think that’s always something we need to consider when we’re looking at observational data.”
In lieu of a randomized, controlled trial, Dr. Bechman noted that the study and its associated findings serve as “the best data we have,” and she described the results as “very informative and positive.”
She added that the large number of patients represents a strength of the study, as does the robust method employed for identifying which patients had COVID-19.
The learnings from this study with respect to outpatient treatment can be applied to more common illnesses that patients with rheumatic disease may develop, such as the flu, according to Dr. Bechman.
“One of the positive aspects from this pandemic is that we’ve learned a huge amount about how best to treat certain viruses and prevent them in patients,” she said. “It would be worth thinking towards the future, what we can do for illnesses that we see very commonly in these populations. There may be treatment regimens that we haven’t really considered until now. You could hypothesize that in the next couple of years, if we have an influenza breakout, that we should be providing some prehospital antiviral treatment to patients, especially the ones that are at high risk.”
The study was conducted without outside funding. Dr. Sparks has received research support from Bristol-Myers Squibb and consulted for AbbVie, Amgen, Boehringer Ingelheim, Bristol-Myers Squibb, Gilead, Inova Diagnostics, Janssen, Optum, and Pfizer unrelated to this work. Dr. Bechman reported no relevant financial relationships.
A version of this article first appeared on Medscape.com.
Outpatient COVID-19 treatment with monoclonal antibodies or antiretroviral medications such as nirmatrelvir-ritonavir (Paxlovid) administered to patients with systemic autoimmune rheumatic disease led to lower odds of having severe outcomes when compared with similar patients who received no outpatient treatment in a real-world, retrospective analysis of cases.
The investigators found that there were nine hospitalizations or deaths (2.1%) among 426 patients who received outpatient treatment, compared with 49 (17.6%) among 278 who did not receive outpatient treatment, yielding an odds ratio of 0.12 (95% confidence interval, 0.05-0.25), after adjusting for age, sex, race, comorbidities, and kidney function. The study was published in Lancet Rheumatology.
“Across the board, there was a really strong association with receiving outpatient treatment and lower risk of severe COVID-19,” senior author Jeffrey A. Sparks, MD, MMSc, assistant professor of medicine, Harvard Medical School and Brigham and Women’s Hospital, Boston, said in an interview. “It is pretty powerful evidence that, in this high-risk group, that treatment still matters related to preventing severe COVID. We found almost all patients who had severe COVID-19, either hospitalized or who had died, were in the untreated group.”
Early outpatient treatment an important tool in patients with rheumatic disease
Dr. Sparks noted that he and his coinvestigators conducted the study because the benefit of outpatient COVID-19 treatments in individuals with systemic autoimmune rheumatic disease was not adequately determined in clinical trials because they had infrequent enrollment of such patients.
The analysis included 704 patients with a mean age of 58.4 years who were seen at Mass General Brigham Integrated Health Care System, a multicenter health care system that includes 14 hospitals and primary care or specialty outpatient centers in the Boston area. A majority were female (76%) and White (84%). Nearly half had rheumatoid arthritis. Of the 704, 426 (61%) received outpatient treatment, which included nirmatrelvir-ritonavir (n = 307), monoclonal antibodies (n = 105), molnupiravir (n = 5), remdesivir (n = 3), and combination treatment (n = 6).
The findings underline the need to individualize approaches to outpatient treatment in those who test positive for SARS-CoV-2 to fend off severe COVID-19, according to Dr. Sparks. “It seems if you are vaccinated and in the general population that you are way less likely to have severe COVID-19 in the current environment, but that doesn’t necessarily apply to some high-risk groups like patients on immunosuppression. There are still patients at risk of severe COVID-19, and some of them are in this group of rheumatic patients. This should be part of the discussion related to deciding whether or not to treat.”
Dr. Sparks noted that vaccination against COVID-19 confers protection against developing severe COVID-19 in patients with rheumatic disease as it does in the general population, but patients with rheumatic diseases remain at increased risk for severe presentation. “Certainly, the vaccines really help our patients too, but there’s still a bit of a gap between the risk for our patients with rheumatic diseases and the general population” in developing severe COVID-19.
Dr. Sparks said he hopes the results represent a “call to action” that even among vaccinated patients there are still some who have poor outcomes, and that early outpatient treatment appears to be an important tool in the fight against poor outcomes from SARS-CoV-2 infection.
COVID-19 rebound
The study also reported on the phenomenon of COVID-19 rebound (recurrence of symptoms and test positivity after regimen completion) after oral outpatient SARS-CoV-2 treatment. “This [COVID-19 rebound] is a downside to treatment,” he said. COVID rebound was not infrequent: A total of 25 (8%) of 318 patients who received oral outpatient treatment had documented COVID-19 rebound.
“It was reassuring because we found no one who had rebound progressed to have severe COVID-19,” Dr. Sparks said. “On the other hand, [rebound] happened pretty frequently in our data, as 8% of patients are documented to have it.”
Dr. Sparks said he and coinvestigators speculate that more patients in the cohort may have experienced COVID-19 rebound but did not communicate this to their health care providers, and, as such, it was not documented in the medical record. The potential development of COVID-19 rebound “is something to counsel your patients about.” COVID-19 rebound is a phenomenon that is being most commonly observed with nirmatrelvir-ritonavir as outpatient treatment.
Possible confounding factors in study
Katie Bechman, MBChB, clinical lecturer in rheumatology at King’s College London, who coauthored an accompanying editorial about the study and its findings, pointed out that the study is limited by its observational design.
“With any study that looks at the efficacy of treatment, especially in an observational cohort, you’re going to have to consider the unmeasured confounding and the difference between these two groups,” Dr. Bechman said. “I know that they did try to adjust for that in this study, but there’s always going to be factors that we can’t [control for]. That is something that needs to be considered. I think that’s always something we need to consider when we’re looking at observational data.”
In lieu of a randomized, controlled trial, Dr. Bechman noted that the study and its associated findings serve as “the best data we have,” and she described the results as “very informative and positive.”
She added that the large number of patients represents a strength of the study, as does the robust method employed for identifying which patients had COVID-19.
The learnings from this study with respect to outpatient treatment can be applied to more common illnesses that patients with rheumatic disease may develop, such as the flu, according to Dr. Bechman.
“One of the positive aspects from this pandemic is that we’ve learned a huge amount about how best to treat certain viruses and prevent them in patients,” she said. “It would be worth thinking towards the future, what we can do for illnesses that we see very commonly in these populations. There may be treatment regimens that we haven’t really considered until now. You could hypothesize that in the next couple of years, if we have an influenza breakout, that we should be providing some prehospital antiviral treatment to patients, especially the ones that are at high risk.”
The study was conducted without outside funding. Dr. Sparks has received research support from Bristol-Myers Squibb and consulted for AbbVie, Amgen, Boehringer Ingelheim, Bristol-Myers Squibb, Gilead, Inova Diagnostics, Janssen, Optum, and Pfizer unrelated to this work. Dr. Bechman reported no relevant financial relationships.
A version of this article first appeared on Medscape.com.
FROM THE LANCET RHEUMATOLOGY
Mothers with disabilities less likely to start breastfeeding
Mothers with intellectual or developmental disabilities are less likely to initiate breastfeeding and to receive in-hospital breastfeeding support than are those without a disability, new data suggest.
In a population-based cohort study of more than 600,000 mothers, patients with an intellectual or developmental disability were about 18% less likely to have a chance to initiate breastfeeding during their hospital stay.
“Overall, we did see lower rates of breastfeeding practices and supports in people with intellectual and developmental disabilities, as well as those with multiple disabilities, compared to people without disabilities,” study author Hilary K. Brown, PhD, assistant professor of health and society at University of Toronto Scarborough in Ontario, told this news organization.
The study was published in The Lancet Public Health.
Disparities in breastfeeding
“There hasn’t been a lot of research on breastfeeding outcomes in people with disabilities,” said Dr. Brown, who noted that the study outcomes were based on the WHO-UNICEF Baby Friendly Hospital Initiative guidelines. “There have been a number of qualitative studies that have suggested that they do experience barriers accessing care related to breastfeeding and different challenges related to breastfeeding. But as far as quantitative outcomes, there has only been a handful of studies.”
To examine these outcomes, the investigators analyzed health administrative data from Ontario. They included in their analysis all birthing parents aged 15-49 years who had a single live birth between April 1, 2012, and March 31, 2018. Patients with a physical disability, sensory disability, intellectual or developmental disability, or two or more disabilities were identified via diagnostic algorithms and were compared with individuals without disabilities with respect to the opportunity to initiate breastfeeding, to engage in in-hospital breastfeeding, to engage in exclusive breastfeeding at hospital discharge, to have skin-to-skin contact, and to be provided with breastfeeding assistance.
The investigators considered a physical disability to encompass conditions such as congenital anomalies, musculoskeletal disorders, neurologic disorders, or permanent injuries. They defined sensory disability as hearing loss or vision loss. Intellectual or developmental disability was defined as having autism spectrum disorder, chromosomal anomaly, fetal alcohol spectrum disorder, or other intellectual disability. Patients with multiple disabilities had two or more of these conditions.
The study population included 634,111 birthing parents, of whom 54,476 (8.6%) had a physical disability, 19,227 (3.0%) had a sensory disability, 1,048 (0.2%) had an intellectual or developmental disability, 4,050 (0.6%) had multiple disabilities, and 555,310 (87.6%) had no disability.
The investigators found that patients with intellectual or developmental disabilities were less likely than were those without a disability to have an opportunity to initiate breastfeeding (adjusted relative risk [aRR], 0.82), to engage in any in-hospital breastfeeding (aRR, 0.85), to be breastfeeding exclusively at hospital discharge (aRR, 0.73), to have skin-to-skin contact (aRR, 0.90), and to receive breastfeeding assistance (aRR, 0.85) compared with patients without a disability.
They also found that individuals with multiple disabilities were less likely to have an opportunity to initiate breastfeeding (aRR, 0.93), to engage in any in-hospital breastfeeding (aRR, 0.93), to be exclusively breastfeeding at hospital discharge (aRR, 0.90), to have skin-to-skin contact (aRR, 0.93), and to receive breastfeeding assistance (aRR, 0.95) compared with patients without a disability.
An understudied population
Commenting on the study, Lori Feldman-Winter, MD, MPH, professor of pediatrics at Rowan University in Camden, N.J., said that one of its strengths is that it included patients who may be excluded from studies of breastfeeding practices. The finding of few differences in breastfeeding practices and supports for people with physical and sensory disabilities, compared with those without disabilities, was positive, she added.
“This is an understudied population, and it is important to call out that there may be practices related to breastfeeding care that suffer, due to implicit bias regarding persons with intellectual and multiple disabilities,” said Dr. Feldman-Winter. “The good news is that other disabilities did not show the same disparities. This study also shows how important it is to measure potential gaps in care across multiple sociodemographic and other variables, such as disabilities, to ensure equitable and inclusive care.”
Health care professionals need to be aware of disparities in breastfeeding care, she added. They need to be open to exploring potential biases when it comes to providing equitable care.
R. Douglas Wilson, MD, president of the Society of Obstetricians and Gynaecologists of Canada and professor emeritus of obstetrics and gynecology at the University of Calgary in Alberta, noted that the size of the cohort represents a strength of the study and that the findings suggest the possible need for closer follow-up of a new mother who is breastfeeding and who has an intellectual disability or multiple disabilities.
“You might keep that patient in hospital for an extra day, and then the home care nurse may look in on them more frequently than they would for someone who does not need that extra oversight,” said Dr. Wilson. When their patients are pregnant, obstetricians and gynecologists can find out whether their patients intend to breastfeed and put them in touch with nurses or lactation consultants to assist them, he added.
The study was funded by the National Institutes of Health and the Canada Research Chairs Program. Dr. Brown, Dr. Feldman-Winter, and Dr. Wilson reported no relevant financial relationships.
A version of this article first appeared on Medscape.com.
Mothers with intellectual or developmental disabilities are less likely to initiate breastfeeding and to receive in-hospital breastfeeding support than are those without a disability, new data suggest.
In a population-based cohort study of more than 600,000 mothers, patients with an intellectual or developmental disability were about 18% less likely to have a chance to initiate breastfeeding during their hospital stay.
“Overall, we did see lower rates of breastfeeding practices and supports in people with intellectual and developmental disabilities, as well as those with multiple disabilities, compared to people without disabilities,” study author Hilary K. Brown, PhD, assistant professor of health and society at University of Toronto Scarborough in Ontario, told this news organization.
The study was published in The Lancet Public Health.
Disparities in breastfeeding
“There hasn’t been a lot of research on breastfeeding outcomes in people with disabilities,” said Dr. Brown, who noted that the study outcomes were based on the WHO-UNICEF Baby Friendly Hospital Initiative guidelines. “There have been a number of qualitative studies that have suggested that they do experience barriers accessing care related to breastfeeding and different challenges related to breastfeeding. But as far as quantitative outcomes, there has only been a handful of studies.”
To examine these outcomes, the investigators analyzed health administrative data from Ontario. They included in their analysis all birthing parents aged 15-49 years who had a single live birth between April 1, 2012, and March 31, 2018. Patients with a physical disability, sensory disability, intellectual or developmental disability, or two or more disabilities were identified via diagnostic algorithms and were compared with individuals without disabilities with respect to the opportunity to initiate breastfeeding, to engage in in-hospital breastfeeding, to engage in exclusive breastfeeding at hospital discharge, to have skin-to-skin contact, and to be provided with breastfeeding assistance.
The investigators considered a physical disability to encompass conditions such as congenital anomalies, musculoskeletal disorders, neurologic disorders, or permanent injuries. They defined sensory disability as hearing loss or vision loss. Intellectual or developmental disability was defined as having autism spectrum disorder, chromosomal anomaly, fetal alcohol spectrum disorder, or other intellectual disability. Patients with multiple disabilities had two or more of these conditions.
The study population included 634,111 birthing parents, of whom 54,476 (8.6%) had a physical disability, 19,227 (3.0%) had a sensory disability, 1,048 (0.2%) had an intellectual or developmental disability, 4,050 (0.6%) had multiple disabilities, and 555,310 (87.6%) had no disability.
The investigators found that patients with intellectual or developmental disabilities were less likely than were those without a disability to have an opportunity to initiate breastfeeding (adjusted relative risk [aRR], 0.82), to engage in any in-hospital breastfeeding (aRR, 0.85), to be breastfeeding exclusively at hospital discharge (aRR, 0.73), to have skin-to-skin contact (aRR, 0.90), and to receive breastfeeding assistance (aRR, 0.85) compared with patients without a disability.
They also found that individuals with multiple disabilities were less likely to have an opportunity to initiate breastfeeding (aRR, 0.93), to engage in any in-hospital breastfeeding (aRR, 0.93), to be exclusively breastfeeding at hospital discharge (aRR, 0.90), to have skin-to-skin contact (aRR, 0.93), and to receive breastfeeding assistance (aRR, 0.95) compared with patients without a disability.
An understudied population
Commenting on the study, Lori Feldman-Winter, MD, MPH, professor of pediatrics at Rowan University in Camden, N.J., said that one of its strengths is that it included patients who may be excluded from studies of breastfeeding practices. The finding of few differences in breastfeeding practices and supports for people with physical and sensory disabilities, compared with those without disabilities, was positive, she added.
“This is an understudied population, and it is important to call out that there may be practices related to breastfeeding care that suffer, due to implicit bias regarding persons with intellectual and multiple disabilities,” said Dr. Feldman-Winter. “The good news is that other disabilities did not show the same disparities. This study also shows how important it is to measure potential gaps in care across multiple sociodemographic and other variables, such as disabilities, to ensure equitable and inclusive care.”
Health care professionals need to be aware of disparities in breastfeeding care, she added. They need to be open to exploring potential biases when it comes to providing equitable care.
R. Douglas Wilson, MD, president of the Society of Obstetricians and Gynaecologists of Canada and professor emeritus of obstetrics and gynecology at the University of Calgary in Alberta, noted that the size of the cohort represents a strength of the study and that the findings suggest the possible need for closer follow-up of a new mother who is breastfeeding and who has an intellectual disability or multiple disabilities.
“You might keep that patient in hospital for an extra day, and then the home care nurse may look in on them more frequently than they would for someone who does not need that extra oversight,” said Dr. Wilson. When their patients are pregnant, obstetricians and gynecologists can find out whether their patients intend to breastfeed and put them in touch with nurses or lactation consultants to assist them, he added.
The study was funded by the National Institutes of Health and the Canada Research Chairs Program. Dr. Brown, Dr. Feldman-Winter, and Dr. Wilson reported no relevant financial relationships.
A version of this article first appeared on Medscape.com.
Mothers with intellectual or developmental disabilities are less likely to initiate breastfeeding and to receive in-hospital breastfeeding support than are those without a disability, new data suggest.
In a population-based cohort study of more than 600,000 mothers, patients with an intellectual or developmental disability were about 18% less likely to have a chance to initiate breastfeeding during their hospital stay.
“Overall, we did see lower rates of breastfeeding practices and supports in people with intellectual and developmental disabilities, as well as those with multiple disabilities, compared to people without disabilities,” study author Hilary K. Brown, PhD, assistant professor of health and society at University of Toronto Scarborough in Ontario, told this news organization.
The study was published in The Lancet Public Health.
Disparities in breastfeeding
“There hasn’t been a lot of research on breastfeeding outcomes in people with disabilities,” said Dr. Brown, who noted that the study outcomes were based on the WHO-UNICEF Baby Friendly Hospital Initiative guidelines. “There have been a number of qualitative studies that have suggested that they do experience barriers accessing care related to breastfeeding and different challenges related to breastfeeding. But as far as quantitative outcomes, there has only been a handful of studies.”
To examine these outcomes, the investigators analyzed health administrative data from Ontario. They included in their analysis all birthing parents aged 15-49 years who had a single live birth between April 1, 2012, and March 31, 2018. Patients with a physical disability, sensory disability, intellectual or developmental disability, or two or more disabilities were identified via diagnostic algorithms and were compared with individuals without disabilities with respect to the opportunity to initiate breastfeeding, to engage in in-hospital breastfeeding, to engage in exclusive breastfeeding at hospital discharge, to have skin-to-skin contact, and to be provided with breastfeeding assistance.
The investigators considered a physical disability to encompass conditions such as congenital anomalies, musculoskeletal disorders, neurologic disorders, or permanent injuries. They defined sensory disability as hearing loss or vision loss. Intellectual or developmental disability was defined as having autism spectrum disorder, chromosomal anomaly, fetal alcohol spectrum disorder, or other intellectual disability. Patients with multiple disabilities had two or more of these conditions.
The study population included 634,111 birthing parents, of whom 54,476 (8.6%) had a physical disability, 19,227 (3.0%) had a sensory disability, 1,048 (0.2%) had an intellectual or developmental disability, 4,050 (0.6%) had multiple disabilities, and 555,310 (87.6%) had no disability.
The investigators found that patients with intellectual or developmental disabilities were less likely than were those without a disability to have an opportunity to initiate breastfeeding (adjusted relative risk [aRR], 0.82), to engage in any in-hospital breastfeeding (aRR, 0.85), to be breastfeeding exclusively at hospital discharge (aRR, 0.73), to have skin-to-skin contact (aRR, 0.90), and to receive breastfeeding assistance (aRR, 0.85) compared with patients without a disability.
They also found that individuals with multiple disabilities were less likely to have an opportunity to initiate breastfeeding (aRR, 0.93), to engage in any in-hospital breastfeeding (aRR, 0.93), to be exclusively breastfeeding at hospital discharge (aRR, 0.90), to have skin-to-skin contact (aRR, 0.93), and to receive breastfeeding assistance (aRR, 0.95) compared with patients without a disability.
An understudied population
Commenting on the study, Lori Feldman-Winter, MD, MPH, professor of pediatrics at Rowan University in Camden, N.J., said that one of its strengths is that it included patients who may be excluded from studies of breastfeeding practices. The finding of few differences in breastfeeding practices and supports for people with physical and sensory disabilities, compared with those without disabilities, was positive, she added.
“This is an understudied population, and it is important to call out that there may be practices related to breastfeeding care that suffer, due to implicit bias regarding persons with intellectual and multiple disabilities,” said Dr. Feldman-Winter. “The good news is that other disabilities did not show the same disparities. This study also shows how important it is to measure potential gaps in care across multiple sociodemographic and other variables, such as disabilities, to ensure equitable and inclusive care.”
Health care professionals need to be aware of disparities in breastfeeding care, she added. They need to be open to exploring potential biases when it comes to providing equitable care.
R. Douglas Wilson, MD, president of the Society of Obstetricians and Gynaecologists of Canada and professor emeritus of obstetrics and gynecology at the University of Calgary in Alberta, noted that the size of the cohort represents a strength of the study and that the findings suggest the possible need for closer follow-up of a new mother who is breastfeeding and who has an intellectual disability or multiple disabilities.
“You might keep that patient in hospital for an extra day, and then the home care nurse may look in on them more frequently than they would for someone who does not need that extra oversight,” said Dr. Wilson. When their patients are pregnant, obstetricians and gynecologists can find out whether their patients intend to breastfeed and put them in touch with nurses or lactation consultants to assist them, he added.
The study was funded by the National Institutes of Health and the Canada Research Chairs Program. Dr. Brown, Dr. Feldman-Winter, and Dr. Wilson reported no relevant financial relationships.
A version of this article first appeared on Medscape.com.
FROM THE LANCET PUBLIC HEALTH
Uncombable hair syndrome: One gene, variants responsible for many cases
that manifests during infancy, investigators have reported.
The findings are from a cohort study published in JAMA Dermatology, which involved 107 unrelated children and adults suspected of having UHS, as well as family members, all of whom were recruited from January 2013 to December 2021. Genetic analyses were conducted in Germany from January 2014 to December 2021 with exome sequencing.
Study builds on prior research
Senior author Regina C. Betz, MD, professor of dermatogenetics at the Institute of Human Genetics, University Hospital Bonn, Germany, said that in 2016, she and her coinvestigators authored a study on the molecular genetics of UHS. That study, which involved 18 people with UHS, identified variants in three genes – PADI3, TCHH, and TGM3 – that encode proteins that play a role in the formation of the hair shaft. The investigators described how a deficiency in the shaping and mechanical strengthening of the hair shaft occurs in the UHS phenotype, which is characterized by dry, frizzy, and wiry hair that cannot be combed flat.
As a result of that previous work, “we base the assignment or confirmation of a clinical diagnosis of UHS on molecular genetic diagnostics,” the authors write in the new study, rather than on the clinical appearance of the hair and the physical examination of the patient, with confirmation on microscopical examination of the hair shaft.
Social media as instrument in finding study participants
Following the 2016 study, Dr. Betz and colleagues were contacted by many clinicians and by the public through Facebook and other social media platforms with details about possible cases of UHS, an autosomal recessive disorder. Through these contacts, blood samples, saliva, or DNA was sent to the investigators’ laboratory from 89 unrelated index patients (69 female patients, 20 male patients) suspected of having UHS. This resulted in the identification of pathogenic variants in 69 cases, the investigators write.
“In the first study, we had 18 patients, and then we tried to collect as many as possible” to determine the main mechanism behind UHS, Dr. Betz said. One question is whether there are additional genes responsible for UHS, she noted. “Even now, we are not sure, because in 25% [of cases in the new study], we didn’t find any mutation in the three known genes.”
The current study resulted in the discovery of eight novel pathogenic variants in PADI3, which are responsible for 71.0% (76) of the 107 cases. Of those, “6 were single observations and 2 were observed in 3 and 2 individuals, respectively,” the investigators write.
Children can grow out of this disorder, but it can also persist into adulthood, Dr. Betz noted. Communication that investigators had with parents of the children with UHS revealed that these children are often the targets of bullying by other children, she added.
She and her and colleagues will continue this research and are currently studying adults who have UHS.
Research leads to possible treatment pathways
Jeff Donovan, MD, FRCPC, FAAD, a dermatologist and medical director of the Donovan Hair Clinic in Whistler, British Columbia, described these findings as fundamental to understanding UHS and creating pathways to possible treatments.
The study “identifies more about the genetic basis of this challenging condition,” said Dr. Donovan, who is also clinical instructor in the department of dermatology at the University of British Columbia, Vancouver, and president of the Canadian Hair Loss Foundation. “We really need this type of information in order to have any sort of clue in terms of how to treat it,” he told this news organization.
“In the hair loss world, it’s pretty clear that if you can understand the genetic basis of things, or the basic science of a condition, whether it’s the basic genetics or the basic immunology, you give yourself the best chance to develop good treatments,” said Dr. Donovan.
The article provides advanced genetic information of the condition, such that geneticists can test for at least three markers if they are suspecting UHS, Dr. Donovan observed.
Condition can lead to bullying
Dr. Donovan also commented that UHS can have a detrimental impact on children with regard to socializing with their peers. “Having hair that sticks out and is very full like this is challenging because kids do get teased,” he said.
“It is often the parents who are the most affected” when a child aged 2-5 years has a hair condition such as UHS. But at age 5-9, “children are developing self-identity and an understanding of various aspects of self-esteem and what they look like and what others look like. And that’s where the teasing really starts. And that’s where it does become troublesome.”
Dr. Betz and Dr. Donovan have disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
that manifests during infancy, investigators have reported.
The findings are from a cohort study published in JAMA Dermatology, which involved 107 unrelated children and adults suspected of having UHS, as well as family members, all of whom were recruited from January 2013 to December 2021. Genetic analyses were conducted in Germany from January 2014 to December 2021 with exome sequencing.
Study builds on prior research
Senior author Regina C. Betz, MD, professor of dermatogenetics at the Institute of Human Genetics, University Hospital Bonn, Germany, said that in 2016, she and her coinvestigators authored a study on the molecular genetics of UHS. That study, which involved 18 people with UHS, identified variants in three genes – PADI3, TCHH, and TGM3 – that encode proteins that play a role in the formation of the hair shaft. The investigators described how a deficiency in the shaping and mechanical strengthening of the hair shaft occurs in the UHS phenotype, which is characterized by dry, frizzy, and wiry hair that cannot be combed flat.
As a result of that previous work, “we base the assignment or confirmation of a clinical diagnosis of UHS on molecular genetic diagnostics,” the authors write in the new study, rather than on the clinical appearance of the hair and the physical examination of the patient, with confirmation on microscopical examination of the hair shaft.
Social media as instrument in finding study participants
Following the 2016 study, Dr. Betz and colleagues were contacted by many clinicians and by the public through Facebook and other social media platforms with details about possible cases of UHS, an autosomal recessive disorder. Through these contacts, blood samples, saliva, or DNA was sent to the investigators’ laboratory from 89 unrelated index patients (69 female patients, 20 male patients) suspected of having UHS. This resulted in the identification of pathogenic variants in 69 cases, the investigators write.
“In the first study, we had 18 patients, and then we tried to collect as many as possible” to determine the main mechanism behind UHS, Dr. Betz said. One question is whether there are additional genes responsible for UHS, she noted. “Even now, we are not sure, because in 25% [of cases in the new study], we didn’t find any mutation in the three known genes.”
The current study resulted in the discovery of eight novel pathogenic variants in PADI3, which are responsible for 71.0% (76) of the 107 cases. Of those, “6 were single observations and 2 were observed in 3 and 2 individuals, respectively,” the investigators write.
Children can grow out of this disorder, but it can also persist into adulthood, Dr. Betz noted. Communication that investigators had with parents of the children with UHS revealed that these children are often the targets of bullying by other children, she added.
She and her and colleagues will continue this research and are currently studying adults who have UHS.
Research leads to possible treatment pathways
Jeff Donovan, MD, FRCPC, FAAD, a dermatologist and medical director of the Donovan Hair Clinic in Whistler, British Columbia, described these findings as fundamental to understanding UHS and creating pathways to possible treatments.
The study “identifies more about the genetic basis of this challenging condition,” said Dr. Donovan, who is also clinical instructor in the department of dermatology at the University of British Columbia, Vancouver, and president of the Canadian Hair Loss Foundation. “We really need this type of information in order to have any sort of clue in terms of how to treat it,” he told this news organization.
“In the hair loss world, it’s pretty clear that if you can understand the genetic basis of things, or the basic science of a condition, whether it’s the basic genetics or the basic immunology, you give yourself the best chance to develop good treatments,” said Dr. Donovan.
The article provides advanced genetic information of the condition, such that geneticists can test for at least three markers if they are suspecting UHS, Dr. Donovan observed.
Condition can lead to bullying
Dr. Donovan also commented that UHS can have a detrimental impact on children with regard to socializing with their peers. “Having hair that sticks out and is very full like this is challenging because kids do get teased,” he said.
“It is often the parents who are the most affected” when a child aged 2-5 years has a hair condition such as UHS. But at age 5-9, “children are developing self-identity and an understanding of various aspects of self-esteem and what they look like and what others look like. And that’s where the teasing really starts. And that’s where it does become troublesome.”
Dr. Betz and Dr. Donovan have disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
that manifests during infancy, investigators have reported.
The findings are from a cohort study published in JAMA Dermatology, which involved 107 unrelated children and adults suspected of having UHS, as well as family members, all of whom were recruited from January 2013 to December 2021. Genetic analyses were conducted in Germany from January 2014 to December 2021 with exome sequencing.
Study builds on prior research
Senior author Regina C. Betz, MD, professor of dermatogenetics at the Institute of Human Genetics, University Hospital Bonn, Germany, said that in 2016, she and her coinvestigators authored a study on the molecular genetics of UHS. That study, which involved 18 people with UHS, identified variants in three genes – PADI3, TCHH, and TGM3 – that encode proteins that play a role in the formation of the hair shaft. The investigators described how a deficiency in the shaping and mechanical strengthening of the hair shaft occurs in the UHS phenotype, which is characterized by dry, frizzy, and wiry hair that cannot be combed flat.
As a result of that previous work, “we base the assignment or confirmation of a clinical diagnosis of UHS on molecular genetic diagnostics,” the authors write in the new study, rather than on the clinical appearance of the hair and the physical examination of the patient, with confirmation on microscopical examination of the hair shaft.
Social media as instrument in finding study participants
Following the 2016 study, Dr. Betz and colleagues were contacted by many clinicians and by the public through Facebook and other social media platforms with details about possible cases of UHS, an autosomal recessive disorder. Through these contacts, blood samples, saliva, or DNA was sent to the investigators’ laboratory from 89 unrelated index patients (69 female patients, 20 male patients) suspected of having UHS. This resulted in the identification of pathogenic variants in 69 cases, the investigators write.
“In the first study, we had 18 patients, and then we tried to collect as many as possible” to determine the main mechanism behind UHS, Dr. Betz said. One question is whether there are additional genes responsible for UHS, she noted. “Even now, we are not sure, because in 25% [of cases in the new study], we didn’t find any mutation in the three known genes.”
The current study resulted in the discovery of eight novel pathogenic variants in PADI3, which are responsible for 71.0% (76) of the 107 cases. Of those, “6 were single observations and 2 were observed in 3 and 2 individuals, respectively,” the investigators write.
Children can grow out of this disorder, but it can also persist into adulthood, Dr. Betz noted. Communication that investigators had with parents of the children with UHS revealed that these children are often the targets of bullying by other children, she added.
She and her and colleagues will continue this research and are currently studying adults who have UHS.
Research leads to possible treatment pathways
Jeff Donovan, MD, FRCPC, FAAD, a dermatologist and medical director of the Donovan Hair Clinic in Whistler, British Columbia, described these findings as fundamental to understanding UHS and creating pathways to possible treatments.
The study “identifies more about the genetic basis of this challenging condition,” said Dr. Donovan, who is also clinical instructor in the department of dermatology at the University of British Columbia, Vancouver, and president of the Canadian Hair Loss Foundation. “We really need this type of information in order to have any sort of clue in terms of how to treat it,” he told this news organization.
“In the hair loss world, it’s pretty clear that if you can understand the genetic basis of things, or the basic science of a condition, whether it’s the basic genetics or the basic immunology, you give yourself the best chance to develop good treatments,” said Dr. Donovan.
The article provides advanced genetic information of the condition, such that geneticists can test for at least three markers if they are suspecting UHS, Dr. Donovan observed.
Condition can lead to bullying
Dr. Donovan also commented that UHS can have a detrimental impact on children with regard to socializing with their peers. “Having hair that sticks out and is very full like this is challenging because kids do get teased,” he said.
“It is often the parents who are the most affected” when a child aged 2-5 years has a hair condition such as UHS. But at age 5-9, “children are developing self-identity and an understanding of various aspects of self-esteem and what they look like and what others look like. And that’s where the teasing really starts. And that’s where it does become troublesome.”
Dr. Betz and Dr. Donovan have disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
FROM JAMA DERMATOLOGY
Cannabis industry cribs Big Tobacco’s social responsibility initiatives
according to recent data.
A qualitative study of cannabis companies’ CSR practices over 10 years found, for example, that dispensary Trulieve provided $15,000 for internships and $20,000 for scholarships to prepare Black students for careers in the cannabis industry. The tobacco industry has used similar initiatives to foster good will and market its products to minority populations.
“The main message from this paper is that this is an industry selling a product with health impacts,” said study author Tanner Wakefield, an associate specialist at the Center for Tobacco Control Research and Education at the University of California, San Francisco. “We have seen how the tobacco industry in the past has used corporate social responsibility practices to insulate itself politically, engender public good will, and encourage consumption of tobacco products with harmful health effects.”
The study was published in JAMA Network Open.
A double agenda
The investigators identified 9 of the 10 largest publicly traded cannabis companies in the United States and Canada and examined the CSR activities that they conducted between Jan. 1, 2012, and Dec. 31, 2021. The investigators also conducted a systematic review of corporate websites and Nexis Uni articles that identified 153 news stories, press releases, and web pages that communicated about cannabis companies’ charitable and philanthropic activities.
Investigators identified themes in CSR activities by categorizing the language and informational patterns in the evidence they collected. They divided CSR practices into five categories, consisting of campaigns supposedly mitigating the harmful effects of past cannabis prohibition; initiatives characterized as promoting or increasing diversity, equity, and inclusion; charitable contributions; researching therapeutic cannabis uses and increasing medical access; and efforts claiming to address harms related to cannabis legalization.
The investigators observed that Green Thumb Industries and Cresco Labs set up “business incubators” and licensing assistance programs targeted toward members of racial and ethnic minority populations and communities most affected by cannabis prohibition. Canopy Growth Corporation supported research into whether medical cannabis could alleviate sleep disorders or treat mental health conditions. The company also collaborated with Canadian Students for Sensible Drug Policy and Parent Action on Drugs to create materials for preventing cannabis abuse among youth.
“I think we need to remember that this is an industry selling a product,” said Mr. Wakefield. “And just because there is merit to addressing certain issues or harms, that doesn’t mean we should forget that they are businesses seeking to make a profit. While CSR activities may have some potential benefits or apparent legitimacy, we have to remember that CSR is also a form of marketing and political influence.”
The investigators concluded that these CSR activities were similar to CSR strategies that the tobacco industry previously had used to encourage consumption, target marginalized communities, influence regulation, and advance corporate interests.
“A similarity to the tobacco industry is that they would provide funding or assistance to nonprofit groups that are not necessarily tied to cannabis or tobacco,” said Mr. Wakefield. For example, the investigators noted that cannabis companies contributed funding for breast cancer research and for veterans.
Moreover, the investigators observed “similarities in terms of focus and orientation toward special interest populations,” said Mr. Wakefield. Those special populations included the LGBTQ communities, and activities included sponsoring or participating in pride celebrations and releasing limited-edition pride products.
Overall, the cannabis industry engages in CSR activities that appear to mitigate the harmful effects of its products and operations, said Mr. Wakefield.
‘Incomplete information’
Jason W. Busse, DC, PhD, associate director of the Michael G. DeGroote Centre for Medicinal Cannabis Research at McMaster University, Hamilton, Ont., described the study as rigorous, but with limitations acknowledged by the authors.
“Understanding how these companies are promoting themselves and justifying themselves as good corporate citizens is important,” said Dr. Busse. “The investigators have undertaken a comprehensive study and identified CSR activities that cannabis companies are engaging in. We know from past experiences with tobacco companies that these activities may be used in part to encourage less regulation and increase market access.”
One constraint of the study is that the investigators used documents that were in the public domain, as opposed to internal company information. “The investigators were limited to the information that they were able to access,” said Dr. Busse. “Unless you use the Freedom of Information Act to compel companies to release internal documents, you don’t have that information. They haven’t done that, and it is almost a certainty that the authors had to work with incomplete information.”
The investigators suggest a need for oversight of the cannabis industry’s CSR practices, and Dr. Busse agreed with this assessment. “While engagement in social responsibility activities by cannabis corporations may have positive results, there should be independent assessment of outcomes. For example, sponsoring research may be problematic if such support comes with strings attached, such as suppressing or modifying unfavorable findings.”
The study was supported by the National Institutes of Health. Dr. Wakefield and Dr. Busse reported no relevant financial relationships.
A version of this article first appeared on Medscape.com.
according to recent data.
A qualitative study of cannabis companies’ CSR practices over 10 years found, for example, that dispensary Trulieve provided $15,000 for internships and $20,000 for scholarships to prepare Black students for careers in the cannabis industry. The tobacco industry has used similar initiatives to foster good will and market its products to minority populations.
“The main message from this paper is that this is an industry selling a product with health impacts,” said study author Tanner Wakefield, an associate specialist at the Center for Tobacco Control Research and Education at the University of California, San Francisco. “We have seen how the tobacco industry in the past has used corporate social responsibility practices to insulate itself politically, engender public good will, and encourage consumption of tobacco products with harmful health effects.”
The study was published in JAMA Network Open.
A double agenda
The investigators identified 9 of the 10 largest publicly traded cannabis companies in the United States and Canada and examined the CSR activities that they conducted between Jan. 1, 2012, and Dec. 31, 2021. The investigators also conducted a systematic review of corporate websites and Nexis Uni articles that identified 153 news stories, press releases, and web pages that communicated about cannabis companies’ charitable and philanthropic activities.
Investigators identified themes in CSR activities by categorizing the language and informational patterns in the evidence they collected. They divided CSR practices into five categories, consisting of campaigns supposedly mitigating the harmful effects of past cannabis prohibition; initiatives characterized as promoting or increasing diversity, equity, and inclusion; charitable contributions; researching therapeutic cannabis uses and increasing medical access; and efforts claiming to address harms related to cannabis legalization.
The investigators observed that Green Thumb Industries and Cresco Labs set up “business incubators” and licensing assistance programs targeted toward members of racial and ethnic minority populations and communities most affected by cannabis prohibition. Canopy Growth Corporation supported research into whether medical cannabis could alleviate sleep disorders or treat mental health conditions. The company also collaborated with Canadian Students for Sensible Drug Policy and Parent Action on Drugs to create materials for preventing cannabis abuse among youth.
“I think we need to remember that this is an industry selling a product,” said Mr. Wakefield. “And just because there is merit to addressing certain issues or harms, that doesn’t mean we should forget that they are businesses seeking to make a profit. While CSR activities may have some potential benefits or apparent legitimacy, we have to remember that CSR is also a form of marketing and political influence.”
The investigators concluded that these CSR activities were similar to CSR strategies that the tobacco industry previously had used to encourage consumption, target marginalized communities, influence regulation, and advance corporate interests.
“A similarity to the tobacco industry is that they would provide funding or assistance to nonprofit groups that are not necessarily tied to cannabis or tobacco,” said Mr. Wakefield. For example, the investigators noted that cannabis companies contributed funding for breast cancer research and for veterans.
Moreover, the investigators observed “similarities in terms of focus and orientation toward special interest populations,” said Mr. Wakefield. Those special populations included the LGBTQ communities, and activities included sponsoring or participating in pride celebrations and releasing limited-edition pride products.
Overall, the cannabis industry engages in CSR activities that appear to mitigate the harmful effects of its products and operations, said Mr. Wakefield.
‘Incomplete information’
Jason W. Busse, DC, PhD, associate director of the Michael G. DeGroote Centre for Medicinal Cannabis Research at McMaster University, Hamilton, Ont., described the study as rigorous, but with limitations acknowledged by the authors.
“Understanding how these companies are promoting themselves and justifying themselves as good corporate citizens is important,” said Dr. Busse. “The investigators have undertaken a comprehensive study and identified CSR activities that cannabis companies are engaging in. We know from past experiences with tobacco companies that these activities may be used in part to encourage less regulation and increase market access.”
One constraint of the study is that the investigators used documents that were in the public domain, as opposed to internal company information. “The investigators were limited to the information that they were able to access,” said Dr. Busse. “Unless you use the Freedom of Information Act to compel companies to release internal documents, you don’t have that information. They haven’t done that, and it is almost a certainty that the authors had to work with incomplete information.”
The investigators suggest a need for oversight of the cannabis industry’s CSR practices, and Dr. Busse agreed with this assessment. “While engagement in social responsibility activities by cannabis corporations may have positive results, there should be independent assessment of outcomes. For example, sponsoring research may be problematic if such support comes with strings attached, such as suppressing or modifying unfavorable findings.”
The study was supported by the National Institutes of Health. Dr. Wakefield and Dr. Busse reported no relevant financial relationships.
A version of this article first appeared on Medscape.com.
according to recent data.
A qualitative study of cannabis companies’ CSR practices over 10 years found, for example, that dispensary Trulieve provided $15,000 for internships and $20,000 for scholarships to prepare Black students for careers in the cannabis industry. The tobacco industry has used similar initiatives to foster good will and market its products to minority populations.
“The main message from this paper is that this is an industry selling a product with health impacts,” said study author Tanner Wakefield, an associate specialist at the Center for Tobacco Control Research and Education at the University of California, San Francisco. “We have seen how the tobacco industry in the past has used corporate social responsibility practices to insulate itself politically, engender public good will, and encourage consumption of tobacco products with harmful health effects.”
The study was published in JAMA Network Open.
A double agenda
The investigators identified 9 of the 10 largest publicly traded cannabis companies in the United States and Canada and examined the CSR activities that they conducted between Jan. 1, 2012, and Dec. 31, 2021. The investigators also conducted a systematic review of corporate websites and Nexis Uni articles that identified 153 news stories, press releases, and web pages that communicated about cannabis companies’ charitable and philanthropic activities.
Investigators identified themes in CSR activities by categorizing the language and informational patterns in the evidence they collected. They divided CSR practices into five categories, consisting of campaigns supposedly mitigating the harmful effects of past cannabis prohibition; initiatives characterized as promoting or increasing diversity, equity, and inclusion; charitable contributions; researching therapeutic cannabis uses and increasing medical access; and efforts claiming to address harms related to cannabis legalization.
The investigators observed that Green Thumb Industries and Cresco Labs set up “business incubators” and licensing assistance programs targeted toward members of racial and ethnic minority populations and communities most affected by cannabis prohibition. Canopy Growth Corporation supported research into whether medical cannabis could alleviate sleep disorders or treat mental health conditions. The company also collaborated with Canadian Students for Sensible Drug Policy and Parent Action on Drugs to create materials for preventing cannabis abuse among youth.
“I think we need to remember that this is an industry selling a product,” said Mr. Wakefield. “And just because there is merit to addressing certain issues or harms, that doesn’t mean we should forget that they are businesses seeking to make a profit. While CSR activities may have some potential benefits or apparent legitimacy, we have to remember that CSR is also a form of marketing and political influence.”
The investigators concluded that these CSR activities were similar to CSR strategies that the tobacco industry previously had used to encourage consumption, target marginalized communities, influence regulation, and advance corporate interests.
“A similarity to the tobacco industry is that they would provide funding or assistance to nonprofit groups that are not necessarily tied to cannabis or tobacco,” said Mr. Wakefield. For example, the investigators noted that cannabis companies contributed funding for breast cancer research and for veterans.
Moreover, the investigators observed “similarities in terms of focus and orientation toward special interest populations,” said Mr. Wakefield. Those special populations included the LGBTQ communities, and activities included sponsoring or participating in pride celebrations and releasing limited-edition pride products.
Overall, the cannabis industry engages in CSR activities that appear to mitigate the harmful effects of its products and operations, said Mr. Wakefield.
‘Incomplete information’
Jason W. Busse, DC, PhD, associate director of the Michael G. DeGroote Centre for Medicinal Cannabis Research at McMaster University, Hamilton, Ont., described the study as rigorous, but with limitations acknowledged by the authors.
“Understanding how these companies are promoting themselves and justifying themselves as good corporate citizens is important,” said Dr. Busse. “The investigators have undertaken a comprehensive study and identified CSR activities that cannabis companies are engaging in. We know from past experiences with tobacco companies that these activities may be used in part to encourage less regulation and increase market access.”
One constraint of the study is that the investigators used documents that were in the public domain, as opposed to internal company information. “The investigators were limited to the information that they were able to access,” said Dr. Busse. “Unless you use the Freedom of Information Act to compel companies to release internal documents, you don’t have that information. They haven’t done that, and it is almost a certainty that the authors had to work with incomplete information.”
The investigators suggest a need for oversight of the cannabis industry’s CSR practices, and Dr. Busse agreed with this assessment. “While engagement in social responsibility activities by cannabis corporations may have positive results, there should be independent assessment of outcomes. For example, sponsoring research may be problematic if such support comes with strings attached, such as suppressing or modifying unfavorable findings.”
The study was supported by the National Institutes of Health. Dr. Wakefield and Dr. Busse reported no relevant financial relationships.
A version of this article first appeared on Medscape.com.
FROM JAMA NETWORK OPEN
Poor physician access linked with unplanned return ED visits
Difficulty in accessing a family physician is associated with a higher risk for unplanned return visits to the emergency department among patients aged 75 years and older, new data indicate.
In a prospective, observational study that included almost 2,000 patients in this age group, 16% of participants attempted to contact their family physicians before their ED visits. Of this group, more than half reported having difficulty seeing their physicians for urgent problems, more than 40% had difficulty speaking with their family physicians by telephone, and more than one-third had difficulty booking appointments for new health problems.
write study author Marc Afilalo, MD, director of the ED at Jewish General Hospital in Montreal, and colleagues. “Therefore, community-based programs that target patient education and improved access to primary care are necessary not only for reducing return visits to the ED, but also for continuity of care and patient satisfaction.”
The study was published in Canadian Family Physician.
Comorbidities increased risk
Researchers have estimated that half of Canadians aged 75 years or older use emergency services. Data indicate that the number of unplanned return visits to the ED is associated with increased functional decline and death. But the question of how patient access to primary care services affects unplanned ED return visits has received little attention, according to the investigators.
They conducted a multicenter study at three tertiary adult teaching hospitals in Montreal. From 2012 to 2014, they recruited patients aged 75 years and older who had visited the ED and who lived in their own homes or in an autonomous residence.
Investigators collected data through structured interviews, administrative databases, and medical chart reviews. They followed up with participants at 3 months by telephone. The study’s main outcome was return visit to the ED.
The researchers identified 4,577 patients and included 1,998 in their analysis. Of that total, 33% were 85 or older, 34% lived alone, and 91% had a family physician. Within 3 months, 562 patients (28%) had made 894 return visits to the ED.
Among patients aged 85 years or older (relative risk, 0.80), as well as those whose triage score was less severe (RR, 0.83) and those who were admitted during the index ED visit (RR, 0.76), rates of return ED visits were lower. Among patients who had trouble booking appointments with their family doctors to address new problems (RR, 1.19), as well as those who had made ED visits within the previous 6 months (RR, 1.47) or had a higher Charlson comorbidity index score (RR, 1.06 for every 1-unit increase), rates of return visits were higher.
Factors associated with a higher likelihood of return visits were visits to the ED in the previous 6 months (odds ratio, 2.11), increased Charlson comorbidity index score (OR, 1.41 for every 1-unit increase), and having received help from local community services (OR, 3.00).
Primary care access
The study suggests that improvements in primary care access are needed to decrease return visits to the ED, Samir Sinha, MD, DPhil, director of geriatrics at Mount Sinai and the University Health Network Hospitals in Toronto, told this news organization. Dr. Sinha was not involved in the study.
“It reminds us of the importance of having a strong primary care system,” he added. “Of this population, 91% had primary care providers. And what the paper demonstrates is that those who are having trouble accessing their primary care providers are more likely to be readmitted to an ED. We can only imagine how much worse the outcomes are for people who don’t have a primary care provider.”
Patients are frequently advised to visit the ED when they contact their primary care providers, said Mark Rosenberg, PhD, professor of geography and planning and the Canada Research Chair in Aging, Health, and Development at Queens University in Kingston, Ont., said in an interview. He noted that primary care is organized as an appointment-based system. Dr. Rosenberg did not participate in the study.
“If I were to call my primary care provider in the middle of the afternoon and say that I have got chest pains, they are going to simply tell me to go to emergency,” said Dr. Rosenberg. “It is not just older people. Many people end up in the ED because they are told to go to the ED.”
Associations with age
“The higher your Charlson comorbidity index, the more multiple, complex health issues you’re dealing with,” said Sinha. He added that the data suggest the frailty of the study population.
The association between age 85 years or older and a lower rate of a return ED visits might mean that the patient did not return to independent living after the ED visit, Dr. Rosenberg speculated. “If it’s a serious health problem, you’re more likely to end up going into long-term care at that stage, and you are not going back to living in the community in your home,” he said. “You’re likely going into some sort of transition care or alternative care.”
People aged 85 years or older who are hospitalized are more likely not to survive their index hospital admission, compared with patients who are aged 75-85 years. There would be no possibility that such patients would revisit the ED in the future, said Dr. Sinha.
Expanding primary care
The major solution to decreasing reliance on the ED lies in revamping primary health care so that it offers an expanded level of care and 24/7 access, said Dr. Rosenberg.
Providing continuity of care, identifying problems, and managing them in the community before they become urgent or require a hospitalization are priorities for primary care and will help shift away from return visits to the ED, which should be a last resort for patients, said Dr. Sinha.
Moreover, patients must be able to access primary care in various ways, be it a telephone consultation, a video consultation, or a face-to-face consultation, he added. Face-to-face consultations can take place in a provider’s office or even in a patient’s home when warranted, he said. “What we need to make sure of is that all three types of consultations are available, so that people can actually get the most appropriate care at the time they’re calling.”
The study had no external funding. Dr. Afilalo, Dr. Sinha, and Dr. Rosenberg have disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
Difficulty in accessing a family physician is associated with a higher risk for unplanned return visits to the emergency department among patients aged 75 years and older, new data indicate.
In a prospective, observational study that included almost 2,000 patients in this age group, 16% of participants attempted to contact their family physicians before their ED visits. Of this group, more than half reported having difficulty seeing their physicians for urgent problems, more than 40% had difficulty speaking with their family physicians by telephone, and more than one-third had difficulty booking appointments for new health problems.
write study author Marc Afilalo, MD, director of the ED at Jewish General Hospital in Montreal, and colleagues. “Therefore, community-based programs that target patient education and improved access to primary care are necessary not only for reducing return visits to the ED, but also for continuity of care and patient satisfaction.”
The study was published in Canadian Family Physician.
Comorbidities increased risk
Researchers have estimated that half of Canadians aged 75 years or older use emergency services. Data indicate that the number of unplanned return visits to the ED is associated with increased functional decline and death. But the question of how patient access to primary care services affects unplanned ED return visits has received little attention, according to the investigators.
They conducted a multicenter study at three tertiary adult teaching hospitals in Montreal. From 2012 to 2014, they recruited patients aged 75 years and older who had visited the ED and who lived in their own homes or in an autonomous residence.
Investigators collected data through structured interviews, administrative databases, and medical chart reviews. They followed up with participants at 3 months by telephone. The study’s main outcome was return visit to the ED.
The researchers identified 4,577 patients and included 1,998 in their analysis. Of that total, 33% were 85 or older, 34% lived alone, and 91% had a family physician. Within 3 months, 562 patients (28%) had made 894 return visits to the ED.
Among patients aged 85 years or older (relative risk, 0.80), as well as those whose triage score was less severe (RR, 0.83) and those who were admitted during the index ED visit (RR, 0.76), rates of return ED visits were lower. Among patients who had trouble booking appointments with their family doctors to address new problems (RR, 1.19), as well as those who had made ED visits within the previous 6 months (RR, 1.47) or had a higher Charlson comorbidity index score (RR, 1.06 for every 1-unit increase), rates of return visits were higher.
Factors associated with a higher likelihood of return visits were visits to the ED in the previous 6 months (odds ratio, 2.11), increased Charlson comorbidity index score (OR, 1.41 for every 1-unit increase), and having received help from local community services (OR, 3.00).
Primary care access
The study suggests that improvements in primary care access are needed to decrease return visits to the ED, Samir Sinha, MD, DPhil, director of geriatrics at Mount Sinai and the University Health Network Hospitals in Toronto, told this news organization. Dr. Sinha was not involved in the study.
“It reminds us of the importance of having a strong primary care system,” he added. “Of this population, 91% had primary care providers. And what the paper demonstrates is that those who are having trouble accessing their primary care providers are more likely to be readmitted to an ED. We can only imagine how much worse the outcomes are for people who don’t have a primary care provider.”
Patients are frequently advised to visit the ED when they contact their primary care providers, said Mark Rosenberg, PhD, professor of geography and planning and the Canada Research Chair in Aging, Health, and Development at Queens University in Kingston, Ont., said in an interview. He noted that primary care is organized as an appointment-based system. Dr. Rosenberg did not participate in the study.
“If I were to call my primary care provider in the middle of the afternoon and say that I have got chest pains, they are going to simply tell me to go to emergency,” said Dr. Rosenberg. “It is not just older people. Many people end up in the ED because they are told to go to the ED.”
Associations with age
“The higher your Charlson comorbidity index, the more multiple, complex health issues you’re dealing with,” said Sinha. He added that the data suggest the frailty of the study population.
The association between age 85 years or older and a lower rate of a return ED visits might mean that the patient did not return to independent living after the ED visit, Dr. Rosenberg speculated. “If it’s a serious health problem, you’re more likely to end up going into long-term care at that stage, and you are not going back to living in the community in your home,” he said. “You’re likely going into some sort of transition care or alternative care.”
People aged 85 years or older who are hospitalized are more likely not to survive their index hospital admission, compared with patients who are aged 75-85 years. There would be no possibility that such patients would revisit the ED in the future, said Dr. Sinha.
Expanding primary care
The major solution to decreasing reliance on the ED lies in revamping primary health care so that it offers an expanded level of care and 24/7 access, said Dr. Rosenberg.
Providing continuity of care, identifying problems, and managing them in the community before they become urgent or require a hospitalization are priorities for primary care and will help shift away from return visits to the ED, which should be a last resort for patients, said Dr. Sinha.
Moreover, patients must be able to access primary care in various ways, be it a telephone consultation, a video consultation, or a face-to-face consultation, he added. Face-to-face consultations can take place in a provider’s office or even in a patient’s home when warranted, he said. “What we need to make sure of is that all three types of consultations are available, so that people can actually get the most appropriate care at the time they’re calling.”
The study had no external funding. Dr. Afilalo, Dr. Sinha, and Dr. Rosenberg have disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
Difficulty in accessing a family physician is associated with a higher risk for unplanned return visits to the emergency department among patients aged 75 years and older, new data indicate.
In a prospective, observational study that included almost 2,000 patients in this age group, 16% of participants attempted to contact their family physicians before their ED visits. Of this group, more than half reported having difficulty seeing their physicians for urgent problems, more than 40% had difficulty speaking with their family physicians by telephone, and more than one-third had difficulty booking appointments for new health problems.
write study author Marc Afilalo, MD, director of the ED at Jewish General Hospital in Montreal, and colleagues. “Therefore, community-based programs that target patient education and improved access to primary care are necessary not only for reducing return visits to the ED, but also for continuity of care and patient satisfaction.”
The study was published in Canadian Family Physician.
Comorbidities increased risk
Researchers have estimated that half of Canadians aged 75 years or older use emergency services. Data indicate that the number of unplanned return visits to the ED is associated with increased functional decline and death. But the question of how patient access to primary care services affects unplanned ED return visits has received little attention, according to the investigators.
They conducted a multicenter study at three tertiary adult teaching hospitals in Montreal. From 2012 to 2014, they recruited patients aged 75 years and older who had visited the ED and who lived in their own homes or in an autonomous residence.
Investigators collected data through structured interviews, administrative databases, and medical chart reviews. They followed up with participants at 3 months by telephone. The study’s main outcome was return visit to the ED.
The researchers identified 4,577 patients and included 1,998 in their analysis. Of that total, 33% were 85 or older, 34% lived alone, and 91% had a family physician. Within 3 months, 562 patients (28%) had made 894 return visits to the ED.
Among patients aged 85 years or older (relative risk, 0.80), as well as those whose triage score was less severe (RR, 0.83) and those who were admitted during the index ED visit (RR, 0.76), rates of return ED visits were lower. Among patients who had trouble booking appointments with their family doctors to address new problems (RR, 1.19), as well as those who had made ED visits within the previous 6 months (RR, 1.47) or had a higher Charlson comorbidity index score (RR, 1.06 for every 1-unit increase), rates of return visits were higher.
Factors associated with a higher likelihood of return visits were visits to the ED in the previous 6 months (odds ratio, 2.11), increased Charlson comorbidity index score (OR, 1.41 for every 1-unit increase), and having received help from local community services (OR, 3.00).
Primary care access
The study suggests that improvements in primary care access are needed to decrease return visits to the ED, Samir Sinha, MD, DPhil, director of geriatrics at Mount Sinai and the University Health Network Hospitals in Toronto, told this news organization. Dr. Sinha was not involved in the study.
“It reminds us of the importance of having a strong primary care system,” he added. “Of this population, 91% had primary care providers. And what the paper demonstrates is that those who are having trouble accessing their primary care providers are more likely to be readmitted to an ED. We can only imagine how much worse the outcomes are for people who don’t have a primary care provider.”
Patients are frequently advised to visit the ED when they contact their primary care providers, said Mark Rosenberg, PhD, professor of geography and planning and the Canada Research Chair in Aging, Health, and Development at Queens University in Kingston, Ont., said in an interview. He noted that primary care is organized as an appointment-based system. Dr. Rosenberg did not participate in the study.
“If I were to call my primary care provider in the middle of the afternoon and say that I have got chest pains, they are going to simply tell me to go to emergency,” said Dr. Rosenberg. “It is not just older people. Many people end up in the ED because they are told to go to the ED.”
Associations with age
“The higher your Charlson comorbidity index, the more multiple, complex health issues you’re dealing with,” said Sinha. He added that the data suggest the frailty of the study population.
The association between age 85 years or older and a lower rate of a return ED visits might mean that the patient did not return to independent living after the ED visit, Dr. Rosenberg speculated. “If it’s a serious health problem, you’re more likely to end up going into long-term care at that stage, and you are not going back to living in the community in your home,” he said. “You’re likely going into some sort of transition care or alternative care.”
People aged 85 years or older who are hospitalized are more likely not to survive their index hospital admission, compared with patients who are aged 75-85 years. There would be no possibility that such patients would revisit the ED in the future, said Dr. Sinha.
Expanding primary care
The major solution to decreasing reliance on the ED lies in revamping primary health care so that it offers an expanded level of care and 24/7 access, said Dr. Rosenberg.
Providing continuity of care, identifying problems, and managing them in the community before they become urgent or require a hospitalization are priorities for primary care and will help shift away from return visits to the ED, which should be a last resort for patients, said Dr. Sinha.
Moreover, patients must be able to access primary care in various ways, be it a telephone consultation, a video consultation, or a face-to-face consultation, he added. Face-to-face consultations can take place in a provider’s office or even in a patient’s home when warranted, he said. “What we need to make sure of is that all three types of consultations are available, so that people can actually get the most appropriate care at the time they’re calling.”
The study had no external funding. Dr. Afilalo, Dr. Sinha, and Dr. Rosenberg have disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
FROM CANADIAN FAMILY PHYSICIAN
Black Americans’ high gout rate stems from social causes
Gout prevalence is more common in Black Americans than White Americans, and the disparity in prevalence is attributable to social determinants of health, according to a recently published article in JAMA Network Open.
“There has been evidence from recent cohort studies in the U.S. that was suggesting that the prevalence and incidence [of gout] was growing among non-White populations,” said Natalie McCormick, PhD, the study’s lead author and postdoctoral research fellow in medicine in the division of rheumatology, allergy, and immunology at Massachusetts General Hospital and Harvard Medical School, both in Boston. “We wanted to do this at the general population level to see how generalizable [that evidence] is.”
Alvin Wells, MD, PhD, director of the department of rheumatology at Advocate Aurora Medical Group, Franklin, Wisc., noted the findings highlight inequities in care for patients with gout that could be improved with greater emphasis on educating patients about their condition.
“I think that what this shows is that in the U.S. ... there still are some disparities in treating gout,” said Dr. Wells, who was not involved with the study. “And that we have ways to mitigate that, with not only aggressive therapy, but also with other tools like counseling patients. At the end of the day, people all want to be educated about the disease.”
Greater prevalence disappears with adjustment for socioclinical factors
The cross-sectional analysis involved data from U.S. adult participants in the National Health and Nutrition Examination Survey (NHANES) from 2007 to 2016 who self-reported Black or White race.
Investigators considered factors such as excess body mass index (BMI), chronic kidney disease (defined as estimated glomerular filtration rate less than 60 mL/min per 1.73 m2), poverty, poor-quality diet, lower educational level, alcohol consumption, and diuretic use in their analysis.
Dr. McCormick and coinvestigators included a total of 18,693 participants, consisting of 3,304 Black women, 6,195 White women, 3,085 Black men, and 6,109 White men.
They determined that the age-standardized prevalence of gout was 3.5% (95% confidence interval, 2.7%-4.3%) in Black women and 2.0% (95% CI, 1.5% - 2.5%) in White women (age-adjusted odds ratio, 1.81; 95% CI, 1.29-2.53). They calculated that the prevalence was 7.0% (95% CI, 6.2%-7.9%) in Black men and 5.4% (95% CI, 4.7%-6.2%) in White men (age-adjusted OR, 1.26; 95% CI, 1.02-1.55). They found similar differences in the prevalence of hyperuricemia between Black and White Americans.
The increased prevalence of gout in Black Americans, compared with White Americans, does not arise from genetics, according to McCormick. “Our conclusion was that it was due to social determinants of health,” she said. “When we adjusted for all socioclinical risk factors, the racial differences in gout and hyperuricemia prevalence disappeared. Importantly, stepwise regression analysis showed the two biggest drivers of the racial difference in gout prevalence among women were poverty itself, and excess BMI, which can be influenced by poverty.”
Dr. McCormick pointed out that in contrast to the current data, there was no racial difference in the prevalence of gout approximately 2 decades earlier, looking at data from the 1988-1994 NHANES III.
Given the findings, which included the fact that significantly more Black women and men were currently taking diuretics, compared with their White counterparts, Dr. McCormick pointed out clinicians should give more thought to medical therapies prescribed for conditions like high blood pressure to patients with gout or at risk for gout.
“One thing we found was that diuretic use was a driver” of gout, Dr. McCormick said. A prescriber “may want to consider different therapies that present a lower risk of gout if someone has hypertension. There could be greater consideration for prescribing alternatives to diuretics.”
More patient education and rheumatology referrals needed
An impediment to providing that education to patients with gout is unconscious bias on the part of the primary care provider, Dr. Wells said.
“It is about what your perspectives are and what you bring to the table,” he explained. “If you saw [a patient] who looked like someone in your family, that person will be treated differently [than someone who does not look like a family member]. That is where the whole concept [of unconscious bias] comes in.”
Primary care providers need to adopt a holistic approach to gout management that involves counseling about good nutrition, smoking cessation, regular exercise, and limiting alcohol consumption, in addition to medication adherence. Primary care providers may have a bias in treating their Black patients, failing to devote sufficient time and attention to assist them in getting their disease under control, he said.
“Gout should be just like any other chronic disease,” Dr. Wells said. “You need to have a target in mind, and you and your patient need to work together to get to that target. When [patients] end up in rheumatology offices, it is almost too late. I think the take-home message here is that in 2022 ... for any patient who has gout, that patient probably needs to be seen by a rheumatologist because, indeed, with aggressive therapy, preventive therapy, [and] education, and if they are on the right medications, they won’t end up with these crippling joints that we see all the time.”
Dr. McCormick and Dr. Wells disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
Gout prevalence is more common in Black Americans than White Americans, and the disparity in prevalence is attributable to social determinants of health, according to a recently published article in JAMA Network Open.
“There has been evidence from recent cohort studies in the U.S. that was suggesting that the prevalence and incidence [of gout] was growing among non-White populations,” said Natalie McCormick, PhD, the study’s lead author and postdoctoral research fellow in medicine in the division of rheumatology, allergy, and immunology at Massachusetts General Hospital and Harvard Medical School, both in Boston. “We wanted to do this at the general population level to see how generalizable [that evidence] is.”
Alvin Wells, MD, PhD, director of the department of rheumatology at Advocate Aurora Medical Group, Franklin, Wisc., noted the findings highlight inequities in care for patients with gout that could be improved with greater emphasis on educating patients about their condition.
“I think that what this shows is that in the U.S. ... there still are some disparities in treating gout,” said Dr. Wells, who was not involved with the study. “And that we have ways to mitigate that, with not only aggressive therapy, but also with other tools like counseling patients. At the end of the day, people all want to be educated about the disease.”
Greater prevalence disappears with adjustment for socioclinical factors
The cross-sectional analysis involved data from U.S. adult participants in the National Health and Nutrition Examination Survey (NHANES) from 2007 to 2016 who self-reported Black or White race.
Investigators considered factors such as excess body mass index (BMI), chronic kidney disease (defined as estimated glomerular filtration rate less than 60 mL/min per 1.73 m2), poverty, poor-quality diet, lower educational level, alcohol consumption, and diuretic use in their analysis.
Dr. McCormick and coinvestigators included a total of 18,693 participants, consisting of 3,304 Black women, 6,195 White women, 3,085 Black men, and 6,109 White men.
They determined that the age-standardized prevalence of gout was 3.5% (95% confidence interval, 2.7%-4.3%) in Black women and 2.0% (95% CI, 1.5% - 2.5%) in White women (age-adjusted odds ratio, 1.81; 95% CI, 1.29-2.53). They calculated that the prevalence was 7.0% (95% CI, 6.2%-7.9%) in Black men and 5.4% (95% CI, 4.7%-6.2%) in White men (age-adjusted OR, 1.26; 95% CI, 1.02-1.55). They found similar differences in the prevalence of hyperuricemia between Black and White Americans.
The increased prevalence of gout in Black Americans, compared with White Americans, does not arise from genetics, according to McCormick. “Our conclusion was that it was due to social determinants of health,” she said. “When we adjusted for all socioclinical risk factors, the racial differences in gout and hyperuricemia prevalence disappeared. Importantly, stepwise regression analysis showed the two biggest drivers of the racial difference in gout prevalence among women were poverty itself, and excess BMI, which can be influenced by poverty.”
Dr. McCormick pointed out that in contrast to the current data, there was no racial difference in the prevalence of gout approximately 2 decades earlier, looking at data from the 1988-1994 NHANES III.
Given the findings, which included the fact that significantly more Black women and men were currently taking diuretics, compared with their White counterparts, Dr. McCormick pointed out clinicians should give more thought to medical therapies prescribed for conditions like high blood pressure to patients with gout or at risk for gout.
“One thing we found was that diuretic use was a driver” of gout, Dr. McCormick said. A prescriber “may want to consider different therapies that present a lower risk of gout if someone has hypertension. There could be greater consideration for prescribing alternatives to diuretics.”
More patient education and rheumatology referrals needed
An impediment to providing that education to patients with gout is unconscious bias on the part of the primary care provider, Dr. Wells said.
“It is about what your perspectives are and what you bring to the table,” he explained. “If you saw [a patient] who looked like someone in your family, that person will be treated differently [than someone who does not look like a family member]. That is where the whole concept [of unconscious bias] comes in.”
Primary care providers need to adopt a holistic approach to gout management that involves counseling about good nutrition, smoking cessation, regular exercise, and limiting alcohol consumption, in addition to medication adherence. Primary care providers may have a bias in treating their Black patients, failing to devote sufficient time and attention to assist them in getting their disease under control, he said.
“Gout should be just like any other chronic disease,” Dr. Wells said. “You need to have a target in mind, and you and your patient need to work together to get to that target. When [patients] end up in rheumatology offices, it is almost too late. I think the take-home message here is that in 2022 ... for any patient who has gout, that patient probably needs to be seen by a rheumatologist because, indeed, with aggressive therapy, preventive therapy, [and] education, and if they are on the right medications, they won’t end up with these crippling joints that we see all the time.”
Dr. McCormick and Dr. Wells disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
Gout prevalence is more common in Black Americans than White Americans, and the disparity in prevalence is attributable to social determinants of health, according to a recently published article in JAMA Network Open.
“There has been evidence from recent cohort studies in the U.S. that was suggesting that the prevalence and incidence [of gout] was growing among non-White populations,” said Natalie McCormick, PhD, the study’s lead author and postdoctoral research fellow in medicine in the division of rheumatology, allergy, and immunology at Massachusetts General Hospital and Harvard Medical School, both in Boston. “We wanted to do this at the general population level to see how generalizable [that evidence] is.”
Alvin Wells, MD, PhD, director of the department of rheumatology at Advocate Aurora Medical Group, Franklin, Wisc., noted the findings highlight inequities in care for patients with gout that could be improved with greater emphasis on educating patients about their condition.
“I think that what this shows is that in the U.S. ... there still are some disparities in treating gout,” said Dr. Wells, who was not involved with the study. “And that we have ways to mitigate that, with not only aggressive therapy, but also with other tools like counseling patients. At the end of the day, people all want to be educated about the disease.”
Greater prevalence disappears with adjustment for socioclinical factors
The cross-sectional analysis involved data from U.S. adult participants in the National Health and Nutrition Examination Survey (NHANES) from 2007 to 2016 who self-reported Black or White race.
Investigators considered factors such as excess body mass index (BMI), chronic kidney disease (defined as estimated glomerular filtration rate less than 60 mL/min per 1.73 m2), poverty, poor-quality diet, lower educational level, alcohol consumption, and diuretic use in their analysis.
Dr. McCormick and coinvestigators included a total of 18,693 participants, consisting of 3,304 Black women, 6,195 White women, 3,085 Black men, and 6,109 White men.
They determined that the age-standardized prevalence of gout was 3.5% (95% confidence interval, 2.7%-4.3%) in Black women and 2.0% (95% CI, 1.5% - 2.5%) in White women (age-adjusted odds ratio, 1.81; 95% CI, 1.29-2.53). They calculated that the prevalence was 7.0% (95% CI, 6.2%-7.9%) in Black men and 5.4% (95% CI, 4.7%-6.2%) in White men (age-adjusted OR, 1.26; 95% CI, 1.02-1.55). They found similar differences in the prevalence of hyperuricemia between Black and White Americans.
The increased prevalence of gout in Black Americans, compared with White Americans, does not arise from genetics, according to McCormick. “Our conclusion was that it was due to social determinants of health,” she said. “When we adjusted for all socioclinical risk factors, the racial differences in gout and hyperuricemia prevalence disappeared. Importantly, stepwise regression analysis showed the two biggest drivers of the racial difference in gout prevalence among women were poverty itself, and excess BMI, which can be influenced by poverty.”
Dr. McCormick pointed out that in contrast to the current data, there was no racial difference in the prevalence of gout approximately 2 decades earlier, looking at data from the 1988-1994 NHANES III.
Given the findings, which included the fact that significantly more Black women and men were currently taking diuretics, compared with their White counterparts, Dr. McCormick pointed out clinicians should give more thought to medical therapies prescribed for conditions like high blood pressure to patients with gout or at risk for gout.
“One thing we found was that diuretic use was a driver” of gout, Dr. McCormick said. A prescriber “may want to consider different therapies that present a lower risk of gout if someone has hypertension. There could be greater consideration for prescribing alternatives to diuretics.”
More patient education and rheumatology referrals needed
An impediment to providing that education to patients with gout is unconscious bias on the part of the primary care provider, Dr. Wells said.
“It is about what your perspectives are and what you bring to the table,” he explained. “If you saw [a patient] who looked like someone in your family, that person will be treated differently [than someone who does not look like a family member]. That is where the whole concept [of unconscious bias] comes in.”
Primary care providers need to adopt a holistic approach to gout management that involves counseling about good nutrition, smoking cessation, regular exercise, and limiting alcohol consumption, in addition to medication adherence. Primary care providers may have a bias in treating their Black patients, failing to devote sufficient time and attention to assist them in getting their disease under control, he said.
“Gout should be just like any other chronic disease,” Dr. Wells said. “You need to have a target in mind, and you and your patient need to work together to get to that target. When [patients] end up in rheumatology offices, it is almost too late. I think the take-home message here is that in 2022 ... for any patient who has gout, that patient probably needs to be seen by a rheumatologist because, indeed, with aggressive therapy, preventive therapy, [and] education, and if they are on the right medications, they won’t end up with these crippling joints that we see all the time.”
Dr. McCormick and Dr. Wells disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
FROM JAMA NETWORK OPEN