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COVID-19–related skin changes: The hidden racism in documentation
Belatedly, the disproportionate impact of COVID-19 on patients of color is getting attention. By now, we’ve read the headlines. Black people in the United States make up about 13% of the population but account for almost three times (34%) as many deaths. This story repeats – in other countries and in other minority communities.
Early detection is critical both to initiate supportive care and to isolate affected individuals and limit spread. Skin manifestations of COVID-19, especially those that occur early in the disease (eg, vesicular eruptions) or have prognostic significance (livedo, retiform purpura, necrosis), are critical to this goal of early recognition.
In this context, a recent systematic literature review looked at all articles describing skin manifestations associated with COVID-19. The investigators identified 46 articles published between March and May 2020 which included a total of 130 clinical images.
The following findings from this study are striking:
- 92% of the published images of COVID-associated skin manifestations were in I-III.
- Only 6% of COVID skin lesions included in the articles were in patients with skin type IV.
- None showed COVID skin lesions in skin types V or VI.
- Only six of the articles reported race and ethnicity demographics. In those, 91% of the patients were White and 9% were Hispanic.
These results reveal a critical lack of representative clinical images of COVID-associated skin manifestations in patients of color. This deficiency is made all the more egregious given the fact that patients of color, including those who are Black, Latinx, and Native American, have been especially hard hit by the COVID-19 pandemic and suffer disproportionate disease-related morbidity and mortality.
As the study authors point out, skin manifestations in people of color often differ significantly from findings in White skin (for example, look at the figure depicting the rash typical of Kawasaki disease in a dark-skinned child compared with a light-skinned child). It is not a stretch to suggest that skin manifestations associated with COVID-19 may look very different in darker skin.
This isn’t a new phenomenon. Almost half of dermatologists feel that they’ve had insufficient exposure to skin disease in darker skin types. Skin of color remains underrepresented in medical journals.
Like other forms of passive, institutional racism, this deficiency will only be improved if dermatologists and dermatology publications actively seek out COVID-associated skin manifestations in patients of color and prioritize sharing these images. A medical student in the United Kingdom has gotten the ball rolling, compiling a handbook of clinical signs in darker skin types as part of a student-staff partnership at St. George’s Hospital and the University of London. At this time, Mind the Gap is looking for a publisher.
Dr. Lipper is an assistant clinical professor at the University of Vermont, Burlington, and a staff physician in the department of dermatology at Danbury (Conn.) Hospital. He has disclosed no relevant financial relationships.
A version of this article originally appeared on Medscape.com.
Belatedly, the disproportionate impact of COVID-19 on patients of color is getting attention. By now, we’ve read the headlines. Black people in the United States make up about 13% of the population but account for almost three times (34%) as many deaths. This story repeats – in other countries and in other minority communities.
Early detection is critical both to initiate supportive care and to isolate affected individuals and limit spread. Skin manifestations of COVID-19, especially those that occur early in the disease (eg, vesicular eruptions) or have prognostic significance (livedo, retiform purpura, necrosis), are critical to this goal of early recognition.
In this context, a recent systematic literature review looked at all articles describing skin manifestations associated with COVID-19. The investigators identified 46 articles published between March and May 2020 which included a total of 130 clinical images.
The following findings from this study are striking:
- 92% of the published images of COVID-associated skin manifestations were in I-III.
- Only 6% of COVID skin lesions included in the articles were in patients with skin type IV.
- None showed COVID skin lesions in skin types V or VI.
- Only six of the articles reported race and ethnicity demographics. In those, 91% of the patients were White and 9% were Hispanic.
These results reveal a critical lack of representative clinical images of COVID-associated skin manifestations in patients of color. This deficiency is made all the more egregious given the fact that patients of color, including those who are Black, Latinx, and Native American, have been especially hard hit by the COVID-19 pandemic and suffer disproportionate disease-related morbidity and mortality.
As the study authors point out, skin manifestations in people of color often differ significantly from findings in White skin (for example, look at the figure depicting the rash typical of Kawasaki disease in a dark-skinned child compared with a light-skinned child). It is not a stretch to suggest that skin manifestations associated with COVID-19 may look very different in darker skin.
This isn’t a new phenomenon. Almost half of dermatologists feel that they’ve had insufficient exposure to skin disease in darker skin types. Skin of color remains underrepresented in medical journals.
Like other forms of passive, institutional racism, this deficiency will only be improved if dermatologists and dermatology publications actively seek out COVID-associated skin manifestations in patients of color and prioritize sharing these images. A medical student in the United Kingdom has gotten the ball rolling, compiling a handbook of clinical signs in darker skin types as part of a student-staff partnership at St. George’s Hospital and the University of London. At this time, Mind the Gap is looking for a publisher.
Dr. Lipper is an assistant clinical professor at the University of Vermont, Burlington, and a staff physician in the department of dermatology at Danbury (Conn.) Hospital. He has disclosed no relevant financial relationships.
A version of this article originally appeared on Medscape.com.
Belatedly, the disproportionate impact of COVID-19 on patients of color is getting attention. By now, we’ve read the headlines. Black people in the United States make up about 13% of the population but account for almost three times (34%) as many deaths. This story repeats – in other countries and in other minority communities.
Early detection is critical both to initiate supportive care and to isolate affected individuals and limit spread. Skin manifestations of COVID-19, especially those that occur early in the disease (eg, vesicular eruptions) or have prognostic significance (livedo, retiform purpura, necrosis), are critical to this goal of early recognition.
In this context, a recent systematic literature review looked at all articles describing skin manifestations associated with COVID-19. The investigators identified 46 articles published between March and May 2020 which included a total of 130 clinical images.
The following findings from this study are striking:
- 92% of the published images of COVID-associated skin manifestations were in I-III.
- Only 6% of COVID skin lesions included in the articles were in patients with skin type IV.
- None showed COVID skin lesions in skin types V or VI.
- Only six of the articles reported race and ethnicity demographics. In those, 91% of the patients were White and 9% were Hispanic.
These results reveal a critical lack of representative clinical images of COVID-associated skin manifestations in patients of color. This deficiency is made all the more egregious given the fact that patients of color, including those who are Black, Latinx, and Native American, have been especially hard hit by the COVID-19 pandemic and suffer disproportionate disease-related morbidity and mortality.
As the study authors point out, skin manifestations in people of color often differ significantly from findings in White skin (for example, look at the figure depicting the rash typical of Kawasaki disease in a dark-skinned child compared with a light-skinned child). It is not a stretch to suggest that skin manifestations associated with COVID-19 may look very different in darker skin.
This isn’t a new phenomenon. Almost half of dermatologists feel that they’ve had insufficient exposure to skin disease in darker skin types. Skin of color remains underrepresented in medical journals.
Like other forms of passive, institutional racism, this deficiency will only be improved if dermatologists and dermatology publications actively seek out COVID-associated skin manifestations in patients of color and prioritize sharing these images. A medical student in the United Kingdom has gotten the ball rolling, compiling a handbook of clinical signs in darker skin types as part of a student-staff partnership at St. George’s Hospital and the University of London. At this time, Mind the Gap is looking for a publisher.
Dr. Lipper is an assistant clinical professor at the University of Vermont, Burlington, and a staff physician in the department of dermatology at Danbury (Conn.) Hospital. He has disclosed no relevant financial relationships.
A version of this article originally appeared on Medscape.com.
Medical student in the UK creates handbook of clinical signs on darker skin
.
Malone Mukwende, a second year student at St. George’s, University of London, had the idea after only being taught about clinical signs and symptoms on White skin.
The handbook is called Mind the Gap. It contains side-by-side images demonstrating how illnesses and diseases can present in light and dark skin.
He hopes the handbook will help future doctors spot and diagnose potentially life-threatening diseases on Black, Asian, and Minority Ethnic (BAME) people.
It comes as nearly 200,000 people have signed a petition calling for medical schools to include BAME representation in clinical teaching.
It points to Kawasaki disease, a rare condition affecting young children. On white skin it appears as a red rash but on darker skin it shows up differently and is much harder to spot.
Medscape UK asked Malone Mukwende about the handbook.
Q&A
Where did the idea come from for Mind the Gap?
On arrival at medical school I noticed the lack of teaching on darker skins. We were often being taught to look for symptoms such as red rashes. I was aware that this would not appear as described in my own skin. When flagging to tutors it was clear that they didn’t know of any other way to describe these conditions and I knew that I had to make a change to that. After extensively asking peer tutors and also lecturers it was clear there was a major gap in the current medical education and a lot of the time I was being told to go and look for it myself.
Following on from that I undertook a staff-student partnership at my university with two members of staff who helped me to create Mind the Gap.
Who did you collaborate with at St. George’s?
I worked with Margot Turner, a senior lecturer in diversity, and Dr. Peter Tamony, a clinical lecturer. We were a dynamic team that had a common goal in mind.
When will the handbook be available?
We are currently working on the best way of disseminating the work to the public. There has been an incredible response since I posted it on my social media, with posts being seen over 3 million times, as well as numerous press features. I am hoping to provide a further update on when the book will be out toward the end of July.
What do you think of the petition to medical schools to include more teaching of the effects of illness and diseases on Black, Asian, and Minority Ethnic people?
The petition closely ties in with the work that I am doing. It is clear that there is an urgent need to increase the medical education on darker skins so that the profession can serve the patient population. We saw in the recent COVID-19 pandemic that the worst affected group of people were from a BAME background.
There are a host of reasons as to why this may have been the case. However another factor may be that healthcare professionals weren’t able to identify these signs and symptoms in time. Some of the coronavirus guidance from royal colleges stated information such as looking for patients to be ‘blue around the lips’. This may have led to slower identification of coronavirus.
To see over 180,000 signatures on the petition was a positive step in the right direction. It is clear to see that this is a big issue. If we fail to act now that the issue has been identified, we run the risk of lives being lost.
A version of this article originally appeared on Medscape.com.
.
Malone Mukwende, a second year student at St. George’s, University of London, had the idea after only being taught about clinical signs and symptoms on White skin.
The handbook is called Mind the Gap. It contains side-by-side images demonstrating how illnesses and diseases can present in light and dark skin.
He hopes the handbook will help future doctors spot and diagnose potentially life-threatening diseases on Black, Asian, and Minority Ethnic (BAME) people.
It comes as nearly 200,000 people have signed a petition calling for medical schools to include BAME representation in clinical teaching.
It points to Kawasaki disease, a rare condition affecting young children. On white skin it appears as a red rash but on darker skin it shows up differently and is much harder to spot.
Medscape UK asked Malone Mukwende about the handbook.
Q&A
Where did the idea come from for Mind the Gap?
On arrival at medical school I noticed the lack of teaching on darker skins. We were often being taught to look for symptoms such as red rashes. I was aware that this would not appear as described in my own skin. When flagging to tutors it was clear that they didn’t know of any other way to describe these conditions and I knew that I had to make a change to that. After extensively asking peer tutors and also lecturers it was clear there was a major gap in the current medical education and a lot of the time I was being told to go and look for it myself.
Following on from that I undertook a staff-student partnership at my university with two members of staff who helped me to create Mind the Gap.
Who did you collaborate with at St. George’s?
I worked with Margot Turner, a senior lecturer in diversity, and Dr. Peter Tamony, a clinical lecturer. We were a dynamic team that had a common goal in mind.
When will the handbook be available?
We are currently working on the best way of disseminating the work to the public. There has been an incredible response since I posted it on my social media, with posts being seen over 3 million times, as well as numerous press features. I am hoping to provide a further update on when the book will be out toward the end of July.
What do you think of the petition to medical schools to include more teaching of the effects of illness and diseases on Black, Asian, and Minority Ethnic people?
The petition closely ties in with the work that I am doing. It is clear that there is an urgent need to increase the medical education on darker skins so that the profession can serve the patient population. We saw in the recent COVID-19 pandemic that the worst affected group of people were from a BAME background.
There are a host of reasons as to why this may have been the case. However another factor may be that healthcare professionals weren’t able to identify these signs and symptoms in time. Some of the coronavirus guidance from royal colleges stated information such as looking for patients to be ‘blue around the lips’. This may have led to slower identification of coronavirus.
To see over 180,000 signatures on the petition was a positive step in the right direction. It is clear to see that this is a big issue. If we fail to act now that the issue has been identified, we run the risk of lives being lost.
A version of this article originally appeared on Medscape.com.
.
Malone Mukwende, a second year student at St. George’s, University of London, had the idea after only being taught about clinical signs and symptoms on White skin.
The handbook is called Mind the Gap. It contains side-by-side images demonstrating how illnesses and diseases can present in light and dark skin.
He hopes the handbook will help future doctors spot and diagnose potentially life-threatening diseases on Black, Asian, and Minority Ethnic (BAME) people.
It comes as nearly 200,000 people have signed a petition calling for medical schools to include BAME representation in clinical teaching.
It points to Kawasaki disease, a rare condition affecting young children. On white skin it appears as a red rash but on darker skin it shows up differently and is much harder to spot.
Medscape UK asked Malone Mukwende about the handbook.
Q&A
Where did the idea come from for Mind the Gap?
On arrival at medical school I noticed the lack of teaching on darker skins. We were often being taught to look for symptoms such as red rashes. I was aware that this would not appear as described in my own skin. When flagging to tutors it was clear that they didn’t know of any other way to describe these conditions and I knew that I had to make a change to that. After extensively asking peer tutors and also lecturers it was clear there was a major gap in the current medical education and a lot of the time I was being told to go and look for it myself.
Following on from that I undertook a staff-student partnership at my university with two members of staff who helped me to create Mind the Gap.
Who did you collaborate with at St. George’s?
I worked with Margot Turner, a senior lecturer in diversity, and Dr. Peter Tamony, a clinical lecturer. We were a dynamic team that had a common goal in mind.
When will the handbook be available?
We are currently working on the best way of disseminating the work to the public. There has been an incredible response since I posted it on my social media, with posts being seen over 3 million times, as well as numerous press features. I am hoping to provide a further update on when the book will be out toward the end of July.
What do you think of the petition to medical schools to include more teaching of the effects of illness and diseases on Black, Asian, and Minority Ethnic people?
The petition closely ties in with the work that I am doing. It is clear that there is an urgent need to increase the medical education on darker skins so that the profession can serve the patient population. We saw in the recent COVID-19 pandemic that the worst affected group of people were from a BAME background.
There are a host of reasons as to why this may have been the case. However another factor may be that healthcare professionals weren’t able to identify these signs and symptoms in time. Some of the coronavirus guidance from royal colleges stated information such as looking for patients to be ‘blue around the lips’. This may have led to slower identification of coronavirus.
To see over 180,000 signatures on the petition was a positive step in the right direction. It is clear to see that this is a big issue. If we fail to act now that the issue has been identified, we run the risk of lives being lost.
A version of this article originally appeared on Medscape.com.
‘Staggering’ increase in COVID-linked depression, anxiety
Since the start of the COVID-19 pandemic, there has been a dramatic increase in depression, anxiety, psychosis, and suicidality, new research shows.
The new data, released by Mental Health America (MHA), came from individuals who completed a voluntary online mental health screen.
As of the end of June, over 169,000 additional participants reported having moderate to severe depression or anxiety, compared with participants who completed the screen prior to the pandemic.
In June alone, 18,000 additional participants were found to be at risk for psychosis, continuing a rising pattern that began in May, when 16,000 reported psychosis risk.
“We continue to see staggering numbers that indicate increased rates in depression and anxiety because of COVID-19,” Paul Gionfriddo, president and CEO of MHA, said in a release.
“In fact, the problem is bigger than anyone imagined, making it clear how the pandemic is affecting people now and will continue to affect people who mourn loved ones and whose serious mental conditions are left untreated. So we need to take this very seriously,” Mr. Gionfriddo said in an interview.
Real-time data
MHA has been conducting online screenings for 6 years. To date, nearly 5.5 million screenings have been completed, making it the largest screening program of its kind in the United States, Mr. Gionfriddo reported.
“At the beginning of the pandemic, we were asked by a member of the media if we could offer any insight about how anxiety in particular was affecting people during the pandemic since we were the only ones with a database that could give quantitative detail,” he said.
The results of their screen could also help find that information “in real time,” he added.
More people are now undergoing mental health screenings, Mr. Gionfriddo noted.
At roughly 7,000 per day in May and June, the number of anxiety and depression screenings that were completed per day were 406% and 457% higher, respectively, than the number completed in January.
The youngest group of participants were those aged 11-17 years; the oldest age group consisted of individuals 65 years and older.
The Patient Health Questionnaire–9 was used to identify those at risk for depression, the General Anxiety Disorder–7 was used to identify those at risk for anxiety, and the Prodromal Questionnaire Brief Version was used to identify those at high risk for psychosis.
Current events
Roughly 90% screened positive for moderate to severe depression, and 80% screened positive for moderate to severe anxiety.
“Kids between the ages of 11 and 17 years have been the most stressed, but it seems to be easier to bear as you get older,” Mr. Gionfriddo said.
Loneliness and isolation were cited as contributors to depression and anxiety by the largest percentage of individuals with these conditions (74% and 65%, respectively).
In June, roughly one quarter of participants also cited grief or loss and financial concerns as contributors to anxiety (25.31% and 24.18%, respectively) and to depression (26.53% and 23.36%).
Current events were cited as an important contributor, leading to more mental health problems in June, compared with May (36.11% vs 29.41 for anxiety; 29.13% vs 21.77% for depression).
The June screen added the category of racism as a potential contributor. Close to 8% reported it as a reason for anxiety, and roughly 5% considered it a reason for depression.
“We will be releasing more data at the end of July, and it will be interesting to see how the racism category compares to data we collected at the end of June,” Mr. Gionfriddo noted.
Dramatic increase
The screen also showed a “dramatic increase” in the number of people who reported being at risk for psychosis, with 18,000 participants screening positive. This represented more than four times the baseline figures recorded through March.
“We were not surprised to see a spike in depression and anxiety, but why were we seeing a spike in psychosis in May/June?” Mr. Gionfriddo asked. He suggested that stress may play a role in driving this increased risk.
“These data, we hope, will get policymakers to pay attention, take it seriously, and intervene to prevent psychosis at an earlier stage before signs and symptoms emerge,” said Mr. Gionfriddo.
One of the most alarming findings was that in June, 25,498 participants who screened positive for depression reported thinking of suicide or self-harm on “more than half of days to nearly every day.” A total of 14,607 participants said they had these thoughts every day.
Overall, the results should reinforce the recommendations of the US Preventive Services Task Force to routinely screen for depression in any clinical setting on a regular basis, Mr. Gionfriddo said.
In addition, policymakers “need to balance reopening vs. quarantining and isolating, and we need to think about what the next 2-4 years look like in terms of balancing physical health risks and mental health risks,” he noted.
“We’ve been treating the pandemic like a sprint and now, 4 or 5 months into it, perhaps as a middle-distance run, when in fact it’s a marathon,” he added.
Advocates needed
The increase in anxiety and depression often centers on the changes and uncertainties in the college experience, such as whether classes will be held in person, online, or a hybrid of the two, said Dr. Ritchie, who was not involved with the research.
Additionally, some college students who have “left the nest” have been forced to “return to the nest,” which compounds stress, she said.
LGBTQ youngsters may be particularly affected because some have “come out of the closet” while away from home and now must negotiate going back to their home of record. They are uncertain whether or not “to go back into the closet,” added Dr. Ritchie, who is also vice chair of psychiatry at Georgetown University, Washington.
Psychiatrists and other mental health professionals should be advocates for “getting services to more people for the greatest good,” she noted.
For example, the MHA data “might be useful in advocating for keeping telehealth accessible and even promoting it,” she said.
The full report is available on MHA’s website.
Mr. Gionfriddo and Dr. Ritchie report no relevant financial relationships.
A version of this article originally appeared on Medscape.com.
Since the start of the COVID-19 pandemic, there has been a dramatic increase in depression, anxiety, psychosis, and suicidality, new research shows.
The new data, released by Mental Health America (MHA), came from individuals who completed a voluntary online mental health screen.
As of the end of June, over 169,000 additional participants reported having moderate to severe depression or anxiety, compared with participants who completed the screen prior to the pandemic.
In June alone, 18,000 additional participants were found to be at risk for psychosis, continuing a rising pattern that began in May, when 16,000 reported psychosis risk.
“We continue to see staggering numbers that indicate increased rates in depression and anxiety because of COVID-19,” Paul Gionfriddo, president and CEO of MHA, said in a release.
“In fact, the problem is bigger than anyone imagined, making it clear how the pandemic is affecting people now and will continue to affect people who mourn loved ones and whose serious mental conditions are left untreated. So we need to take this very seriously,” Mr. Gionfriddo said in an interview.
Real-time data
MHA has been conducting online screenings for 6 years. To date, nearly 5.5 million screenings have been completed, making it the largest screening program of its kind in the United States, Mr. Gionfriddo reported.
“At the beginning of the pandemic, we were asked by a member of the media if we could offer any insight about how anxiety in particular was affecting people during the pandemic since we were the only ones with a database that could give quantitative detail,” he said.
The results of their screen could also help find that information “in real time,” he added.
More people are now undergoing mental health screenings, Mr. Gionfriddo noted.
At roughly 7,000 per day in May and June, the number of anxiety and depression screenings that were completed per day were 406% and 457% higher, respectively, than the number completed in January.
The youngest group of participants were those aged 11-17 years; the oldest age group consisted of individuals 65 years and older.
The Patient Health Questionnaire–9 was used to identify those at risk for depression, the General Anxiety Disorder–7 was used to identify those at risk for anxiety, and the Prodromal Questionnaire Brief Version was used to identify those at high risk for psychosis.
Current events
Roughly 90% screened positive for moderate to severe depression, and 80% screened positive for moderate to severe anxiety.
“Kids between the ages of 11 and 17 years have been the most stressed, but it seems to be easier to bear as you get older,” Mr. Gionfriddo said.
Loneliness and isolation were cited as contributors to depression and anxiety by the largest percentage of individuals with these conditions (74% and 65%, respectively).
In June, roughly one quarter of participants also cited grief or loss and financial concerns as contributors to anxiety (25.31% and 24.18%, respectively) and to depression (26.53% and 23.36%).
Current events were cited as an important contributor, leading to more mental health problems in June, compared with May (36.11% vs 29.41 for anxiety; 29.13% vs 21.77% for depression).
The June screen added the category of racism as a potential contributor. Close to 8% reported it as a reason for anxiety, and roughly 5% considered it a reason for depression.
“We will be releasing more data at the end of July, and it will be interesting to see how the racism category compares to data we collected at the end of June,” Mr. Gionfriddo noted.
Dramatic increase
The screen also showed a “dramatic increase” in the number of people who reported being at risk for psychosis, with 18,000 participants screening positive. This represented more than four times the baseline figures recorded through March.
“We were not surprised to see a spike in depression and anxiety, but why were we seeing a spike in psychosis in May/June?” Mr. Gionfriddo asked. He suggested that stress may play a role in driving this increased risk.
“These data, we hope, will get policymakers to pay attention, take it seriously, and intervene to prevent psychosis at an earlier stage before signs and symptoms emerge,” said Mr. Gionfriddo.
One of the most alarming findings was that in June, 25,498 participants who screened positive for depression reported thinking of suicide or self-harm on “more than half of days to nearly every day.” A total of 14,607 participants said they had these thoughts every day.
Overall, the results should reinforce the recommendations of the US Preventive Services Task Force to routinely screen for depression in any clinical setting on a regular basis, Mr. Gionfriddo said.
In addition, policymakers “need to balance reopening vs. quarantining and isolating, and we need to think about what the next 2-4 years look like in terms of balancing physical health risks and mental health risks,” he noted.
“We’ve been treating the pandemic like a sprint and now, 4 or 5 months into it, perhaps as a middle-distance run, when in fact it’s a marathon,” he added.
Advocates needed
The increase in anxiety and depression often centers on the changes and uncertainties in the college experience, such as whether classes will be held in person, online, or a hybrid of the two, said Dr. Ritchie, who was not involved with the research.
Additionally, some college students who have “left the nest” have been forced to “return to the nest,” which compounds stress, she said.
LGBTQ youngsters may be particularly affected because some have “come out of the closet” while away from home and now must negotiate going back to their home of record. They are uncertain whether or not “to go back into the closet,” added Dr. Ritchie, who is also vice chair of psychiatry at Georgetown University, Washington.
Psychiatrists and other mental health professionals should be advocates for “getting services to more people for the greatest good,” she noted.
For example, the MHA data “might be useful in advocating for keeping telehealth accessible and even promoting it,” she said.
The full report is available on MHA’s website.
Mr. Gionfriddo and Dr. Ritchie report no relevant financial relationships.
A version of this article originally appeared on Medscape.com.
Since the start of the COVID-19 pandemic, there has been a dramatic increase in depression, anxiety, psychosis, and suicidality, new research shows.
The new data, released by Mental Health America (MHA), came from individuals who completed a voluntary online mental health screen.
As of the end of June, over 169,000 additional participants reported having moderate to severe depression or anxiety, compared with participants who completed the screen prior to the pandemic.
In June alone, 18,000 additional participants were found to be at risk for psychosis, continuing a rising pattern that began in May, when 16,000 reported psychosis risk.
“We continue to see staggering numbers that indicate increased rates in depression and anxiety because of COVID-19,” Paul Gionfriddo, president and CEO of MHA, said in a release.
“In fact, the problem is bigger than anyone imagined, making it clear how the pandemic is affecting people now and will continue to affect people who mourn loved ones and whose serious mental conditions are left untreated. So we need to take this very seriously,” Mr. Gionfriddo said in an interview.
Real-time data
MHA has been conducting online screenings for 6 years. To date, nearly 5.5 million screenings have been completed, making it the largest screening program of its kind in the United States, Mr. Gionfriddo reported.
“At the beginning of the pandemic, we were asked by a member of the media if we could offer any insight about how anxiety in particular was affecting people during the pandemic since we were the only ones with a database that could give quantitative detail,” he said.
The results of their screen could also help find that information “in real time,” he added.
More people are now undergoing mental health screenings, Mr. Gionfriddo noted.
At roughly 7,000 per day in May and June, the number of anxiety and depression screenings that were completed per day were 406% and 457% higher, respectively, than the number completed in January.
The youngest group of participants were those aged 11-17 years; the oldest age group consisted of individuals 65 years and older.
The Patient Health Questionnaire–9 was used to identify those at risk for depression, the General Anxiety Disorder–7 was used to identify those at risk for anxiety, and the Prodromal Questionnaire Brief Version was used to identify those at high risk for psychosis.
Current events
Roughly 90% screened positive for moderate to severe depression, and 80% screened positive for moderate to severe anxiety.
“Kids between the ages of 11 and 17 years have been the most stressed, but it seems to be easier to bear as you get older,” Mr. Gionfriddo said.
Loneliness and isolation were cited as contributors to depression and anxiety by the largest percentage of individuals with these conditions (74% and 65%, respectively).
In June, roughly one quarter of participants also cited grief or loss and financial concerns as contributors to anxiety (25.31% and 24.18%, respectively) and to depression (26.53% and 23.36%).
Current events were cited as an important contributor, leading to more mental health problems in June, compared with May (36.11% vs 29.41 for anxiety; 29.13% vs 21.77% for depression).
The June screen added the category of racism as a potential contributor. Close to 8% reported it as a reason for anxiety, and roughly 5% considered it a reason for depression.
“We will be releasing more data at the end of July, and it will be interesting to see how the racism category compares to data we collected at the end of June,” Mr. Gionfriddo noted.
Dramatic increase
The screen also showed a “dramatic increase” in the number of people who reported being at risk for psychosis, with 18,000 participants screening positive. This represented more than four times the baseline figures recorded through March.
“We were not surprised to see a spike in depression and anxiety, but why were we seeing a spike in psychosis in May/June?” Mr. Gionfriddo asked. He suggested that stress may play a role in driving this increased risk.
“These data, we hope, will get policymakers to pay attention, take it seriously, and intervene to prevent psychosis at an earlier stage before signs and symptoms emerge,” said Mr. Gionfriddo.
One of the most alarming findings was that in June, 25,498 participants who screened positive for depression reported thinking of suicide or self-harm on “more than half of days to nearly every day.” A total of 14,607 participants said they had these thoughts every day.
Overall, the results should reinforce the recommendations of the US Preventive Services Task Force to routinely screen for depression in any clinical setting on a regular basis, Mr. Gionfriddo said.
In addition, policymakers “need to balance reopening vs. quarantining and isolating, and we need to think about what the next 2-4 years look like in terms of balancing physical health risks and mental health risks,” he noted.
“We’ve been treating the pandemic like a sprint and now, 4 or 5 months into it, perhaps as a middle-distance run, when in fact it’s a marathon,” he added.
Advocates needed
The increase in anxiety and depression often centers on the changes and uncertainties in the college experience, such as whether classes will be held in person, online, or a hybrid of the two, said Dr. Ritchie, who was not involved with the research.
Additionally, some college students who have “left the nest” have been forced to “return to the nest,” which compounds stress, she said.
LGBTQ youngsters may be particularly affected because some have “come out of the closet” while away from home and now must negotiate going back to their home of record. They are uncertain whether or not “to go back into the closet,” added Dr. Ritchie, who is also vice chair of psychiatry at Georgetown University, Washington.
Psychiatrists and other mental health professionals should be advocates for “getting services to more people for the greatest good,” she noted.
For example, the MHA data “might be useful in advocating for keeping telehealth accessible and even promoting it,” she said.
The full report is available on MHA’s website.
Mr. Gionfriddo and Dr. Ritchie report no relevant financial relationships.
A version of this article originally appeared on Medscape.com.
Ankylosing Spondylitis Overview
In epilepsy, brain-responsive stimulation passes long-term tests
Two new long-term studies, one an extension trial and the other an analysis of real-world experience, show that Both studies showed that the benefit from the devices increased over time.
That accruing benefit may be because of improved protocols as clinicians gain experience with the device or because of network remodeling that occurs over time as seizures are controlled. “I think it’s both,” said Martha Morrell, MD, a clinical professor of neurology at Stanford (Calif.) University and chief medical officer at NeuroPace, the company that has marketed the device since it gained FDA approval in 2013.
In both studies, the slope of improvement over time was similar, but the real-world study showed greater improvement at the beginning of treatment. “I think the slopes represent physiological changes, but the fact that [the real-world study] starts with better outcomes is, I think, directly attributable to learning. When the long-term study was started in 2004, this had never been done before, and we had to make a highly educated guess about what we should do, and the initial stimulatory parameters were programmed in a way that’s very similar to what was used for movement disorders,” Dr. Morrell said in an interview.
The long-term treatment study appeared online July 20 in the journal Neurology, while the real-world analysis was published July 13 in Epilepsia.
An alternative option
Medications can effectively treat some seizures, but 30%-40% of patients must turn to other options for control. Surgery can sometimes be curative, but is not suitable for some patients. Other stimulation devices include vagus nerve stimulation (VNS), which sends pulses from a chest implant to the vagus nerve, reducing epileptic attacks through an unknown mechanism. Deep brain stimulation (DBS) places electrodes that deliver stimulation to the anterior nucleus of the thalamus, which can spread initially localized seizures.
The RNS device consists of a neurostimulator implanted cranially and connected to leads that are placed based on the individual patient’s seizure focus or foci. It also continuously monitors brain activity and delivers stimulation only when its signal suggests the beginning of a seizure.
That capacity for recording is a key benefit because the information can be stored and analyzed, according to Vikram Rao, MD, PhD, a coinvestigator in the real-world trial and an associate professor and the epilepsy division chief at the University of California, San Francisco, which was one of the trial centers. “You know more precisely than we previously did how many seizures a patient is having. Many of our patients are not able to quantify their seizures with perfect accuracy, so we’re better quantifying their seizure burden,” Dr. Rao said in an interview.
The ability to monitor patients can also improve clinical management. Dr. Morrell recounted an elderly patient who for many years has driven 5 hours for appointments. Recently she was able to review his data from the RNS System remotely. She determined that he was doing fine and, after a telephone consultation, told him he didn’t need to come in for a scheduled visit.
Real-world analysis
In the real-world analysis, researchers led by Babak Razavi, PhD, and Casey Halpern, MD, at Stanford University conducted a chart review of 150 patients at eight centers who underwent treatment with the RNS system between 2013 and 2018. All patients were followed at least 1 year, with a mean of 2.3 years. Patients had a median of 7.7 disabling seizures per month. The mean value was 52 and the numbers ranged from 0.1 to 3,000. A total of 60% had abnormal brain MRI findings.
At 1 year, subjects achieved a mean 67% decrease in seizure frequency (interquartile range, 50%-94%). At 2 years, that grew to 77%; at 3 or more years, 84%. There was no significant difference in seizure reduction at 1 year according to age, age at epilepsy onset, duration of epilepsy, location of seizure foci, presence of brain MRI abnormalities, prior intracranial monitoring, prior epilepsy surgery, or prior VNS treatment. When patients who underwent a resection at the time of RNS placement were excluded, the results were similar. There were no significant differences in outcome by center.
A total of 11.3% of patients experienced a device-related serious adverse event, and 4% developed infections. The rate of infection was not significantly different between patients who had the neurostimulator and leads implanted alone (3.0%) and patients who had intracranial EEG diagnostic monitoring (ICM) electrodes removed at the same time (6.1%; P = .38).
Although about one-third of the patients who started the long-term study dropped out before completion, most were because the participants moved away from treatment centers, according to Dr. Morrell, and other evidence points squarely to patient satisfaction. “At the end of the battery’s longevity, the neurostimulator needs to be replaced. It’s an outpatient, 45-minute procedure. Over 90% of patients chose to have it replaced. It’s not the answer for everybody, but the substantial majority of patients choose to continue,” she said.
Extension trial
The open-label extension trial, led by Dileep Nair, MD, of the Cleveland Clinic Foundation and Dr. Morrell, followed 230 of the 256 patients who participated in 2-year phase 3 study or feasibility studies, extending device usage to 9 years. A total of 162 completed follow-up (mean, 7.5 years). The median reduction of seizure frequency was 58% at the end of year 3, and 75% by year 9 (P < .0001; Wilcoxon signed rank). Although patient population enrichment could have explained this observation, other analyses confirmed that the improvement was real.
Nearly 75% had at least a 50% reduction in seizure frequency; 35% had a 90% or greater reduction in seizure frequency. Some patients (18.4%) had at least a full year with no seizures, and 62% who had a 1-year seizure-free period experienced no seizures at the latest follow-up. Overall, 21% had no seizures in the last 6 months of follow-up.
For those with a seizure-free period of more than 1 year, the average duration was 3.2 years (range, 1.04-9.6 years). There was no difference in response among patients based on previous antiseizure medication use or previous epilepsy surgery, VNS treatment, or intracranial monitoring, and there were no differences by patient age at enrollment, age of seizure onset, brain imaging abnormality, seizure onset locality, or number of foci.
The researchers noted improvement in overall Quality of Life in Epilepsy Inventory–89 scores at 1 year (mean, +3.2; P < .0001), which continued through year 9 (mean, +1.9; P < .05). Improvements were also seen in epilepsy targeted (mean, +4.5; P < .001) and cognitive domains (mean, +2.5; P = .005). Risk of infection was 4.1% per procedure, and 12.1% of subjects overall experienced a serious device-related implant infection. Of 35 infections, 16 led to device removal.
The extension study was funded by NeuroPace. NeuroPace supported data entry and institutional review board submission for the real-world trial. Dr. Morrell owns stock and is an employee of NeuroPace. Dr Rao has received support from and/or consulted for NeuroPace.
SOURCE: Nair DR et al. Neurology. 2020 Jul 20. doi: 10.1212/WNL.0000000000010154. Razavi B et al. Epilepsia. 2020 Jul 13. doi: 10.1111/epi.16593.
Two new long-term studies, one an extension trial and the other an analysis of real-world experience, show that Both studies showed that the benefit from the devices increased over time.
That accruing benefit may be because of improved protocols as clinicians gain experience with the device or because of network remodeling that occurs over time as seizures are controlled. “I think it’s both,” said Martha Morrell, MD, a clinical professor of neurology at Stanford (Calif.) University and chief medical officer at NeuroPace, the company that has marketed the device since it gained FDA approval in 2013.
In both studies, the slope of improvement over time was similar, but the real-world study showed greater improvement at the beginning of treatment. “I think the slopes represent physiological changes, but the fact that [the real-world study] starts with better outcomes is, I think, directly attributable to learning. When the long-term study was started in 2004, this had never been done before, and we had to make a highly educated guess about what we should do, and the initial stimulatory parameters were programmed in a way that’s very similar to what was used for movement disorders,” Dr. Morrell said in an interview.
The long-term treatment study appeared online July 20 in the journal Neurology, while the real-world analysis was published July 13 in Epilepsia.
An alternative option
Medications can effectively treat some seizures, but 30%-40% of patients must turn to other options for control. Surgery can sometimes be curative, but is not suitable for some patients. Other stimulation devices include vagus nerve stimulation (VNS), which sends pulses from a chest implant to the vagus nerve, reducing epileptic attacks through an unknown mechanism. Deep brain stimulation (DBS) places electrodes that deliver stimulation to the anterior nucleus of the thalamus, which can spread initially localized seizures.
The RNS device consists of a neurostimulator implanted cranially and connected to leads that are placed based on the individual patient’s seizure focus or foci. It also continuously monitors brain activity and delivers stimulation only when its signal suggests the beginning of a seizure.
That capacity for recording is a key benefit because the information can be stored and analyzed, according to Vikram Rao, MD, PhD, a coinvestigator in the real-world trial and an associate professor and the epilepsy division chief at the University of California, San Francisco, which was one of the trial centers. “You know more precisely than we previously did how many seizures a patient is having. Many of our patients are not able to quantify their seizures with perfect accuracy, so we’re better quantifying their seizure burden,” Dr. Rao said in an interview.
The ability to monitor patients can also improve clinical management. Dr. Morrell recounted an elderly patient who for many years has driven 5 hours for appointments. Recently she was able to review his data from the RNS System remotely. She determined that he was doing fine and, after a telephone consultation, told him he didn’t need to come in for a scheduled visit.
Real-world analysis
In the real-world analysis, researchers led by Babak Razavi, PhD, and Casey Halpern, MD, at Stanford University conducted a chart review of 150 patients at eight centers who underwent treatment with the RNS system between 2013 and 2018. All patients were followed at least 1 year, with a mean of 2.3 years. Patients had a median of 7.7 disabling seizures per month. The mean value was 52 and the numbers ranged from 0.1 to 3,000. A total of 60% had abnormal brain MRI findings.
At 1 year, subjects achieved a mean 67% decrease in seizure frequency (interquartile range, 50%-94%). At 2 years, that grew to 77%; at 3 or more years, 84%. There was no significant difference in seizure reduction at 1 year according to age, age at epilepsy onset, duration of epilepsy, location of seizure foci, presence of brain MRI abnormalities, prior intracranial monitoring, prior epilepsy surgery, or prior VNS treatment. When patients who underwent a resection at the time of RNS placement were excluded, the results were similar. There were no significant differences in outcome by center.
A total of 11.3% of patients experienced a device-related serious adverse event, and 4% developed infections. The rate of infection was not significantly different between patients who had the neurostimulator and leads implanted alone (3.0%) and patients who had intracranial EEG diagnostic monitoring (ICM) electrodes removed at the same time (6.1%; P = .38).
Although about one-third of the patients who started the long-term study dropped out before completion, most were because the participants moved away from treatment centers, according to Dr. Morrell, and other evidence points squarely to patient satisfaction. “At the end of the battery’s longevity, the neurostimulator needs to be replaced. It’s an outpatient, 45-minute procedure. Over 90% of patients chose to have it replaced. It’s not the answer for everybody, but the substantial majority of patients choose to continue,” she said.
Extension trial
The open-label extension trial, led by Dileep Nair, MD, of the Cleveland Clinic Foundation and Dr. Morrell, followed 230 of the 256 patients who participated in 2-year phase 3 study or feasibility studies, extending device usage to 9 years. A total of 162 completed follow-up (mean, 7.5 years). The median reduction of seizure frequency was 58% at the end of year 3, and 75% by year 9 (P < .0001; Wilcoxon signed rank). Although patient population enrichment could have explained this observation, other analyses confirmed that the improvement was real.
Nearly 75% had at least a 50% reduction in seizure frequency; 35% had a 90% or greater reduction in seizure frequency. Some patients (18.4%) had at least a full year with no seizures, and 62% who had a 1-year seizure-free period experienced no seizures at the latest follow-up. Overall, 21% had no seizures in the last 6 months of follow-up.
For those with a seizure-free period of more than 1 year, the average duration was 3.2 years (range, 1.04-9.6 years). There was no difference in response among patients based on previous antiseizure medication use or previous epilepsy surgery, VNS treatment, or intracranial monitoring, and there were no differences by patient age at enrollment, age of seizure onset, brain imaging abnormality, seizure onset locality, or number of foci.
The researchers noted improvement in overall Quality of Life in Epilepsy Inventory–89 scores at 1 year (mean, +3.2; P < .0001), which continued through year 9 (mean, +1.9; P < .05). Improvements were also seen in epilepsy targeted (mean, +4.5; P < .001) and cognitive domains (mean, +2.5; P = .005). Risk of infection was 4.1% per procedure, and 12.1% of subjects overall experienced a serious device-related implant infection. Of 35 infections, 16 led to device removal.
The extension study was funded by NeuroPace. NeuroPace supported data entry and institutional review board submission for the real-world trial. Dr. Morrell owns stock and is an employee of NeuroPace. Dr Rao has received support from and/or consulted for NeuroPace.
SOURCE: Nair DR et al. Neurology. 2020 Jul 20. doi: 10.1212/WNL.0000000000010154. Razavi B et al. Epilepsia. 2020 Jul 13. doi: 10.1111/epi.16593.
Two new long-term studies, one an extension trial and the other an analysis of real-world experience, show that Both studies showed that the benefit from the devices increased over time.
That accruing benefit may be because of improved protocols as clinicians gain experience with the device or because of network remodeling that occurs over time as seizures are controlled. “I think it’s both,” said Martha Morrell, MD, a clinical professor of neurology at Stanford (Calif.) University and chief medical officer at NeuroPace, the company that has marketed the device since it gained FDA approval in 2013.
In both studies, the slope of improvement over time was similar, but the real-world study showed greater improvement at the beginning of treatment. “I think the slopes represent physiological changes, but the fact that [the real-world study] starts with better outcomes is, I think, directly attributable to learning. When the long-term study was started in 2004, this had never been done before, and we had to make a highly educated guess about what we should do, and the initial stimulatory parameters were programmed in a way that’s very similar to what was used for movement disorders,” Dr. Morrell said in an interview.
The long-term treatment study appeared online July 20 in the journal Neurology, while the real-world analysis was published July 13 in Epilepsia.
An alternative option
Medications can effectively treat some seizures, but 30%-40% of patients must turn to other options for control. Surgery can sometimes be curative, but is not suitable for some patients. Other stimulation devices include vagus nerve stimulation (VNS), which sends pulses from a chest implant to the vagus nerve, reducing epileptic attacks through an unknown mechanism. Deep brain stimulation (DBS) places electrodes that deliver stimulation to the anterior nucleus of the thalamus, which can spread initially localized seizures.
The RNS device consists of a neurostimulator implanted cranially and connected to leads that are placed based on the individual patient’s seizure focus or foci. It also continuously monitors brain activity and delivers stimulation only when its signal suggests the beginning of a seizure.
That capacity for recording is a key benefit because the information can be stored and analyzed, according to Vikram Rao, MD, PhD, a coinvestigator in the real-world trial and an associate professor and the epilepsy division chief at the University of California, San Francisco, which was one of the trial centers. “You know more precisely than we previously did how many seizures a patient is having. Many of our patients are not able to quantify their seizures with perfect accuracy, so we’re better quantifying their seizure burden,” Dr. Rao said in an interview.
The ability to monitor patients can also improve clinical management. Dr. Morrell recounted an elderly patient who for many years has driven 5 hours for appointments. Recently she was able to review his data from the RNS System remotely. She determined that he was doing fine and, after a telephone consultation, told him he didn’t need to come in for a scheduled visit.
Real-world analysis
In the real-world analysis, researchers led by Babak Razavi, PhD, and Casey Halpern, MD, at Stanford University conducted a chart review of 150 patients at eight centers who underwent treatment with the RNS system between 2013 and 2018. All patients were followed at least 1 year, with a mean of 2.3 years. Patients had a median of 7.7 disabling seizures per month. The mean value was 52 and the numbers ranged from 0.1 to 3,000. A total of 60% had abnormal brain MRI findings.
At 1 year, subjects achieved a mean 67% decrease in seizure frequency (interquartile range, 50%-94%). At 2 years, that grew to 77%; at 3 or more years, 84%. There was no significant difference in seizure reduction at 1 year according to age, age at epilepsy onset, duration of epilepsy, location of seizure foci, presence of brain MRI abnormalities, prior intracranial monitoring, prior epilepsy surgery, or prior VNS treatment. When patients who underwent a resection at the time of RNS placement were excluded, the results were similar. There were no significant differences in outcome by center.
A total of 11.3% of patients experienced a device-related serious adverse event, and 4% developed infections. The rate of infection was not significantly different between patients who had the neurostimulator and leads implanted alone (3.0%) and patients who had intracranial EEG diagnostic monitoring (ICM) electrodes removed at the same time (6.1%; P = .38).
Although about one-third of the patients who started the long-term study dropped out before completion, most were because the participants moved away from treatment centers, according to Dr. Morrell, and other evidence points squarely to patient satisfaction. “At the end of the battery’s longevity, the neurostimulator needs to be replaced. It’s an outpatient, 45-minute procedure. Over 90% of patients chose to have it replaced. It’s not the answer for everybody, but the substantial majority of patients choose to continue,” she said.
Extension trial
The open-label extension trial, led by Dileep Nair, MD, of the Cleveland Clinic Foundation and Dr. Morrell, followed 230 of the 256 patients who participated in 2-year phase 3 study or feasibility studies, extending device usage to 9 years. A total of 162 completed follow-up (mean, 7.5 years). The median reduction of seizure frequency was 58% at the end of year 3, and 75% by year 9 (P < .0001; Wilcoxon signed rank). Although patient population enrichment could have explained this observation, other analyses confirmed that the improvement was real.
Nearly 75% had at least a 50% reduction in seizure frequency; 35% had a 90% or greater reduction in seizure frequency. Some patients (18.4%) had at least a full year with no seizures, and 62% who had a 1-year seizure-free period experienced no seizures at the latest follow-up. Overall, 21% had no seizures in the last 6 months of follow-up.
For those with a seizure-free period of more than 1 year, the average duration was 3.2 years (range, 1.04-9.6 years). There was no difference in response among patients based on previous antiseizure medication use or previous epilepsy surgery, VNS treatment, or intracranial monitoring, and there were no differences by patient age at enrollment, age of seizure onset, brain imaging abnormality, seizure onset locality, or number of foci.
The researchers noted improvement in overall Quality of Life in Epilepsy Inventory–89 scores at 1 year (mean, +3.2; P < .0001), which continued through year 9 (mean, +1.9; P < .05). Improvements were also seen in epilepsy targeted (mean, +4.5; P < .001) and cognitive domains (mean, +2.5; P = .005). Risk of infection was 4.1% per procedure, and 12.1% of subjects overall experienced a serious device-related implant infection. Of 35 infections, 16 led to device removal.
The extension study was funded by NeuroPace. NeuroPace supported data entry and institutional review board submission for the real-world trial. Dr. Morrell owns stock and is an employee of NeuroPace. Dr Rao has received support from and/or consulted for NeuroPace.
SOURCE: Nair DR et al. Neurology. 2020 Jul 20. doi: 10.1212/WNL.0000000000010154. Razavi B et al. Epilepsia. 2020 Jul 13. doi: 10.1111/epi.16593.
FROM EPILEPSIA AND FROM NEUROLOGY
OK to treat many cancer patients despite pandemic, says ESMO
Not all are highly vulnerable to COVID-19
Another important recommendation is to stop labeling all patients with cancer as being vulnerable to infection with the virus as it can lead to inappropriate care with potential negative outcomes.
“Although it was reasonable to adopt over-protective measures for our patients at the outbreak of a novel infective disease which was not previously observed in humans, we now need to step away from the assumption that all cancer patients are vulnerable to COVID-19,” said first author of the consensus article Giuseppe Curigliano, MD, PhD, of the European Institute of Oncology, Milan, Italy, in a statement. “The implications have been important because for some patients treatment was delayed or interrupted over the last few months, and I believe that we will see the impact of this over-precautionary approach in the...future.”
The recommendations were issued by the European Society of Medical Oncology (ESMO) to help guide physicians in “optimizing the pathway to cancer care” as well as to improve outcomes during the pandemic. The recommendations were published online July 31 in Annals of Oncology.
Studies have found that patients with cancer face a higher risk of serious complications and death if they develop COVID-19. Data from the COVID-19 and Cancer Consortium registry, for example, showed that patients with progressing cancer and COVID-19 infection had a fivefold increase in the risk of 30-day mortality compared with COVID-19–positive cancer patients who were in remission or had no evidence of cancer.
But while this may be true for some patients, Curigliano and colleagues emphasize that individuals with cancer are not a heterogeneous group and that the term “cancer” itself represents myriad different diseases. The European experts note that current evidence suggests many patients with solid tumors are not more vulnerable to serious complications than the general population.
Thus, cancer prognoses vary considerably, and addressing all patients with cancer as being “COVID-19-vulnerable is probably neither reasonable nor informative,” say the authors.
Dramatic changes were initiated in cancer management for all cancer types, nevertheless, and although these changes seemed reasonable in an acute pandemic situation, note the authors, they were made in the absence of strong supportive evidence. Attempts to define the individualized risk for a given patient, taking into account their primary tumor subtype, stage, age, and gender, have been limited.
“Based on current evidence, only patients who are elderly, with multiple comorbidities, and receiving chemotherapy are vulnerable to the infection,” explained Curigliano.
However, on a positive note, a recently published prospective cohort study looked at approximately 800 patients with cancer – who had symptomatic COVID-19 – in the United Kingdom. The analysis showed no association at all between the risk for death and receiving chemotherapy or immunotherapy, points out Medscape commentator David Kerr, MD, of the University of Oxford, UK, in a recent commentary.
Key recommendations
An international consortium was established by ESMO, and the interdisciplinary expert panel consisted of 64 experts and one voting patient advocate. They agreed on 28 statements that can be used to help with many of the current clinical and technical areas of uncertainty that range from diagnosis to treatment decisions.
The following are several of the key recommendations:
- Patients with cancer who face the highest risk of severe COVID-19 are characterized by active and progressive cancer, advanced age, poor performance status, smoking status, comorbidities, and possibly type of cancer.
- Telehealth and digital health can be excellent tools for some types of care such as primary care triage and counseling, but meeting in person may be more effective for situations that include delivery of key cancer-related information and for patients with complex cancer needs.
- Prior to hospital admission, patients with cancer should be tested for COVID-19, if feasible, and if they are considered at high risk, regardless of symptoms or chest radiological findings.
- Patients with cancer and COVID-19 have a higher risk of thromboembolic events, and prophylaxis using low molecular weight or novel oral anticoagulants is recommended.
- Immune checkpoint inhibitors should not be withheld or delayed when there is a significant survival benefit, but use should be postponed in patients who test positive for COVID-19 until they recover.
- Use of high-dose steroids in patients with cancer infected with COVID-19 could potentially increase the risk of mortality, and a switch should be made to another immunosuppressant, if possible.
- The decision to use tyrosine kinase inhibitors (TKIs) of the PI3K/AKT/mTOR or RAS/RAF/MEK axis is complex, as they interfere with critical pathways involved in innate or adaptive immune responses. Stopping or withholding therapy depends on the risk-benefit balance, and the magnitude of benefit from the TKI needs to be considered.
The authors conclude that “ultimately, this set of statements will serve as a dynamic knowledge repository that will be better informed by accumulating data on SARS-CoV-2 biology, COVID-19 pandemic characteristics, on the risk of cancer patients for COVID-19 and its modulating factors, and finally, on optimal cancer care in the presence of the virus.”
No funding was reported for the current study. Several authors have disclosed relationships with industry, which are listed in the article.
This article first appeared on Medscape.com.
Not all are highly vulnerable to COVID-19
Not all are highly vulnerable to COVID-19
Another important recommendation is to stop labeling all patients with cancer as being vulnerable to infection with the virus as it can lead to inappropriate care with potential negative outcomes.
“Although it was reasonable to adopt over-protective measures for our patients at the outbreak of a novel infective disease which was not previously observed in humans, we now need to step away from the assumption that all cancer patients are vulnerable to COVID-19,” said first author of the consensus article Giuseppe Curigliano, MD, PhD, of the European Institute of Oncology, Milan, Italy, in a statement. “The implications have been important because for some patients treatment was delayed or interrupted over the last few months, and I believe that we will see the impact of this over-precautionary approach in the...future.”
The recommendations were issued by the European Society of Medical Oncology (ESMO) to help guide physicians in “optimizing the pathway to cancer care” as well as to improve outcomes during the pandemic. The recommendations were published online July 31 in Annals of Oncology.
Studies have found that patients with cancer face a higher risk of serious complications and death if they develop COVID-19. Data from the COVID-19 and Cancer Consortium registry, for example, showed that patients with progressing cancer and COVID-19 infection had a fivefold increase in the risk of 30-day mortality compared with COVID-19–positive cancer patients who were in remission or had no evidence of cancer.
But while this may be true for some patients, Curigliano and colleagues emphasize that individuals with cancer are not a heterogeneous group and that the term “cancer” itself represents myriad different diseases. The European experts note that current evidence suggests many patients with solid tumors are not more vulnerable to serious complications than the general population.
Thus, cancer prognoses vary considerably, and addressing all patients with cancer as being “COVID-19-vulnerable is probably neither reasonable nor informative,” say the authors.
Dramatic changes were initiated in cancer management for all cancer types, nevertheless, and although these changes seemed reasonable in an acute pandemic situation, note the authors, they were made in the absence of strong supportive evidence. Attempts to define the individualized risk for a given patient, taking into account their primary tumor subtype, stage, age, and gender, have been limited.
“Based on current evidence, only patients who are elderly, with multiple comorbidities, and receiving chemotherapy are vulnerable to the infection,” explained Curigliano.
However, on a positive note, a recently published prospective cohort study looked at approximately 800 patients with cancer – who had symptomatic COVID-19 – in the United Kingdom. The analysis showed no association at all between the risk for death and receiving chemotherapy or immunotherapy, points out Medscape commentator David Kerr, MD, of the University of Oxford, UK, in a recent commentary.
Key recommendations
An international consortium was established by ESMO, and the interdisciplinary expert panel consisted of 64 experts and one voting patient advocate. They agreed on 28 statements that can be used to help with many of the current clinical and technical areas of uncertainty that range from diagnosis to treatment decisions.
The following are several of the key recommendations:
- Patients with cancer who face the highest risk of severe COVID-19 are characterized by active and progressive cancer, advanced age, poor performance status, smoking status, comorbidities, and possibly type of cancer.
- Telehealth and digital health can be excellent tools for some types of care such as primary care triage and counseling, but meeting in person may be more effective for situations that include delivery of key cancer-related information and for patients with complex cancer needs.
- Prior to hospital admission, patients with cancer should be tested for COVID-19, if feasible, and if they are considered at high risk, regardless of symptoms or chest radiological findings.
- Patients with cancer and COVID-19 have a higher risk of thromboembolic events, and prophylaxis using low molecular weight or novel oral anticoagulants is recommended.
- Immune checkpoint inhibitors should not be withheld or delayed when there is a significant survival benefit, but use should be postponed in patients who test positive for COVID-19 until they recover.
- Use of high-dose steroids in patients with cancer infected with COVID-19 could potentially increase the risk of mortality, and a switch should be made to another immunosuppressant, if possible.
- The decision to use tyrosine kinase inhibitors (TKIs) of the PI3K/AKT/mTOR or RAS/RAF/MEK axis is complex, as they interfere with critical pathways involved in innate or adaptive immune responses. Stopping or withholding therapy depends on the risk-benefit balance, and the magnitude of benefit from the TKI needs to be considered.
The authors conclude that “ultimately, this set of statements will serve as a dynamic knowledge repository that will be better informed by accumulating data on SARS-CoV-2 biology, COVID-19 pandemic characteristics, on the risk of cancer patients for COVID-19 and its modulating factors, and finally, on optimal cancer care in the presence of the virus.”
No funding was reported for the current study. Several authors have disclosed relationships with industry, which are listed in the article.
This article first appeared on Medscape.com.
Another important recommendation is to stop labeling all patients with cancer as being vulnerable to infection with the virus as it can lead to inappropriate care with potential negative outcomes.
“Although it was reasonable to adopt over-protective measures for our patients at the outbreak of a novel infective disease which was not previously observed in humans, we now need to step away from the assumption that all cancer patients are vulnerable to COVID-19,” said first author of the consensus article Giuseppe Curigliano, MD, PhD, of the European Institute of Oncology, Milan, Italy, in a statement. “The implications have been important because for some patients treatment was delayed or interrupted over the last few months, and I believe that we will see the impact of this over-precautionary approach in the...future.”
The recommendations were issued by the European Society of Medical Oncology (ESMO) to help guide physicians in “optimizing the pathway to cancer care” as well as to improve outcomes during the pandemic. The recommendations were published online July 31 in Annals of Oncology.
Studies have found that patients with cancer face a higher risk of serious complications and death if they develop COVID-19. Data from the COVID-19 and Cancer Consortium registry, for example, showed that patients with progressing cancer and COVID-19 infection had a fivefold increase in the risk of 30-day mortality compared with COVID-19–positive cancer patients who were in remission or had no evidence of cancer.
But while this may be true for some patients, Curigliano and colleagues emphasize that individuals with cancer are not a heterogeneous group and that the term “cancer” itself represents myriad different diseases. The European experts note that current evidence suggests many patients with solid tumors are not more vulnerable to serious complications than the general population.
Thus, cancer prognoses vary considerably, and addressing all patients with cancer as being “COVID-19-vulnerable is probably neither reasonable nor informative,” say the authors.
Dramatic changes were initiated in cancer management for all cancer types, nevertheless, and although these changes seemed reasonable in an acute pandemic situation, note the authors, they were made in the absence of strong supportive evidence. Attempts to define the individualized risk for a given patient, taking into account their primary tumor subtype, stage, age, and gender, have been limited.
“Based on current evidence, only patients who are elderly, with multiple comorbidities, and receiving chemotherapy are vulnerable to the infection,” explained Curigliano.
However, on a positive note, a recently published prospective cohort study looked at approximately 800 patients with cancer – who had symptomatic COVID-19 – in the United Kingdom. The analysis showed no association at all between the risk for death and receiving chemotherapy or immunotherapy, points out Medscape commentator David Kerr, MD, of the University of Oxford, UK, in a recent commentary.
Key recommendations
An international consortium was established by ESMO, and the interdisciplinary expert panel consisted of 64 experts and one voting patient advocate. They agreed on 28 statements that can be used to help with many of the current clinical and technical areas of uncertainty that range from diagnosis to treatment decisions.
The following are several of the key recommendations:
- Patients with cancer who face the highest risk of severe COVID-19 are characterized by active and progressive cancer, advanced age, poor performance status, smoking status, comorbidities, and possibly type of cancer.
- Telehealth and digital health can be excellent tools for some types of care such as primary care triage and counseling, but meeting in person may be more effective for situations that include delivery of key cancer-related information and for patients with complex cancer needs.
- Prior to hospital admission, patients with cancer should be tested for COVID-19, if feasible, and if they are considered at high risk, regardless of symptoms or chest radiological findings.
- Patients with cancer and COVID-19 have a higher risk of thromboembolic events, and prophylaxis using low molecular weight or novel oral anticoagulants is recommended.
- Immune checkpoint inhibitors should not be withheld or delayed when there is a significant survival benefit, but use should be postponed in patients who test positive for COVID-19 until they recover.
- Use of high-dose steroids in patients with cancer infected with COVID-19 could potentially increase the risk of mortality, and a switch should be made to another immunosuppressant, if possible.
- The decision to use tyrosine kinase inhibitors (TKIs) of the PI3K/AKT/mTOR or RAS/RAF/MEK axis is complex, as they interfere with critical pathways involved in innate or adaptive immune responses. Stopping or withholding therapy depends on the risk-benefit balance, and the magnitude of benefit from the TKI needs to be considered.
The authors conclude that “ultimately, this set of statements will serve as a dynamic knowledge repository that will be better informed by accumulating data on SARS-CoV-2 biology, COVID-19 pandemic characteristics, on the risk of cancer patients for COVID-19 and its modulating factors, and finally, on optimal cancer care in the presence of the virus.”
No funding was reported for the current study. Several authors have disclosed relationships with industry, which are listed in the article.
This article first appeared on Medscape.com.
Psychiatrists report rare case of woman who thinks she’s a chicken
LEUVEN, Belgium — A 54-year-old woman has suffered the delusion of thinking she is a chicken for 24 hours. This very rare condition, known as zoanthropy, in which people think they are an animal is often not recognised, say researchers from the University of Leuven.
Zoanthropy can include people believing they are, or behaving like, any kind of animal: from a dog, to a lion or tiger, crocodile, snake, or bee.
It’s important to recognise this as a potential symptom of something serious, say the researchers in the July issue of the Belgian Journal of Psychiatry, Tijdschrift voor Psychiatrie.
“Additional investigations with brain imaging and electroencephalogram are therefore advised,” say the authors.
Psychiatrists Need to Be Aware That Clinical Zoanthropy Exists
In their paper, they describe the case of the woman who briefly thought she was a chicken, which was followed by her having a generalized epileptic seizure.
“Clinically, we saw a lady who perspired profusely, trembled, blew up her cheeks, and ... seemed to imitate a chicken, [making noises] like clucking, cackling, and crowing like a rooster,” they say.
“After about 10 minutes she seemed to tighten her muscles for a few seconds, her face turned red and for a short time she didn’t react. These symptoms repeated themselves at intervals of a few minutes [and her] consciousness was fluctuating,” with the patient “disoriented in time and space.”
Lead author Dr Athena Beckers of University Psychiatric Centre, KU Leuven, Belgium, said in an interview with MediQuality: “With only 56 case descriptions in the medical literature from 1850 to the present day, the condition is rare. It amounts to about one description every 3 years.
“We suspect, however, that the delusion is not always noticed: the patient shows bizarre behaviour or makes animal sounds, it is probably often catalogued under the general term ‘psychosis’.”
Dr Beckers adds that it is important that the symptoms are recognised, because of the possible underlying causes which can include epilepsy. So this might require a different or complementary treatment “with, for example, antiepileptic drugs”.
“I myself have only seen this type of delusion once, but I ... heard anecdotal stories from other patients whose family member, for example with schizophrenia, sometimes thought he was a cow [during] ... a psychosis.
“After the publication of my article I was also contacted by someone who told me they had experienced the same thing 30 years ago – he thought he was a chicken.
“I think it’s a good thing that we psychiatrists are aware of the fact that clinical zoanthropy exists and may require additional research,” she observed.
Fortunately, this woman’s experience ended well. After about one year of disability, the patient was able to return to work progressively. Her mood remained stable and there were no more psychotic symptoms or any indication of epileptic episodes.
Such Delusions Are Rare
Dr Georges Otte, a recently retired neuropsychiatrist who formerly worked at Ghent University, Belgium, gave his thoughts to Mediquality: “The interface between neurology and psychiatry ... is a fertile meadow on which many crops thrive. But it is in the darkest corners of psychosis that one finds the most bizarre and also rarest excesses.”
There are a number of delusions of identity, said Dr Otte.
These include Cotard’s syndrome, a rare condition marked by the false belief that the person or their body parts are dead, dying, or don’t exist, or Capgras delusion, where the affected person believes that a spouse or close family member has been replaced with an imposter. Delusions can also occur as a result of substance abuse, for example after using psilocybin (magic mushrooms), he added.
“Delusions in which patients are convinced of ‘shape shifting’ (man to animal) are quite rare,” Dr Otte observed.
“In the literature we know that lycanthropy [a person thinks he or she is turning into a werewolf],” has been reported, and has “apparently inspired many authors of horror stories,” he added.
“But it’s not every day that as a psychiatrist, you will encounter such an extreme psychotic depersonalization as someone turning into a chicken.”
This article first appeared on Medscape.com.
LEUVEN, Belgium — A 54-year-old woman has suffered the delusion of thinking she is a chicken for 24 hours. This very rare condition, known as zoanthropy, in which people think they are an animal is often not recognised, say researchers from the University of Leuven.
Zoanthropy can include people believing they are, or behaving like, any kind of animal: from a dog, to a lion or tiger, crocodile, snake, or bee.
It’s important to recognise this as a potential symptom of something serious, say the researchers in the July issue of the Belgian Journal of Psychiatry, Tijdschrift voor Psychiatrie.
“Additional investigations with brain imaging and electroencephalogram are therefore advised,” say the authors.
Psychiatrists Need to Be Aware That Clinical Zoanthropy Exists
In their paper, they describe the case of the woman who briefly thought she was a chicken, which was followed by her having a generalized epileptic seizure.
“Clinically, we saw a lady who perspired profusely, trembled, blew up her cheeks, and ... seemed to imitate a chicken, [making noises] like clucking, cackling, and crowing like a rooster,” they say.
“After about 10 minutes she seemed to tighten her muscles for a few seconds, her face turned red and for a short time she didn’t react. These symptoms repeated themselves at intervals of a few minutes [and her] consciousness was fluctuating,” with the patient “disoriented in time and space.”
Lead author Dr Athena Beckers of University Psychiatric Centre, KU Leuven, Belgium, said in an interview with MediQuality: “With only 56 case descriptions in the medical literature from 1850 to the present day, the condition is rare. It amounts to about one description every 3 years.
“We suspect, however, that the delusion is not always noticed: the patient shows bizarre behaviour or makes animal sounds, it is probably often catalogued under the general term ‘psychosis’.”
Dr Beckers adds that it is important that the symptoms are recognised, because of the possible underlying causes which can include epilepsy. So this might require a different or complementary treatment “with, for example, antiepileptic drugs”.
“I myself have only seen this type of delusion once, but I ... heard anecdotal stories from other patients whose family member, for example with schizophrenia, sometimes thought he was a cow [during] ... a psychosis.
“After the publication of my article I was also contacted by someone who told me they had experienced the same thing 30 years ago – he thought he was a chicken.
“I think it’s a good thing that we psychiatrists are aware of the fact that clinical zoanthropy exists and may require additional research,” she observed.
Fortunately, this woman’s experience ended well. After about one year of disability, the patient was able to return to work progressively. Her mood remained stable and there were no more psychotic symptoms or any indication of epileptic episodes.
Such Delusions Are Rare
Dr Georges Otte, a recently retired neuropsychiatrist who formerly worked at Ghent University, Belgium, gave his thoughts to Mediquality: “The interface between neurology and psychiatry ... is a fertile meadow on which many crops thrive. But it is in the darkest corners of psychosis that one finds the most bizarre and also rarest excesses.”
There are a number of delusions of identity, said Dr Otte.
These include Cotard’s syndrome, a rare condition marked by the false belief that the person or their body parts are dead, dying, or don’t exist, or Capgras delusion, where the affected person believes that a spouse or close family member has been replaced with an imposter. Delusions can also occur as a result of substance abuse, for example after using psilocybin (magic mushrooms), he added.
“Delusions in which patients are convinced of ‘shape shifting’ (man to animal) are quite rare,” Dr Otte observed.
“In the literature we know that lycanthropy [a person thinks he or she is turning into a werewolf],” has been reported, and has “apparently inspired many authors of horror stories,” he added.
“But it’s not every day that as a psychiatrist, you will encounter such an extreme psychotic depersonalization as someone turning into a chicken.”
This article first appeared on Medscape.com.
LEUVEN, Belgium — A 54-year-old woman has suffered the delusion of thinking she is a chicken for 24 hours. This very rare condition, known as zoanthropy, in which people think they are an animal is often not recognised, say researchers from the University of Leuven.
Zoanthropy can include people believing they are, or behaving like, any kind of animal: from a dog, to a lion or tiger, crocodile, snake, or bee.
It’s important to recognise this as a potential symptom of something serious, say the researchers in the July issue of the Belgian Journal of Psychiatry, Tijdschrift voor Psychiatrie.
“Additional investigations with brain imaging and electroencephalogram are therefore advised,” say the authors.
Psychiatrists Need to Be Aware That Clinical Zoanthropy Exists
In their paper, they describe the case of the woman who briefly thought she was a chicken, which was followed by her having a generalized epileptic seizure.
“Clinically, we saw a lady who perspired profusely, trembled, blew up her cheeks, and ... seemed to imitate a chicken, [making noises] like clucking, cackling, and crowing like a rooster,” they say.
“After about 10 minutes she seemed to tighten her muscles for a few seconds, her face turned red and for a short time she didn’t react. These symptoms repeated themselves at intervals of a few minutes [and her] consciousness was fluctuating,” with the patient “disoriented in time and space.”
Lead author Dr Athena Beckers of University Psychiatric Centre, KU Leuven, Belgium, said in an interview with MediQuality: “With only 56 case descriptions in the medical literature from 1850 to the present day, the condition is rare. It amounts to about one description every 3 years.
“We suspect, however, that the delusion is not always noticed: the patient shows bizarre behaviour or makes animal sounds, it is probably often catalogued under the general term ‘psychosis’.”
Dr Beckers adds that it is important that the symptoms are recognised, because of the possible underlying causes which can include epilepsy. So this might require a different or complementary treatment “with, for example, antiepileptic drugs”.
“I myself have only seen this type of delusion once, but I ... heard anecdotal stories from other patients whose family member, for example with schizophrenia, sometimes thought he was a cow [during] ... a psychosis.
“After the publication of my article I was also contacted by someone who told me they had experienced the same thing 30 years ago – he thought he was a chicken.
“I think it’s a good thing that we psychiatrists are aware of the fact that clinical zoanthropy exists and may require additional research,” she observed.
Fortunately, this woman’s experience ended well. After about one year of disability, the patient was able to return to work progressively. Her mood remained stable and there were no more psychotic symptoms or any indication of epileptic episodes.
Such Delusions Are Rare
Dr Georges Otte, a recently retired neuropsychiatrist who formerly worked at Ghent University, Belgium, gave his thoughts to Mediquality: “The interface between neurology and psychiatry ... is a fertile meadow on which many crops thrive. But it is in the darkest corners of psychosis that one finds the most bizarre and also rarest excesses.”
There are a number of delusions of identity, said Dr Otte.
These include Cotard’s syndrome, a rare condition marked by the false belief that the person or their body parts are dead, dying, or don’t exist, or Capgras delusion, where the affected person believes that a spouse or close family member has been replaced with an imposter. Delusions can also occur as a result of substance abuse, for example after using psilocybin (magic mushrooms), he added.
“Delusions in which patients are convinced of ‘shape shifting’ (man to animal) are quite rare,” Dr Otte observed.
“In the literature we know that lycanthropy [a person thinks he or she is turning into a werewolf],” has been reported, and has “apparently inspired many authors of horror stories,” he added.
“But it’s not every day that as a psychiatrist, you will encounter such an extreme psychotic depersonalization as someone turning into a chicken.”
This article first appeared on Medscape.com.
DDSEP® 9 Quick Quiz
Q2. Correct answer: D
Rationale
Episodic hepatic encephalopathy is usually precipitant-induced in over 80% of cases and includes dehydration, infections, over diuresis, gastrointestinal bleeding, constipation, and the use of narcotics and sedatives. Key is to identify and treat the precipitant. A diagnostic workup to rule out other disorders that can alter brain function and mimic hepatic encephalopathy should also be performed.
Reference
1. Viltstrup H et al. Hepatic encephalopathy in chronic liver disease: 2014 Practice Guideline by the American Association for the Study of Liver Diseases and the European Association for the Study of the Liver. Hepatology. 2014;60(2):715-35.
ginews@gastro.org
Q2. Correct answer: D
Rationale
Episodic hepatic encephalopathy is usually precipitant-induced in over 80% of cases and includes dehydration, infections, over diuresis, gastrointestinal bleeding, constipation, and the use of narcotics and sedatives. Key is to identify and treat the precipitant. A diagnostic workup to rule out other disorders that can alter brain function and mimic hepatic encephalopathy should also be performed.
Reference
1. Viltstrup H et al. Hepatic encephalopathy in chronic liver disease: 2014 Practice Guideline by the American Association for the Study of Liver Diseases and the European Association for the Study of the Liver. Hepatology. 2014;60(2):715-35.
ginews@gastro.org
Q2. Correct answer: D
Rationale
Episodic hepatic encephalopathy is usually precipitant-induced in over 80% of cases and includes dehydration, infections, over diuresis, gastrointestinal bleeding, constipation, and the use of narcotics and sedatives. Key is to identify and treat the precipitant. A diagnostic workup to rule out other disorders that can alter brain function and mimic hepatic encephalopathy should also be performed.
Reference
1. Viltstrup H et al. Hepatic encephalopathy in chronic liver disease: 2014 Practice Guideline by the American Association for the Study of Liver Diseases and the European Association for the Study of the Liver. Hepatology. 2014;60(2):715-35.
ginews@gastro.org
A 62-year-old man with hepatitis C cirrhosis is admitted with altered mental status. He had a recent dental procedure and was given pain medication and a short course of antibiotics. He is only taking spironolactone 50 mg for small ascites. Patient is alert but not oriented to place and time. He has evidence of asterixis. His mucous membranes are dry and he has no evidence of ascites on exam. His labs include WBC, 4.7 × 103 mm3; AST, 45 U/L; ALT, 40 U/L; total bilirubin of 2.5 mg/dL; albumin of 3.7 g/dL; sodium 142 mEq/L; and a creatinine of 0.5 mg/dL.
DDSEP® 9 Quick Quiz
Q1. Correct answer: A
Rationale
In the United States, pigmented stones (black and brown) are less common than cholesterol gallstones. Both types of pigmented stones contain an excess of unconjugated bilirubin and are composed of calcium hydrogen bilirubinate, which is oxidized and polymerized in the hard black stones but unpolymerized in softer brown stones. Black pigmented gallstones are frequently radiopaque and form in sterile bile. Risk factors for black pigmented stones include hemolysis (example, sickle cell disease), cirrhosis, cystic fibrosis, and diseases affecting the ileum (example, Crohn's disease). In contrast, brown stones are more likely to occur in the bile ducts, are radiolucent, and form secondary to biliary stasis (example, biliary stricture) and infection (example, Clonorchis sinensis).
Obesity, female sex, and hyperlipidemia are risk factors for cholesterol gallstone formation. Octreotide decreases gallbladder motility and long-term use can increase the risk of cholelithiasis.
References
1. Stinton LM, Myers RP, Shaffer EA. Epidemiology of gallstones. Gastroenterol Clin N Am. 2010;39:157-69.
2. Vitek L, Carey MC. New pathophysiological concepts underlying pathogenesis of pigment gallstones. Clin Res Hepatol Gastroenterol. 2012;36:122-9.
ginews@gastro.org
Q1. Correct answer: A
Rationale
In the United States, pigmented stones (black and brown) are less common than cholesterol gallstones. Both types of pigmented stones contain an excess of unconjugated bilirubin and are composed of calcium hydrogen bilirubinate, which is oxidized and polymerized in the hard black stones but unpolymerized in softer brown stones. Black pigmented gallstones are frequently radiopaque and form in sterile bile. Risk factors for black pigmented stones include hemolysis (example, sickle cell disease), cirrhosis, cystic fibrosis, and diseases affecting the ileum (example, Crohn's disease). In contrast, brown stones are more likely to occur in the bile ducts, are radiolucent, and form secondary to biliary stasis (example, biliary stricture) and infection (example, Clonorchis sinensis).
Obesity, female sex, and hyperlipidemia are risk factors for cholesterol gallstone formation. Octreotide decreases gallbladder motility and long-term use can increase the risk of cholelithiasis.
References
1. Stinton LM, Myers RP, Shaffer EA. Epidemiology of gallstones. Gastroenterol Clin N Am. 2010;39:157-69.
2. Vitek L, Carey MC. New pathophysiological concepts underlying pathogenesis of pigment gallstones. Clin Res Hepatol Gastroenterol. 2012;36:122-9.
ginews@gastro.org
Q1. Correct answer: A
Rationale
In the United States, pigmented stones (black and brown) are less common than cholesterol gallstones. Both types of pigmented stones contain an excess of unconjugated bilirubin and are composed of calcium hydrogen bilirubinate, which is oxidized and polymerized in the hard black stones but unpolymerized in softer brown stones. Black pigmented gallstones are frequently radiopaque and form in sterile bile. Risk factors for black pigmented stones include hemolysis (example, sickle cell disease), cirrhosis, cystic fibrosis, and diseases affecting the ileum (example, Crohn's disease). In contrast, brown stones are more likely to occur in the bile ducts, are radiolucent, and form secondary to biliary stasis (example, biliary stricture) and infection (example, Clonorchis sinensis).
Obesity, female sex, and hyperlipidemia are risk factors for cholesterol gallstone formation. Octreotide decreases gallbladder motility and long-term use can increase the risk of cholelithiasis.
References
1. Stinton LM, Myers RP, Shaffer EA. Epidemiology of gallstones. Gastroenterol Clin N Am. 2010;39:157-69.
2. Vitek L, Carey MC. New pathophysiological concepts underlying pathogenesis of pigment gallstones. Clin Res Hepatol Gastroenterol. 2012;36:122-9.
ginews@gastro.org
A 56-year-old woman presents for evaluation of right upper-quadrant pain. Her medical history is remarkable for obesity with a BMI of 31 kg/m2, hyperlipidemia, diabetes mellitus, NASH cirrhosis, and a recent admission for melena. During her prior admission, she was treated with a proton pump inhibitor and octreotide. Esophagogastroduodenoscopy revealed a gastric ulcer with signs of recent bleeding and small esophageal varices without red wale signs.
Her lab evaluation is as follows: AST, 69 U/L; ALT, 35 U/L; total bilirubin, 1.6 mg/dL; alkaline phosphatase, 121 U/L, leukocytes 7,500/microL. An abdominal ultrasound is notable for a positive sonographic Murphy's sign, cholelithiasis, an 8-mm gallbladder wall, normal appearing bile ducts, and a cirrhotic appearing liver with splenomegaly. She undergoes cholecystectomy. Examination of the gallbladder reveals numerous hard gallstones, which are predominately composed of calcium bilirubinate.
How often does risk-reducing salpingo-oophorectomy identify cancer?
Among women with BRCA mutations who underwent risk-reducing bilateral salpingo-oophorectomy, the procedure led to a cancer diagnosis in 3%, according to research presented at the virtual annual scientific meeting of the Society of Gynecologic Surgeons.
Of 269 patients, 8 (3%) received a cancer diagnosis. In five cases, the cancer was diagnosed on final pathology, and three had immediate conversion to staging.
The data suggest that gynecologists as well as gynecologic oncologists may perform the procedure, but gynecologists may be less likely to obtain pelvic washings in accordance with guidelines for this indication.
said study author Coralee Toal, MD, of UPMC Magee-Womans Hospital in Pittsburgh. “It is often a diagnosis that is found at the time of pathology, so the initial procedure would not have been changed either way.”
Still, doctors who perform the procedure should follow recommended practices such as obtaining pelvic washings and identifying patients for the procedure within target age ranges, Dr. Toal said.
BRCA1 and BRCA2 mutations confer an increased risk of ovarian and breast cancer, but there is no effective form of ovarian cancer screening. Women with a known mutation may have a bilateral salpingo-oophorectomy to reduce the risk of cancer. The recommended age range for the procedure is 35-40 years for women with BRCA1 mutations and 40-45 years for women with BRCA2 mutations.
When the procedure is performed for this indication, various recommendations apply that may differ from those when the procedure is performed under different circumstances.
During risk-reducing bilateral salpingo-oophorectomy, the surgeon should thoroughly evaluate the abdominal cavity, obtain pelvic washings for cytology, remove at least 2 cm of the infundibulopelvic ligament, and divide the fallopian tube at the uterine cornua.
To assess the incidence of occult ovarian cancer at the time of risk-reducing bilateral salpingo-oophorectomy and surgeon adherence to recommended practices, Dr. Toal and colleagues performed a retrospective chart review.
They included patients who had a known BRCA mutation and underwent a risk-reducing bilateral salpingo-oophorectomy between July 2007 and September 2018. They excluded patients who had a suspicious adnexal mass before the procedure but not a known diagnosis, as well as patients with another malignancy or genetic syndrome.
The researchers evaluated adherence to recommendations by reviewing operative reports.
In all, they reviewed data from 269 patients. In 220 cases, a gynecologic oncologist performed the procedure, and in 49 cases a gynecologist performed the procedure.
Patients tended to be older than would be expected, said Dr. Toal. Patients with BRCA1 mutations had an average age of 46 years, and patients with BRCA2 mutations had an average age of 49 years.
Patients who received a cancer diagnosis were significantly older on average, compared with the other patients: 58 years versus 48 years.
Pelvic washings were performed during 95% of the procedures performed by a gynecologic oncologist, compared with 63% of the procedures performed by a gynecologist. In addition, patients who had the procedure performed by a gynecologist were significantly older than those who had the procedure performed by a gynecologic oncologist (49 vs. 47 years).
Miles Murphy, MD, president of the Society of Gynecologic Surgeons, asked how doctors should weigh the possibility of risk-reducing oophorectomy at the time of benign hysterectomy in patients without a family history of female cancer.
It could be that genetic testing would be appropriate for some of those patients, Dr. Toal said. It is “important to take a thorough family history to make sure that you are identifying anybody who may benefit from genetic counseling and genetic testing, where you might identify an otherwise not known mutation prior to an otherwise benign or routine surgery,” Dr. Toal said. “Then you would have the opportunity to perform this.”
For patients without known mutations, however, “we do know the benefit of ovaries remaining in situ ... including cardiac health,” she said. “You have to remember that people can die of a broken hip as well. The risk of osteoporosis and those things is not zero and in fact may be much higher than their ovarian cancer risk.”
One of the study authors is a surgeon educator for Covidien and Medtronic.
SOURCE: Newcomb LK et al. SGS 2020, Abstract 18.
Among women with BRCA mutations who underwent risk-reducing bilateral salpingo-oophorectomy, the procedure led to a cancer diagnosis in 3%, according to research presented at the virtual annual scientific meeting of the Society of Gynecologic Surgeons.
Of 269 patients, 8 (3%) received a cancer diagnosis. In five cases, the cancer was diagnosed on final pathology, and three had immediate conversion to staging.
The data suggest that gynecologists as well as gynecologic oncologists may perform the procedure, but gynecologists may be less likely to obtain pelvic washings in accordance with guidelines for this indication.
said study author Coralee Toal, MD, of UPMC Magee-Womans Hospital in Pittsburgh. “It is often a diagnosis that is found at the time of pathology, so the initial procedure would not have been changed either way.”
Still, doctors who perform the procedure should follow recommended practices such as obtaining pelvic washings and identifying patients for the procedure within target age ranges, Dr. Toal said.
BRCA1 and BRCA2 mutations confer an increased risk of ovarian and breast cancer, but there is no effective form of ovarian cancer screening. Women with a known mutation may have a bilateral salpingo-oophorectomy to reduce the risk of cancer. The recommended age range for the procedure is 35-40 years for women with BRCA1 mutations and 40-45 years for women with BRCA2 mutations.
When the procedure is performed for this indication, various recommendations apply that may differ from those when the procedure is performed under different circumstances.
During risk-reducing bilateral salpingo-oophorectomy, the surgeon should thoroughly evaluate the abdominal cavity, obtain pelvic washings for cytology, remove at least 2 cm of the infundibulopelvic ligament, and divide the fallopian tube at the uterine cornua.
To assess the incidence of occult ovarian cancer at the time of risk-reducing bilateral salpingo-oophorectomy and surgeon adherence to recommended practices, Dr. Toal and colleagues performed a retrospective chart review.
They included patients who had a known BRCA mutation and underwent a risk-reducing bilateral salpingo-oophorectomy between July 2007 and September 2018. They excluded patients who had a suspicious adnexal mass before the procedure but not a known diagnosis, as well as patients with another malignancy or genetic syndrome.
The researchers evaluated adherence to recommendations by reviewing operative reports.
In all, they reviewed data from 269 patients. In 220 cases, a gynecologic oncologist performed the procedure, and in 49 cases a gynecologist performed the procedure.
Patients tended to be older than would be expected, said Dr. Toal. Patients with BRCA1 mutations had an average age of 46 years, and patients with BRCA2 mutations had an average age of 49 years.
Patients who received a cancer diagnosis were significantly older on average, compared with the other patients: 58 years versus 48 years.
Pelvic washings were performed during 95% of the procedures performed by a gynecologic oncologist, compared with 63% of the procedures performed by a gynecologist. In addition, patients who had the procedure performed by a gynecologist were significantly older than those who had the procedure performed by a gynecologic oncologist (49 vs. 47 years).
Miles Murphy, MD, president of the Society of Gynecologic Surgeons, asked how doctors should weigh the possibility of risk-reducing oophorectomy at the time of benign hysterectomy in patients without a family history of female cancer.
It could be that genetic testing would be appropriate for some of those patients, Dr. Toal said. It is “important to take a thorough family history to make sure that you are identifying anybody who may benefit from genetic counseling and genetic testing, where you might identify an otherwise not known mutation prior to an otherwise benign or routine surgery,” Dr. Toal said. “Then you would have the opportunity to perform this.”
For patients without known mutations, however, “we do know the benefit of ovaries remaining in situ ... including cardiac health,” she said. “You have to remember that people can die of a broken hip as well. The risk of osteoporosis and those things is not zero and in fact may be much higher than their ovarian cancer risk.”
One of the study authors is a surgeon educator for Covidien and Medtronic.
SOURCE: Newcomb LK et al. SGS 2020, Abstract 18.
Among women with BRCA mutations who underwent risk-reducing bilateral salpingo-oophorectomy, the procedure led to a cancer diagnosis in 3%, according to research presented at the virtual annual scientific meeting of the Society of Gynecologic Surgeons.
Of 269 patients, 8 (3%) received a cancer diagnosis. In five cases, the cancer was diagnosed on final pathology, and three had immediate conversion to staging.
The data suggest that gynecologists as well as gynecologic oncologists may perform the procedure, but gynecologists may be less likely to obtain pelvic washings in accordance with guidelines for this indication.
said study author Coralee Toal, MD, of UPMC Magee-Womans Hospital in Pittsburgh. “It is often a diagnosis that is found at the time of pathology, so the initial procedure would not have been changed either way.”
Still, doctors who perform the procedure should follow recommended practices such as obtaining pelvic washings and identifying patients for the procedure within target age ranges, Dr. Toal said.
BRCA1 and BRCA2 mutations confer an increased risk of ovarian and breast cancer, but there is no effective form of ovarian cancer screening. Women with a known mutation may have a bilateral salpingo-oophorectomy to reduce the risk of cancer. The recommended age range for the procedure is 35-40 years for women with BRCA1 mutations and 40-45 years for women with BRCA2 mutations.
When the procedure is performed for this indication, various recommendations apply that may differ from those when the procedure is performed under different circumstances.
During risk-reducing bilateral salpingo-oophorectomy, the surgeon should thoroughly evaluate the abdominal cavity, obtain pelvic washings for cytology, remove at least 2 cm of the infundibulopelvic ligament, and divide the fallopian tube at the uterine cornua.
To assess the incidence of occult ovarian cancer at the time of risk-reducing bilateral salpingo-oophorectomy and surgeon adherence to recommended practices, Dr. Toal and colleagues performed a retrospective chart review.
They included patients who had a known BRCA mutation and underwent a risk-reducing bilateral salpingo-oophorectomy between July 2007 and September 2018. They excluded patients who had a suspicious adnexal mass before the procedure but not a known diagnosis, as well as patients with another malignancy or genetic syndrome.
The researchers evaluated adherence to recommendations by reviewing operative reports.
In all, they reviewed data from 269 patients. In 220 cases, a gynecologic oncologist performed the procedure, and in 49 cases a gynecologist performed the procedure.
Patients tended to be older than would be expected, said Dr. Toal. Patients with BRCA1 mutations had an average age of 46 years, and patients with BRCA2 mutations had an average age of 49 years.
Patients who received a cancer diagnosis were significantly older on average, compared with the other patients: 58 years versus 48 years.
Pelvic washings were performed during 95% of the procedures performed by a gynecologic oncologist, compared with 63% of the procedures performed by a gynecologist. In addition, patients who had the procedure performed by a gynecologist were significantly older than those who had the procedure performed by a gynecologic oncologist (49 vs. 47 years).
Miles Murphy, MD, president of the Society of Gynecologic Surgeons, asked how doctors should weigh the possibility of risk-reducing oophorectomy at the time of benign hysterectomy in patients without a family history of female cancer.
It could be that genetic testing would be appropriate for some of those patients, Dr. Toal said. It is “important to take a thorough family history to make sure that you are identifying anybody who may benefit from genetic counseling and genetic testing, where you might identify an otherwise not known mutation prior to an otherwise benign or routine surgery,” Dr. Toal said. “Then you would have the opportunity to perform this.”
For patients without known mutations, however, “we do know the benefit of ovaries remaining in situ ... including cardiac health,” she said. “You have to remember that people can die of a broken hip as well. The risk of osteoporosis and those things is not zero and in fact may be much higher than their ovarian cancer risk.”
One of the study authors is a surgeon educator for Covidien and Medtronic.
SOURCE: Newcomb LK et al. SGS 2020, Abstract 18.
FROM SGS 2020