Although slightly fewer than 1% of hospitalizations for chronic obstructive pulmonary disease (COPD) are complicated by sepsis, this complication increases the risk for in-hospital mortality fivefold, investigators who studied a representative national sample found.

Among nearly 7 million hospitalizations in which the primary diagnosis was COPD, nearly 65,000 (0.93%) patients experienced sepsis as a complication. In all, 31% of patients with COPD and sepsis were discharged from the hospital to another care facility, and 19% of patients died in hospital, report Harshil Shah, MD, from Guthrie Corning (N.Y.) Hospital and colleagues.

“Our study highlights the need for better risk stratification in patients with COPD developing sepsis to improve the outcomes. Further studies are warranted to consider factoring some of the modifiable factors into account and to ameliorate the outcomes of sepsis during COPD hospitalizations,” Dr. Shah and colleagues write in a poster presented during the at the annual meeting of the American College of Chest Physicians, held virtually this year.

COPD has been associated with increased risk for sepsis because of the use of corticosteroids, underlying comorbidities, and, potentially, because of impaired barrier function, the authors note.
 

Nationwide sample

To determine the effects of sepsis and predictors of poor outcomes among patients hospitalized for COPD, the investigators used standard diagnostic codes to identify patients with a primary diagnosis of COPD from the Nationwide Inpatient Sample for the period 2007 through 2018 and sepsis from codes in secondary fields in the International Classification of Diseases (9th/10th Editions) Clinical Modification.

They identified a total of 6,940,615 hospitalizations in which the primary diagnosis was COPD; in 64,748 of those cases, sepsis was a complication.

As noted, the in-hospital death rate, one of two primary outcomes, was 19% for patients with COPD and sepsis, and the rate of discharge to other facilities was 31%.

In analysis adjusted for confounding factors, sepsis was associated with an odds ratio for mortality of 4.9 (P < .01) and an OR for discharge to a facility of 2.2 (P < .01).

With regard to trends, the investigators saw that, although the adjusted odds for in-hospital mortality remained stable over time, discharge to facilities increased significantly. In 2007, the adjusted OR was 2.2, whereas in 2018, it was 2.6 (P for trend = .02).

Predictors of in-hospital mortality among patients with sepsis included increasing age (OR, not shown), White ethnicity (OR, 1.2), treatment in the Northeast region (OR, 1.4), disseminated intravascular coagulation (OR, 3.7), pneumococcal infection (OR, 1.2), congestive heart failure (OR, 1.2), and renal failure (OR, 1.4; P < .01 for all comparisons).
 

Mortality risk for many patients

A COPD specialist who was not involved in the study told this news organization that sepsis is an uncommon but serious complication, not just for patients with COPD but also for those with other severe illnesses.

“Sepsis has a high risk for mortality whether a person has COPD or not,” commented David M. Mannino III MD, FCCP, FERS, professor of medicine at the University of Kentucky, Lexington, and a cofounder and co–medical director of the COPD Foundation.

“It’s not surprising that sepsis is lethal in this population; the question is, if you have COPD, are you more likely to have sepsis? And I think the answer is probably yes. The connection there is that people with COPD have a higher risk for pneumonia, and pneumonia itself is probably one of the biggest risk factors, or certainly an important risk factor, for the development of sepsis,” he said in an interview.

It would be interesting to see the relationship between sepsis and in-hospital mortality for patients with other chronic diseases or people without COPD, he said, and he would have liked to have seen more detailed information about trends over time than Dr. Shah and colleagues provided.

No funding source for the study was reported. Dr. Shah and colleagues and Dr. Mannino have disclosed no relevant financial relationships.

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

Although slightly fewer than 1% of hospitalizations for chronic obstructive pulmonary disease (COPD) are complicated by sepsis, this complication increases the risk for in-hospital mortality fivefold, investigators who studied a representative national sample found.

Among nearly 7 million hospitalizations in which the primary diagnosis was COPD, nearly 65,000 (0.93%) patients experienced sepsis as a complication. In all, 31% of patients with COPD and sepsis were discharged from the hospital to another care facility, and 19% of patients died in hospital, report Harshil Shah, MD, from Guthrie Corning (N.Y.) Hospital and colleagues.

“Our study highlights the need for better risk stratification in patients with COPD developing sepsis to improve the outcomes. Further studies are warranted to consider factoring some of the modifiable factors into account and to ameliorate the outcomes of sepsis during COPD hospitalizations,” Dr. Shah and colleagues write in a poster presented during the at the annual meeting of the American College of Chest Physicians, held virtually this year.

COPD has been associated with increased risk for sepsis because of the use of corticosteroids, underlying comorbidities, and, potentially, because of impaired barrier function, the authors note.
 

Nationwide sample

To determine the effects of sepsis and predictors of poor outcomes among patients hospitalized for COPD, the investigators used standard diagnostic codes to identify patients with a primary diagnosis of COPD from the Nationwide Inpatient Sample for the period 2007 through 2018 and sepsis from codes in secondary fields in the International Classification of Diseases (9th/10th Editions) Clinical Modification.

They identified a total of 6,940,615 hospitalizations in which the primary diagnosis was COPD; in 64,748 of those cases, sepsis was a complication.

As noted, the in-hospital death rate, one of two primary outcomes, was 19% for patients with COPD and sepsis, and the rate of discharge to other facilities was 31%.

In analysis adjusted for confounding factors, sepsis was associated with an odds ratio for mortality of 4.9 (P < .01) and an OR for discharge to a facility of 2.2 (P < .01).

With regard to trends, the investigators saw that, although the adjusted odds for in-hospital mortality remained stable over time, discharge to facilities increased significantly. In 2007, the adjusted OR was 2.2, whereas in 2018, it was 2.6 (P for trend = .02).

Predictors of in-hospital mortality among patients with sepsis included increasing age (OR, not shown), White ethnicity (OR, 1.2), treatment in the Northeast region (OR, 1.4), disseminated intravascular coagulation (OR, 3.7), pneumococcal infection (OR, 1.2), congestive heart failure (OR, 1.2), and renal failure (OR, 1.4; P < .01 for all comparisons).
 

Mortality risk for many patients

A COPD specialist who was not involved in the study told this news organization that sepsis is an uncommon but serious complication, not just for patients with COPD but also for those with other severe illnesses.

“Sepsis has a high risk for mortality whether a person has COPD or not,” commented David M. Mannino III MD, FCCP, FERS, professor of medicine at the University of Kentucky, Lexington, and a cofounder and co–medical director of the COPD Foundation.

“It’s not surprising that sepsis is lethal in this population; the question is, if you have COPD, are you more likely to have sepsis? And I think the answer is probably yes. The connection there is that people with COPD have a higher risk for pneumonia, and pneumonia itself is probably one of the biggest risk factors, or certainly an important risk factor, for the development of sepsis,” he said in an interview.

It would be interesting to see the relationship between sepsis and in-hospital mortality for patients with other chronic diseases or people without COPD, he said, and he would have liked to have seen more detailed information about trends over time than Dr. Shah and colleagues provided.

No funding source for the study was reported. Dr. Shah and colleagues and Dr. Mannino have disclosed no relevant financial relationships.

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

Although slightly fewer than 1% of hospitalizations for chronic obstructive pulmonary disease (COPD) are complicated by sepsis, this complication increases the risk for in-hospital mortality fivefold, investigators who studied a representative national sample found.

Among nearly 7 million hospitalizations in which the primary diagnosis was COPD, nearly 65,000 (0.93%) patients experienced sepsis as a complication. In all, 31% of patients with COPD and sepsis were discharged from the hospital to another care facility, and 19% of patients died in hospital, report Harshil Shah, MD, from Guthrie Corning (N.Y.) Hospital and colleagues.

“Our study highlights the need for better risk stratification in patients with COPD developing sepsis to improve the outcomes. Further studies are warranted to consider factoring some of the modifiable factors into account and to ameliorate the outcomes of sepsis during COPD hospitalizations,” Dr. Shah and colleagues write in a poster presented during the at the annual meeting of the American College of Chest Physicians, held virtually this year.

COPD has been associated with increased risk for sepsis because of the use of corticosteroids, underlying comorbidities, and, potentially, because of impaired barrier function, the authors note.
 

Nationwide sample

To determine the effects of sepsis and predictors of poor outcomes among patients hospitalized for COPD, the investigators used standard diagnostic codes to identify patients with a primary diagnosis of COPD from the Nationwide Inpatient Sample for the period 2007 through 2018 and sepsis from codes in secondary fields in the International Classification of Diseases (9th/10th Editions) Clinical Modification.

They identified a total of 6,940,615 hospitalizations in which the primary diagnosis was COPD; in 64,748 of those cases, sepsis was a complication.

As noted, the in-hospital death rate, one of two primary outcomes, was 19% for patients with COPD and sepsis, and the rate of discharge to other facilities was 31%.

In analysis adjusted for confounding factors, sepsis was associated with an odds ratio for mortality of 4.9 (P < .01) and an OR for discharge to a facility of 2.2 (P < .01).

With regard to trends, the investigators saw that, although the adjusted odds for in-hospital mortality remained stable over time, discharge to facilities increased significantly. In 2007, the adjusted OR was 2.2, whereas in 2018, it was 2.6 (P for trend = .02).

Predictors of in-hospital mortality among patients with sepsis included increasing age (OR, not shown), White ethnicity (OR, 1.2), treatment in the Northeast region (OR, 1.4), disseminated intravascular coagulation (OR, 3.7), pneumococcal infection (OR, 1.2), congestive heart failure (OR, 1.2), and renal failure (OR, 1.4; P < .01 for all comparisons).
 

Mortality risk for many patients

A COPD specialist who was not involved in the study told this news organization that sepsis is an uncommon but serious complication, not just for patients with COPD but also for those with other severe illnesses.

“Sepsis has a high risk for mortality whether a person has COPD or not,” commented David M. Mannino III MD, FCCP, FERS, professor of medicine at the University of Kentucky, Lexington, and a cofounder and co–medical director of the COPD Foundation.

“It’s not surprising that sepsis is lethal in this population; the question is, if you have COPD, are you more likely to have sepsis? And I think the answer is probably yes. The connection there is that people with COPD have a higher risk for pneumonia, and pneumonia itself is probably one of the biggest risk factors, or certainly an important risk factor, for the development of sepsis,” he said in an interview.

It would be interesting to see the relationship between sepsis and in-hospital mortality for patients with other chronic diseases or people without COPD, he said, and he would have liked to have seen more detailed information about trends over time than Dr. Shah and colleagues provided.

No funding source for the study was reported. Dr. Shah and colleagues and Dr. Mannino have disclosed no relevant financial relationships.

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

The U.S. Food and Drug Administration has given marketing clearance to CognICA, an artificial intelligence–powered integrated cognitive assessment for the early detection of dementia.

Developed by Cognetivity Neurosciences, CognICA is a 5-minute, computerized cognitive assessment that is completed using an iPad. The test offers several advantages over traditional pen-and-paper–based cognitive tests, the company said in a news release.

“These include its high sensitivity to early-stage cognitive impairment, avoidance of cultural or educational bias, and absence of learning effect upon repeat testing,” the company notes.

Because the test runs on a computer, it can support remote, self-administered testing at scale and is geared toward seamless integration with existing electronic health record systems, they add.

According to the latest Alzheimer’s Disease Facts and Figures, published by the Alzheimer’s Association, more than 6 million Americans are now living with Alzheimer’s disease. That number is projected to increase to 12.7 million by 2050.

“We’re excited about the opportunity to revolutionize the way cognitive impairment is assessed and managed in the U.S. and make a positive impact on the health and wellbeing of millions of Americans,” Sina Habibi, PhD, cofounder and CEO of Cognetivity, said in the news release.

The test has already received European regulatory approval as a CE-marked medical device and has been deployed in both primary and specialist clinical care in the U.K.’s National Health Service.

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

The U.S. Food and Drug Administration has given marketing clearance to CognICA, an artificial intelligence–powered integrated cognitive assessment for the early detection of dementia.

Developed by Cognetivity Neurosciences, CognICA is a 5-minute, computerized cognitive assessment that is completed using an iPad. The test offers several advantages over traditional pen-and-paper–based cognitive tests, the company said in a news release.

“These include its high sensitivity to early-stage cognitive impairment, avoidance of cultural or educational bias, and absence of learning effect upon repeat testing,” the company notes.

Because the test runs on a computer, it can support remote, self-administered testing at scale and is geared toward seamless integration with existing electronic health record systems, they add.

According to the latest Alzheimer’s Disease Facts and Figures, published by the Alzheimer’s Association, more than 6 million Americans are now living with Alzheimer’s disease. That number is projected to increase to 12.7 million by 2050.

“We’re excited about the opportunity to revolutionize the way cognitive impairment is assessed and managed in the U.S. and make a positive impact on the health and wellbeing of millions of Americans,” Sina Habibi, PhD, cofounder and CEO of Cognetivity, said in the news release.

The test has already received European regulatory approval as a CE-marked medical device and has been deployed in both primary and specialist clinical care in the U.K.’s National Health Service.

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

The U.S. Food and Drug Administration has given marketing clearance to CognICA, an artificial intelligence–powered integrated cognitive assessment for the early detection of dementia.

Developed by Cognetivity Neurosciences, CognICA is a 5-minute, computerized cognitive assessment that is completed using an iPad. The test offers several advantages over traditional pen-and-paper–based cognitive tests, the company said in a news release.

“These include its high sensitivity to early-stage cognitive impairment, avoidance of cultural or educational bias, and absence of learning effect upon repeat testing,” the company notes.

Because the test runs on a computer, it can support remote, self-administered testing at scale and is geared toward seamless integration with existing electronic health record systems, they add.

According to the latest Alzheimer’s Disease Facts and Figures, published by the Alzheimer’s Association, more than 6 million Americans are now living with Alzheimer’s disease. That number is projected to increase to 12.7 million by 2050.

“We’re excited about the opportunity to revolutionize the way cognitive impairment is assessed and managed in the U.S. and make a positive impact on the health and wellbeing of millions of Americans,” Sina Habibi, PhD, cofounder and CEO of Cognetivity, said in the news release.

The test has already received European regulatory approval as a CE-marked medical device and has been deployed in both primary and specialist clinical care in the U.K.’s National Health Service.

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

Adenoma miss rates were significantly lower with the use of an artificial intelligence (AI)–based computer-aided detection (CADe) system than with high-definition white light (HDWL), according to a new prospective, multicenter, single-blind randomized study based on data from more than 200 colonoscopies.

Missed adenomas can be generally categorized as adenomas fully obscured from the visual field or those appearing partly or fully in the visual field but missed by an endoscopist, wrote Jeremy R. Glissen Brown, MD, of Harvard Medical School, Boston, and colleagues. While retrospective and prospective studies in China, Italy, and Japan have shown that deep-learning CADe improves adenoma identification during colonoscopy, there have been no prospective U.S. studies on CADe in a diverse population, they noted.

In the study published in Clinical Gastroenterology and Hepatology, the researchers reviewed data from 223 adults aged 22 years and older who underwent screening colonoscopies across four U.S. academic medical centers between 2019 and 2020. The procedure indication was primary colorectal cancer screening for 59.6% of the patients and postpolypectomy surveillance for 40.4%. Among this cohort, 45.3% (101) were female, 67.7% (151) were White, and 21% (133) were African American. Participants were randomized to receive either CADe colonoscopy first or HDWL colonoscopy first; the patients immediately underwent the other procedure in tandem fashion from the same endoscopist.

The primary outcome of the study was adenoma miss rate (AMR), defined as “the number of histologically confirmed adenomas detected during the second colonoscopy in either arm divided by the total number of adenomas detected during both procedures.” Sessile serrated lesion (SSL) miss rates and adenomas per colonoscopy (APC) were secondary outcomes.

Overall, the primary outcome of AMR was significantly lower in the CADe-first group, compared with the HDWL-first group (20.12% vs. 31.25%; P = .0247), with an odds ratio of 1.8048 (95% CI, 1.0780-3.0217). The CADe-first group yielded a lower SSL miss rate, compared with the HDLW-first group (7.14% vs. 42.11%; P = .0482), as well as a lower polyp miss rate (20.70% vs. 33.71%; P = .0007). The first-pass number of APC was significantly higher in the CADe-first group, compared with the HDWL-first group (1.19 [SD 2.03] vs. 0.90 [SD 1.55]; P = .0323). In addition, the first-pass adenoma detection rate (ADR) was not significantly different in the CADe-first group, compared with the HDWL-first group (50.44% vs. 43.64%; P = .3091), and the median withdrawal time was significantly shorter with CADe, compared with HDWL (9.5 minutes vs. 8.5 minutes; P = .0098).

There were no significant observable differences between the two groups regarding missed adenomas arranged by size or location. Moreover, there were no significant differences in miss rates for hyperplastic polyps or advanced adenomas. Factors significantly associated with missed adenomas included being in the HDLW-first group, age 65 years or younger, and the right colon vs. other locations. No immediate adverse events occurred in either group.

According to the researchers, while previous studies in China and Italy have shown increased ADR using CADe systems, these results are not generalizable to the U.S. population for several reasons, notably the studies’ inclusion of colonoscopy indications other than colorectal cancer screening and surveillance. Though the present study showed a significantly lower AMR with CADe, it still represents missed adenomas. The researchers note: “In the present study, in which CADe detected 285 polyps, there were only three false negatives (defined as polyps that were visualized by the endoscopist but not by the CADe system). Overall, this suggests that the ‘missed polyps’ in the CADe arm may have been obscured behind folds rather than in the visual field.” They added, “Further research is needed on combining CADe technologies with mucosal exposure devices, as the benefits of these tools for polyp detection may be additive.”

The study findings were limited by several factors, including the inability to detect a difference in overall ADR, the limited generalizability of the tandem study design to real-world practice, the inclusion of only experienced endoscopists, and the use of a second monitor that may have impacted gaze patterns, the researchers noted. However, the results represent the first examination of deep-learning CADe in a diverse U.S. population and showed a decrease in adenoma miss rates and decreased miss rates for polyps and SSLs, compared with HDWL. Based on these findings, the authors concluded CADe “has the potential to decrease inter-provider variability in colonoscopy quality by reducing adenoma miss rate even in experienced providers.”
 

Reducing miss rates matters

“Missed adenomas can be associated with the development of interval colorectal cancer, so whether novel technologies such as artificial intelligence-based computer-aided polyp detection system can decrease adenoma miss rate is of interest,” said Atsushi Sakuraba, MD, of the University of Chicago, in an interview.

Dr Sakuraba said he was not surprised by the current study findings, as several pilot and randomized studies have shown the benefits of AI-based polyp detection systems. As for how the AI-assisted technology might improve practice, he said it may be a valuable addition. “Adenoma miss rate was significantly lower with an AI-based polyp detection system, so it might lead to decreased colorectal cancer,” he explained. “Various methods to improve adenoma detection should complement each other. 

Dr. Sakuraba also commented that additional research is needed outside of academic centers, noting “further studies in the community setting involving various endoscopists are required to confirm generalizability.”

Lead author Dr. Glissen Brown had no financial conflicts to disclose. This was an investigator-initiated study, with research software and study funding provided by Wision. Dr. Sakuraba disclosed collaborative research with Fuji film, which was not involved in this study.

Adenoma miss rates were significantly lower with the use of an artificial intelligence (AI)–based computer-aided detection (CADe) system than with high-definition white light (HDWL), according to a new prospective, multicenter, single-blind randomized study based on data from more than 200 colonoscopies.

Missed adenomas can be generally categorized as adenomas fully obscured from the visual field or those appearing partly or fully in the visual field but missed by an endoscopist, wrote Jeremy R. Glissen Brown, MD, of Harvard Medical School, Boston, and colleagues. While retrospective and prospective studies in China, Italy, and Japan have shown that deep-learning CADe improves adenoma identification during colonoscopy, there have been no prospective U.S. studies on CADe in a diverse population, they noted.

In the study published in Clinical Gastroenterology and Hepatology, the researchers reviewed data from 223 adults aged 22 years and older who underwent screening colonoscopies across four U.S. academic medical centers between 2019 and 2020. The procedure indication was primary colorectal cancer screening for 59.6% of the patients and postpolypectomy surveillance for 40.4%. Among this cohort, 45.3% (101) were female, 67.7% (151) were White, and 21% (133) were African American. Participants were randomized to receive either CADe colonoscopy first or HDWL colonoscopy first; the patients immediately underwent the other procedure in tandem fashion from the same endoscopist.

The primary outcome of the study was adenoma miss rate (AMR), defined as “the number of histologically confirmed adenomas detected during the second colonoscopy in either arm divided by the total number of adenomas detected during both procedures.” Sessile serrated lesion (SSL) miss rates and adenomas per colonoscopy (APC) were secondary outcomes.

Overall, the primary outcome of AMR was significantly lower in the CADe-first group, compared with the HDWL-first group (20.12% vs. 31.25%; P = .0247), with an odds ratio of 1.8048 (95% CI, 1.0780-3.0217). The CADe-first group yielded a lower SSL miss rate, compared with the HDLW-first group (7.14% vs. 42.11%; P = .0482), as well as a lower polyp miss rate (20.70% vs. 33.71%; P = .0007). The first-pass number of APC was significantly higher in the CADe-first group, compared with the HDWL-first group (1.19 [SD 2.03] vs. 0.90 [SD 1.55]; P = .0323). In addition, the first-pass adenoma detection rate (ADR) was not significantly different in the CADe-first group, compared with the HDWL-first group (50.44% vs. 43.64%; P = .3091), and the median withdrawal time was significantly shorter with CADe, compared with HDWL (9.5 minutes vs. 8.5 minutes; P = .0098).

There were no significant observable differences between the two groups regarding missed adenomas arranged by size or location. Moreover, there were no significant differences in miss rates for hyperplastic polyps or advanced adenomas. Factors significantly associated with missed adenomas included being in the HDLW-first group, age 65 years or younger, and the right colon vs. other locations. No immediate adverse events occurred in either group.

According to the researchers, while previous studies in China and Italy have shown increased ADR using CADe systems, these results are not generalizable to the U.S. population for several reasons, notably the studies’ inclusion of colonoscopy indications other than colorectal cancer screening and surveillance. Though the present study showed a significantly lower AMR with CADe, it still represents missed adenomas. The researchers note: “In the present study, in which CADe detected 285 polyps, there were only three false negatives (defined as polyps that were visualized by the endoscopist but not by the CADe system). Overall, this suggests that the ‘missed polyps’ in the CADe arm may have been obscured behind folds rather than in the visual field.” They added, “Further research is needed on combining CADe technologies with mucosal exposure devices, as the benefits of these tools for polyp detection may be additive.”

The study findings were limited by several factors, including the inability to detect a difference in overall ADR, the limited generalizability of the tandem study design to real-world practice, the inclusion of only experienced endoscopists, and the use of a second monitor that may have impacted gaze patterns, the researchers noted. However, the results represent the first examination of deep-learning CADe in a diverse U.S. population and showed a decrease in adenoma miss rates and decreased miss rates for polyps and SSLs, compared with HDWL. Based on these findings, the authors concluded CADe “has the potential to decrease inter-provider variability in colonoscopy quality by reducing adenoma miss rate even in experienced providers.”
 

Reducing miss rates matters

“Missed adenomas can be associated with the development of interval colorectal cancer, so whether novel technologies such as artificial intelligence-based computer-aided polyp detection system can decrease adenoma miss rate is of interest,” said Atsushi Sakuraba, MD, of the University of Chicago, in an interview.

Dr Sakuraba said he was not surprised by the current study findings, as several pilot and randomized studies have shown the benefits of AI-based polyp detection systems. As for how the AI-assisted technology might improve practice, he said it may be a valuable addition. “Adenoma miss rate was significantly lower with an AI-based polyp detection system, so it might lead to decreased colorectal cancer,” he explained. “Various methods to improve adenoma detection should complement each other. 

Dr. Sakuraba also commented that additional research is needed outside of academic centers, noting “further studies in the community setting involving various endoscopists are required to confirm generalizability.”

Lead author Dr. Glissen Brown had no financial conflicts to disclose. This was an investigator-initiated study, with research software and study funding provided by Wision. Dr. Sakuraba disclosed collaborative research with Fuji film, which was not involved in this study.

Adenoma miss rates were significantly lower with the use of an artificial intelligence (AI)–based computer-aided detection (CADe) system than with high-definition white light (HDWL), according to a new prospective, multicenter, single-blind randomized study based on data from more than 200 colonoscopies.

Missed adenomas can be generally categorized as adenomas fully obscured from the visual field or those appearing partly or fully in the visual field but missed by an endoscopist, wrote Jeremy R. Glissen Brown, MD, of Harvard Medical School, Boston, and colleagues. While retrospective and prospective studies in China, Italy, and Japan have shown that deep-learning CADe improves adenoma identification during colonoscopy, there have been no prospective U.S. studies on CADe in a diverse population, they noted.

In the study published in Clinical Gastroenterology and Hepatology, the researchers reviewed data from 223 adults aged 22 years and older who underwent screening colonoscopies across four U.S. academic medical centers between 2019 and 2020. The procedure indication was primary colorectal cancer screening for 59.6% of the patients and postpolypectomy surveillance for 40.4%. Among this cohort, 45.3% (101) were female, 67.7% (151) were White, and 21% (133) were African American. Participants were randomized to receive either CADe colonoscopy first or HDWL colonoscopy first; the patients immediately underwent the other procedure in tandem fashion from the same endoscopist.

The primary outcome of the study was adenoma miss rate (AMR), defined as “the number of histologically confirmed adenomas detected during the second colonoscopy in either arm divided by the total number of adenomas detected during both procedures.” Sessile serrated lesion (SSL) miss rates and adenomas per colonoscopy (APC) were secondary outcomes.

Overall, the primary outcome of AMR was significantly lower in the CADe-first group, compared with the HDWL-first group (20.12% vs. 31.25%; P = .0247), with an odds ratio of 1.8048 (95% CI, 1.0780-3.0217). The CADe-first group yielded a lower SSL miss rate, compared with the HDLW-first group (7.14% vs. 42.11%; P = .0482), as well as a lower polyp miss rate (20.70% vs. 33.71%; P = .0007). The first-pass number of APC was significantly higher in the CADe-first group, compared with the HDWL-first group (1.19 [SD 2.03] vs. 0.90 [SD 1.55]; P = .0323). In addition, the first-pass adenoma detection rate (ADR) was not significantly different in the CADe-first group, compared with the HDWL-first group (50.44% vs. 43.64%; P = .3091), and the median withdrawal time was significantly shorter with CADe, compared with HDWL (9.5 minutes vs. 8.5 minutes; P = .0098).

There were no significant observable differences between the two groups regarding missed adenomas arranged by size or location. Moreover, there were no significant differences in miss rates for hyperplastic polyps or advanced adenomas. Factors significantly associated with missed adenomas included being in the HDLW-first group, age 65 years or younger, and the right colon vs. other locations. No immediate adverse events occurred in either group.

According to the researchers, while previous studies in China and Italy have shown increased ADR using CADe systems, these results are not generalizable to the U.S. population for several reasons, notably the studies’ inclusion of colonoscopy indications other than colorectal cancer screening and surveillance. Though the present study showed a significantly lower AMR with CADe, it still represents missed adenomas. The researchers note: “In the present study, in which CADe detected 285 polyps, there were only three false negatives (defined as polyps that were visualized by the endoscopist but not by the CADe system). Overall, this suggests that the ‘missed polyps’ in the CADe arm may have been obscured behind folds rather than in the visual field.” They added, “Further research is needed on combining CADe technologies with mucosal exposure devices, as the benefits of these tools for polyp detection may be additive.”

The study findings were limited by several factors, including the inability to detect a difference in overall ADR, the limited generalizability of the tandem study design to real-world practice, the inclusion of only experienced endoscopists, and the use of a second monitor that may have impacted gaze patterns, the researchers noted. However, the results represent the first examination of deep-learning CADe in a diverse U.S. population and showed a decrease in adenoma miss rates and decreased miss rates for polyps and SSLs, compared with HDWL. Based on these findings, the authors concluded CADe “has the potential to decrease inter-provider variability in colonoscopy quality by reducing adenoma miss rate even in experienced providers.”
 

Reducing miss rates matters

“Missed adenomas can be associated with the development of interval colorectal cancer, so whether novel technologies such as artificial intelligence-based computer-aided polyp detection system can decrease adenoma miss rate is of interest,” said Atsushi Sakuraba, MD, of the University of Chicago, in an interview.

Dr Sakuraba said he was not surprised by the current study findings, as several pilot and randomized studies have shown the benefits of AI-based polyp detection systems. As for how the AI-assisted technology might improve practice, he said it may be a valuable addition. “Adenoma miss rate was significantly lower with an AI-based polyp detection system, so it might lead to decreased colorectal cancer,” he explained. “Various methods to improve adenoma detection should complement each other. 

Dr. Sakuraba also commented that additional research is needed outside of academic centers, noting “further studies in the community setting involving various endoscopists are required to confirm generalizability.”

Lead author Dr. Glissen Brown had no financial conflicts to disclose. This was an investigator-initiated study, with research software and study funding provided by Wision. Dr. Sakuraba disclosed collaborative research with Fuji film, which was not involved in this study.

As a pediatric kidney doctor, Elaine S. Kamil, MD, is used to long hours helping children and teens with a variety of issues, some very serious, and also makes time to give back to her specialty.

In late 2013, she was in Washington, D.C., planning a meeting of the American Society of Nephrology. When the organizers decided at the last minute that another session was needed, she stayed late, putting it together. Then she hopped on a plane and returned home to Los Angeles on a Saturday night.

Right after midnight, Dr. Kamil knew something was wrong.

“I had really severe chest pain,” she says. “I have reflux, and I know what that feels like. This was much more intense. It really hurt.” She debated: “Should I wake up my husband?”

Soon, the pain got so bad, she had to.

At the hospital, an electrocardiogram was slightly abnormal, as was a blood test that measures damage to the heart. Next, she got an angiogram, an imaging technique to visualize the heart. Once doctors looked at the image on the screen during the angiogram, they knew the diagnosis: Broken heart syndrome, known medically as takotsubo cardiomyopathy or stress-induced cardiomyopathy. As the name suggests, it’s triggered by extreme stress or loss.

The common symptoms are chest pain that can seem to come from a heart attack, shortness of breath, and fainting. The telltale clue to the diagnosis is the appearance of the walls of the heart’s left ventricle, its main pumping chamber. When the condition is present, the left ventricle changes shape, developing a narrow neck and a round bottom, resembling an octopus pot called takotsubo used by fishermen in Japan, where the condition was first recognized in 1990.

Like most who are affected, Dr. Kamil, now 74, is fine now. She is still actively working, as a researcher and professor emerita at Cedars-Sinai Medical Center and a health sciences clinical professor of pediatrics at UCLA. But she focuses more now on stress reduction.
 

Study: condition on the rise

New research from Cedars-Sinai suggests that broken heart syndrome, while still not common, is not as rare as once thought. And it’s on the rise, especially among middle-age and older women.

This ‘’middle” group – women ages 50 to 74 – had the greatest rate of increase over the years studied, 2006-2017, says Susan Cheng, MD, lead author of the study, published in the Journal of the American Heart Association. She is the director of the Institute for Research on Healthy Aging at the Smidt Heart Institute at Cedars-Sinai Medical Center.

Dr. Cheng and her team used national hospital inpatient data collected from more than 135,000 men and women diagnosed with the condition during the 12 years of the study. More than 88% of all cases were women, especially in those age 50 or older. When the researchers looked more closely, they found the diagnosis has been increasing at least 6 to 10 times more rapidly for women in the 50-to-74 age group than in any other group.

For every case of the condition in younger women, or in men of all age groups, the researchers found an additional 10 cases for middle-aged women and six additional cases for older women. For example, while the syndrome occurred in 15 younger women per million per year, it occurred in 128 middle aged women per year.

The age groups found most at risk was surprising, says Dr. Cheng, who expected the risk would be highest in the oldest age group of women, those over 75.

While doctors are more aware of the condition now, “it’s not just the increased recognition,” she says. “There is something going on” driving the continual increase. It probably has something to do with environmental changes, she says.

Hormones and hormonal differences between men and women aren’t the whole story either, she says. Her team will study it further, hoping eventually to find who might be more likely to get the condition by talking to those who have had it and collecting clues. “There probably is some underlying genetic predisposition,” she says.

“The neural hormones that drive the flight-or-fight response (such as adrenaline) are definitely elevated,” she says. “The brain and the heart are talking to each other.”

Experts say these surging stress hormones essentially “stun” the heart, affecting how it functions. The question is, what makes women particularly more susceptible to being excessively triggered when exposed to stress? That is unclear, Dr. Cheng says.

While the condition is a frightening experience, ‘’the overall prognosis is much better than having a garden-variety heart attack,” she says.

But researchers are still figuring out long-term outcomes, and she can’t tell patients if they are likely to have another episode.
 

Research findings reflected in practice

Other cardiologists say they are not surprised by the new findings.

“I think it’s very consistent with what I am seeing clinically,” says Tracy Stevens, MD, a cardiologist at Saint Luke’s Mid America Heart Institute in Kansas City, MO. In the last 5 years, she has diagnosed at least 100 cases, she says. The increase is partly but not entirely due to increased awareness by doctors of the condition, she agrees.

If a postmenopausal woman comes to the hospital with chest pain, the condition is more likely now than in the past to be suspected, says Dr. Stevens, who’s also the medical director of the Muriel I. Kauffman Women’s Heart Center at Saint Luke’s. The octopus pot-like image is hard to miss.

“What we see at the base of the left ventricle is, it is squeezing like crazy, it is ballooning.”

“We probably see at least five to ten a month,” says Kevin Bybee, MD, an associate professor of medicine at the University of Missouri-Kansas City School of Medicine.

The increase in numbers found by the Los Angeles researchers may not even capture the true picture of how many people have gotten this condition, he says. He suspects some women whose deaths are blamed on sudden cardiac death might actually have had broken heart syndrome.

“I have always wondered how many don’t make it to the hospital.”

Dr. Bybee, who’s also medical director of cardiovascular services at St. Luke’s South in Overland Park, KS, became interested in the syndrome during his fellowship at Mayo Clinic when he diagnosed three patients in just 2 months. He and his team published the case histories of seven patients in 2004. Since then, many more reports have been published.

Researchers from Texas used the same national database as the Cedars researchers to look at cases from 2005 to 2014, and also found an increase. But study co-author Abhijeet Dhoble, MD, a cardiologist and associate professor of medicine at UT Health Science Center and Memorial Hermann-Texas Medical Center in Houston, believes more recognition explains most of the increase.

And the pandemic is now playing a role in driving up cases, he says.

“In the last 2 years, we have been noticing increasing numbers of cases, probably due to the pandemic,” he says.
 

Profiles of cases

Over the years, Dr. Bybee has collected information on what is happening before the heart begins to go haywire.

“Fifteen to twenty percent of the time, there is no obvious trigger,” he says.

Other times, a stressful emotional event, such as the death of a spouse or a severe car accident, can trigger it.

One patient with an extreme fear of public speaking had to give a talk in front of a large group when she was new to a job. Another woman lost money at a casino before it happened, Dr. Bybee says. Yet another patient took her dog out for a walk in the woods, and the dog got caught in a raccoon trap.

Fierce arguments as well as surprise parties have triggered the condition, Dr. Bybee says. Physical problems such as asthma or sepsis, a life-threatening complication of an infection, can also trigger broken heart.

“It’s challenging because this is unpredictable,” he says.
 

Treatments and recovery

The condition is rarely fatal, say experts from Harvard and Mayo Clinic, but some can have complications such as heart failure.

There are no standard guidelines for treatment, Dr. Dhoble, of Memorial Hermann, says. “We give medications to keep blood pressures in the optimal range.” Doctors may also prescribe lipid-lowering medicines and blood thinner medications. “Most patients recover within 3 to 7 days.”

“Usually within a month, their [heart] function returns to normal,” Dr. Stevens says.

Getting one’s full energy back can take longer, as Dr. Kamil found. “It was about 6 months before I was up to speed.”
 

Survivors talk

Looking back, Dr. Kamil realizes now how much stress she was under before her episode.

“I took care of chronically ill kids,” she says, and worried about them. “I’m kind of a mother hen.”

Besides patient care and her cross-county meeting planning, she was flying back and forth to Florida to tend to her mother, who had chronic health problems. She was also managing that year’s annual media prize at a San Diego university that she and her husband established after the death of their adult son several years before.

“I was busy with that, and it is a bittersweet experience,” she says.

She is trying to take her cardiologist’s advice to slow down.

“I used to be notorious for saying, ‘I need to get one more thing done,’” she says.

Joanie Simpson says she, too, has slowed down. She was diagnosed with broken heart in 2016, after a cascade of stressful events. Her son was facing back surgery, her son-in-law had lost his job, and her tiny Yorkshire terrier Meha died. And she and her husband, Benny, had issues with their rental property.

Now 66 and retired in Camp Wood, Texas, she has learned to enjoy life and worry a little less. Music is one way.

“We’re Parrotheads,” she says, referencing the nickname given to fans of singer Jimmy Buffett. “We listen to Buffett and to ’60s, ’70s, ’80s music. We dance around the house. We aren’t big tavern goers, so we dance around the living room and hope we don’t fall over the coffee table. So far, so good.”

They have plans to buy a small pontoon boat and go fishing. Benny especially loves that idea, she says, laughing, as he finds it’s the only time she stops talking.
 

Reducing the what-ifs

Patients have a common question and worry: What if it happens again?

“I definitely worried more about it in the beginning,” Dr. Kamil says. “Could I have permanent heart damage? Will I be a cardiac cripple?” Her worry has eased.

If you suspect the condition, ‘’get yourself to a provider who knows about it,” she says.

Cardiologists are very likely to suspect the condition, Dr. Bybee says, as are doctors working in a large-volume emergency department.

Dr. Stevens, of St. Luke’s, is straightforward, telling her patients what is known and what is not about the condition. She recommends her patients go to cardiac rehab.

“It gives them that confidence to know what they can do,” she says.

She also gives lifestyle advice, suggesting patients get a home blood pressure cuff and use it. She suggests paying attention to good nutrition and exercise and not lifting anything so heavy that grunting is necessary.

Focus on protecting heart health, Dr. Cheng tells patients. She encourages them to find the stress reduction plan that works for them. Most important, she tells patients to understand that it is not their fault.

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

As a pediatric kidney doctor, Elaine S. Kamil, MD, is used to long hours helping children and teens with a variety of issues, some very serious, and also makes time to give back to her specialty.

In late 2013, she was in Washington, D.C., planning a meeting of the American Society of Nephrology. When the organizers decided at the last minute that another session was needed, she stayed late, putting it together. Then she hopped on a plane and returned home to Los Angeles on a Saturday night.

Right after midnight, Dr. Kamil knew something was wrong.

“I had really severe chest pain,” she says. “I have reflux, and I know what that feels like. This was much more intense. It really hurt.” She debated: “Should I wake up my husband?”

Soon, the pain got so bad, she had to.

At the hospital, an electrocardiogram was slightly abnormal, as was a blood test that measures damage to the heart. Next, she got an angiogram, an imaging technique to visualize the heart. Once doctors looked at the image on the screen during the angiogram, they knew the diagnosis: Broken heart syndrome, known medically as takotsubo cardiomyopathy or stress-induced cardiomyopathy. As the name suggests, it’s triggered by extreme stress or loss.

The common symptoms are chest pain that can seem to come from a heart attack, shortness of breath, and fainting. The telltale clue to the diagnosis is the appearance of the walls of the heart’s left ventricle, its main pumping chamber. When the condition is present, the left ventricle changes shape, developing a narrow neck and a round bottom, resembling an octopus pot called takotsubo used by fishermen in Japan, where the condition was first recognized in 1990.

Like most who are affected, Dr. Kamil, now 74, is fine now. She is still actively working, as a researcher and professor emerita at Cedars-Sinai Medical Center and a health sciences clinical professor of pediatrics at UCLA. But she focuses more now on stress reduction.
 

Study: condition on the rise

New research from Cedars-Sinai suggests that broken heart syndrome, while still not common, is not as rare as once thought. And it’s on the rise, especially among middle-age and older women.

This ‘’middle” group – women ages 50 to 74 – had the greatest rate of increase over the years studied, 2006-2017, says Susan Cheng, MD, lead author of the study, published in the Journal of the American Heart Association. She is the director of the Institute for Research on Healthy Aging at the Smidt Heart Institute at Cedars-Sinai Medical Center.

Dr. Cheng and her team used national hospital inpatient data collected from more than 135,000 men and women diagnosed with the condition during the 12 years of the study. More than 88% of all cases were women, especially in those age 50 or older. When the researchers looked more closely, they found the diagnosis has been increasing at least 6 to 10 times more rapidly for women in the 50-to-74 age group than in any other group.

For every case of the condition in younger women, or in men of all age groups, the researchers found an additional 10 cases for middle-aged women and six additional cases for older women. For example, while the syndrome occurred in 15 younger women per million per year, it occurred in 128 middle aged women per year.

The age groups found most at risk was surprising, says Dr. Cheng, who expected the risk would be highest in the oldest age group of women, those over 75.

While doctors are more aware of the condition now, “it’s not just the increased recognition,” she says. “There is something going on” driving the continual increase. It probably has something to do with environmental changes, she says.

Hormones and hormonal differences between men and women aren’t the whole story either, she says. Her team will study it further, hoping eventually to find who might be more likely to get the condition by talking to those who have had it and collecting clues. “There probably is some underlying genetic predisposition,” she says.

“The neural hormones that drive the flight-or-fight response (such as adrenaline) are definitely elevated,” she says. “The brain and the heart are talking to each other.”

Experts say these surging stress hormones essentially “stun” the heart, affecting how it functions. The question is, what makes women particularly more susceptible to being excessively triggered when exposed to stress? That is unclear, Dr. Cheng says.

While the condition is a frightening experience, ‘’the overall prognosis is much better than having a garden-variety heart attack,” she says.

But researchers are still figuring out long-term outcomes, and she can’t tell patients if they are likely to have another episode.
 

Research findings reflected in practice

Other cardiologists say they are not surprised by the new findings.

“I think it’s very consistent with what I am seeing clinically,” says Tracy Stevens, MD, a cardiologist at Saint Luke’s Mid America Heart Institute in Kansas City, MO. In the last 5 years, she has diagnosed at least 100 cases, she says. The increase is partly but not entirely due to increased awareness by doctors of the condition, she agrees.

If a postmenopausal woman comes to the hospital with chest pain, the condition is more likely now than in the past to be suspected, says Dr. Stevens, who’s also the medical director of the Muriel I. Kauffman Women’s Heart Center at Saint Luke’s. The octopus pot-like image is hard to miss.

“What we see at the base of the left ventricle is, it is squeezing like crazy, it is ballooning.”

“We probably see at least five to ten a month,” says Kevin Bybee, MD, an associate professor of medicine at the University of Missouri-Kansas City School of Medicine.

The increase in numbers found by the Los Angeles researchers may not even capture the true picture of how many people have gotten this condition, he says. He suspects some women whose deaths are blamed on sudden cardiac death might actually have had broken heart syndrome.

“I have always wondered how many don’t make it to the hospital.”

Dr. Bybee, who’s also medical director of cardiovascular services at St. Luke’s South in Overland Park, KS, became interested in the syndrome during his fellowship at Mayo Clinic when he diagnosed three patients in just 2 months. He and his team published the case histories of seven patients in 2004. Since then, many more reports have been published.

Researchers from Texas used the same national database as the Cedars researchers to look at cases from 2005 to 2014, and also found an increase. But study co-author Abhijeet Dhoble, MD, a cardiologist and associate professor of medicine at UT Health Science Center and Memorial Hermann-Texas Medical Center in Houston, believes more recognition explains most of the increase.

And the pandemic is now playing a role in driving up cases, he says.

“In the last 2 years, we have been noticing increasing numbers of cases, probably due to the pandemic,” he says.
 

Profiles of cases

Over the years, Dr. Bybee has collected information on what is happening before the heart begins to go haywire.

“Fifteen to twenty percent of the time, there is no obvious trigger,” he says.

Other times, a stressful emotional event, such as the death of a spouse or a severe car accident, can trigger it.

One patient with an extreme fear of public speaking had to give a talk in front of a large group when she was new to a job. Another woman lost money at a casino before it happened, Dr. Bybee says. Yet another patient took her dog out for a walk in the woods, and the dog got caught in a raccoon trap.

Fierce arguments as well as surprise parties have triggered the condition, Dr. Bybee says. Physical problems such as asthma or sepsis, a life-threatening complication of an infection, can also trigger broken heart.

“It’s challenging because this is unpredictable,” he says.
 

Treatments and recovery

The condition is rarely fatal, say experts from Harvard and Mayo Clinic, but some can have complications such as heart failure.

There are no standard guidelines for treatment, Dr. Dhoble, of Memorial Hermann, says. “We give medications to keep blood pressures in the optimal range.” Doctors may also prescribe lipid-lowering medicines and blood thinner medications. “Most patients recover within 3 to 7 days.”

“Usually within a month, their [heart] function returns to normal,” Dr. Stevens says.

Getting one’s full energy back can take longer, as Dr. Kamil found. “It was about 6 months before I was up to speed.”
 

Survivors talk

Looking back, Dr. Kamil realizes now how much stress she was under before her episode.

“I took care of chronically ill kids,” she says, and worried about them. “I’m kind of a mother hen.”

Besides patient care and her cross-county meeting planning, she was flying back and forth to Florida to tend to her mother, who had chronic health problems. She was also managing that year’s annual media prize at a San Diego university that she and her husband established after the death of their adult son several years before.

“I was busy with that, and it is a bittersweet experience,” she says.

She is trying to take her cardiologist’s advice to slow down.

“I used to be notorious for saying, ‘I need to get one more thing done,’” she says.

Joanie Simpson says she, too, has slowed down. She was diagnosed with broken heart in 2016, after a cascade of stressful events. Her son was facing back surgery, her son-in-law had lost his job, and her tiny Yorkshire terrier Meha died. And she and her husband, Benny, had issues with their rental property.

Now 66 and retired in Camp Wood, Texas, she has learned to enjoy life and worry a little less. Music is one way.

“We’re Parrotheads,” she says, referencing the nickname given to fans of singer Jimmy Buffett. “We listen to Buffett and to ’60s, ’70s, ’80s music. We dance around the house. We aren’t big tavern goers, so we dance around the living room and hope we don’t fall over the coffee table. So far, so good.”

They have plans to buy a small pontoon boat and go fishing. Benny especially loves that idea, she says, laughing, as he finds it’s the only time she stops talking.
 

Reducing the what-ifs

Patients have a common question and worry: What if it happens again?

“I definitely worried more about it in the beginning,” Dr. Kamil says. “Could I have permanent heart damage? Will I be a cardiac cripple?” Her worry has eased.

If you suspect the condition, ‘’get yourself to a provider who knows about it,” she says.

Cardiologists are very likely to suspect the condition, Dr. Bybee says, as are doctors working in a large-volume emergency department.

Dr. Stevens, of St. Luke’s, is straightforward, telling her patients what is known and what is not about the condition. She recommends her patients go to cardiac rehab.

“It gives them that confidence to know what they can do,” she says.

She also gives lifestyle advice, suggesting patients get a home blood pressure cuff and use it. She suggests paying attention to good nutrition and exercise and not lifting anything so heavy that grunting is necessary.

Focus on protecting heart health, Dr. Cheng tells patients. She encourages them to find the stress reduction plan that works for them. Most important, she tells patients to understand that it is not their fault.

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

As a pediatric kidney doctor, Elaine S. Kamil, MD, is used to long hours helping children and teens with a variety of issues, some very serious, and also makes time to give back to her specialty.

In late 2013, she was in Washington, D.C., planning a meeting of the American Society of Nephrology. When the organizers decided at the last minute that another session was needed, she stayed late, putting it together. Then she hopped on a plane and returned home to Los Angeles on a Saturday night.

Right after midnight, Dr. Kamil knew something was wrong.

“I had really severe chest pain,” she says. “I have reflux, and I know what that feels like. This was much more intense. It really hurt.” She debated: “Should I wake up my husband?”

Soon, the pain got so bad, she had to.

At the hospital, an electrocardiogram was slightly abnormal, as was a blood test that measures damage to the heart. Next, she got an angiogram, an imaging technique to visualize the heart. Once doctors looked at the image on the screen during the angiogram, they knew the diagnosis: Broken heart syndrome, known medically as takotsubo cardiomyopathy or stress-induced cardiomyopathy. As the name suggests, it’s triggered by extreme stress or loss.

The common symptoms are chest pain that can seem to come from a heart attack, shortness of breath, and fainting. The telltale clue to the diagnosis is the appearance of the walls of the heart’s left ventricle, its main pumping chamber. When the condition is present, the left ventricle changes shape, developing a narrow neck and a round bottom, resembling an octopus pot called takotsubo used by fishermen in Japan, where the condition was first recognized in 1990.

Like most who are affected, Dr. Kamil, now 74, is fine now. She is still actively working, as a researcher and professor emerita at Cedars-Sinai Medical Center and a health sciences clinical professor of pediatrics at UCLA. But she focuses more now on stress reduction.
 

Study: condition on the rise

New research from Cedars-Sinai suggests that broken heart syndrome, while still not common, is not as rare as once thought. And it’s on the rise, especially among middle-age and older women.

This ‘’middle” group – women ages 50 to 74 – had the greatest rate of increase over the years studied, 2006-2017, says Susan Cheng, MD, lead author of the study, published in the Journal of the American Heart Association. She is the director of the Institute for Research on Healthy Aging at the Smidt Heart Institute at Cedars-Sinai Medical Center.

Dr. Cheng and her team used national hospital inpatient data collected from more than 135,000 men and women diagnosed with the condition during the 12 years of the study. More than 88% of all cases were women, especially in those age 50 or older. When the researchers looked more closely, they found the diagnosis has been increasing at least 6 to 10 times more rapidly for women in the 50-to-74 age group than in any other group.

For every case of the condition in younger women, or in men of all age groups, the researchers found an additional 10 cases for middle-aged women and six additional cases for older women. For example, while the syndrome occurred in 15 younger women per million per year, it occurred in 128 middle aged women per year.

The age groups found most at risk was surprising, says Dr. Cheng, who expected the risk would be highest in the oldest age group of women, those over 75.

While doctors are more aware of the condition now, “it’s not just the increased recognition,” she says. “There is something going on” driving the continual increase. It probably has something to do with environmental changes, she says.

Hormones and hormonal differences between men and women aren’t the whole story either, she says. Her team will study it further, hoping eventually to find who might be more likely to get the condition by talking to those who have had it and collecting clues. “There probably is some underlying genetic predisposition,” she says.

“The neural hormones that drive the flight-or-fight response (such as adrenaline) are definitely elevated,” she says. “The brain and the heart are talking to each other.”

Experts say these surging stress hormones essentially “stun” the heart, affecting how it functions. The question is, what makes women particularly more susceptible to being excessively triggered when exposed to stress? That is unclear, Dr. Cheng says.

While the condition is a frightening experience, ‘’the overall prognosis is much better than having a garden-variety heart attack,” she says.

But researchers are still figuring out long-term outcomes, and she can’t tell patients if they are likely to have another episode.
 

Research findings reflected in practice

Other cardiologists say they are not surprised by the new findings.

“I think it’s very consistent with what I am seeing clinically,” says Tracy Stevens, MD, a cardiologist at Saint Luke’s Mid America Heart Institute in Kansas City, MO. In the last 5 years, she has diagnosed at least 100 cases, she says. The increase is partly but not entirely due to increased awareness by doctors of the condition, she agrees.

If a postmenopausal woman comes to the hospital with chest pain, the condition is more likely now than in the past to be suspected, says Dr. Stevens, who’s also the medical director of the Muriel I. Kauffman Women’s Heart Center at Saint Luke’s. The octopus pot-like image is hard to miss.

“What we see at the base of the left ventricle is, it is squeezing like crazy, it is ballooning.”

“We probably see at least five to ten a month,” says Kevin Bybee, MD, an associate professor of medicine at the University of Missouri-Kansas City School of Medicine.

The increase in numbers found by the Los Angeles researchers may not even capture the true picture of how many people have gotten this condition, he says. He suspects some women whose deaths are blamed on sudden cardiac death might actually have had broken heart syndrome.

“I have always wondered how many don’t make it to the hospital.”

Dr. Bybee, who’s also medical director of cardiovascular services at St. Luke’s South in Overland Park, KS, became interested in the syndrome during his fellowship at Mayo Clinic when he diagnosed three patients in just 2 months. He and his team published the case histories of seven patients in 2004. Since then, many more reports have been published.

Researchers from Texas used the same national database as the Cedars researchers to look at cases from 2005 to 2014, and also found an increase. But study co-author Abhijeet Dhoble, MD, a cardiologist and associate professor of medicine at UT Health Science Center and Memorial Hermann-Texas Medical Center in Houston, believes more recognition explains most of the increase.

And the pandemic is now playing a role in driving up cases, he says.

“In the last 2 years, we have been noticing increasing numbers of cases, probably due to the pandemic,” he says.
 

Profiles of cases

Over the years, Dr. Bybee has collected information on what is happening before the heart begins to go haywire.

“Fifteen to twenty percent of the time, there is no obvious trigger,” he says.

Other times, a stressful emotional event, such as the death of a spouse or a severe car accident, can trigger it.

One patient with an extreme fear of public speaking had to give a talk in front of a large group when she was new to a job. Another woman lost money at a casino before it happened, Dr. Bybee says. Yet another patient took her dog out for a walk in the woods, and the dog got caught in a raccoon trap.

Fierce arguments as well as surprise parties have triggered the condition, Dr. Bybee says. Physical problems such as asthma or sepsis, a life-threatening complication of an infection, can also trigger broken heart.

“It’s challenging because this is unpredictable,” he says.
 

Treatments and recovery

The condition is rarely fatal, say experts from Harvard and Mayo Clinic, but some can have complications such as heart failure.

There are no standard guidelines for treatment, Dr. Dhoble, of Memorial Hermann, says. “We give medications to keep blood pressures in the optimal range.” Doctors may also prescribe lipid-lowering medicines and blood thinner medications. “Most patients recover within 3 to 7 days.”

“Usually within a month, their [heart] function returns to normal,” Dr. Stevens says.

Getting one’s full energy back can take longer, as Dr. Kamil found. “It was about 6 months before I was up to speed.”
 

Survivors talk

Looking back, Dr. Kamil realizes now how much stress she was under before her episode.

“I took care of chronically ill kids,” she says, and worried about them. “I’m kind of a mother hen.”

Besides patient care and her cross-county meeting planning, she was flying back and forth to Florida to tend to her mother, who had chronic health problems. She was also managing that year’s annual media prize at a San Diego university that she and her husband established after the death of their adult son several years before.

“I was busy with that, and it is a bittersweet experience,” she says.

She is trying to take her cardiologist’s advice to slow down.

“I used to be notorious for saying, ‘I need to get one more thing done,’” she says.

Joanie Simpson says she, too, has slowed down. She was diagnosed with broken heart in 2016, after a cascade of stressful events. Her son was facing back surgery, her son-in-law had lost his job, and her tiny Yorkshire terrier Meha died. And she and her husband, Benny, had issues with their rental property.

Now 66 and retired in Camp Wood, Texas, she has learned to enjoy life and worry a little less. Music is one way.

“We’re Parrotheads,” she says, referencing the nickname given to fans of singer Jimmy Buffett. “We listen to Buffett and to ’60s, ’70s, ’80s music. We dance around the house. We aren’t big tavern goers, so we dance around the living room and hope we don’t fall over the coffee table. So far, so good.”

They have plans to buy a small pontoon boat and go fishing. Benny especially loves that idea, she says, laughing, as he finds it’s the only time she stops talking.
 

Reducing the what-ifs

Patients have a common question and worry: What if it happens again?

“I definitely worried more about it in the beginning,” Dr. Kamil says. “Could I have permanent heart damage? Will I be a cardiac cripple?” Her worry has eased.

If you suspect the condition, ‘’get yourself to a provider who knows about it,” she says.

Cardiologists are very likely to suspect the condition, Dr. Bybee says, as are doctors working in a large-volume emergency department.

Dr. Stevens, of St. Luke’s, is straightforward, telling her patients what is known and what is not about the condition. She recommends her patients go to cardiac rehab.

“It gives them that confidence to know what they can do,” she says.

She also gives lifestyle advice, suggesting patients get a home blood pressure cuff and use it. She suggests paying attention to good nutrition and exercise and not lifting anything so heavy that grunting is necessary.

Focus on protecting heart health, Dr. Cheng tells patients. She encourages them to find the stress reduction plan that works for them. Most important, she tells patients to understand that it is not their fault.

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

As the famous saying goes, “laughter is the best medicine.”

So it’s no surprise that humor is a great way to connect with different people and across various groups.

Memes are usually conveyed as images and texts that communicate ideas or thoughts. A meme, or “imitated thing” (translation from the Greek mimeme), was reappropriated from Richard Dawkins in his book The Selfish Gene; we can characterize “meme” with the word “gene” insofar as both self-replicate and are translated from person to person.

I am a big fan of memes. In fact, I can confidently say that one-third of my camera roll is dedicated to saved memes from Facebook, Instagram, and friends. Shameless to say, I’m also part of a few online groups dedicated to memes. They are relatable, as well as quick and fun ways to make light of an otherwise dull or upsetting situation.

Memes are contagious. From the moment they are created, they can be shared from one person to another, be edited or changed to adapt to the current situation, and become viral. They can be used to augment a conversation or replace the need for text communication entirely – in a sense, they are an entire language in and of themselves. They are constantly undergoing selection, repacking, and filtration. As a result, the most popular, successful, and, usually, relatable meme comes out on top, whereas the others fall behind and become “extinct.”

Memes generally adopt a form of word- or image-play that resonates well with people. The type of content varies from general lighthearted harmless animal humor to wry political and/or social commentary. They can be nearly universal or target specific groups (for example, students).

The popularity of memes depends on two factors: likability and “viralability.” Likability refers to how stimulating or engaging the content is, whereas “viralability” refers to the ability of the content to create a similar effect of user engagement across multiple people. Both factors are dynamic and can be quantified on the basis of the number of likes, shares, and/or comments.

In a content analysis of 1,000 memes on Facebook, researchers found that affiliative and aggressive humor styles were the most prevalent. Affiliative humor refers to a style of banter or joke that portrays others in a positive light, whereas aggressive humor achieves the opposite (that is, portrays others in a negative light). Interestingly, the type of humor that achieved the average most likes and shares was self-defeating humor (that is, disparaging one’s own situation in a negative perspective).

Self-defeating memes are suggested to have higher meme fitness. Meme fitness refers to the replicability of a meme. In this context, self-defeating memes have a unique ability to resonate with peoples’ thoughts and feelings in a sarcastic way and create laughter in contexts of general hardships (for example, failed relationships, academic hardships, or general life weaknesses). In a way, I’ve found that self-defeating memes offer a branch of support; to know that I am not going through certain problems alone, and that others can understand these difficulties, is comforting.

Memes can target emotional pain, neutralize the threat, and turn discomfort into a discourse of playfulness and warmth. Especially during times of great uncertainty, a bit of banter and wry humor may be just what we need to make light of difficult situations.

Leanna M.W. Lui, HBSc, completed an HBSc global health specialist degree at the University of Toronto, where she is now an MSc student.

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

As the famous saying goes, “laughter is the best medicine.”

So it’s no surprise that humor is a great way to connect with different people and across various groups.

Memes are usually conveyed as images and texts that communicate ideas or thoughts. A meme, or “imitated thing” (translation from the Greek mimeme), was reappropriated from Richard Dawkins in his book The Selfish Gene; we can characterize “meme” with the word “gene” insofar as both self-replicate and are translated from person to person.

I am a big fan of memes. In fact, I can confidently say that one-third of my camera roll is dedicated to saved memes from Facebook, Instagram, and friends. Shameless to say, I’m also part of a few online groups dedicated to memes. They are relatable, as well as quick and fun ways to make light of an otherwise dull or upsetting situation.

Memes are contagious. From the moment they are created, they can be shared from one person to another, be edited or changed to adapt to the current situation, and become viral. They can be used to augment a conversation or replace the need for text communication entirely – in a sense, they are an entire language in and of themselves. They are constantly undergoing selection, repacking, and filtration. As a result, the most popular, successful, and, usually, relatable meme comes out on top, whereas the others fall behind and become “extinct.”

Memes generally adopt a form of word- or image-play that resonates well with people. The type of content varies from general lighthearted harmless animal humor to wry political and/or social commentary. They can be nearly universal or target specific groups (for example, students).

The popularity of memes depends on two factors: likability and “viralability.” Likability refers to how stimulating or engaging the content is, whereas “viralability” refers to the ability of the content to create a similar effect of user engagement across multiple people. Both factors are dynamic and can be quantified on the basis of the number of likes, shares, and/or comments.

In a content analysis of 1,000 memes on Facebook, researchers found that affiliative and aggressive humor styles were the most prevalent. Affiliative humor refers to a style of banter or joke that portrays others in a positive light, whereas aggressive humor achieves the opposite (that is, portrays others in a negative light). Interestingly, the type of humor that achieved the average most likes and shares was self-defeating humor (that is, disparaging one’s own situation in a negative perspective).

Self-defeating memes are suggested to have higher meme fitness. Meme fitness refers to the replicability of a meme. In this context, self-defeating memes have a unique ability to resonate with peoples’ thoughts and feelings in a sarcastic way and create laughter in contexts of general hardships (for example, failed relationships, academic hardships, or general life weaknesses). In a way, I’ve found that self-defeating memes offer a branch of support; to know that I am not going through certain problems alone, and that others can understand these difficulties, is comforting.

Memes can target emotional pain, neutralize the threat, and turn discomfort into a discourse of playfulness and warmth. Especially during times of great uncertainty, a bit of banter and wry humor may be just what we need to make light of difficult situations.

Leanna M.W. Lui, HBSc, completed an HBSc global health specialist degree at the University of Toronto, where she is now an MSc student.

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

As the famous saying goes, “laughter is the best medicine.”

So it’s no surprise that humor is a great way to connect with different people and across various groups.

Memes are usually conveyed as images and texts that communicate ideas or thoughts. A meme, or “imitated thing” (translation from the Greek mimeme), was reappropriated from Richard Dawkins in his book The Selfish Gene; we can characterize “meme” with the word “gene” insofar as both self-replicate and are translated from person to person.

I am a big fan of memes. In fact, I can confidently say that one-third of my camera roll is dedicated to saved memes from Facebook, Instagram, and friends. Shameless to say, I’m also part of a few online groups dedicated to memes. They are relatable, as well as quick and fun ways to make light of an otherwise dull or upsetting situation.

Memes are contagious. From the moment they are created, they can be shared from one person to another, be edited or changed to adapt to the current situation, and become viral. They can be used to augment a conversation or replace the need for text communication entirely – in a sense, they are an entire language in and of themselves. They are constantly undergoing selection, repacking, and filtration. As a result, the most popular, successful, and, usually, relatable meme comes out on top, whereas the others fall behind and become “extinct.”

Memes generally adopt a form of word- or image-play that resonates well with people. The type of content varies from general lighthearted harmless animal humor to wry political and/or social commentary. They can be nearly universal or target specific groups (for example, students).

The popularity of memes depends on two factors: likability and “viralability.” Likability refers to how stimulating or engaging the content is, whereas “viralability” refers to the ability of the content to create a similar effect of user engagement across multiple people. Both factors are dynamic and can be quantified on the basis of the number of likes, shares, and/or comments.

In a content analysis of 1,000 memes on Facebook, researchers found that affiliative and aggressive humor styles were the most prevalent. Affiliative humor refers to a style of banter or joke that portrays others in a positive light, whereas aggressive humor achieves the opposite (that is, portrays others in a negative light). Interestingly, the type of humor that achieved the average most likes and shares was self-defeating humor (that is, disparaging one’s own situation in a negative perspective).

Self-defeating memes are suggested to have higher meme fitness. Meme fitness refers to the replicability of a meme. In this context, self-defeating memes have a unique ability to resonate with peoples’ thoughts and feelings in a sarcastic way and create laughter in contexts of general hardships (for example, failed relationships, academic hardships, or general life weaknesses). In a way, I’ve found that self-defeating memes offer a branch of support; to know that I am not going through certain problems alone, and that others can understand these difficulties, is comforting.

Memes can target emotional pain, neutralize the threat, and turn discomfort into a discourse of playfulness and warmth. Especially during times of great uncertainty, a bit of banter and wry humor may be just what we need to make light of difficult situations.

Leanna M.W. Lui, HBSc, completed an HBSc global health specialist degree at the University of Toronto, where she is now an MSc student.

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

EVIDENCE SUMMARY

General exercise offers benefit …at least for chronic LBP

A 2017 systematic review of 4 systematic reviews and 50 RCTs (122 total trials) evaluated general exercise vs usual care for acute (< 4 weeks), subacute (4 to 12 weeks), or chronic (≥ 12 weeks) LBP with or without radiculopathy in adults.¹ Exercise was not consistently associated with decreased pain in acute or subacute LBP. For chronic LBP, 3 RCTs (n = 200) associated exercise with decreased pain (weighted mean difference [WMD] = –9.2 on a 0-100 point visual acuity scale; 95% CI, –16.0 to –2.4) and improved function (WMD = –12.4 on the Oswestry Disability Index; 95% CI, –23.0 to –1.7) at short-term follow-up (≤ 3 months). This effect was found to decrease at long-term (≥ 1 year) follow-up (WMD for pain = –4.9; 95% CI, –10.5 to 0.6 and WMD for function = –3.2; 95% CI, 6.0 to –0.4). In a meta-analysis of 10 studies (n = 1992) included in this systematic review, exercise was associated with a lower likelihood of work disability (odds ratio, 0.66; CI, 0.48 to 0.92) at 12 months.¹

Yoga, Pilates, and motor control exercise: Your results may vary

Several reviews have explored the effects of specific exercise modalities on LBP. A 2017 meta-analysis of 9 RCTs in the United States, United Kingdom, and India of nonpregnant adults (≥ 18 years old) with chronic LBP (N = 810) found that yoga (any tradition of yoga with a physical component) vs no exercise demonstrated a statistically, but not clinically, significant decrease in pain at 3 to 4 months (mean difference [MD] = –4.6 on a 0-100 point scale; 95% CI, –7.0 to –2.1), 6 months (MD = –7.8; 95% CI, –13.4 to –2.3), and 12 months (MD = –5.4; 95% CI, –14.5 to –3.7). Clinically significant pain benefit was considered a change of 15 or more points.²

A 2015 meta-analysis of RCTs (10 trials; N = 510) comparing the effects of Pilates (a form of body conditioning involving isometric contractions and core exercises focusing on stability) vs minimal intervention on chronic (> 12 weeks) LBP in nonpregnant adults (≥ 16 years old) found low-quality evidence for decreased pain at short-term follow-up (≤ 3 months; MD = –14.1 on a 0-100 point scale; 95% CI, –18.9 to –9.2). There was moderate-quality evidence for decreased pain at intermediate follow-up (3-12 months; MD = –10.5; 95% CI, –18.5 to –2.6).³

A 2016 systematic review evaluated motor control exercise (MCE; a form of exercise that focuses on trunk muscle control and coordination) in adults (≥ 16 years old) with chronic LBP (≥ 12 weeks). There was low- to moderate-quality evidence that, compared to minimal intervention, MCE decreases pain at short-term (≤ 6 months; 4 RCTs; MD = –10.0 on a 0-100 point scale; 95% CI, –15.7 to –4.4), intermediate (6-12 months; 4 RCTs; MD = –12.6; 95% CI, –20.5 to –4.7), and long-term follow-up (> 12 months; 3 RCTs; MD = –13.0; 95% CI, –18.5 to –7.4). When comparing MCE to general exercise, there were no clinically significant differences in pain or disability at intermediate and long-term follow-up.⁴Common limitations included heterogeneity of intervention methodology, inability to blind results, inability to assess cointerventions, and in some cases, small sample sizes of trials.

Recommendations from others

The 2017 American College of Physicians (ACP) clinical practice guideline on noninvasive treatments for LBP does not recommend exercise therapy in acute or subacute LBP; recommended therapies include superficial heat, massage, acupuncture, or spinal manipulation.⁵ The ACP recommends general exercise, yoga, tai chi, or MCE for chronic LBP, in addition to multidisciplinary rehabilitation, acupuncture, mindfulness-based stress reduction, progressive relaxation, biofeedback, laser therapy, operant therapy, cognitive behavioral therapy, or spinal manipulation.

The 2017 US Department of Veterans Affairs and US Department of Defense clinical practice guideline on treatment of LBP notes insufficient evidence for benefit of clinician-guided exercise therapy in acute LBP.⁶ For chronic LBP, clinician-directed exercise, yoga, tai chi, or Pilates is recommended.

Editor’s takeaway

Convincing evidence demonstrates that exercise modestly improves chronic LBP—but only modestly (4% to 15%), and not in acute LBP. This small magnitude of effect may disappoint expectations, but exercise remains among our better interventions for this common chronic problem. Few—if any—interventions have proven better, and exercise has beneficial side effects, a low cost, and widespread availability.

EVIDENCE SUMMARY

General exercise offers benefit …at least for chronic LBP

A 2017 systematic review of 4 systematic reviews and 50 RCTs (122 total trials) evaluated general exercise vs usual care for acute (< 4 weeks), subacute (4 to 12 weeks), or chronic (≥ 12 weeks) LBP with or without radiculopathy in adults.¹ Exercise was not consistently associated with decreased pain in acute or subacute LBP. For chronic LBP, 3 RCTs (n = 200) associated exercise with decreased pain (weighted mean difference [WMD] = –9.2 on a 0-100 point visual acuity scale; 95% CI, –16.0 to –2.4) and improved function (WMD = –12.4 on the Oswestry Disability Index; 95% CI, –23.0 to –1.7) at short-term follow-up (≤ 3 months). This effect was found to decrease at long-term (≥ 1 year) follow-up (WMD for pain = –4.9; 95% CI, –10.5 to 0.6 and WMD for function = –3.2; 95% CI, 6.0 to –0.4). In a meta-analysis of 10 studies (n = 1992) included in this systematic review, exercise was associated with a lower likelihood of work disability (odds ratio, 0.66; CI, 0.48 to 0.92) at 12 months.¹

Yoga, Pilates, and motor control exercise: Your results may vary

Several reviews have explored the effects of specific exercise modalities on LBP. A 2017 meta-analysis of 9 RCTs in the United States, United Kingdom, and India of nonpregnant adults (≥ 18 years old) with chronic LBP (N = 810) found that yoga (any tradition of yoga with a physical component) vs no exercise demonstrated a statistically, but not clinically, significant decrease in pain at 3 to 4 months (mean difference [MD] = –4.6 on a 0-100 point scale; 95% CI, –7.0 to –2.1), 6 months (MD = –7.8; 95% CI, –13.4 to –2.3), and 12 months (MD = –5.4; 95% CI, –14.5 to –3.7). Clinically significant pain benefit was considered a change of 15 or more points.²

A 2015 meta-analysis of RCTs (10 trials; N = 510) comparing the effects of Pilates (a form of body conditioning involving isometric contractions and core exercises focusing on stability) vs minimal intervention on chronic (> 12 weeks) LBP in nonpregnant adults (≥ 16 years old) found low-quality evidence for decreased pain at short-term follow-up (≤ 3 months; MD = –14.1 on a 0-100 point scale; 95% CI, –18.9 to –9.2). There was moderate-quality evidence for decreased pain at intermediate follow-up (3-12 months; MD = –10.5; 95% CI, –18.5 to –2.6).³

A 2016 systematic review evaluated motor control exercise (MCE; a form of exercise that focuses on trunk muscle control and coordination) in adults (≥ 16 years old) with chronic LBP (≥ 12 weeks). There was low- to moderate-quality evidence that, compared to minimal intervention, MCE decreases pain at short-term (≤ 6 months; 4 RCTs; MD = –10.0 on a 0-100 point scale; 95% CI, –15.7 to –4.4), intermediate (6-12 months; 4 RCTs; MD = –12.6; 95% CI, –20.5 to –4.7), and long-term follow-up (> 12 months; 3 RCTs; MD = –13.0; 95% CI, –18.5 to –7.4). When comparing MCE to general exercise, there were no clinically significant differences in pain or disability at intermediate and long-term follow-up.⁴Common limitations included heterogeneity of intervention methodology, inability to blind results, inability to assess cointerventions, and in some cases, small sample sizes of trials.

Recommendations from others

The 2017 American College of Physicians (ACP) clinical practice guideline on noninvasive treatments for LBP does not recommend exercise therapy in acute or subacute LBP; recommended therapies include superficial heat, massage, acupuncture, or spinal manipulation.⁵ The ACP recommends general exercise, yoga, tai chi, or MCE for chronic LBP, in addition to multidisciplinary rehabilitation, acupuncture, mindfulness-based stress reduction, progressive relaxation, biofeedback, laser therapy, operant therapy, cognitive behavioral therapy, or spinal manipulation.

The 2017 US Department of Veterans Affairs and US Department of Defense clinical practice guideline on treatment of LBP notes insufficient evidence for benefit of clinician-guided exercise therapy in acute LBP.⁶ For chronic LBP, clinician-directed exercise, yoga, tai chi, or Pilates is recommended.

Editor’s takeaway

Convincing evidence demonstrates that exercise modestly improves chronic LBP—but only modestly (4% to 15%), and not in acute LBP. This small magnitude of effect may disappoint expectations, but exercise remains among our better interventions for this common chronic problem. Few—if any—interventions have proven better, and exercise has beneficial side effects, a low cost, and widespread availability.

EVIDENCE SUMMARY

General exercise offers benefit …at least for chronic LBP

A 2017 systematic review of 4 systematic reviews and 50 RCTs (122 total trials) evaluated general exercise vs usual care for acute (< 4 weeks), subacute (4 to 12 weeks), or chronic (≥ 12 weeks) LBP with or without radiculopathy in adults.¹ Exercise was not consistently associated with decreased pain in acute or subacute LBP. For chronic LBP, 3 RCTs (n = 200) associated exercise with decreased pain (weighted mean difference [WMD] = –9.2 on a 0-100 point visual acuity scale; 95% CI, –16.0 to –2.4) and improved function (WMD = –12.4 on the Oswestry Disability Index; 95% CI, –23.0 to –1.7) at short-term follow-up (≤ 3 months). This effect was found to decrease at long-term (≥ 1 year) follow-up (WMD for pain = –4.9; 95% CI, –10.5 to 0.6 and WMD for function = –3.2; 95% CI, 6.0 to –0.4). In a meta-analysis of 10 studies (n = 1992) included in this systematic review, exercise was associated with a lower likelihood of work disability (odds ratio, 0.66; CI, 0.48 to 0.92) at 12 months.¹

Yoga, Pilates, and motor control exercise: Your results may vary

Several reviews have explored the effects of specific exercise modalities on LBP. A 2017 meta-analysis of 9 RCTs in the United States, United Kingdom, and India of nonpregnant adults (≥ 18 years old) with chronic LBP (N = 810) found that yoga (any tradition of yoga with a physical component) vs no exercise demonstrated a statistically, but not clinically, significant decrease in pain at 3 to 4 months (mean difference [MD] = –4.6 on a 0-100 point scale; 95% CI, –7.0 to –2.1), 6 months (MD = –7.8; 95% CI, –13.4 to –2.3), and 12 months (MD = –5.4; 95% CI, –14.5 to –3.7). Clinically significant pain benefit was considered a change of 15 or more points.²

A 2015 meta-analysis of RCTs (10 trials; N = 510) comparing the effects of Pilates (a form of body conditioning involving isometric contractions and core exercises focusing on stability) vs minimal intervention on chronic (> 12 weeks) LBP in nonpregnant adults (≥ 16 years old) found low-quality evidence for decreased pain at short-term follow-up (≤ 3 months; MD = –14.1 on a 0-100 point scale; 95% CI, –18.9 to –9.2). There was moderate-quality evidence for decreased pain at intermediate follow-up (3-12 months; MD = –10.5; 95% CI, –18.5 to –2.6).³

A 2016 systematic review evaluated motor control exercise (MCE; a form of exercise that focuses on trunk muscle control and coordination) in adults (≥ 16 years old) with chronic LBP (≥ 12 weeks). There was low- to moderate-quality evidence that, compared to minimal intervention, MCE decreases pain at short-term (≤ 6 months; 4 RCTs; MD = –10.0 on a 0-100 point scale; 95% CI, –15.7 to –4.4), intermediate (6-12 months; 4 RCTs; MD = –12.6; 95% CI, –20.5 to –4.7), and long-term follow-up (> 12 months; 3 RCTs; MD = –13.0; 95% CI, –18.5 to –7.4). When comparing MCE to general exercise, there were no clinically significant differences in pain or disability at intermediate and long-term follow-up.⁴Common limitations included heterogeneity of intervention methodology, inability to blind results, inability to assess cointerventions, and in some cases, small sample sizes of trials.

Recommendations from others

The 2017 American College of Physicians (ACP) clinical practice guideline on noninvasive treatments for LBP does not recommend exercise therapy in acute or subacute LBP; recommended therapies include superficial heat, massage, acupuncture, or spinal manipulation.⁵ The ACP recommends general exercise, yoga, tai chi, or MCE for chronic LBP, in addition to multidisciplinary rehabilitation, acupuncture, mindfulness-based stress reduction, progressive relaxation, biofeedback, laser therapy, operant therapy, cognitive behavioral therapy, or spinal manipulation.

The 2017 US Department of Veterans Affairs and US Department of Defense clinical practice guideline on treatment of LBP notes insufficient evidence for benefit of clinician-guided exercise therapy in acute LBP.⁶ For chronic LBP, clinician-directed exercise, yoga, tai chi, or Pilates is recommended.

Editor’s takeaway

Convincing evidence demonstrates that exercise modestly improves chronic LBP—but only modestly (4% to 15%), and not in acute LBP. This small magnitude of effect may disappoint expectations, but exercise remains among our better interventions for this common chronic problem. Few—if any—interventions have proven better, and exercise has beneficial side effects, a low cost, and widespread availability.

Dementia remains a major cause of disability in older adults. In addition, it places a strain on family members and other caregivers taking care of these patients.

It is estimated that by the year 2060, 13.9 million Americans over the age of 65 will be diagnosed with dementia. Few good treatments are currently available.

Earlier this year, the American Psychological Association (APA) Task Force issued clinical guidelines “for the Evaluation of Dementia and Age-Related Cognitive Change.” While these 16 guidelines are aimed at psychologists, primary care doctors are often the first ones to evaluate a patient who may have dementia. As a family physician, I find having these guidelines especially helpful.
 

Neuropsychiatric testing and defining severity and type

This new guidance places emphasis on neuropsychiatric testing and defining the severity and type of dementia present.

Over the past 2 decades, diagnoses of mild neurocognitive disorders have increased, and this, in part, is due to diagnosing these problems earlier and with greater precision. It is also important to know that biomarkers are being increasingly researched, and it is imperative that we stay current with this research.

Cognitive decline may also occur with the coexistence of other mental health disorders, such as depression, so it is important that we screen for these as well. This is often difficult given the behavioral changes that can arise in dementia, but, as primary care doctors, we must differentiate these to treat our patients appropriately.
 

Informed consent

Informed consent can become an issue with patients with dementia. It must be assessed whether the patient has the capacity to make an informed decision and can competently communicate that decision.

The diagnosis of dementia alone does not preclude a patient from giving informed consent. A patient’s mental capacity must be determined, and if they are not capable of making an informed decision, the person legally responsible for giving informed consent on behalf of the patient must be identified.

Patients with dementia often have other medical comorbidities and take several medications. It is imperative to keep accurate medical records and medication lists. Sometimes, patients with dementia cannot provide this information. If that is the case, every attempt should be made to obtain records from every possible source.
 

Cultural competence

The guidelines also stress that there may be cultural differences when applying neuropsychiatric tests. It is our duty to maintain cultural competence and understand these differences. We all need to work to ensure we control our biases, and it is suggested that we review relevant evidence-based literature.

While ageism is common in our society, it shouldn’t be in our practices. For these reasons, outreach in at-risk populations is very important.
 

Pertinent data

The guidelines also suggest obtaining all possible information in our evaluation, especially when the patient is unable to give it to us.

Often, as primary care physicians, we refer these patients to other providers, and we should be providing all pertinent data to those we are referring these patients to. If all information is not available at the time of evaluation, follow-up visits should be scheduled.

If possible, family members should be present at the time of visit. They often provide valuable information regarding the extent and progression of the decline. Also, they know how the patient is functioning in the home setting and how much assistance they need with activities of daily living.
 

Caretaker support

Another important factor to consider is caretaker burnout. Caretakers are often under a lot of stress and have high rates of depression. It is important to provide them with education and support, as well as resources that may be available to them. For some, accepting the diagnosis that their loved one has dementia may be a struggle.

As doctors treating dementia patients, we need to know the resources that are available to assist dementia patients and their families. There are many local organizations that can help.

Also, research into dementia is ongoing and we need to stay current. The diagnosis of dementia should be made as early as possible using appropriate screening tools. The sooner the diagnosis is made, the quicker interventions can be started and the family members, as well as the patient, can come to accept the diagnosis.

As the population ages, we can expect the demands of dementia to rise as well. Primary care doctors are in a unique position to diagnose dementia once it starts to appear.
 

Dr. Girgis practices family medicine in South River, N.J., and is a clinical assistant professor of family medicine at Robert Wood Johnson Medical School, New Brunswick, N.J. You can contact her at fpnews@mdedge.com.

Dementia remains a major cause of disability in older adults. In addition, it places a strain on family members and other caregivers taking care of these patients.

It is estimated that by the year 2060, 13.9 million Americans over the age of 65 will be diagnosed with dementia. Few good treatments are currently available.

Earlier this year, the American Psychological Association (APA) Task Force issued clinical guidelines “for the Evaluation of Dementia and Age-Related Cognitive Change.” While these 16 guidelines are aimed at psychologists, primary care doctors are often the first ones to evaluate a patient who may have dementia. As a family physician, I find having these guidelines especially helpful.
 

Neuropsychiatric testing and defining severity and type

This new guidance places emphasis on neuropsychiatric testing and defining the severity and type of dementia present.

Over the past 2 decades, diagnoses of mild neurocognitive disorders have increased, and this, in part, is due to diagnosing these problems earlier and with greater precision. It is also important to know that biomarkers are being increasingly researched, and it is imperative that we stay current with this research.

Cognitive decline may also occur with the coexistence of other mental health disorders, such as depression, so it is important that we screen for these as well. This is often difficult given the behavioral changes that can arise in dementia, but, as primary care doctors, we must differentiate these to treat our patients appropriately.
 

Informed consent

Informed consent can become an issue with patients with dementia. It must be assessed whether the patient has the capacity to make an informed decision and can competently communicate that decision.

The diagnosis of dementia alone does not preclude a patient from giving informed consent. A patient’s mental capacity must be determined, and if they are not capable of making an informed decision, the person legally responsible for giving informed consent on behalf of the patient must be identified.

Patients with dementia often have other medical comorbidities and take several medications. It is imperative to keep accurate medical records and medication lists. Sometimes, patients with dementia cannot provide this information. If that is the case, every attempt should be made to obtain records from every possible source.
 

Cultural competence

The guidelines also stress that there may be cultural differences when applying neuropsychiatric tests. It is our duty to maintain cultural competence and understand these differences. We all need to work to ensure we control our biases, and it is suggested that we review relevant evidence-based literature.

While ageism is common in our society, it shouldn’t be in our practices. For these reasons, outreach in at-risk populations is very important.
 

Pertinent data

The guidelines also suggest obtaining all possible information in our evaluation, especially when the patient is unable to give it to us.

Often, as primary care physicians, we refer these patients to other providers, and we should be providing all pertinent data to those we are referring these patients to. If all information is not available at the time of evaluation, follow-up visits should be scheduled.

If possible, family members should be present at the time of visit. They often provide valuable information regarding the extent and progression of the decline. Also, they know how the patient is functioning in the home setting and how much assistance they need with activities of daily living.
 

Caretaker support

Another important factor to consider is caretaker burnout. Caretakers are often under a lot of stress and have high rates of depression. It is important to provide them with education and support, as well as resources that may be available to them. For some, accepting the diagnosis that their loved one has dementia may be a struggle.

As doctors treating dementia patients, we need to know the resources that are available to assist dementia patients and their families. There are many local organizations that can help.

Also, research into dementia is ongoing and we need to stay current. The diagnosis of dementia should be made as early as possible using appropriate screening tools. The sooner the diagnosis is made, the quicker interventions can be started and the family members, as well as the patient, can come to accept the diagnosis.

As the population ages, we can expect the demands of dementia to rise as well. Primary care doctors are in a unique position to diagnose dementia once it starts to appear.
 

Dr. Girgis practices family medicine in South River, N.J., and is a clinical assistant professor of family medicine at Robert Wood Johnson Medical School, New Brunswick, N.J. You can contact her at fpnews@mdedge.com.

Dementia remains a major cause of disability in older adults. In addition, it places a strain on family members and other caregivers taking care of these patients.

It is estimated that by the year 2060, 13.9 million Americans over the age of 65 will be diagnosed with dementia. Few good treatments are currently available.

Earlier this year, the American Psychological Association (APA) Task Force issued clinical guidelines “for the Evaluation of Dementia and Age-Related Cognitive Change.” While these 16 guidelines are aimed at psychologists, primary care doctors are often the first ones to evaluate a patient who may have dementia. As a family physician, I find having these guidelines especially helpful.
 

Neuropsychiatric testing and defining severity and type

This new guidance places emphasis on neuropsychiatric testing and defining the severity and type of dementia present.

Over the past 2 decades, diagnoses of mild neurocognitive disorders have increased, and this, in part, is due to diagnosing these problems earlier and with greater precision. It is also important to know that biomarkers are being increasingly researched, and it is imperative that we stay current with this research.

Cognitive decline may also occur with the coexistence of other mental health disorders, such as depression, so it is important that we screen for these as well. This is often difficult given the behavioral changes that can arise in dementia, but, as primary care doctors, we must differentiate these to treat our patients appropriately.
 

Informed consent

Informed consent can become an issue with patients with dementia. It must be assessed whether the patient has the capacity to make an informed decision and can competently communicate that decision.

The diagnosis of dementia alone does not preclude a patient from giving informed consent. A patient’s mental capacity must be determined, and if they are not capable of making an informed decision, the person legally responsible for giving informed consent on behalf of the patient must be identified.

Patients with dementia often have other medical comorbidities and take several medications. It is imperative to keep accurate medical records and medication lists. Sometimes, patients with dementia cannot provide this information. If that is the case, every attempt should be made to obtain records from every possible source.
 

Cultural competence

The guidelines also stress that there may be cultural differences when applying neuropsychiatric tests. It is our duty to maintain cultural competence and understand these differences. We all need to work to ensure we control our biases, and it is suggested that we review relevant evidence-based literature.

While ageism is common in our society, it shouldn’t be in our practices. For these reasons, outreach in at-risk populations is very important.
 

Pertinent data

The guidelines also suggest obtaining all possible information in our evaluation, especially when the patient is unable to give it to us.

Often, as primary care physicians, we refer these patients to other providers, and we should be providing all pertinent data to those we are referring these patients to. If all information is not available at the time of evaluation, follow-up visits should be scheduled.

If possible, family members should be present at the time of visit. They often provide valuable information regarding the extent and progression of the decline. Also, they know how the patient is functioning in the home setting and how much assistance they need with activities of daily living.
 

Caretaker support

Another important factor to consider is caretaker burnout. Caretakers are often under a lot of stress and have high rates of depression. It is important to provide them with education and support, as well as resources that may be available to them. For some, accepting the diagnosis that their loved one has dementia may be a struggle.

As doctors treating dementia patients, we need to know the resources that are available to assist dementia patients and their families. There are many local organizations that can help.

Also, research into dementia is ongoing and we need to stay current. The diagnosis of dementia should be made as early as possible using appropriate screening tools. The sooner the diagnosis is made, the quicker interventions can be started and the family members, as well as the patient, can come to accept the diagnosis.

As the population ages, we can expect the demands of dementia to rise as well. Primary care doctors are in a unique position to diagnose dementia once it starts to appear.
 

Dr. Girgis practices family medicine in South River, N.J., and is a clinical assistant professor of family medicine at Robert Wood Johnson Medical School, New Brunswick, N.J. You can contact her at fpnews@mdedge.com.

This month’s cover story, “A 4-pronged approach to foster healthy aging in older adults,” by Wilson and colleagues (page 376) provides a wealth of information about aspects of healthy aging that we should consider when we see our older patients. After reading this manuscript, I was a bit overwhelmed by the amount of information presented and, more so, by the thought of attempting to incorporate into my practice all of the possible screenings and interventions available to help older adults improve and maintain their health.

There is no debate about the importance of issues such as diet, exercise and mobility, mental health and cognition, vision and hearing, and strong social connections for maintaining health as we age. The difficulty comes in deciding how to spend our limited time with older patients during office encounters. Most older adults have several chronic diseases that need our attention, and they often have various medications that need to be monitored for effectiveness and safety, which can be time consuming. And, of course, we need to take time to screen for cardiovascular risk and cancer, too. Where to start?

Dr. Wilson’s solution makes sense to me: Take advantage of the annual wellness visit to discuss diet, exercise, mental health, vision and hearing, and social relationships. I am not so sure, however, if using formal screening instruments is the best way to do this, especially since there is no strong research that demonstrates improved patient-relevant outcomes using screening instruments, except, perhaps, for periodically screening for anxiety and depression.

It may be effective to use the “chat technique” and ask open-ended questions, such as: How are things going for you?

It may be as effective to use what I will call the “chat technique.” Start with open-ended questions and statements, such as: “How are things going for you?” “Tell me about your family.” “What do you do for physical activity?” and “How has your mood been lately?”

An excellent complement to the chat technique is the goal-setting approach championed by geriatrician and family physician Jim Mold.¹ His premise is that health itself is not the most important goal for most people, but rather a means to an end. That end is very specific to every person. An elderly, frail woman’s main life goal, for example, might be to remain in her own home for as long as possible or to live long enough to attend her great-grandson’s wedding.

Goal setting provides an excellent context for true shared decision-making. I agree with Dr. Wilson’s closing statement:

“As family physicians, it is important to capitalize on longitudinal relationships with patients and begin educating younger patients using this multidimensional framework to promote living ‘a productive and meaningful life’at any age.”

This month’s cover story, “A 4-pronged approach to foster healthy aging in older adults,” by Wilson and colleagues (page 376) provides a wealth of information about aspects of healthy aging that we should consider when we see our older patients. After reading this manuscript, I was a bit overwhelmed by the amount of information presented and, more so, by the thought of attempting to incorporate into my practice all of the possible screenings and interventions available to help older adults improve and maintain their health.

There is no debate about the importance of issues such as diet, exercise and mobility, mental health and cognition, vision and hearing, and strong social connections for maintaining health as we age. The difficulty comes in deciding how to spend our limited time with older patients during office encounters. Most older adults have several chronic diseases that need our attention, and they often have various medications that need to be monitored for effectiveness and safety, which can be time consuming. And, of course, we need to take time to screen for cardiovascular risk and cancer, too. Where to start?

Dr. Wilson’s solution makes sense to me: Take advantage of the annual wellness visit to discuss diet, exercise, mental health, vision and hearing, and social relationships. I am not so sure, however, if using formal screening instruments is the best way to do this, especially since there is no strong research that demonstrates improved patient-relevant outcomes using screening instruments, except, perhaps, for periodically screening for anxiety and depression.

It may be effective to use the “chat technique” and ask open-ended questions, such as: How are things going for you?

It may be as effective to use what I will call the “chat technique.” Start with open-ended questions and statements, such as: “How are things going for you?” “Tell me about your family.” “What do you do for physical activity?” and “How has your mood been lately?”

An excellent complement to the chat technique is the goal-setting approach championed by geriatrician and family physician Jim Mold.¹ His premise is that health itself is not the most important goal for most people, but rather a means to an end. That end is very specific to every person. An elderly, frail woman’s main life goal, for example, might be to remain in her own home for as long as possible or to live long enough to attend her great-grandson’s wedding.

Goal setting provides an excellent context for true shared decision-making. I agree with Dr. Wilson’s closing statement:

“As family physicians, it is important to capitalize on longitudinal relationships with patients and begin educating younger patients using this multidimensional framework to promote living ‘a productive and meaningful life’at any age.”

This month’s cover story, “A 4-pronged approach to foster healthy aging in older adults,” by Wilson and colleagues (page 376) provides a wealth of information about aspects of healthy aging that we should consider when we see our older patients. After reading this manuscript, I was a bit overwhelmed by the amount of information presented and, more so, by the thought of attempting to incorporate into my practice all of the possible screenings and interventions available to help older adults improve and maintain their health.

There is no debate about the importance of issues such as diet, exercise and mobility, mental health and cognition, vision and hearing, and strong social connections for maintaining health as we age. The difficulty comes in deciding how to spend our limited time with older patients during office encounters. Most older adults have several chronic diseases that need our attention, and they often have various medications that need to be monitored for effectiveness and safety, which can be time consuming. And, of course, we need to take time to screen for cardiovascular risk and cancer, too. Where to start?

Dr. Wilson’s solution makes sense to me: Take advantage of the annual wellness visit to discuss diet, exercise, mental health, vision and hearing, and social relationships. I am not so sure, however, if using formal screening instruments is the best way to do this, especially since there is no strong research that demonstrates improved patient-relevant outcomes using screening instruments, except, perhaps, for periodically screening for anxiety and depression.

It may be effective to use the “chat technique” and ask open-ended questions, such as: How are things going for you?

It may be as effective to use what I will call the “chat technique.” Start with open-ended questions and statements, such as: “How are things going for you?” “Tell me about your family.” “What do you do for physical activity?” and “How has your mood been lately?”

An excellent complement to the chat technique is the goal-setting approach championed by geriatrician and family physician Jim Mold.¹ His premise is that health itself is not the most important goal for most people, but rather a means to an end. That end is very specific to every person. An elderly, frail woman’s main life goal, for example, might be to remain in her own home for as long as possible or to live long enough to attend her great-grandson’s wedding.

Goal setting provides an excellent context for true shared decision-making. I agree with Dr. Wilson’s closing statement:

“As family physicians, it is important to capitalize on longitudinal relationships with patients and begin educating younger patients using this multidimensional framework to promote living ‘a productive and meaningful life’at any age.”

Background: A large proportion of Italian patients with COVID-19 presented with symptoms, most commonly cough, fever, dyspnea, myalgias, anosmia, and gastrointestinal symptoms. Information is lacking on persistent symptoms after recovery.

From April 21 to May 29, 2020, 179 patients were potentially eligible; 143 ultimately were included. During hospitalization, 72.7% of participants had evidence of interstitial pneumonia. Patients were assessed a mean of 60.3 days after onset of the first COVID-19 symptom. Only 18 (12.6%) were completely free of any COVID-19–related symptoms, 32% had one or two symptoms, and 55% had three or more. Worsened quality of life was observed among 44.1% of patients.

Bottom line: 87.4% of patients who had recovered from COVID-19 reported persistence of at least one symptom, particularly fatigue and dyspnea.

Citation: Carfi A et al. Persistent symptoms in patients after acute COVID-19. JAMA. 2020;324(6):603-5.

Dr. Walker is a hospitalist at the Lexington (Ky.) VA Health Care System.

Background: A large proportion of Italian patients with COVID-19 presented with symptoms, most commonly cough, fever, dyspnea, myalgias, anosmia, and gastrointestinal symptoms. Information is lacking on persistent symptoms after recovery.

From April 21 to May 29, 2020, 179 patients were potentially eligible; 143 ultimately were included. During hospitalization, 72.7% of participants had evidence of interstitial pneumonia. Patients were assessed a mean of 60.3 days after onset of the first COVID-19 symptom. Only 18 (12.6%) were completely free of any COVID-19–related symptoms, 32% had one or two symptoms, and 55% had three or more. Worsened quality of life was observed among 44.1% of patients.

Bottom line: 87.4% of patients who had recovered from COVID-19 reported persistence of at least one symptom, particularly fatigue and dyspnea.

Citation: Carfi A et al. Persistent symptoms in patients after acute COVID-19. JAMA. 2020;324(6):603-5.

Dr. Walker is a hospitalist at the Lexington (Ky.) VA Health Care System.

Background: A large proportion of Italian patients with COVID-19 presented with symptoms, most commonly cough, fever, dyspnea, myalgias, anosmia, and gastrointestinal symptoms. Information is lacking on persistent symptoms after recovery.

From April 21 to May 29, 2020, 179 patients were potentially eligible; 143 ultimately were included. During hospitalization, 72.7% of participants had evidence of interstitial pneumonia. Patients were assessed a mean of 60.3 days after onset of the first COVID-19 symptom. Only 18 (12.6%) were completely free of any COVID-19–related symptoms, 32% had one or two symptoms, and 55% had three or more. Worsened quality of life was observed among 44.1% of patients.

Bottom line: 87.4% of patients who had recovered from COVID-19 reported persistence of at least one symptom, particularly fatigue and dyspnea.

Citation: Carfi A et al. Persistent symptoms in patients after acute COVID-19. JAMA. 2020;324(6):603-5.

Dr. Walker is a hospitalist at the Lexington (Ky.) VA Health Care System.

A survey of more than 12,000 women of reproductive age found that one in three had experienced changes to their menstrual cycles and symptoms during the COVID-19 pandemic. Noticeably higher stress levels than prepandemic benchmarks could be affecting menstruation.

This has implications for women trying to conceive or struggling with infertility, said Shannon M. Malloy, a research and data associate with Ovia Health, a women’s and family health technology company in Boston. Ms. Malloy presented this study at the American Society of Reproductive Medicine’s 2021 meeting.

COVID-19 has introduced new psychosocial, interpersonal, and environmental stressors. The pandemic is “one of the most stressful, collectively experienced disasters modern society has ever seen,” said Ms. Malloy. Once imagined as an explicit event in time, COVID-19 has ingrained itself into daily life for the foreseeable future.

Research has shown that chronic, long-term stress produces high cortisol levels, which can alter endocrinology and regulation of menstrual cycles. This can make family building even more challenging, said Ms. Malloy. Physicians and other providers have always taken stress into account when managing patients, but never at this level of chronic, episodic stress, she said.
 

Survey examines impact on ART

Ovia Health decided to investigate the relationship between perceived stress and menstrual cycle and symptom changes during the COVID-19 pandemic, to see how it might affect assisted reproductive technology (ART).

From March 2020 to April 2021, users of Ovia Health’s Fertility mobile application in the United States took part in a survey. Items captured changes in menstruation pattern and symptomatology and included the Perceived Stress Scale 4-item version (PSS-4). A paired t-test evaluated differences between groups (menstrual changes versus no menstrual changes). The survey asked participants what changes they noticed in their menstrual cycle and why they thought cycle patterns or symptoms changed.
 

One-third report changes in cycle, symptoms

Among 12,302 respondents, 1 in 3 (36%) reported changes in cycle or symptoms. Eighty-seven percent said that their cycle started early or late. Twenty-nine percent reported stronger symptoms during menstruation such as low back pain, cramping, or discharge changes, and 27% said bleeding was heavier during periods.

These results are similar to other studies investigating the affect of episodic stress on menstruation, said Ms. Malloy.

Those who reported menstrual cycle or symptom changes scored higher on average on the PSS-4 compared with those who didn’t report any changes (8.5 v. 8.3, respectively, P < .05). PSS-4 scores across the board were notably higher in all respondents, regardless of cycle/symptom irregularity, compared with prepandemic benchmarking in similar populations.

Slightly more than half (55%) thought stress contributed to their menstrual cycle pattern and/or symptom changes, whereas 33% pointed to changes in mental health, such as depression or anxiety. “Interestingly, many users believed the COVID-19 vaccine impacted their menstrual cycle symptom changes,” said Ms. Malloy.
 

No definitive link between vaccine, menstruation

While known side effects of the vaccine include sore arm, fever, fatigue, and myalgia, some women have reported changes in their menstrual cycle, Mark P. Trolice, MD, professor of obstetrics and gynecology at the University of Central Florida and director of the IVF Center in Orlando, said in an interview.

“Vaccination reaction from the immune response rather than the vaccine may be the implicating factor,” said Dr. Trolice, who was not involved in the study.

Currently, there’s no direct link between the vaccine and subsequent effects on menstruation, he continued. “Most women experience resumption of normal intervals 1 month following vaccination. Further, there is no credible evidence that links the vaccine to infertility.

“Nevertheless, research in this area is vital and underway,” he added.
 

Physicians can help with stress

Menstrual cycle disruption is especially frustrating for women trying to build a family, said Ms. Malloy. Providers may be observing more menstrual irregularity in their patient populations, and seeing more patients struggle to conceive on their own, turning to ART.

Providers can’t make COVID-19 go away, but they could help patients by doing a better job of integrating mental health screening, connecting patients to treatments that optimize conception and fertility treatment outcomes, said Ms. Malloy.

The survey was limited in that its questions didn’t consider proper diagnostic criteria for irregularity, versus self-reported changes. But it does highlight the need for more research on the pandemic’s affect on menstruation and the vaccine on menstruation, said Ms. Malloy. “The National Institutes of Health in August committed $1.6 million to explore this connection. We’re looking forward to seeing what their results are.” 

Dr. Trolice and Ms. Malloy had no disclosures.

A survey of more than 12,000 women of reproductive age found that one in three had experienced changes to their menstrual cycles and symptoms during the COVID-19 pandemic. Noticeably higher stress levels than prepandemic benchmarks could be affecting menstruation.

This has implications for women trying to conceive or struggling with infertility, said Shannon M. Malloy, a research and data associate with Ovia Health, a women’s and family health technology company in Boston. Ms. Malloy presented this study at the American Society of Reproductive Medicine’s 2021 meeting.

COVID-19 has introduced new psychosocial, interpersonal, and environmental stressors. The pandemic is “one of the most stressful, collectively experienced disasters modern society has ever seen,” said Ms. Malloy. Once imagined as an explicit event in time, COVID-19 has ingrained itself into daily life for the foreseeable future.

Research has shown that chronic, long-term stress produces high cortisol levels, which can alter endocrinology and regulation of menstrual cycles. This can make family building even more challenging, said Ms. Malloy. Physicians and other providers have always taken stress into account when managing patients, but never at this level of chronic, episodic stress, she said.
 

Survey examines impact on ART

Ovia Health decided to investigate the relationship between perceived stress and menstrual cycle and symptom changes during the COVID-19 pandemic, to see how it might affect assisted reproductive technology (ART).

From March 2020 to April 2021, users of Ovia Health’s Fertility mobile application in the United States took part in a survey. Items captured changes in menstruation pattern and symptomatology and included the Perceived Stress Scale 4-item version (PSS-4). A paired t-test evaluated differences between groups (menstrual changes versus no menstrual changes). The survey asked participants what changes they noticed in their menstrual cycle and why they thought cycle patterns or symptoms changed.
 

One-third report changes in cycle, symptoms

Among 12,302 respondents, 1 in 3 (36%) reported changes in cycle or symptoms. Eighty-seven percent said that their cycle started early or late. Twenty-nine percent reported stronger symptoms during menstruation such as low back pain, cramping, or discharge changes, and 27% said bleeding was heavier during periods.

These results are similar to other studies investigating the affect of episodic stress on menstruation, said Ms. Malloy.

Those who reported menstrual cycle or symptom changes scored higher on average on the PSS-4 compared with those who didn’t report any changes (8.5 v. 8.3, respectively, P < .05). PSS-4 scores across the board were notably higher in all respondents, regardless of cycle/symptom irregularity, compared with prepandemic benchmarking in similar populations.

Slightly more than half (55%) thought stress contributed to their menstrual cycle pattern and/or symptom changes, whereas 33% pointed to changes in mental health, such as depression or anxiety. “Interestingly, many users believed the COVID-19 vaccine impacted their menstrual cycle symptom changes,” said Ms. Malloy.
 

No definitive link between vaccine, menstruation

While known side effects of the vaccine include sore arm, fever, fatigue, and myalgia, some women have reported changes in their menstrual cycle, Mark P. Trolice, MD, professor of obstetrics and gynecology at the University of Central Florida and director of the IVF Center in Orlando, said in an interview.

“Vaccination reaction from the immune response rather than the vaccine may be the implicating factor,” said Dr. Trolice, who was not involved in the study.

Currently, there’s no direct link between the vaccine and subsequent effects on menstruation, he continued. “Most women experience resumption of normal intervals 1 month following vaccination. Further, there is no credible evidence that links the vaccine to infertility.

“Nevertheless, research in this area is vital and underway,” he added.
 

Physicians can help with stress

Menstrual cycle disruption is especially frustrating for women trying to build a family, said Ms. Malloy. Providers may be observing more menstrual irregularity in their patient populations, and seeing more patients struggle to conceive on their own, turning to ART.

Providers can’t make COVID-19 go away, but they could help patients by doing a better job of integrating mental health screening, connecting patients to treatments that optimize conception and fertility treatment outcomes, said Ms. Malloy.

The survey was limited in that its questions didn’t consider proper diagnostic criteria for irregularity, versus self-reported changes. But it does highlight the need for more research on the pandemic’s affect on menstruation and the vaccine on menstruation, said Ms. Malloy. “The National Institutes of Health in August committed $1.6 million to explore this connection. We’re looking forward to seeing what their results are.” 

Dr. Trolice and Ms. Malloy had no disclosures.

A survey of more than 12,000 women of reproductive age found that one in three had experienced changes to their menstrual cycles and symptoms during the COVID-19 pandemic. Noticeably higher stress levels than prepandemic benchmarks could be affecting menstruation.

This has implications for women trying to conceive or struggling with infertility, said Shannon M. Malloy, a research and data associate with Ovia Health, a women’s and family health technology company in Boston. Ms. Malloy presented this study at the American Society of Reproductive Medicine’s 2021 meeting.

COVID-19 has introduced new psychosocial, interpersonal, and environmental stressors. The pandemic is “one of the most stressful, collectively experienced disasters modern society has ever seen,” said Ms. Malloy. Once imagined as an explicit event in time, COVID-19 has ingrained itself into daily life for the foreseeable future.

Research has shown that chronic, long-term stress produces high cortisol levels, which can alter endocrinology and regulation of menstrual cycles. This can make family building even more challenging, said Ms. Malloy. Physicians and other providers have always taken stress into account when managing patients, but never at this level of chronic, episodic stress, she said.
 

Survey examines impact on ART

Ovia Health decided to investigate the relationship between perceived stress and menstrual cycle and symptom changes during the COVID-19 pandemic, to see how it might affect assisted reproductive technology (ART).

From March 2020 to April 2021, users of Ovia Health’s Fertility mobile application in the United States took part in a survey. Items captured changes in menstruation pattern and symptomatology and included the Perceived Stress Scale 4-item version (PSS-4). A paired t-test evaluated differences between groups (menstrual changes versus no menstrual changes). The survey asked participants what changes they noticed in their menstrual cycle and why they thought cycle patterns or symptoms changed.
 

One-third report changes in cycle, symptoms

Among 12,302 respondents, 1 in 3 (36%) reported changes in cycle or symptoms. Eighty-seven percent said that their cycle started early or late. Twenty-nine percent reported stronger symptoms during menstruation such as low back pain, cramping, or discharge changes, and 27% said bleeding was heavier during periods.

These results are similar to other studies investigating the affect of episodic stress on menstruation, said Ms. Malloy.

Those who reported menstrual cycle or symptom changes scored higher on average on the PSS-4 compared with those who didn’t report any changes (8.5 v. 8.3, respectively, P < .05). PSS-4 scores across the board were notably higher in all respondents, regardless of cycle/symptom irregularity, compared with prepandemic benchmarking in similar populations.

Slightly more than half (55%) thought stress contributed to their menstrual cycle pattern and/or symptom changes, whereas 33% pointed to changes in mental health, such as depression or anxiety. “Interestingly, many users believed the COVID-19 vaccine impacted their menstrual cycle symptom changes,” said Ms. Malloy.
 

No definitive link between vaccine, menstruation

While known side effects of the vaccine include sore arm, fever, fatigue, and myalgia, some women have reported changes in their menstrual cycle, Mark P. Trolice, MD, professor of obstetrics and gynecology at the University of Central Florida and director of the IVF Center in Orlando, said in an interview.

“Vaccination reaction from the immune response rather than the vaccine may be the implicating factor,” said Dr. Trolice, who was not involved in the study.

Currently, there’s no direct link between the vaccine and subsequent effects on menstruation, he continued. “Most women experience resumption of normal intervals 1 month following vaccination. Further, there is no credible evidence that links the vaccine to infertility.

“Nevertheless, research in this area is vital and underway,” he added.
 

Physicians can help with stress

Menstrual cycle disruption is especially frustrating for women trying to build a family, said Ms. Malloy. Providers may be observing more menstrual irregularity in their patient populations, and seeing more patients struggle to conceive on their own, turning to ART.

Providers can’t make COVID-19 go away, but they could help patients by doing a better job of integrating mental health screening, connecting patients to treatments that optimize conception and fertility treatment outcomes, said Ms. Malloy.

The survey was limited in that its questions didn’t consider proper diagnostic criteria for irregularity, versus self-reported changes. But it does highlight the need for more research on the pandemic’s affect on menstruation and the vaccine on menstruation, said Ms. Malloy. “The National Institutes of Health in August committed $1.6 million to explore this connection. We’re looking forward to seeing what their results are.” 

Dr. Trolice and Ms. Malloy had no disclosures.