User login
Kidney transplant for GPA boosts survival
SAN DIEGO – Receiving a kidney transplant increased the likelihood of survival in patients with end-stage renal disease (ESRD) due to granulomatosis with polyangiitis, a study showed.
“We found that there was a huge survival advantage of having a renal transplant,” lead author Zachary S. Wallace, MD, MS, of Harvard Medical School, Boston, said in an interview. “In addition, this improvement in survival seems to be due to a dramatic reduction in death due to cardiovascular disease.”
An estimated 25% of patients with GPA develop ESRD, according to Dr. Wallace, who also works at the vasculitis and glomerulonephritis center at Massachusetts General Hospital, Boston. “GPA and ANCA [antineutrophil cytoplasmic autoantibody]–associated vasculitis in general have a propensity to affect the kidneys, and the reason for that is not entirely known,” he said during the interview. “In the kidney, it most commonly causes a rapidly progressive glomerulonephritis which can cause irreversible renal failure if not aggressively treated.”
Dr. Wallace and his colleagues launched their study to better understand the impact of kidney transplants. “We know that patients with ESRD from more common causes – such as diabetes and hypertension – benefit in terms of survival and quality of life from transplantation,” he said in the interview. “It was unknown if GPA patients similarly benefit. Often, GPA patients have fewer comorbidities than patients with ESRD due to diabetes or hypertension. Since they may be relatively healthier, one might wonder if the survival benefit would be as great in ESRD patients with GPA.”
Dr. Wallace and his colleagues tracked 2,471 cases of ESRD due to GPA from the U.S. Renal Data System. All were wait-listed for a kidney transplant from 1995 to 2014, and the researchers tracked them as late as Jan. 1, 2016. Of the patients studied, 946 received a transplant. The study’s participants tended to be male (59%) and white (86-87%), and they rarely had comorbidities outside of diabetes (64-67%).
There were 438 deaths in the entire group. Those who received transplants were much less likely to die than those who didn’t (adjusted hazard ratio, 0.30; 95% confidence interval, 0.25-0.37; P less than .001), he reported at the annual meeting of the American College of Rheumatology.
Also, those who received transplants were much less likely than those who didn’t to die of cardiovascular disease (adjusted HR, 0.13; 95% CI, 0.08-0.22; P less than .001) and infection (adjusted HR, 0.61; 95% CI, 0.34-1.08; P = .09). There was no statistically significant difference between the groups in terms of deaths from cancer.
“The improvement in survival seems to be due to a dramatic reduction in death due to cardiovascular disease,” Dr. Wallace said in the interview. “While cardiovascular disease is a common cause of death in GPA and ESRD due to other causes, this was not known specifically in patients with ESRD due to GPA.”
The findings provide the following messages to rheumatologists: Renal transplantation in patients with ESRD due to GPA offers a significant survival benefit, and it is important to refer patients early to a renal transplant center, he noted.
“[Rheumatologists] should work closely with primary care physicians and nephrologists to make sure that the patient’s cardiovascular disease risk is being assessed – checking lipids, A1c, etc. – and addressed as necessary,” Dr. Wallace added.
The study authors reported no relevant financial disclosures. Funding included support from the Rheumatology Research Foundation, the Executive Committee on Research at Massachusetts General, and the National Institutes of Health Loan Repayment Program.
SAN DIEGO – Receiving a kidney transplant increased the likelihood of survival in patients with end-stage renal disease (ESRD) due to granulomatosis with polyangiitis, a study showed.
“We found that there was a huge survival advantage of having a renal transplant,” lead author Zachary S. Wallace, MD, MS, of Harvard Medical School, Boston, said in an interview. “In addition, this improvement in survival seems to be due to a dramatic reduction in death due to cardiovascular disease.”
An estimated 25% of patients with GPA develop ESRD, according to Dr. Wallace, who also works at the vasculitis and glomerulonephritis center at Massachusetts General Hospital, Boston. “GPA and ANCA [antineutrophil cytoplasmic autoantibody]–associated vasculitis in general have a propensity to affect the kidneys, and the reason for that is not entirely known,” he said during the interview. “In the kidney, it most commonly causes a rapidly progressive glomerulonephritis which can cause irreversible renal failure if not aggressively treated.”
Dr. Wallace and his colleagues launched their study to better understand the impact of kidney transplants. “We know that patients with ESRD from more common causes – such as diabetes and hypertension – benefit in terms of survival and quality of life from transplantation,” he said in the interview. “It was unknown if GPA patients similarly benefit. Often, GPA patients have fewer comorbidities than patients with ESRD due to diabetes or hypertension. Since they may be relatively healthier, one might wonder if the survival benefit would be as great in ESRD patients with GPA.”
Dr. Wallace and his colleagues tracked 2,471 cases of ESRD due to GPA from the U.S. Renal Data System. All were wait-listed for a kidney transplant from 1995 to 2014, and the researchers tracked them as late as Jan. 1, 2016. Of the patients studied, 946 received a transplant. The study’s participants tended to be male (59%) and white (86-87%), and they rarely had comorbidities outside of diabetes (64-67%).
There were 438 deaths in the entire group. Those who received transplants were much less likely to die than those who didn’t (adjusted hazard ratio, 0.30; 95% confidence interval, 0.25-0.37; P less than .001), he reported at the annual meeting of the American College of Rheumatology.
Also, those who received transplants were much less likely than those who didn’t to die of cardiovascular disease (adjusted HR, 0.13; 95% CI, 0.08-0.22; P less than .001) and infection (adjusted HR, 0.61; 95% CI, 0.34-1.08; P = .09). There was no statistically significant difference between the groups in terms of deaths from cancer.
“The improvement in survival seems to be due to a dramatic reduction in death due to cardiovascular disease,” Dr. Wallace said in the interview. “While cardiovascular disease is a common cause of death in GPA and ESRD due to other causes, this was not known specifically in patients with ESRD due to GPA.”
The findings provide the following messages to rheumatologists: Renal transplantation in patients with ESRD due to GPA offers a significant survival benefit, and it is important to refer patients early to a renal transplant center, he noted.
“[Rheumatologists] should work closely with primary care physicians and nephrologists to make sure that the patient’s cardiovascular disease risk is being assessed – checking lipids, A1c, etc. – and addressed as necessary,” Dr. Wallace added.
The study authors reported no relevant financial disclosures. Funding included support from the Rheumatology Research Foundation, the Executive Committee on Research at Massachusetts General, and the National Institutes of Health Loan Repayment Program.
SAN DIEGO – Receiving a kidney transplant increased the likelihood of survival in patients with end-stage renal disease (ESRD) due to granulomatosis with polyangiitis, a study showed.
“We found that there was a huge survival advantage of having a renal transplant,” lead author Zachary S. Wallace, MD, MS, of Harvard Medical School, Boston, said in an interview. “In addition, this improvement in survival seems to be due to a dramatic reduction in death due to cardiovascular disease.”
An estimated 25% of patients with GPA develop ESRD, according to Dr. Wallace, who also works at the vasculitis and glomerulonephritis center at Massachusetts General Hospital, Boston. “GPA and ANCA [antineutrophil cytoplasmic autoantibody]–associated vasculitis in general have a propensity to affect the kidneys, and the reason for that is not entirely known,” he said during the interview. “In the kidney, it most commonly causes a rapidly progressive glomerulonephritis which can cause irreversible renal failure if not aggressively treated.”
Dr. Wallace and his colleagues launched their study to better understand the impact of kidney transplants. “We know that patients with ESRD from more common causes – such as diabetes and hypertension – benefit in terms of survival and quality of life from transplantation,” he said in the interview. “It was unknown if GPA patients similarly benefit. Often, GPA patients have fewer comorbidities than patients with ESRD due to diabetes or hypertension. Since they may be relatively healthier, one might wonder if the survival benefit would be as great in ESRD patients with GPA.”
Dr. Wallace and his colleagues tracked 2,471 cases of ESRD due to GPA from the U.S. Renal Data System. All were wait-listed for a kidney transplant from 1995 to 2014, and the researchers tracked them as late as Jan. 1, 2016. Of the patients studied, 946 received a transplant. The study’s participants tended to be male (59%) and white (86-87%), and they rarely had comorbidities outside of diabetes (64-67%).
There were 438 deaths in the entire group. Those who received transplants were much less likely to die than those who didn’t (adjusted hazard ratio, 0.30; 95% confidence interval, 0.25-0.37; P less than .001), he reported at the annual meeting of the American College of Rheumatology.
Also, those who received transplants were much less likely than those who didn’t to die of cardiovascular disease (adjusted HR, 0.13; 95% CI, 0.08-0.22; P less than .001) and infection (adjusted HR, 0.61; 95% CI, 0.34-1.08; P = .09). There was no statistically significant difference between the groups in terms of deaths from cancer.
“The improvement in survival seems to be due to a dramatic reduction in death due to cardiovascular disease,” Dr. Wallace said in the interview. “While cardiovascular disease is a common cause of death in GPA and ESRD due to other causes, this was not known specifically in patients with ESRD due to GPA.”
The findings provide the following messages to rheumatologists: Renal transplantation in patients with ESRD due to GPA offers a significant survival benefit, and it is important to refer patients early to a renal transplant center, he noted.
“[Rheumatologists] should work closely with primary care physicians and nephrologists to make sure that the patient’s cardiovascular disease risk is being assessed – checking lipids, A1c, etc. – and addressed as necessary,” Dr. Wallace added.
The study authors reported no relevant financial disclosures. Funding included support from the Rheumatology Research Foundation, the Executive Committee on Research at Massachusetts General, and the National Institutes of Health Loan Repayment Program.
AT ACR 2017
Key clinical point:
Major finding: Compared with patients who were wait-listed for a transplant but didn’t receive one, those who got transplants were much less likely to die during the study period (adjusted HR, 0.30; 95% CI, 0.25-0.37; P less than .001).
Data source: 2,471 patients with ESRD due to GPA who were wait-listed for a kidney transplant from 1995 to 2014 and tracked as late as 2016; 946 received a transplant.
Disclosures: The study authors reported no relevant financial disclosures. Funding included support from the Rheumatology Research Foundation, the Executive Committee on Research at Massachusetts General, and the National Institutes of Health Loan Repayment Program.
Higher water intake linked to less hyperuricemia in gout
SAN DIEGO – While more hydration seems to improve gout, there’s little research into the connection between the two. Now, a new study suggests a strong link between low water consumption and hyperuricemia, a possible sign that boosting water intake will help some gout patients.
While it’s too early to confirm a clinically relevant connection, “there is a statistically significant inverse association between water consumption and high uric acid levels,” said Patricia Kachur, MD, a third-year internal medicine resident at the University of Central Florida, Ocala (Fla.) Regional Medical Center. Dr. Kachur, who spoke about the findings in an interview, is lead author of a study presented at the annual meeting of the American College of Rheumatology.
An abstract presented at the 2009 ACR annual meeting reported fewer gout attacks (adjusted odds ratio, 0.54; 95% confidence interval, 0.32-0.90) in 535 gout patients who reported drinking more than eight glasses of water over a 24-hour period, compared with those who drank one or fewer.
For the new study, Dr. Kachur and her colleagues examined findings from 539 participants with gout (but not chronic kidney disease) out of 17,321 individuals who took part in the National Health and Nutrition Examination Survey from 2009 to 2014.
Of the 539 participants, 39% were defined as having hyperuricemia (6.0 mg/dL or greater), with the rest having a low or normal level. Those with hyperuricemia were significantly more likely to be male and have obesity and hypertension.
The investigators defined high water intake as three or more liters of water per day for men and 2.2 or more liters for women. Of the 539 participants, 116 (22%) had high water intake.
The researchers found a lower risk of developing hyperuricemia in those with higher water intake, compared with those with lower intake (adjusted OR, 0.421; 95% CI, 0.262-0.679; P = .0007).
“These findings do not say anything about water and gout – not yet anyway,” Dr. Kachur said. “Rather there is a possibility that outpatient water intake has an association with lower uric acid levels in people afflicted by gout even after considering multiple other factors such as gender, race, BMI, age, hypertension, and diabetes mellitus.”
Indeed, she and her colleagues decided against publishing the results of their 2009 study “because there is a major challenge in interpreting these data.”
“Given that people only consume a finite amount of liquids each day, is it that consuming more water is beneficial or that drinking less of ‘bad’ fluids (for example, sodas, sugar-sweetened juices) is beneficial? We were not able to disentangle this issue,” she explained.
Still, she said, there are explanations about why water intake could be beneficial for gout. “Intravascular volume depletion increases the concentration of serum urate, and increased serum urate beyond the saturation threshold can result in crystallization,” she said. “With heat-related dehydration, there may also be metabolic acidosis and/or electrolyte abnormalities that can lead to decreased urate secretion in renal tubules, and an acidic pH can decrease solubility of serum urate.”
Dr. Neogi does encourage appropriate gout patients to make sure they drink enough water, especially if it is hot. She cowrote a 2014 study that linked gout flares to high temperatures and extremes of humidity, which can lead to dehydration (Am J Epidemiol. 2014 Aug 15;180[4]:372-7).
“The amount of water intake that is beneficial for gout is not known, so patients should follow general recommendations for water intake. In addition, I strongly encourage patients with gout to avoid or limit the amount of liquid consumed in the form of regular sodas and sweetened drinks or juices, particularly those with high-fructose corn syrup, and alcohol,” she said. “With regards to tea or coffee, if patients drink either tea or coffee, they can continue to do so and to use only low-fat or nonfat milk and little or no sugar.”
Meanwhile, she said, “there are some data to suggest that cherry juice – true natural cherry juice from fruit, not ‘cherry drinks’ – can be beneficial for gout. We are formally testing cherry juice in a trial.”
What’s next for research into water intake and gout? “The clinical correlation is missing in the study,” said Dr. Kachur, lead author of the new study. “Targeted surveys of gout patients, hopefully followed by a randomized controlled trial regulating water intake, can help make those connections.”
Dr. Kachur and other study authors reported having no relevant disclosures. Dr. Neogi reported having no relevant disclosures. No specific study funding was reported.
SAN DIEGO – While more hydration seems to improve gout, there’s little research into the connection between the two. Now, a new study suggests a strong link between low water consumption and hyperuricemia, a possible sign that boosting water intake will help some gout patients.
While it’s too early to confirm a clinically relevant connection, “there is a statistically significant inverse association between water consumption and high uric acid levels,” said Patricia Kachur, MD, a third-year internal medicine resident at the University of Central Florida, Ocala (Fla.) Regional Medical Center. Dr. Kachur, who spoke about the findings in an interview, is lead author of a study presented at the annual meeting of the American College of Rheumatology.
An abstract presented at the 2009 ACR annual meeting reported fewer gout attacks (adjusted odds ratio, 0.54; 95% confidence interval, 0.32-0.90) in 535 gout patients who reported drinking more than eight glasses of water over a 24-hour period, compared with those who drank one or fewer.
For the new study, Dr. Kachur and her colleagues examined findings from 539 participants with gout (but not chronic kidney disease) out of 17,321 individuals who took part in the National Health and Nutrition Examination Survey from 2009 to 2014.
Of the 539 participants, 39% were defined as having hyperuricemia (6.0 mg/dL or greater), with the rest having a low or normal level. Those with hyperuricemia were significantly more likely to be male and have obesity and hypertension.
The investigators defined high water intake as three or more liters of water per day for men and 2.2 or more liters for women. Of the 539 participants, 116 (22%) had high water intake.
The researchers found a lower risk of developing hyperuricemia in those with higher water intake, compared with those with lower intake (adjusted OR, 0.421; 95% CI, 0.262-0.679; P = .0007).
“These findings do not say anything about water and gout – not yet anyway,” Dr. Kachur said. “Rather there is a possibility that outpatient water intake has an association with lower uric acid levels in people afflicted by gout even after considering multiple other factors such as gender, race, BMI, age, hypertension, and diabetes mellitus.”
Indeed, she and her colleagues decided against publishing the results of their 2009 study “because there is a major challenge in interpreting these data.”
“Given that people only consume a finite amount of liquids each day, is it that consuming more water is beneficial or that drinking less of ‘bad’ fluids (for example, sodas, sugar-sweetened juices) is beneficial? We were not able to disentangle this issue,” she explained.
Still, she said, there are explanations about why water intake could be beneficial for gout. “Intravascular volume depletion increases the concentration of serum urate, and increased serum urate beyond the saturation threshold can result in crystallization,” she said. “With heat-related dehydration, there may also be metabolic acidosis and/or electrolyte abnormalities that can lead to decreased urate secretion in renal tubules, and an acidic pH can decrease solubility of serum urate.”
Dr. Neogi does encourage appropriate gout patients to make sure they drink enough water, especially if it is hot. She cowrote a 2014 study that linked gout flares to high temperatures and extremes of humidity, which can lead to dehydration (Am J Epidemiol. 2014 Aug 15;180[4]:372-7).
“The amount of water intake that is beneficial for gout is not known, so patients should follow general recommendations for water intake. In addition, I strongly encourage patients with gout to avoid or limit the amount of liquid consumed in the form of regular sodas and sweetened drinks or juices, particularly those with high-fructose corn syrup, and alcohol,” she said. “With regards to tea or coffee, if patients drink either tea or coffee, they can continue to do so and to use only low-fat or nonfat milk and little or no sugar.”
Meanwhile, she said, “there are some data to suggest that cherry juice – true natural cherry juice from fruit, not ‘cherry drinks’ – can be beneficial for gout. We are formally testing cherry juice in a trial.”
What’s next for research into water intake and gout? “The clinical correlation is missing in the study,” said Dr. Kachur, lead author of the new study. “Targeted surveys of gout patients, hopefully followed by a randomized controlled trial regulating water intake, can help make those connections.”
Dr. Kachur and other study authors reported having no relevant disclosures. Dr. Neogi reported having no relevant disclosures. No specific study funding was reported.
SAN DIEGO – While more hydration seems to improve gout, there’s little research into the connection between the two. Now, a new study suggests a strong link between low water consumption and hyperuricemia, a possible sign that boosting water intake will help some gout patients.
While it’s too early to confirm a clinically relevant connection, “there is a statistically significant inverse association between water consumption and high uric acid levels,” said Patricia Kachur, MD, a third-year internal medicine resident at the University of Central Florida, Ocala (Fla.) Regional Medical Center. Dr. Kachur, who spoke about the findings in an interview, is lead author of a study presented at the annual meeting of the American College of Rheumatology.
An abstract presented at the 2009 ACR annual meeting reported fewer gout attacks (adjusted odds ratio, 0.54; 95% confidence interval, 0.32-0.90) in 535 gout patients who reported drinking more than eight glasses of water over a 24-hour period, compared with those who drank one or fewer.
For the new study, Dr. Kachur and her colleagues examined findings from 539 participants with gout (but not chronic kidney disease) out of 17,321 individuals who took part in the National Health and Nutrition Examination Survey from 2009 to 2014.
Of the 539 participants, 39% were defined as having hyperuricemia (6.0 mg/dL or greater), with the rest having a low or normal level. Those with hyperuricemia were significantly more likely to be male and have obesity and hypertension.
The investigators defined high water intake as three or more liters of water per day for men and 2.2 or more liters for women. Of the 539 participants, 116 (22%) had high water intake.
The researchers found a lower risk of developing hyperuricemia in those with higher water intake, compared with those with lower intake (adjusted OR, 0.421; 95% CI, 0.262-0.679; P = .0007).
“These findings do not say anything about water and gout – not yet anyway,” Dr. Kachur said. “Rather there is a possibility that outpatient water intake has an association with lower uric acid levels in people afflicted by gout even after considering multiple other factors such as gender, race, BMI, age, hypertension, and diabetes mellitus.”
Indeed, she and her colleagues decided against publishing the results of their 2009 study “because there is a major challenge in interpreting these data.”
“Given that people only consume a finite amount of liquids each day, is it that consuming more water is beneficial or that drinking less of ‘bad’ fluids (for example, sodas, sugar-sweetened juices) is beneficial? We were not able to disentangle this issue,” she explained.
Still, she said, there are explanations about why water intake could be beneficial for gout. “Intravascular volume depletion increases the concentration of serum urate, and increased serum urate beyond the saturation threshold can result in crystallization,” she said. “With heat-related dehydration, there may also be metabolic acidosis and/or electrolyte abnormalities that can lead to decreased urate secretion in renal tubules, and an acidic pH can decrease solubility of serum urate.”
Dr. Neogi does encourage appropriate gout patients to make sure they drink enough water, especially if it is hot. She cowrote a 2014 study that linked gout flares to high temperatures and extremes of humidity, which can lead to dehydration (Am J Epidemiol. 2014 Aug 15;180[4]:372-7).
“The amount of water intake that is beneficial for gout is not known, so patients should follow general recommendations for water intake. In addition, I strongly encourage patients with gout to avoid or limit the amount of liquid consumed in the form of regular sodas and sweetened drinks or juices, particularly those with high-fructose corn syrup, and alcohol,” she said. “With regards to tea or coffee, if patients drink either tea or coffee, they can continue to do so and to use only low-fat or nonfat milk and little or no sugar.”
Meanwhile, she said, “there are some data to suggest that cherry juice – true natural cherry juice from fruit, not ‘cherry drinks’ – can be beneficial for gout. We are formally testing cherry juice in a trial.”
What’s next for research into water intake and gout? “The clinical correlation is missing in the study,” said Dr. Kachur, lead author of the new study. “Targeted surveys of gout patients, hopefully followed by a randomized controlled trial regulating water intake, can help make those connections.”
Dr. Kachur and other study authors reported having no relevant disclosures. Dr. Neogi reported having no relevant disclosures. No specific study funding was reported.
AT ACR 2017
Key clinical point:
Major finding: Gout patients with the highest water intake were less likely than others to have hyperuricemia (aOR, 0.421).
Data source: 539 participants with gout (but not chronic kidney disease) out of 17,321 in the National Health and Nutrition Examination Survey, 2009-2014.
Disclosures: The study authors reported having no relevant disclosures. No specific study funding was reported.
Hispanics trail blacks, whites in bariatric surgery rates
SAN DIEGO – A study of procedures at academic centers provides evidence that obese Hispanics in the United States undergo bariatric surgery at a much lower rate than whites and blacks. It also reveals marked regional variations in overall weight-loss surgery.
“Our findings do suggest that severely obese Hispanics are utilizing bariatric surgery much lower than other ethnic groups,” said study coauthor Ninh T. Nguyen, MD, FACS, chair of the department of surgery at the University of California Irvine Medical Center, in an interview. “Our research does not specifically address the reasons for this gap in the delivery of care. Further research will need to be done to understand the reasons and the ways to close this gap.”
According to Dr. Nguyen, the researchers undertook the study to better understand how bariatric surgery is delivered across ethnicities and geographic regions in the United States.
The researchers analyzed statistics from the Vizient health care performance database for the years 2013-2015. They focused on patients at about 120 academic centers who underwent 73,119 laparoscopic sleeve gastrectomy, laparoscopic Roux-en-Y gastric bypass, and laparoscopic adjustable gastric banding procedures. The patients were stratified by race and region.
Researchers found that bariatric procedures were performed at a much higher rate in the Northeast academic centers (2.21 per 1,000 obese persons), compared with the Midwest (0.73), South (0.50), and West (0.33).
In regard to race, the rates for blacks and whites were fairly similar in the Northwest (2.02 and 2.35 bariatric procedures per 1,000 obese persons, respectively), the South (0.59 and 0.63, respectively) and the West (0.45 and 0.43, respectively). There was a wider gap in the Midwest, with whites at 0.69 and blacks at 1.07.
Across the country, however, obese Hispanics were less likely than persons of the other two races to undergo weight-loss surgery. The gap was fairly small in the Northeast, where 1.74 per 1,000 obese Hispanics underwent weight-loss surgery, compared with rates of 2.02 and 2.35 among whites and blacks, respectively. But the disparity was much larger in the other parts of the country, with rates at 0.14 in the West, 0.11 in the South and 0.33 in the Midwest, compared with rates from 0.43 to 1.07 among blacks and whites.
The reasons for the surgery gap are unknown. Dr. Nguyen pointed to several possible explanations: “lack of education of obesity as a disease by the primary care providers and the need for referral to a bariatric surgeon for patients with body mass index greater than 40 kg/m2 or 35 kg/m2 with obesity-related comorbidities; poor understanding of the benefits of bariatric surgery and its low risk; lack of understanding of the urgency for treatment by the patient and provider; and hurdles in obtaining coverage for the operation by insurers.”
John Magaña Morton, MD, FACS, chief of bariatric and minimally invasive surgery at Stanford (Calif.) University School of Medicine and past president of the American Society for Metabolic and Bariatric Surgery, doesn’t think discrimination is causing the disparity.
“It’s probably a reflection of insurance status – Hispanics tend to be less insured than Caucasian or African American patients – as well as preference for patients to go to nonacademic centers,” he said.
Indeed, a Kaiser Family Foundation analysis found that 21% of the 52 million Hispanics younger than 65 years in the United States were uninsured in 2015, compared with 9% of whites and 13% of blacks. Only Native Americans/Alaska Natives had an uninsured rate as high as Hispanics.
“In terms of need [for weight-loss features], it’s certainly there for Hispanics,” said Dr. Morton. “[Hispanic patients] have high rates of obesity and diabetes, both of which are helped by bariatric surgery.”
He said about 40% of patients in his Palo Alto, Calif., practice are Hispanic, reflecting the high number in the local population.
It helps that Dr. Morton and several of his partners speak Spanish. “If you have a welcoming environment,” he said, “that can make a difference.”
The study authors and Dr. Morton report no relevant disclosures. No specific study funding is reported.
SAN DIEGO – A study of procedures at academic centers provides evidence that obese Hispanics in the United States undergo bariatric surgery at a much lower rate than whites and blacks. It also reveals marked regional variations in overall weight-loss surgery.
“Our findings do suggest that severely obese Hispanics are utilizing bariatric surgery much lower than other ethnic groups,” said study coauthor Ninh T. Nguyen, MD, FACS, chair of the department of surgery at the University of California Irvine Medical Center, in an interview. “Our research does not specifically address the reasons for this gap in the delivery of care. Further research will need to be done to understand the reasons and the ways to close this gap.”
According to Dr. Nguyen, the researchers undertook the study to better understand how bariatric surgery is delivered across ethnicities and geographic regions in the United States.
The researchers analyzed statistics from the Vizient health care performance database for the years 2013-2015. They focused on patients at about 120 academic centers who underwent 73,119 laparoscopic sleeve gastrectomy, laparoscopic Roux-en-Y gastric bypass, and laparoscopic adjustable gastric banding procedures. The patients were stratified by race and region.
Researchers found that bariatric procedures were performed at a much higher rate in the Northeast academic centers (2.21 per 1,000 obese persons), compared with the Midwest (0.73), South (0.50), and West (0.33).
In regard to race, the rates for blacks and whites were fairly similar in the Northwest (2.02 and 2.35 bariatric procedures per 1,000 obese persons, respectively), the South (0.59 and 0.63, respectively) and the West (0.45 and 0.43, respectively). There was a wider gap in the Midwest, with whites at 0.69 and blacks at 1.07.
Across the country, however, obese Hispanics were less likely than persons of the other two races to undergo weight-loss surgery. The gap was fairly small in the Northeast, where 1.74 per 1,000 obese Hispanics underwent weight-loss surgery, compared with rates of 2.02 and 2.35 among whites and blacks, respectively. But the disparity was much larger in the other parts of the country, with rates at 0.14 in the West, 0.11 in the South and 0.33 in the Midwest, compared with rates from 0.43 to 1.07 among blacks and whites.
The reasons for the surgery gap are unknown. Dr. Nguyen pointed to several possible explanations: “lack of education of obesity as a disease by the primary care providers and the need for referral to a bariatric surgeon for patients with body mass index greater than 40 kg/m2 or 35 kg/m2 with obesity-related comorbidities; poor understanding of the benefits of bariatric surgery and its low risk; lack of understanding of the urgency for treatment by the patient and provider; and hurdles in obtaining coverage for the operation by insurers.”
John Magaña Morton, MD, FACS, chief of bariatric and minimally invasive surgery at Stanford (Calif.) University School of Medicine and past president of the American Society for Metabolic and Bariatric Surgery, doesn’t think discrimination is causing the disparity.
“It’s probably a reflection of insurance status – Hispanics tend to be less insured than Caucasian or African American patients – as well as preference for patients to go to nonacademic centers,” he said.
Indeed, a Kaiser Family Foundation analysis found that 21% of the 52 million Hispanics younger than 65 years in the United States were uninsured in 2015, compared with 9% of whites and 13% of blacks. Only Native Americans/Alaska Natives had an uninsured rate as high as Hispanics.
“In terms of need [for weight-loss features], it’s certainly there for Hispanics,” said Dr. Morton. “[Hispanic patients] have high rates of obesity and diabetes, both of which are helped by bariatric surgery.”
He said about 40% of patients in his Palo Alto, Calif., practice are Hispanic, reflecting the high number in the local population.
It helps that Dr. Morton and several of his partners speak Spanish. “If you have a welcoming environment,” he said, “that can make a difference.”
The study authors and Dr. Morton report no relevant disclosures. No specific study funding is reported.
SAN DIEGO – A study of procedures at academic centers provides evidence that obese Hispanics in the United States undergo bariatric surgery at a much lower rate than whites and blacks. It also reveals marked regional variations in overall weight-loss surgery.
“Our findings do suggest that severely obese Hispanics are utilizing bariatric surgery much lower than other ethnic groups,” said study coauthor Ninh T. Nguyen, MD, FACS, chair of the department of surgery at the University of California Irvine Medical Center, in an interview. “Our research does not specifically address the reasons for this gap in the delivery of care. Further research will need to be done to understand the reasons and the ways to close this gap.”
According to Dr. Nguyen, the researchers undertook the study to better understand how bariatric surgery is delivered across ethnicities and geographic regions in the United States.
The researchers analyzed statistics from the Vizient health care performance database for the years 2013-2015. They focused on patients at about 120 academic centers who underwent 73,119 laparoscopic sleeve gastrectomy, laparoscopic Roux-en-Y gastric bypass, and laparoscopic adjustable gastric banding procedures. The patients were stratified by race and region.
Researchers found that bariatric procedures were performed at a much higher rate in the Northeast academic centers (2.21 per 1,000 obese persons), compared with the Midwest (0.73), South (0.50), and West (0.33).
In regard to race, the rates for blacks and whites were fairly similar in the Northwest (2.02 and 2.35 bariatric procedures per 1,000 obese persons, respectively), the South (0.59 and 0.63, respectively) and the West (0.45 and 0.43, respectively). There was a wider gap in the Midwest, with whites at 0.69 and blacks at 1.07.
Across the country, however, obese Hispanics were less likely than persons of the other two races to undergo weight-loss surgery. The gap was fairly small in the Northeast, where 1.74 per 1,000 obese Hispanics underwent weight-loss surgery, compared with rates of 2.02 and 2.35 among whites and blacks, respectively. But the disparity was much larger in the other parts of the country, with rates at 0.14 in the West, 0.11 in the South and 0.33 in the Midwest, compared with rates from 0.43 to 1.07 among blacks and whites.
The reasons for the surgery gap are unknown. Dr. Nguyen pointed to several possible explanations: “lack of education of obesity as a disease by the primary care providers and the need for referral to a bariatric surgeon for patients with body mass index greater than 40 kg/m2 or 35 kg/m2 with obesity-related comorbidities; poor understanding of the benefits of bariatric surgery and its low risk; lack of understanding of the urgency for treatment by the patient and provider; and hurdles in obtaining coverage for the operation by insurers.”
John Magaña Morton, MD, FACS, chief of bariatric and minimally invasive surgery at Stanford (Calif.) University School of Medicine and past president of the American Society for Metabolic and Bariatric Surgery, doesn’t think discrimination is causing the disparity.
“It’s probably a reflection of insurance status – Hispanics tend to be less insured than Caucasian or African American patients – as well as preference for patients to go to nonacademic centers,” he said.
Indeed, a Kaiser Family Foundation analysis found that 21% of the 52 million Hispanics younger than 65 years in the United States were uninsured in 2015, compared with 9% of whites and 13% of blacks. Only Native Americans/Alaska Natives had an uninsured rate as high as Hispanics.
“In terms of need [for weight-loss features], it’s certainly there for Hispanics,” said Dr. Morton. “[Hispanic patients] have high rates of obesity and diabetes, both of which are helped by bariatric surgery.”
He said about 40% of patients in his Palo Alto, Calif., practice are Hispanic, reflecting the high number in the local population.
It helps that Dr. Morton and several of his partners speak Spanish. “If you have a welcoming environment,” he said, “that can make a difference.”
The study authors and Dr. Morton report no relevant disclosures. No specific study funding is reported.
AT THE ACS CLINICAL CONGRESS
Key clinical point: At academic centers, obese Hispanics undergo bariatric surgery at a much lower rate than blacks and whites. U.S. regions outside the Northeast have lower rates of weight-loss procedures overall.
Major finding: Outside the Northeast, the bariatric surgery rate per 1,000 obese people is much lower for Hispanics (range, 0.11-0.33) than for blacks and whites (range, 0.43-1.07).
Data source: Analysis of 73,119 bariatric procedures from 2013-2015 at about 120 academic centers.
Disclosures: The study authors report no relevant disclosures. No specific study funding is reported.
Mixed results for rheumatologists on Medicare quality measures
SAN DIEGO – As quality measures are poised to become crucial to U.S. physician incomes in 2019, an analysis of a nationwide registry sample finds that rheumatologists overall have decent scores on several fronts. But they still need to boost their record on preventive measures that are not geared specifically to their specialty.
“Rheumatologists are performing well, so far, on aspects of care coordination, such as communication with the health care team post osteoporotic fracture and on several patient safety measures, such as avoiding high-risk drugs in the elderly,” said Jinoos Yazdany, MD, of the University of California, San Francisco. However, “in some preventive care measures, such as tobacco screening, there is room for improvement compared to benchmarks that the Centers for Medicare & Medicaid Services has set across providers.”
The ACR created the registry “to help rheumatology harness the power of electronic health record data to advance our understanding of the natural history, treatment, and outcomes of rheumatic disease,” Dr. Yazdany said. “Another important goal was to harness the power of a national registry to measure and improve quality of care and outcomes. Practices can use RISE to see where they are performing well and where there is room for improvement.”
Since 2016, the registry has passively collected data on 2.5 million patients and 13.7 million encounters.
“The quality measures in RISE serve several purposes,” Dr. Yazdany said. “First, they fulfill reporting requirements to CMS through the Merit-Based Incentive Payment System [MIPS]. Second, the measures provide information to practices that can be used to track quality improvement and population health management. Finally, the measures create unprecedented opportunities to learn from practices that are excelling and to adapt successful work flows to improve care for our patients.”
These measures matter. In 2019, payments for many physicians under Medicare Part B will be adjusted based on their performance in these areas in previous years. Most rheumatologists will take part, Dr. Yazdany said.
“Rather than focusing on a single measure, the key number in 2017 for the MIPS program is 70 points across the three domains of Quality, Advancing Care Information, and Improvement Activities,” she said. “Above that threshold, rheumatologists will qualify for an ‘exceptional performance bonus.’ That means they will get a minimum of an additional 0.5% on their Medicare billing.”
She added that “there is no reason that most rheumatologists should not cross the 70-point threshold. Proactively monitoring their progress in RISE will help them succeed.”
The ACR session focused on a registry sample of 225 practices and 750 rheumatologists. The analysis measured their performance from January to September 2017 in the Quality, Advancing Care Information, and Improvement Activities areas.
In terms of meeting benchmarks, the rheumatologists in the sample performed especially well in several areas.
On the drug safety front, across elderly patients, an average of just 3.6% were prescribed one or more high-risk medications, and 0.2% were prescribed two or more.
On rheumatoid arthritis measures, 52% of patients had documentation of tuberculosis screening before biologics, and 46.3% underwent functional status assessments. And in the care coordination and documentation measure, 92.9% documented current medications in the EHR.
Rheumatologists lagged in terms of preventive care, compared with other physicians nationally: The average performance across patients was 77.2% for tobacco screening and counseling, 42.7% for body mass index screening and counseling, and 60.2% for blood pressure management.
Why are these preventive care measures being tracked in rheumatology instead of more rheumatology-specific measures? “CMS requires that physicians submit an outcome measure. Unfortunately, we don’t have validated outcome measures in rheumatology, so we had to adopt outcome measures like controlling blood pressure,” Dr. Yazdany said. “Also, many preventive care measures are designated ‘high priority,’ which enables physicians to get bonus points. We wanted rheumatologists to have access to these extra points and therefore included these measures in RISE.”
The ACR is working on developing outcome measures, she said, “and hopefully we’ll have outcomes to put in the registry in coming years.”
What are the chances that rheumatologists will do well? “Our analyses show that most rheumatologists participating in RISE are well positioned to succeed. If they complete their improvement activities (15% of MIPS), and advancing care information (25% of MIPS) modules, that gets them to 40 points. That means they only need 30 additional points in the quality domain to get to the exceptional performance threshold and qualify for a bonus,” she said. “All 15 of the rheumatologists who have completed all three MIPS categories have reached 70 points, and we anticipate that many others will by the end of the year.”
Even just participating in RISE will boost points, she said. “It is clear that CMS is encouraging the large-scale development of quality improvement registries like RISE.”
In the big picture, she said, “the key point is that rheumatologists should be proactive. They need to understand their performance on measures, pick areas to focus on, including areas where they can easily improve their scores.”
Dr. Yazdany reported no relevant disclosures. The study was funded by ACR.
SAN DIEGO – As quality measures are poised to become crucial to U.S. physician incomes in 2019, an analysis of a nationwide registry sample finds that rheumatologists overall have decent scores on several fronts. But they still need to boost their record on preventive measures that are not geared specifically to their specialty.
“Rheumatologists are performing well, so far, on aspects of care coordination, such as communication with the health care team post osteoporotic fracture and on several patient safety measures, such as avoiding high-risk drugs in the elderly,” said Jinoos Yazdany, MD, of the University of California, San Francisco. However, “in some preventive care measures, such as tobacco screening, there is room for improvement compared to benchmarks that the Centers for Medicare & Medicaid Services has set across providers.”
The ACR created the registry “to help rheumatology harness the power of electronic health record data to advance our understanding of the natural history, treatment, and outcomes of rheumatic disease,” Dr. Yazdany said. “Another important goal was to harness the power of a national registry to measure and improve quality of care and outcomes. Practices can use RISE to see where they are performing well and where there is room for improvement.”
Since 2016, the registry has passively collected data on 2.5 million patients and 13.7 million encounters.
“The quality measures in RISE serve several purposes,” Dr. Yazdany said. “First, they fulfill reporting requirements to CMS through the Merit-Based Incentive Payment System [MIPS]. Second, the measures provide information to practices that can be used to track quality improvement and population health management. Finally, the measures create unprecedented opportunities to learn from practices that are excelling and to adapt successful work flows to improve care for our patients.”
These measures matter. In 2019, payments for many physicians under Medicare Part B will be adjusted based on their performance in these areas in previous years. Most rheumatologists will take part, Dr. Yazdany said.
“Rather than focusing on a single measure, the key number in 2017 for the MIPS program is 70 points across the three domains of Quality, Advancing Care Information, and Improvement Activities,” she said. “Above that threshold, rheumatologists will qualify for an ‘exceptional performance bonus.’ That means they will get a minimum of an additional 0.5% on their Medicare billing.”
She added that “there is no reason that most rheumatologists should not cross the 70-point threshold. Proactively monitoring their progress in RISE will help them succeed.”
The ACR session focused on a registry sample of 225 practices and 750 rheumatologists. The analysis measured their performance from January to September 2017 in the Quality, Advancing Care Information, and Improvement Activities areas.
In terms of meeting benchmarks, the rheumatologists in the sample performed especially well in several areas.
On the drug safety front, across elderly patients, an average of just 3.6% were prescribed one or more high-risk medications, and 0.2% were prescribed two or more.
On rheumatoid arthritis measures, 52% of patients had documentation of tuberculosis screening before biologics, and 46.3% underwent functional status assessments. And in the care coordination and documentation measure, 92.9% documented current medications in the EHR.
Rheumatologists lagged in terms of preventive care, compared with other physicians nationally: The average performance across patients was 77.2% for tobacco screening and counseling, 42.7% for body mass index screening and counseling, and 60.2% for blood pressure management.
Why are these preventive care measures being tracked in rheumatology instead of more rheumatology-specific measures? “CMS requires that physicians submit an outcome measure. Unfortunately, we don’t have validated outcome measures in rheumatology, so we had to adopt outcome measures like controlling blood pressure,” Dr. Yazdany said. “Also, many preventive care measures are designated ‘high priority,’ which enables physicians to get bonus points. We wanted rheumatologists to have access to these extra points and therefore included these measures in RISE.”
The ACR is working on developing outcome measures, she said, “and hopefully we’ll have outcomes to put in the registry in coming years.”
What are the chances that rheumatologists will do well? “Our analyses show that most rheumatologists participating in RISE are well positioned to succeed. If they complete their improvement activities (15% of MIPS), and advancing care information (25% of MIPS) modules, that gets them to 40 points. That means they only need 30 additional points in the quality domain to get to the exceptional performance threshold and qualify for a bonus,” she said. “All 15 of the rheumatologists who have completed all three MIPS categories have reached 70 points, and we anticipate that many others will by the end of the year.”
Even just participating in RISE will boost points, she said. “It is clear that CMS is encouraging the large-scale development of quality improvement registries like RISE.”
In the big picture, she said, “the key point is that rheumatologists should be proactive. They need to understand their performance on measures, pick areas to focus on, including areas where they can easily improve their scores.”
Dr. Yazdany reported no relevant disclosures. The study was funded by ACR.
SAN DIEGO – As quality measures are poised to become crucial to U.S. physician incomes in 2019, an analysis of a nationwide registry sample finds that rheumatologists overall have decent scores on several fronts. But they still need to boost their record on preventive measures that are not geared specifically to their specialty.
“Rheumatologists are performing well, so far, on aspects of care coordination, such as communication with the health care team post osteoporotic fracture and on several patient safety measures, such as avoiding high-risk drugs in the elderly,” said Jinoos Yazdany, MD, of the University of California, San Francisco. However, “in some preventive care measures, such as tobacco screening, there is room for improvement compared to benchmarks that the Centers for Medicare & Medicaid Services has set across providers.”
The ACR created the registry “to help rheumatology harness the power of electronic health record data to advance our understanding of the natural history, treatment, and outcomes of rheumatic disease,” Dr. Yazdany said. “Another important goal was to harness the power of a national registry to measure and improve quality of care and outcomes. Practices can use RISE to see where they are performing well and where there is room for improvement.”
Since 2016, the registry has passively collected data on 2.5 million patients and 13.7 million encounters.
“The quality measures in RISE serve several purposes,” Dr. Yazdany said. “First, they fulfill reporting requirements to CMS through the Merit-Based Incentive Payment System [MIPS]. Second, the measures provide information to practices that can be used to track quality improvement and population health management. Finally, the measures create unprecedented opportunities to learn from practices that are excelling and to adapt successful work flows to improve care for our patients.”
These measures matter. In 2019, payments for many physicians under Medicare Part B will be adjusted based on their performance in these areas in previous years. Most rheumatologists will take part, Dr. Yazdany said.
“Rather than focusing on a single measure, the key number in 2017 for the MIPS program is 70 points across the three domains of Quality, Advancing Care Information, and Improvement Activities,” she said. “Above that threshold, rheumatologists will qualify for an ‘exceptional performance bonus.’ That means they will get a minimum of an additional 0.5% on their Medicare billing.”
She added that “there is no reason that most rheumatologists should not cross the 70-point threshold. Proactively monitoring their progress in RISE will help them succeed.”
The ACR session focused on a registry sample of 225 practices and 750 rheumatologists. The analysis measured their performance from January to September 2017 in the Quality, Advancing Care Information, and Improvement Activities areas.
In terms of meeting benchmarks, the rheumatologists in the sample performed especially well in several areas.
On the drug safety front, across elderly patients, an average of just 3.6% were prescribed one or more high-risk medications, and 0.2% were prescribed two or more.
On rheumatoid arthritis measures, 52% of patients had documentation of tuberculosis screening before biologics, and 46.3% underwent functional status assessments. And in the care coordination and documentation measure, 92.9% documented current medications in the EHR.
Rheumatologists lagged in terms of preventive care, compared with other physicians nationally: The average performance across patients was 77.2% for tobacco screening and counseling, 42.7% for body mass index screening and counseling, and 60.2% for blood pressure management.
Why are these preventive care measures being tracked in rheumatology instead of more rheumatology-specific measures? “CMS requires that physicians submit an outcome measure. Unfortunately, we don’t have validated outcome measures in rheumatology, so we had to adopt outcome measures like controlling blood pressure,” Dr. Yazdany said. “Also, many preventive care measures are designated ‘high priority,’ which enables physicians to get bonus points. We wanted rheumatologists to have access to these extra points and therefore included these measures in RISE.”
The ACR is working on developing outcome measures, she said, “and hopefully we’ll have outcomes to put in the registry in coming years.”
What are the chances that rheumatologists will do well? “Our analyses show that most rheumatologists participating in RISE are well positioned to succeed. If they complete their improvement activities (15% of MIPS), and advancing care information (25% of MIPS) modules, that gets them to 40 points. That means they only need 30 additional points in the quality domain to get to the exceptional performance threshold and qualify for a bonus,” she said. “All 15 of the rheumatologists who have completed all three MIPS categories have reached 70 points, and we anticipate that many others will by the end of the year.”
Even just participating in RISE will boost points, she said. “It is clear that CMS is encouraging the large-scale development of quality improvement registries like RISE.”
In the big picture, she said, “the key point is that rheumatologists should be proactive. They need to understand their performance on measures, pick areas to focus on, including areas where they can easily improve their scores.”
Dr. Yazdany reported no relevant disclosures. The study was funded by ACR.
AT ACR 2017
VIDEO: Beware of over-relying on MRI findings in axSpA
SAN DIEGO – Healthy individuals can show signs of spinal and pelvic inflammation on MRI, but these scans can be misleading if relied on to make a diagnosis of axial spondyloarthritis, according to findings from three separate studies at the annual meeting of the American College of Rheumatology.
“Don’t rely on MRI alone is our message,” said Robert Landewé, MD, PhD, of the University of Amsterdam, who was a coauthor of one of the three studies. “A positive MRI may occur in individuals that are completely healthy. We need to make sure that not too many patients with chronic lower back pain are diagnosed with a disease they don’t have.”
The axial form of spondyloarthritis (axSpA) affects the spinal and pelvic joints of an estimated 1.4% of the U.S. population, and the term encompasses the diagnosis of ankylosing spondylitis (0.5% of U.S. population) in which advanced sacroiliitis is seen on conventional radiography, according to the ACR. Axial SpA is particularly common in young people, especially males, in their teens and 20s.
Researchers believe that MRI scans can misleadingly suggest that patients have the condition. “We know that MRI is a sensitive method, but there’s a lack of data regarding its specificity,” Thomas Renson, MD, of Ghent (Belgium) University, said at a press conference during the meeting.
Dr. Landewé led a study that compared MRIs of sacroiliac joints in 47 healthy people, 47 axSpA patients matched for gender and age, 47 chronic back pain patients, 7 women with postpartum back pain, and 24 frequent runners. Positive MRIs were common in the axSpA patients (43 of 47), but they were also found in healthy people (11 of 47), chronic back pain patients (3 of 47), frequent runners (3 of 24), and women with postpartum back pain (4 of 7).
In another study, Dr. Renson and his colleagues sought to understand whether a sustained period of intense physical activity affected spinal findings in 22 healthy military recruits who did not have SpA.
However, there was a statistically significant increase of combined structural and inflammatory lesions (P = .038) from baseline to post training.
The findings underscore “the importance of interpretation of imaging in the right clinical context,” Dr. Renson said, since they point to the possibility of an incorrect diagnosis “even in a young, active population.”
Another study, led by Ulrich Weber, MD, of King Christian 10th Hospital for Rheumatic Diseases, Gråsten, Denmark, sought to understand levels of normal low-grade BME in 20 amateur runners (8 men) and 22 professional Danish hockey players (all men). On average, the researchers found signs of BME in 3.1 sacroiliac joint quadrants in the runners before and after they ran a race. Hockey players were scanned at the end of the competitive season and showed signs of BME in an average of 3.6 sacroiliac joint quadrants.
In an interview, Dr. Landewé said the studies point to how common positive MRIs are in healthy people. “It was far higher than we would have thought 10 years ago,” he said.
Are MRIs still useful then? Dr. Weber said MRI scans are still helpful in axSpA diagnoses even though they have major limitations. “The imaging method is the only one that’s halfway reliable,” he said. “These joints are deep in the body, so we have virtually no clinical ways to diagnose this.”
However, Dr. Landewé said, “you should do it only when you have sufficient suspicion of spondyloarthritis” – due to accompanying conditions such as positive family history, acute anterior uveitis, psoriasis, or peripheral arthritis – and not just when a patient has chronic back pain.
Dr. Renson reported having no relevant disclosures; two of his coauthors reported extensive disclosures. Dr. Weber and his coauthors reported having no relevant disclosures. Dr. Landewé reported having no relevant disclosures; several of his coauthors reported various disclosures. Funding for the studies was not reported.
SAN DIEGO – Healthy individuals can show signs of spinal and pelvic inflammation on MRI, but these scans can be misleading if relied on to make a diagnosis of axial spondyloarthritis, according to findings from three separate studies at the annual meeting of the American College of Rheumatology.
“Don’t rely on MRI alone is our message,” said Robert Landewé, MD, PhD, of the University of Amsterdam, who was a coauthor of one of the three studies. “A positive MRI may occur in individuals that are completely healthy. We need to make sure that not too many patients with chronic lower back pain are diagnosed with a disease they don’t have.”
The axial form of spondyloarthritis (axSpA) affects the spinal and pelvic joints of an estimated 1.4% of the U.S. population, and the term encompasses the diagnosis of ankylosing spondylitis (0.5% of U.S. population) in which advanced sacroiliitis is seen on conventional radiography, according to the ACR. Axial SpA is particularly common in young people, especially males, in their teens and 20s.
Researchers believe that MRI scans can misleadingly suggest that patients have the condition. “We know that MRI is a sensitive method, but there’s a lack of data regarding its specificity,” Thomas Renson, MD, of Ghent (Belgium) University, said at a press conference during the meeting.
Dr. Landewé led a study that compared MRIs of sacroiliac joints in 47 healthy people, 47 axSpA patients matched for gender and age, 47 chronic back pain patients, 7 women with postpartum back pain, and 24 frequent runners. Positive MRIs were common in the axSpA patients (43 of 47), but they were also found in healthy people (11 of 47), chronic back pain patients (3 of 47), frequent runners (3 of 24), and women with postpartum back pain (4 of 7).
In another study, Dr. Renson and his colleagues sought to understand whether a sustained period of intense physical activity affected spinal findings in 22 healthy military recruits who did not have SpA.
However, there was a statistically significant increase of combined structural and inflammatory lesions (P = .038) from baseline to post training.
The findings underscore “the importance of interpretation of imaging in the right clinical context,” Dr. Renson said, since they point to the possibility of an incorrect diagnosis “even in a young, active population.”
Another study, led by Ulrich Weber, MD, of King Christian 10th Hospital for Rheumatic Diseases, Gråsten, Denmark, sought to understand levels of normal low-grade BME in 20 amateur runners (8 men) and 22 professional Danish hockey players (all men). On average, the researchers found signs of BME in 3.1 sacroiliac joint quadrants in the runners before and after they ran a race. Hockey players were scanned at the end of the competitive season and showed signs of BME in an average of 3.6 sacroiliac joint quadrants.
In an interview, Dr. Landewé said the studies point to how common positive MRIs are in healthy people. “It was far higher than we would have thought 10 years ago,” he said.
Are MRIs still useful then? Dr. Weber said MRI scans are still helpful in axSpA diagnoses even though they have major limitations. “The imaging method is the only one that’s halfway reliable,” he said. “These joints are deep in the body, so we have virtually no clinical ways to diagnose this.”
However, Dr. Landewé said, “you should do it only when you have sufficient suspicion of spondyloarthritis” – due to accompanying conditions such as positive family history, acute anterior uveitis, psoriasis, or peripheral arthritis – and not just when a patient has chronic back pain.
Dr. Renson reported having no relevant disclosures; two of his coauthors reported extensive disclosures. Dr. Weber and his coauthors reported having no relevant disclosures. Dr. Landewé reported having no relevant disclosures; several of his coauthors reported various disclosures. Funding for the studies was not reported.
SAN DIEGO – Healthy individuals can show signs of spinal and pelvic inflammation on MRI, but these scans can be misleading if relied on to make a diagnosis of axial spondyloarthritis, according to findings from three separate studies at the annual meeting of the American College of Rheumatology.
“Don’t rely on MRI alone is our message,” said Robert Landewé, MD, PhD, of the University of Amsterdam, who was a coauthor of one of the three studies. “A positive MRI may occur in individuals that are completely healthy. We need to make sure that not too many patients with chronic lower back pain are diagnosed with a disease they don’t have.”
The axial form of spondyloarthritis (axSpA) affects the spinal and pelvic joints of an estimated 1.4% of the U.S. population, and the term encompasses the diagnosis of ankylosing spondylitis (0.5% of U.S. population) in which advanced sacroiliitis is seen on conventional radiography, according to the ACR. Axial SpA is particularly common in young people, especially males, in their teens and 20s.
Researchers believe that MRI scans can misleadingly suggest that patients have the condition. “We know that MRI is a sensitive method, but there’s a lack of data regarding its specificity,” Thomas Renson, MD, of Ghent (Belgium) University, said at a press conference during the meeting.
Dr. Landewé led a study that compared MRIs of sacroiliac joints in 47 healthy people, 47 axSpA patients matched for gender and age, 47 chronic back pain patients, 7 women with postpartum back pain, and 24 frequent runners. Positive MRIs were common in the axSpA patients (43 of 47), but they were also found in healthy people (11 of 47), chronic back pain patients (3 of 47), frequent runners (3 of 24), and women with postpartum back pain (4 of 7).
In another study, Dr. Renson and his colleagues sought to understand whether a sustained period of intense physical activity affected spinal findings in 22 healthy military recruits who did not have SpA.
However, there was a statistically significant increase of combined structural and inflammatory lesions (P = .038) from baseline to post training.
The findings underscore “the importance of interpretation of imaging in the right clinical context,” Dr. Renson said, since they point to the possibility of an incorrect diagnosis “even in a young, active population.”
Another study, led by Ulrich Weber, MD, of King Christian 10th Hospital for Rheumatic Diseases, Gråsten, Denmark, sought to understand levels of normal low-grade BME in 20 amateur runners (8 men) and 22 professional Danish hockey players (all men). On average, the researchers found signs of BME in 3.1 sacroiliac joint quadrants in the runners before and after they ran a race. Hockey players were scanned at the end of the competitive season and showed signs of BME in an average of 3.6 sacroiliac joint quadrants.
In an interview, Dr. Landewé said the studies point to how common positive MRIs are in healthy people. “It was far higher than we would have thought 10 years ago,” he said.
Are MRIs still useful then? Dr. Weber said MRI scans are still helpful in axSpA diagnoses even though they have major limitations. “The imaging method is the only one that’s halfway reliable,” he said. “These joints are deep in the body, so we have virtually no clinical ways to diagnose this.”
However, Dr. Landewé said, “you should do it only when you have sufficient suspicion of spondyloarthritis” – due to accompanying conditions such as positive family history, acute anterior uveitis, psoriasis, or peripheral arthritis – and not just when a patient has chronic back pain.
Dr. Renson reported having no relevant disclosures; two of his coauthors reported extensive disclosures. Dr. Weber and his coauthors reported having no relevant disclosures. Dr. Landewé reported having no relevant disclosures; several of his coauthors reported various disclosures. Funding for the studies was not reported.
AT ACR 2017
Obesity linked to pain, fatigue in SLE
SAN DIEGO – A new study offers a double message about the potential impact of obesity on systemic lupus erythematosus (SLE) in women: Excess pounds are linked to a higher risk of patient-reported outcomes such as pain and fatigue, and body mass index may be an appropriate tool to study weight issues in this population.
Researchers found “a strong relationship between body composition and worse outcomes,” Sarah Patterson, MD, a fellow in rheumatology at the University of California, San Francisco, and the lead study author, said at the annual meeting of the American College of Rheumatology.
For the new study, Dr. Patterson and her colleagues analyzed findings from surveys of 148 participants in the Arthritis Body Composition and Disability study. All participants were women with a verified SLE diagnosis.
About two-thirds of the sample were white, 14% were Asian, and 13% were African American. The average age was 48 years, the average disease duration was 16 years, and 45% took glucocorticoids.
Researchers used two measurements of obesity: BMI of 30 kg/m2 or greater and fat mass index (FMI) of 13 kg/m2 or greater.
They calculated FMI with data collected via whole dual x-ray absorptiometry. Of the participants, 32% and 30% met criteria for obesity under FMI and BMI definitions, respectively.
Researchers also collected survey data regarding measurements of disease activity, depressive symptoms, pain and fatigue.
The study authors controlled their results to account for factors such as age, race, and prednisone use. They found that those defined as obese via FMI had more disease activity and depression than did nonobese women: 14.8 versus 11.5, P = .010, on the Systemic Lupus Activity Questionnaire scale, and 19.8 versus 13.1, P = .004, on the Center for Epidemiologic Studies Depression scale.
On two other scales of pain and fatigue, obese patients scored lower – a sign of worse status – compared with nonobese women: 38.7 versus 44.2, P = .004, on the Short Form 36 (SF-36) Health Survey pain subscale and 39.6 versus 45.2, P = .010, on the SF-36 vitality subscale. The researchers reported similar findings when using BMI to assess obesity.
It’s not clear why obesity and lupus may be linked, Dr. Patterson said, though she noted that inflammation is a shared factor. “People with lupus have arthritis and chronic pain, so there may be this vicious feedback cycle with hindrances to be able to live healthy lifestyles,” she added.
The study has limitations, including that the sample is largely white, while lupus is more common among minority women. In addition, the study does not include underweight patients or track patients over time. “It will be important to look at obesity and patient-reported outcomes to determine whether weight loss results in better outcomes,” Dr. Patterson said.
The study does provide an extra benefit by suggesting that BMI is not an inferior tool to measure the effects of obesity in the SLE population, Dr. Patterson said. BMI has been criticized as a misleading measurement of obesity. But the BMI and FMI measures produced similar results in this study. “That’s really good news in a way for the practicalities of using this information,” she said.
But FMI may still be a better measurement of obesity in the general population, where BMI may be more likely to be thrown off by high muscle mass.
It may seem obvious that obesity is linked to worse lupus outcomes, but rheumatologist Bryant England, MD, of the University of Nebraska, Omaha, said that this research is noteworthy because it highlights the importance of focusing on obesity in the clinic.
Rheumatologists shouldn’t leave obesity to primary care physicians but instead confront it themselves, said Dr. England, who moderated a discussion of new research at an ACR annual meeting press conference. But he cautioned that prudence is especially important when talking about obesity with lupus patients because they may be sensitive about medication-related weight gain.
Dr. Patterson and the other study authors reported having no relevant disclosures. Dr. England also reported no relevant disclosures. The study was funded by the National Institute of Arthritis and Musculoskeletal and Skin Diseases.
SAN DIEGO – A new study offers a double message about the potential impact of obesity on systemic lupus erythematosus (SLE) in women: Excess pounds are linked to a higher risk of patient-reported outcomes such as pain and fatigue, and body mass index may be an appropriate tool to study weight issues in this population.
Researchers found “a strong relationship between body composition and worse outcomes,” Sarah Patterson, MD, a fellow in rheumatology at the University of California, San Francisco, and the lead study author, said at the annual meeting of the American College of Rheumatology.
For the new study, Dr. Patterson and her colleagues analyzed findings from surveys of 148 participants in the Arthritis Body Composition and Disability study. All participants were women with a verified SLE diagnosis.
About two-thirds of the sample were white, 14% were Asian, and 13% were African American. The average age was 48 years, the average disease duration was 16 years, and 45% took glucocorticoids.
Researchers used two measurements of obesity: BMI of 30 kg/m2 or greater and fat mass index (FMI) of 13 kg/m2 or greater.
They calculated FMI with data collected via whole dual x-ray absorptiometry. Of the participants, 32% and 30% met criteria for obesity under FMI and BMI definitions, respectively.
Researchers also collected survey data regarding measurements of disease activity, depressive symptoms, pain and fatigue.
The study authors controlled their results to account for factors such as age, race, and prednisone use. They found that those defined as obese via FMI had more disease activity and depression than did nonobese women: 14.8 versus 11.5, P = .010, on the Systemic Lupus Activity Questionnaire scale, and 19.8 versus 13.1, P = .004, on the Center for Epidemiologic Studies Depression scale.
On two other scales of pain and fatigue, obese patients scored lower – a sign of worse status – compared with nonobese women: 38.7 versus 44.2, P = .004, on the Short Form 36 (SF-36) Health Survey pain subscale and 39.6 versus 45.2, P = .010, on the SF-36 vitality subscale. The researchers reported similar findings when using BMI to assess obesity.
It’s not clear why obesity and lupus may be linked, Dr. Patterson said, though she noted that inflammation is a shared factor. “People with lupus have arthritis and chronic pain, so there may be this vicious feedback cycle with hindrances to be able to live healthy lifestyles,” she added.
The study has limitations, including that the sample is largely white, while lupus is more common among minority women. In addition, the study does not include underweight patients or track patients over time. “It will be important to look at obesity and patient-reported outcomes to determine whether weight loss results in better outcomes,” Dr. Patterson said.
The study does provide an extra benefit by suggesting that BMI is not an inferior tool to measure the effects of obesity in the SLE population, Dr. Patterson said. BMI has been criticized as a misleading measurement of obesity. But the BMI and FMI measures produced similar results in this study. “That’s really good news in a way for the practicalities of using this information,” she said.
But FMI may still be a better measurement of obesity in the general population, where BMI may be more likely to be thrown off by high muscle mass.
It may seem obvious that obesity is linked to worse lupus outcomes, but rheumatologist Bryant England, MD, of the University of Nebraska, Omaha, said that this research is noteworthy because it highlights the importance of focusing on obesity in the clinic.
Rheumatologists shouldn’t leave obesity to primary care physicians but instead confront it themselves, said Dr. England, who moderated a discussion of new research at an ACR annual meeting press conference. But he cautioned that prudence is especially important when talking about obesity with lupus patients because they may be sensitive about medication-related weight gain.
Dr. Patterson and the other study authors reported having no relevant disclosures. Dr. England also reported no relevant disclosures. The study was funded by the National Institute of Arthritis and Musculoskeletal and Skin Diseases.
SAN DIEGO – A new study offers a double message about the potential impact of obesity on systemic lupus erythematosus (SLE) in women: Excess pounds are linked to a higher risk of patient-reported outcomes such as pain and fatigue, and body mass index may be an appropriate tool to study weight issues in this population.
Researchers found “a strong relationship between body composition and worse outcomes,” Sarah Patterson, MD, a fellow in rheumatology at the University of California, San Francisco, and the lead study author, said at the annual meeting of the American College of Rheumatology.
For the new study, Dr. Patterson and her colleagues analyzed findings from surveys of 148 participants in the Arthritis Body Composition and Disability study. All participants were women with a verified SLE diagnosis.
About two-thirds of the sample were white, 14% were Asian, and 13% were African American. The average age was 48 years, the average disease duration was 16 years, and 45% took glucocorticoids.
Researchers used two measurements of obesity: BMI of 30 kg/m2 or greater and fat mass index (FMI) of 13 kg/m2 or greater.
They calculated FMI with data collected via whole dual x-ray absorptiometry. Of the participants, 32% and 30% met criteria for obesity under FMI and BMI definitions, respectively.
Researchers also collected survey data regarding measurements of disease activity, depressive symptoms, pain and fatigue.
The study authors controlled their results to account for factors such as age, race, and prednisone use. They found that those defined as obese via FMI had more disease activity and depression than did nonobese women: 14.8 versus 11.5, P = .010, on the Systemic Lupus Activity Questionnaire scale, and 19.8 versus 13.1, P = .004, on the Center for Epidemiologic Studies Depression scale.
On two other scales of pain and fatigue, obese patients scored lower – a sign of worse status – compared with nonobese women: 38.7 versus 44.2, P = .004, on the Short Form 36 (SF-36) Health Survey pain subscale and 39.6 versus 45.2, P = .010, on the SF-36 vitality subscale. The researchers reported similar findings when using BMI to assess obesity.
It’s not clear why obesity and lupus may be linked, Dr. Patterson said, though she noted that inflammation is a shared factor. “People with lupus have arthritis and chronic pain, so there may be this vicious feedback cycle with hindrances to be able to live healthy lifestyles,” she added.
The study has limitations, including that the sample is largely white, while lupus is more common among minority women. In addition, the study does not include underweight patients or track patients over time. “It will be important to look at obesity and patient-reported outcomes to determine whether weight loss results in better outcomes,” Dr. Patterson said.
The study does provide an extra benefit by suggesting that BMI is not an inferior tool to measure the effects of obesity in the SLE population, Dr. Patterson said. BMI has been criticized as a misleading measurement of obesity. But the BMI and FMI measures produced similar results in this study. “That’s really good news in a way for the practicalities of using this information,” she said.
But FMI may still be a better measurement of obesity in the general population, where BMI may be more likely to be thrown off by high muscle mass.
It may seem obvious that obesity is linked to worse lupus outcomes, but rheumatologist Bryant England, MD, of the University of Nebraska, Omaha, said that this research is noteworthy because it highlights the importance of focusing on obesity in the clinic.
Rheumatologists shouldn’t leave obesity to primary care physicians but instead confront it themselves, said Dr. England, who moderated a discussion of new research at an ACR annual meeting press conference. But he cautioned that prudence is especially important when talking about obesity with lupus patients because they may be sensitive about medication-related weight gain.
Dr. Patterson and the other study authors reported having no relevant disclosures. Dr. England also reported no relevant disclosures. The study was funded by the National Institute of Arthritis and Musculoskeletal and Skin Diseases.
AT ACR 2017
Key clinical point:
Major finding: Obese women with SLE had more disease activity than did nonobese women (14.8 versus 11.5, P = .010).
Data source: An analysis of 148 SLE patients (65% white, mean age 48, about 31% obese) with obesity measured by body mass index or fat mass index.
Disclosures: The study authors reported having no relevant disclosures. The National Institute of Arthritis and Musculoskeletal and Skin Diseases funded the study.
Obesity linked to RA disease activity, disability
SAN DIEGO – In what may be the largest study of its kind, British researchers have linked obesity to significantly higher odds of rheumatoid arthritis disease activity and disability.
“This study emphasizes that obesity can have a profound effect on treatment goals in rheumatoid arthritis,” says Elena Nikiphorou, MD, of King’s College London, who presented the study findings at the annual meeting of the American College of Rheumatology. “Obesity reduced the odds of achieving remission or low disease activity by around 30%. And the odds of having disability were increased by 63%. This confirms what’s been shown in other, smaller studies.”
Despite obesity having been tied to decreased joint damage in established RA, Eric L. Matteson, MD, noted in an interview, that“the biomechanical effect of [being] overweight, especially on the weight-bearing joints” is one of the two “especially important” mechanisms explaining the link between RA and obesity. “The other is that fat cells produce inflammatory proteins, which contribute to the disease process and make it more difficult to treat,” said Dr. Matteson, a rheumatologist at the Mayo Clinic, Rochester, Minn.
“In my view the mechanical risk to the joint outweighs any possible ‘protective’ effect of RA,” Dr. Matteson added in an interview.
For the new study, Dr. Nikiphorou and colleagues compiled statistics from two consecutive United Kingdom RA inception cohorts. One tracked 1,465 patients for up to 25 years (median follow-up, 10 years), and the other tracked 1,236 patients for as many as 10 years (median follow-up, 6 years).
At baseline, 37.2% of 2,420 patients (90% of total) were overweight, and 21.3% were obese. Average body mass index (BMI) rose between the two consecutive studies from 25.5 to 27.6.
The researchers found that obesity was linked to lower likelihoods of remission and low disease activity status (odds ratio, 0.71; 95% confidence interval, 0.55-0.93 and OR, 0.69; 95% CI, 0.55-0.87, respectively.) After controlling for factors such as age and gender, they also saw slightly lower odds of remission in those with higher BMI (OR, 0.97; 95% CI, 0.95-0.99). But there was no statistically significant link between higher BMI and low disease activity status.
The study also connected obesity to higher odds of disability (OR, 1.63; 95% CI, 1.20-2.23). Furthermore, higher BMI was linked to higher odds of disability (OR, 1.04; 95% CI, 1.01-1.06).
Study lead author Dr. Nikiphorou, who spoke in an interview and in comments at an ACR press conference, said “this study emphasizes that obesity can have a profound effect on treatment goals in rheumatoid arthritis. It creates a strong case for addressing BMI and addressing obesity, flagging it up to primary care.”
She added that rheumatologists too often focus on only rheumatoid conditions. “We place so much evidence on disease activity scores,” she said. “How often do we really address the patient in terms of other things going on, including obesity? What we can do is include discussion of BMI, exercise, nutrition.”
Dr. Nikiphorou and Dr. Matteson report no relevant disclosures. No specific study funding is reported.
This article was updated 11/10/17.
SAN DIEGO – In what may be the largest study of its kind, British researchers have linked obesity to significantly higher odds of rheumatoid arthritis disease activity and disability.
“This study emphasizes that obesity can have a profound effect on treatment goals in rheumatoid arthritis,” says Elena Nikiphorou, MD, of King’s College London, who presented the study findings at the annual meeting of the American College of Rheumatology. “Obesity reduced the odds of achieving remission or low disease activity by around 30%. And the odds of having disability were increased by 63%. This confirms what’s been shown in other, smaller studies.”
Despite obesity having been tied to decreased joint damage in established RA, Eric L. Matteson, MD, noted in an interview, that“the biomechanical effect of [being] overweight, especially on the weight-bearing joints” is one of the two “especially important” mechanisms explaining the link between RA and obesity. “The other is that fat cells produce inflammatory proteins, which contribute to the disease process and make it more difficult to treat,” said Dr. Matteson, a rheumatologist at the Mayo Clinic, Rochester, Minn.
“In my view the mechanical risk to the joint outweighs any possible ‘protective’ effect of RA,” Dr. Matteson added in an interview.
For the new study, Dr. Nikiphorou and colleagues compiled statistics from two consecutive United Kingdom RA inception cohorts. One tracked 1,465 patients for up to 25 years (median follow-up, 10 years), and the other tracked 1,236 patients for as many as 10 years (median follow-up, 6 years).
At baseline, 37.2% of 2,420 patients (90% of total) were overweight, and 21.3% were obese. Average body mass index (BMI) rose between the two consecutive studies from 25.5 to 27.6.
The researchers found that obesity was linked to lower likelihoods of remission and low disease activity status (odds ratio, 0.71; 95% confidence interval, 0.55-0.93 and OR, 0.69; 95% CI, 0.55-0.87, respectively.) After controlling for factors such as age and gender, they also saw slightly lower odds of remission in those with higher BMI (OR, 0.97; 95% CI, 0.95-0.99). But there was no statistically significant link between higher BMI and low disease activity status.
The study also connected obesity to higher odds of disability (OR, 1.63; 95% CI, 1.20-2.23). Furthermore, higher BMI was linked to higher odds of disability (OR, 1.04; 95% CI, 1.01-1.06).
Study lead author Dr. Nikiphorou, who spoke in an interview and in comments at an ACR press conference, said “this study emphasizes that obesity can have a profound effect on treatment goals in rheumatoid arthritis. It creates a strong case for addressing BMI and addressing obesity, flagging it up to primary care.”
She added that rheumatologists too often focus on only rheumatoid conditions. “We place so much evidence on disease activity scores,” she said. “How often do we really address the patient in terms of other things going on, including obesity? What we can do is include discussion of BMI, exercise, nutrition.”
Dr. Nikiphorou and Dr. Matteson report no relevant disclosures. No specific study funding is reported.
This article was updated 11/10/17.
SAN DIEGO – In what may be the largest study of its kind, British researchers have linked obesity to significantly higher odds of rheumatoid arthritis disease activity and disability.
“This study emphasizes that obesity can have a profound effect on treatment goals in rheumatoid arthritis,” says Elena Nikiphorou, MD, of King’s College London, who presented the study findings at the annual meeting of the American College of Rheumatology. “Obesity reduced the odds of achieving remission or low disease activity by around 30%. And the odds of having disability were increased by 63%. This confirms what’s been shown in other, smaller studies.”
Despite obesity having been tied to decreased joint damage in established RA, Eric L. Matteson, MD, noted in an interview, that“the biomechanical effect of [being] overweight, especially on the weight-bearing joints” is one of the two “especially important” mechanisms explaining the link between RA and obesity. “The other is that fat cells produce inflammatory proteins, which contribute to the disease process and make it more difficult to treat,” said Dr. Matteson, a rheumatologist at the Mayo Clinic, Rochester, Minn.
“In my view the mechanical risk to the joint outweighs any possible ‘protective’ effect of RA,” Dr. Matteson added in an interview.
For the new study, Dr. Nikiphorou and colleagues compiled statistics from two consecutive United Kingdom RA inception cohorts. One tracked 1,465 patients for up to 25 years (median follow-up, 10 years), and the other tracked 1,236 patients for as many as 10 years (median follow-up, 6 years).
At baseline, 37.2% of 2,420 patients (90% of total) were overweight, and 21.3% were obese. Average body mass index (BMI) rose between the two consecutive studies from 25.5 to 27.6.
The researchers found that obesity was linked to lower likelihoods of remission and low disease activity status (odds ratio, 0.71; 95% confidence interval, 0.55-0.93 and OR, 0.69; 95% CI, 0.55-0.87, respectively.) After controlling for factors such as age and gender, they also saw slightly lower odds of remission in those with higher BMI (OR, 0.97; 95% CI, 0.95-0.99). But there was no statistically significant link between higher BMI and low disease activity status.
The study also connected obesity to higher odds of disability (OR, 1.63; 95% CI, 1.20-2.23). Furthermore, higher BMI was linked to higher odds of disability (OR, 1.04; 95% CI, 1.01-1.06).
Study lead author Dr. Nikiphorou, who spoke in an interview and in comments at an ACR press conference, said “this study emphasizes that obesity can have a profound effect on treatment goals in rheumatoid arthritis. It creates a strong case for addressing BMI and addressing obesity, flagging it up to primary care.”
She added that rheumatologists too often focus on only rheumatoid conditions. “We place so much evidence on disease activity scores,” she said. “How often do we really address the patient in terms of other things going on, including obesity? What we can do is include discussion of BMI, exercise, nutrition.”
Dr. Nikiphorou and Dr. Matteson report no relevant disclosures. No specific study funding is reported.
This article was updated 11/10/17.
AT ACR 2017
Key clinical point: Obesity may worsen the risk of disease activity and disability in rheumatoid arthritis.
Major finding: In an adjusted analysis, obese patients with RA were less likely to reach remission and low disease activity status (OR, 0.71; 95% CI, 0.55-0.93 and OR, 0.69; 95% CI, 0.55-0.87, respectively).
Data source: Two consecutive inception cohorts with a total of 1,236 RA patients followed for up to 25 years.
Disclosures: The lead study author reports no disclosures, and no other disclosures are reported. No specific study funding is reported.
Inside the Las Vegas crisis: Surgeons answered the call
SAN DIEGO– Long before the horrific night of Oct. 1, the three trauma centers in the Las Vegas region were ready for a mass casualty event. It was understood among hospital leaders that the city could be the scene of a disaster that would demand a coordinated response from the city’s health care centers.
Then came the deadliest mass shooting in modern American history, and the extensive preparation turned out to have been well worth the time and effort, according to four trauma surgeons who spoke about the medical response to the massacre during a session at the annual clinical congress of the American College of Surgeons.
The killing spree was unusual in a variety of ways, including the fact that it occurred at a site “that’s almost strategically surrounded by trauma centers,” Dr. Fildes said.
UMC is Nevada’s only level I trauma center, while Sunrise is a level II. St. Rose Dominican, in the neighboring city of Henderson is a level III. Only one other Nevada hospital, in Reno, is a verified trauma center.
While the trauma centers received hundreds of patients, “every hospital in the valley saw patients from this event,” Dr. Fildes said. “There were 22,000 people on scene, and when the shooting started, they extricated themselves and went to safety by one means or another. Some drove home to their neighborhood and sought care there. Some drove until they found an acute care facility, whether it was a trauma center or not. Others were transported by Uber or taxi. The drivers knew where the trauma centers were, and decided where to go based on how the patients looked.”
According to Dr. Fildes, Las Vegas–area hospitals kept in touch with each other by phone, and UMC accepted some transfers from other hospitals. “We were ready for transfers,” he said, “and we expected more than we got.”
The trauma centers faced a variety of challenges from confusion and false reports to overcrowding and a media onslaught.
“We knew there was a strong possibility this would happen where we live, so we practiced this,” said Sean Dort, MD, medical director of the hospital’s trauma center. “We have talked and walked through it.”
Indeed, all hospitals in the Las Vegas area take part in regional disaster drills twice a year, and UMC runs other drills during the year such as an active shooter drill, Dr. Fildes said in an interview.
Together, the three hospitals treated hundreds of patients. Three weeks later, a handful were still inpatients.
In the aftermath, Las Vegas trauma surgeons are focusing on missed opportunities and lessons learned.
Dr. Fildes said more attention needs to be paid to how to handle situations when tides of patients bring themselves to the emergency department. “The issue of self-delivery has to be reconsidered, restudied,” he said, and he suggested that it may be a good idea to equip taxis with bleeding control kits.
He said his hospital heard from a doctor who’d treated patients during the Pulse nightclub massacre in Orlando last year. “One of their lessons learned was to position all gurneys and wheelchairs near the intake triage area,” he said. “We did that, and it improved the movement of patients to areas of the hospital that were matched to the intensity of care that they required.”
At Sunrise, the flood of unidentified patients overwhelmed the hospital’s trauma patient alias system, and some names were repeated. “In the future, I think a better naming system should be employed,” said trauma surgeon Matthew S. Johnson, MD.
To that end, he said, the hospital has begun examining how hurricanes are named.
And when it comes to planning, he said, there’s no room for excuses or resistance. “Everyone knew their role,” he said. “You can’t start figuring this out when it happens. You have to push people through it when they don’t want to do it, and they’re busy.”
Dr. Fildes said that the UMC staff were physically and emotionally exhausted by the ordeal, but proud of what they were able to do for these patients, and that pride carried them through the experience. “We had support from all over the country; people sent banners with hundreds of signatures. Something like 1,100 pizzas were sent to the UMC staff, and dozens and dozens of surgeons from all over the country offered to come help us.”
Dr. Fildes noted that he is not easily surprised given his daily work, but he was impressed by the generosity and courage of the patients in this crisis situation.
He concluded that, “This was all made possible because of planning, training, commitment by staff and ultimately, the bravery of the patients.”
Dr. Dort, Dr. Fildes, Dr. Kuhls, and Dr. Johnson had no relevant financial disclosures.
I was at home and in bed with a book when my phone went off at 10:22 p.m. on that Sunday. It was a text message from one of my fellow residents who was on call at Sunrise: She wrote: “Mass casualty incident. Shooting on the Strip. You have to come now.”
There were multiple blood trails tracking from various parts of the ambulance bay into the ED. Medics were walking from bedside to bedside putting in lines. Two anesthesia attendings were frantically intubating patients. Two nurses were performing chest compressions.
I picked the nearest bed and started assessing patients. I placed 2 endotracheal tubes and black tagged 4 more patients within minutes of my arrival.
In the initial moments in the ER and in the OR, I focused on caring for the patient and blocked out any other thoughts or emotions. There was no time and no room for my horror or my tears.
As I went bedside to bedside in the ER, I was practically chanting in my head “airway, breathing, circulation, vital signs, other injuries.”
In the OR, I was working on controlling intra-abdominal bleeding from multiple sources, and again, my training became something of a mantra in my head. “Pack, control bleeding, assess injuries, repair.”
We saw well over 200 patients from the Route 91 shooting and operated on 95 of them within the first 24 hours.
Dylan Davey, MD, PhD, General Surgery Resident, PGY-4, Sunrise Hospital & Medical Center.
I was at home and in bed with a book when my phone went off at 10:22 p.m. on that Sunday. It was a text message from one of my fellow residents who was on call at Sunrise: She wrote: “Mass casualty incident. Shooting on the Strip. You have to come now.”
There were multiple blood trails tracking from various parts of the ambulance bay into the ED. Medics were walking from bedside to bedside putting in lines. Two anesthesia attendings were frantically intubating patients. Two nurses were performing chest compressions.
I picked the nearest bed and started assessing patients. I placed 2 endotracheal tubes and black tagged 4 more patients within minutes of my arrival.
In the initial moments in the ER and in the OR, I focused on caring for the patient and blocked out any other thoughts or emotions. There was no time and no room for my horror or my tears.
As I went bedside to bedside in the ER, I was practically chanting in my head “airway, breathing, circulation, vital signs, other injuries.”
In the OR, I was working on controlling intra-abdominal bleeding from multiple sources, and again, my training became something of a mantra in my head. “Pack, control bleeding, assess injuries, repair.”
We saw well over 200 patients from the Route 91 shooting and operated on 95 of them within the first 24 hours.
Dylan Davey, MD, PhD, General Surgery Resident, PGY-4, Sunrise Hospital & Medical Center.
I was at home and in bed with a book when my phone went off at 10:22 p.m. on that Sunday. It was a text message from one of my fellow residents who was on call at Sunrise: She wrote: “Mass casualty incident. Shooting on the Strip. You have to come now.”
There were multiple blood trails tracking from various parts of the ambulance bay into the ED. Medics were walking from bedside to bedside putting in lines. Two anesthesia attendings were frantically intubating patients. Two nurses were performing chest compressions.
I picked the nearest bed and started assessing patients. I placed 2 endotracheal tubes and black tagged 4 more patients within minutes of my arrival.
In the initial moments in the ER and in the OR, I focused on caring for the patient and blocked out any other thoughts or emotions. There was no time and no room for my horror or my tears.
As I went bedside to bedside in the ER, I was practically chanting in my head “airway, breathing, circulation, vital signs, other injuries.”
In the OR, I was working on controlling intra-abdominal bleeding from multiple sources, and again, my training became something of a mantra in my head. “Pack, control bleeding, assess injuries, repair.”
We saw well over 200 patients from the Route 91 shooting and operated on 95 of them within the first 24 hours.
Dylan Davey, MD, PhD, General Surgery Resident, PGY-4, Sunrise Hospital & Medical Center.
SAN DIEGO– Long before the horrific night of Oct. 1, the three trauma centers in the Las Vegas region were ready for a mass casualty event. It was understood among hospital leaders that the city could be the scene of a disaster that would demand a coordinated response from the city’s health care centers.
Then came the deadliest mass shooting in modern American history, and the extensive preparation turned out to have been well worth the time and effort, according to four trauma surgeons who spoke about the medical response to the massacre during a session at the annual clinical congress of the American College of Surgeons.
The killing spree was unusual in a variety of ways, including the fact that it occurred at a site “that’s almost strategically surrounded by trauma centers,” Dr. Fildes said.
UMC is Nevada’s only level I trauma center, while Sunrise is a level II. St. Rose Dominican, in the neighboring city of Henderson is a level III. Only one other Nevada hospital, in Reno, is a verified trauma center.
While the trauma centers received hundreds of patients, “every hospital in the valley saw patients from this event,” Dr. Fildes said. “There were 22,000 people on scene, and when the shooting started, they extricated themselves and went to safety by one means or another. Some drove home to their neighborhood and sought care there. Some drove until they found an acute care facility, whether it was a trauma center or not. Others were transported by Uber or taxi. The drivers knew where the trauma centers were, and decided where to go based on how the patients looked.”
According to Dr. Fildes, Las Vegas–area hospitals kept in touch with each other by phone, and UMC accepted some transfers from other hospitals. “We were ready for transfers,” he said, “and we expected more than we got.”
The trauma centers faced a variety of challenges from confusion and false reports to overcrowding and a media onslaught.
“We knew there was a strong possibility this would happen where we live, so we practiced this,” said Sean Dort, MD, medical director of the hospital’s trauma center. “We have talked and walked through it.”
Indeed, all hospitals in the Las Vegas area take part in regional disaster drills twice a year, and UMC runs other drills during the year such as an active shooter drill, Dr. Fildes said in an interview.
Together, the three hospitals treated hundreds of patients. Three weeks later, a handful were still inpatients.
In the aftermath, Las Vegas trauma surgeons are focusing on missed opportunities and lessons learned.
Dr. Fildes said more attention needs to be paid to how to handle situations when tides of patients bring themselves to the emergency department. “The issue of self-delivery has to be reconsidered, restudied,” he said, and he suggested that it may be a good idea to equip taxis with bleeding control kits.
He said his hospital heard from a doctor who’d treated patients during the Pulse nightclub massacre in Orlando last year. “One of their lessons learned was to position all gurneys and wheelchairs near the intake triage area,” he said. “We did that, and it improved the movement of patients to areas of the hospital that were matched to the intensity of care that they required.”
At Sunrise, the flood of unidentified patients overwhelmed the hospital’s trauma patient alias system, and some names were repeated. “In the future, I think a better naming system should be employed,” said trauma surgeon Matthew S. Johnson, MD.
To that end, he said, the hospital has begun examining how hurricanes are named.
And when it comes to planning, he said, there’s no room for excuses or resistance. “Everyone knew their role,” he said. “You can’t start figuring this out when it happens. You have to push people through it when they don’t want to do it, and they’re busy.”
Dr. Fildes said that the UMC staff were physically and emotionally exhausted by the ordeal, but proud of what they were able to do for these patients, and that pride carried them through the experience. “We had support from all over the country; people sent banners with hundreds of signatures. Something like 1,100 pizzas were sent to the UMC staff, and dozens and dozens of surgeons from all over the country offered to come help us.”
Dr. Fildes noted that he is not easily surprised given his daily work, but he was impressed by the generosity and courage of the patients in this crisis situation.
He concluded that, “This was all made possible because of planning, training, commitment by staff and ultimately, the bravery of the patients.”
Dr. Dort, Dr. Fildes, Dr. Kuhls, and Dr. Johnson had no relevant financial disclosures.
SAN DIEGO– Long before the horrific night of Oct. 1, the three trauma centers in the Las Vegas region were ready for a mass casualty event. It was understood among hospital leaders that the city could be the scene of a disaster that would demand a coordinated response from the city’s health care centers.
Then came the deadliest mass shooting in modern American history, and the extensive preparation turned out to have been well worth the time and effort, according to four trauma surgeons who spoke about the medical response to the massacre during a session at the annual clinical congress of the American College of Surgeons.
The killing spree was unusual in a variety of ways, including the fact that it occurred at a site “that’s almost strategically surrounded by trauma centers,” Dr. Fildes said.
UMC is Nevada’s only level I trauma center, while Sunrise is a level II. St. Rose Dominican, in the neighboring city of Henderson is a level III. Only one other Nevada hospital, in Reno, is a verified trauma center.
While the trauma centers received hundreds of patients, “every hospital in the valley saw patients from this event,” Dr. Fildes said. “There were 22,000 people on scene, and when the shooting started, they extricated themselves and went to safety by one means or another. Some drove home to their neighborhood and sought care there. Some drove until they found an acute care facility, whether it was a trauma center or not. Others were transported by Uber or taxi. The drivers knew where the trauma centers were, and decided where to go based on how the patients looked.”
According to Dr. Fildes, Las Vegas–area hospitals kept in touch with each other by phone, and UMC accepted some transfers from other hospitals. “We were ready for transfers,” he said, “and we expected more than we got.”
The trauma centers faced a variety of challenges from confusion and false reports to overcrowding and a media onslaught.
“We knew there was a strong possibility this would happen where we live, so we practiced this,” said Sean Dort, MD, medical director of the hospital’s trauma center. “We have talked and walked through it.”
Indeed, all hospitals in the Las Vegas area take part in regional disaster drills twice a year, and UMC runs other drills during the year such as an active shooter drill, Dr. Fildes said in an interview.
Together, the three hospitals treated hundreds of patients. Three weeks later, a handful were still inpatients.
In the aftermath, Las Vegas trauma surgeons are focusing on missed opportunities and lessons learned.
Dr. Fildes said more attention needs to be paid to how to handle situations when tides of patients bring themselves to the emergency department. “The issue of self-delivery has to be reconsidered, restudied,” he said, and he suggested that it may be a good idea to equip taxis with bleeding control kits.
He said his hospital heard from a doctor who’d treated patients during the Pulse nightclub massacre in Orlando last year. “One of their lessons learned was to position all gurneys and wheelchairs near the intake triage area,” he said. “We did that, and it improved the movement of patients to areas of the hospital that were matched to the intensity of care that they required.”
At Sunrise, the flood of unidentified patients overwhelmed the hospital’s trauma patient alias system, and some names were repeated. “In the future, I think a better naming system should be employed,” said trauma surgeon Matthew S. Johnson, MD.
To that end, he said, the hospital has begun examining how hurricanes are named.
And when it comes to planning, he said, there’s no room for excuses or resistance. “Everyone knew their role,” he said. “You can’t start figuring this out when it happens. You have to push people through it when they don’t want to do it, and they’re busy.”
Dr. Fildes said that the UMC staff were physically and emotionally exhausted by the ordeal, but proud of what they were able to do for these patients, and that pride carried them through the experience. “We had support from all over the country; people sent banners with hundreds of signatures. Something like 1,100 pizzas were sent to the UMC staff, and dozens and dozens of surgeons from all over the country offered to come help us.”
Dr. Fildes noted that he is not easily surprised given his daily work, but he was impressed by the generosity and courage of the patients in this crisis situation.
He concluded that, “This was all made possible because of planning, training, commitment by staff and ultimately, the bravery of the patients.”
Dr. Dort, Dr. Fildes, Dr. Kuhls, and Dr. Johnson had no relevant financial disclosures.
AT THE ACS CLINICAL CONGRESS
Methotrexate holiday linked to better flu vaccine immunogenicity
SAN DIEGO – Patients with well-controlled rheumatoid arthritis (RA) fared well during a 2-week holiday from methotrexate after flu vaccination and later showed signs of boosted immunity against the flu in comparison with patients who had not stopped the drug, according to results from a randomized controlled trial.
The research doesn’t confirm that vaccinated patients who take a break from methotrexate actually have lower rates of flu. Still, the findings suggest that brief holidays from methotrexate could be feasible in a variety of situations, such as after vaccinations and prior to surgery, said Jin Kyun Park, MD, of Seoul (South Korea) National University Hospital, lead author of the study presented at the annual meeting of the American College of Rheumatology.
The study notes that RA patients are especially prone to infections for two reasons: dysfunctional immune systems and immunity-weakening treatments. According to Dr. Park, methotrexate reduces the effectiveness of flu vaccines by 15%-20%.
In a previous study, Dr. Park and his colleagues found no statistically significant sign of increased flares in patients who went without methotrexate for 2 weeks before and 2 weeks after vaccination, 4 weeks after vaccination, and 4 weeks before vaccination (Ann Rheum Dis. 2017 Sep;76[9]:1559-65).
The earlier findings also suggested that flu vaccine uptake is highest in those who stop methotrexate after vaccination.
For the new study, a randomized controlled trial, researchers recruited patients with well-controlled RA. They assigned 159 to continue weekly doses of methotrexate after flu vaccination and 161 to stop it for 2 weeks.
The groups in the final analysis (156 and 160 subjects, respectively) were similar – about 85% women, average age of 52-53 years, and about half took glucocorticoids. Their methotrexate dose per week was about 13 mg.
At 4 weeks, just over three-quarters of the patients who had briefly stopped methotrexate showed at least a fourfold increase in hemagglutination inhibition antibody titer against two or more vaccine strains. Of those who continued the medication, just 54.5% showed this level of response, which the researchers considered to be satisfactory.
The researchers reported that there was no appreciable increase in RA disease activity.
Dr. Park cautioned that vaccine titers don’t directly reflect immunoprotection levels. Patients who took a break from methotrexate were less likely to develop a flulike illness, but the difference wasn’t statistically significant.
The research raises questions about whether methotrexate could be stopped a week or two before surgery to lower the risk of infections, Dr. Park said.
Dr. Park said that future research should focus on whether stopping methotrexate briefly affects whether patients go on to develop the flu. He would also like to look at whether a break from the medication will boost the immune response in RA patients who get herpes zoster (shingles) vaccines.
Paul Sufka, MD, of HealthPartners and Regions Hospital in St. Paul, Minn., praised the research. The 2-week break from methotrexate is “a fairly pragmatic approach,” said Dr. Sufka, who moderated a press conference where Dr. Park presented his research.
“You can actually pull this off,” he said, versus telling patients to stop the medication for the 2 weeks before they get vaccinated. He cautioned, however, that “these people have a fairly low disease activity. You may not be able to pull this off with those who have high disease activity.”
Dr. Park and Dr. Sufka reported no relevant disclosures. A study author reported consulting for Pfizer and receiving research grants from Green Cross Corp. and Hanmi Pharmaceutical. The study was funded by Green Cross.
SAN DIEGO – Patients with well-controlled rheumatoid arthritis (RA) fared well during a 2-week holiday from methotrexate after flu vaccination and later showed signs of boosted immunity against the flu in comparison with patients who had not stopped the drug, according to results from a randomized controlled trial.
The research doesn’t confirm that vaccinated patients who take a break from methotrexate actually have lower rates of flu. Still, the findings suggest that brief holidays from methotrexate could be feasible in a variety of situations, such as after vaccinations and prior to surgery, said Jin Kyun Park, MD, of Seoul (South Korea) National University Hospital, lead author of the study presented at the annual meeting of the American College of Rheumatology.
The study notes that RA patients are especially prone to infections for two reasons: dysfunctional immune systems and immunity-weakening treatments. According to Dr. Park, methotrexate reduces the effectiveness of flu vaccines by 15%-20%.
In a previous study, Dr. Park and his colleagues found no statistically significant sign of increased flares in patients who went without methotrexate for 2 weeks before and 2 weeks after vaccination, 4 weeks after vaccination, and 4 weeks before vaccination (Ann Rheum Dis. 2017 Sep;76[9]:1559-65).
The earlier findings also suggested that flu vaccine uptake is highest in those who stop methotrexate after vaccination.
For the new study, a randomized controlled trial, researchers recruited patients with well-controlled RA. They assigned 159 to continue weekly doses of methotrexate after flu vaccination and 161 to stop it for 2 weeks.
The groups in the final analysis (156 and 160 subjects, respectively) were similar – about 85% women, average age of 52-53 years, and about half took glucocorticoids. Their methotrexate dose per week was about 13 mg.
At 4 weeks, just over three-quarters of the patients who had briefly stopped methotrexate showed at least a fourfold increase in hemagglutination inhibition antibody titer against two or more vaccine strains. Of those who continued the medication, just 54.5% showed this level of response, which the researchers considered to be satisfactory.
The researchers reported that there was no appreciable increase in RA disease activity.
Dr. Park cautioned that vaccine titers don’t directly reflect immunoprotection levels. Patients who took a break from methotrexate were less likely to develop a flulike illness, but the difference wasn’t statistically significant.
The research raises questions about whether methotrexate could be stopped a week or two before surgery to lower the risk of infections, Dr. Park said.
Dr. Park said that future research should focus on whether stopping methotrexate briefly affects whether patients go on to develop the flu. He would also like to look at whether a break from the medication will boost the immune response in RA patients who get herpes zoster (shingles) vaccines.
Paul Sufka, MD, of HealthPartners and Regions Hospital in St. Paul, Minn., praised the research. The 2-week break from methotrexate is “a fairly pragmatic approach,” said Dr. Sufka, who moderated a press conference where Dr. Park presented his research.
“You can actually pull this off,” he said, versus telling patients to stop the medication for the 2 weeks before they get vaccinated. He cautioned, however, that “these people have a fairly low disease activity. You may not be able to pull this off with those who have high disease activity.”
Dr. Park and Dr. Sufka reported no relevant disclosures. A study author reported consulting for Pfizer and receiving research grants from Green Cross Corp. and Hanmi Pharmaceutical. The study was funded by Green Cross.
SAN DIEGO – Patients with well-controlled rheumatoid arthritis (RA) fared well during a 2-week holiday from methotrexate after flu vaccination and later showed signs of boosted immunity against the flu in comparison with patients who had not stopped the drug, according to results from a randomized controlled trial.
The research doesn’t confirm that vaccinated patients who take a break from methotrexate actually have lower rates of flu. Still, the findings suggest that brief holidays from methotrexate could be feasible in a variety of situations, such as after vaccinations and prior to surgery, said Jin Kyun Park, MD, of Seoul (South Korea) National University Hospital, lead author of the study presented at the annual meeting of the American College of Rheumatology.
The study notes that RA patients are especially prone to infections for two reasons: dysfunctional immune systems and immunity-weakening treatments. According to Dr. Park, methotrexate reduces the effectiveness of flu vaccines by 15%-20%.
In a previous study, Dr. Park and his colleagues found no statistically significant sign of increased flares in patients who went without methotrexate for 2 weeks before and 2 weeks after vaccination, 4 weeks after vaccination, and 4 weeks before vaccination (Ann Rheum Dis. 2017 Sep;76[9]:1559-65).
The earlier findings also suggested that flu vaccine uptake is highest in those who stop methotrexate after vaccination.
For the new study, a randomized controlled trial, researchers recruited patients with well-controlled RA. They assigned 159 to continue weekly doses of methotrexate after flu vaccination and 161 to stop it for 2 weeks.
The groups in the final analysis (156 and 160 subjects, respectively) were similar – about 85% women, average age of 52-53 years, and about half took glucocorticoids. Their methotrexate dose per week was about 13 mg.
At 4 weeks, just over three-quarters of the patients who had briefly stopped methotrexate showed at least a fourfold increase in hemagglutination inhibition antibody titer against two or more vaccine strains. Of those who continued the medication, just 54.5% showed this level of response, which the researchers considered to be satisfactory.
The researchers reported that there was no appreciable increase in RA disease activity.
Dr. Park cautioned that vaccine titers don’t directly reflect immunoprotection levels. Patients who took a break from methotrexate were less likely to develop a flulike illness, but the difference wasn’t statistically significant.
The research raises questions about whether methotrexate could be stopped a week or two before surgery to lower the risk of infections, Dr. Park said.
Dr. Park said that future research should focus on whether stopping methotrexate briefly affects whether patients go on to develop the flu. He would also like to look at whether a break from the medication will boost the immune response in RA patients who get herpes zoster (shingles) vaccines.
Paul Sufka, MD, of HealthPartners and Regions Hospital in St. Paul, Minn., praised the research. The 2-week break from methotrexate is “a fairly pragmatic approach,” said Dr. Sufka, who moderated a press conference where Dr. Park presented his research.
“You can actually pull this off,” he said, versus telling patients to stop the medication for the 2 weeks before they get vaccinated. He cautioned, however, that “these people have a fairly low disease activity. You may not be able to pull this off with those who have high disease activity.”
Dr. Park and Dr. Sufka reported no relevant disclosures. A study author reported consulting for Pfizer and receiving research grants from Green Cross Corp. and Hanmi Pharmaceutical. The study was funded by Green Cross.
AT ACR 2017
Key clinical point:
Major finding: More than three-quarters of patients who had briefly stopped methotrexate and 54.5% of patients who kept using methotrexate showed at least a fourfold increase in hemagglutination inhibition antibody titer against two or more vaccine strains at 4 weeks.
Data source: A randomized controlled trial of 320 patients with RA who were taking methotrexate.
Disclosures: The study was funded by Green Cross Corp. The presenter reported no relevant disclosures. A study author reported consulting for Pfizer and receiving research grants from Green Cross and Hanmi Pharmaceutical.
New, persistent opioid use more common after bariatric surgery
SAN DIEGO – Bariatric patients are nearly 50% more likely than general surgery patients to start using opioids after their procedures and continue taking the painkillers for a year, a new study finds.
It’s not clear why bariatric patients are at higher risk of continued opioid use, nor whether they are more likely to become addicted. Still, bariatric patients are a target for “intervention, enhanced education, early referral to specialists, protocols minimizing inpatient and outpatient narcotics, opioid-free operations, system-based interventions and prescribing guidelines,” says study lead author Sanjay Mohanty, MD, a surgery resident with the Henry Ford Health System, who spoke in a presentation at the annual clinical congress of the American College of Surgeons.
There’s been little research into opioid use among bariatric patients, said Dr. Mohanty. In 2013, a retrospective study found that 8% of 11,719 bariatric patients were chronic opioid users, and more than three-quarters of those remained so after 1 year. However, that study was completed in 2010 before the height of the opioid epidemic (JAMA. 2013;310(13):1369-76).
More recently, a 2017 study found that opioid use among 1,892 bariatric patients who weren’t using at baseline grew from 5.8% at 6 months to 14.2% at 7 years. The study tracked patients until January 2015 (Surg Obes Relat Dis. 2017 Aug;13 (8):1337-46).
For the new study, researchers tracked 14,063 bariatric patients in the Michigan Bariatric Surgery Collaborative, a group of Michigan hospitals and health systems, from 2006-2017.
Of the patients, 73% were opioid-naive at baseline and 27% were users. At 1 year after procedure, overall use dropped slightly to 24%. However, 905 patients – 8.8% of the initial opioid-native group – were new and persistent opioid users.
According to Dr. Carlin, this is almost 50% higher than in patients after general surgical procedures.
These users were significantly more likely to be black (OR 1.67), less likely to have private insurance (0.76 OR), more likely to have income under $25,000 (OR 1.43), and more likely to have a mobility limitation (OR 1.78).
The researchers also found evidence linking a higher risk of new and persistent opioid use to lack of unemployment, depression, musculoskeletal disorders, tobacco use and gastric bypass procedures.
Why might bariatric patients in general be more susceptible to new and persistent opioid use? “We don’t know that answer,” Dr. Carlin said. “Maybe there’s some addiction transfer. Or maybe it’s something physiologic. We’re doing an operation on the gut, and that could have an impact on absorption.”
As for solutions, Dr. Carlin says “prescribe less, prescribe differently, be more patient-specific. We’re looking at different modalities to treat the pain such as nerve blocks during surgery, anti-inflammatories and muscle relaxants.”
And if patients aren’t using opioids in the hospital and not having that much pain, he said, physicians don’t send any pills home with them.
The next steps should include research into links between opioids and perioperative complications and surgical outcomes, the researchers suggested.
Dr. Carlin and Dr. Mohanty report no relevant disclosures.
SAN DIEGO – Bariatric patients are nearly 50% more likely than general surgery patients to start using opioids after their procedures and continue taking the painkillers for a year, a new study finds.
It’s not clear why bariatric patients are at higher risk of continued opioid use, nor whether they are more likely to become addicted. Still, bariatric patients are a target for “intervention, enhanced education, early referral to specialists, protocols minimizing inpatient and outpatient narcotics, opioid-free operations, system-based interventions and prescribing guidelines,” says study lead author Sanjay Mohanty, MD, a surgery resident with the Henry Ford Health System, who spoke in a presentation at the annual clinical congress of the American College of Surgeons.
There’s been little research into opioid use among bariatric patients, said Dr. Mohanty. In 2013, a retrospective study found that 8% of 11,719 bariatric patients were chronic opioid users, and more than three-quarters of those remained so after 1 year. However, that study was completed in 2010 before the height of the opioid epidemic (JAMA. 2013;310(13):1369-76).
More recently, a 2017 study found that opioid use among 1,892 bariatric patients who weren’t using at baseline grew from 5.8% at 6 months to 14.2% at 7 years. The study tracked patients until January 2015 (Surg Obes Relat Dis. 2017 Aug;13 (8):1337-46).
For the new study, researchers tracked 14,063 bariatric patients in the Michigan Bariatric Surgery Collaborative, a group of Michigan hospitals and health systems, from 2006-2017.
Of the patients, 73% were opioid-naive at baseline and 27% were users. At 1 year after procedure, overall use dropped slightly to 24%. However, 905 patients – 8.8% of the initial opioid-native group – were new and persistent opioid users.
According to Dr. Carlin, this is almost 50% higher than in patients after general surgical procedures.
These users were significantly more likely to be black (OR 1.67), less likely to have private insurance (0.76 OR), more likely to have income under $25,000 (OR 1.43), and more likely to have a mobility limitation (OR 1.78).
The researchers also found evidence linking a higher risk of new and persistent opioid use to lack of unemployment, depression, musculoskeletal disorders, tobacco use and gastric bypass procedures.
Why might bariatric patients in general be more susceptible to new and persistent opioid use? “We don’t know that answer,” Dr. Carlin said. “Maybe there’s some addiction transfer. Or maybe it’s something physiologic. We’re doing an operation on the gut, and that could have an impact on absorption.”
As for solutions, Dr. Carlin says “prescribe less, prescribe differently, be more patient-specific. We’re looking at different modalities to treat the pain such as nerve blocks during surgery, anti-inflammatories and muscle relaxants.”
And if patients aren’t using opioids in the hospital and not having that much pain, he said, physicians don’t send any pills home with them.
The next steps should include research into links between opioids and perioperative complications and surgical outcomes, the researchers suggested.
Dr. Carlin and Dr. Mohanty report no relevant disclosures.
SAN DIEGO – Bariatric patients are nearly 50% more likely than general surgery patients to start using opioids after their procedures and continue taking the painkillers for a year, a new study finds.
It’s not clear why bariatric patients are at higher risk of continued opioid use, nor whether they are more likely to become addicted. Still, bariatric patients are a target for “intervention, enhanced education, early referral to specialists, protocols minimizing inpatient and outpatient narcotics, opioid-free operations, system-based interventions and prescribing guidelines,” says study lead author Sanjay Mohanty, MD, a surgery resident with the Henry Ford Health System, who spoke in a presentation at the annual clinical congress of the American College of Surgeons.
There’s been little research into opioid use among bariatric patients, said Dr. Mohanty. In 2013, a retrospective study found that 8% of 11,719 bariatric patients were chronic opioid users, and more than three-quarters of those remained so after 1 year. However, that study was completed in 2010 before the height of the opioid epidemic (JAMA. 2013;310(13):1369-76).
More recently, a 2017 study found that opioid use among 1,892 bariatric patients who weren’t using at baseline grew from 5.8% at 6 months to 14.2% at 7 years. The study tracked patients until January 2015 (Surg Obes Relat Dis. 2017 Aug;13 (8):1337-46).
For the new study, researchers tracked 14,063 bariatric patients in the Michigan Bariatric Surgery Collaborative, a group of Michigan hospitals and health systems, from 2006-2017.
Of the patients, 73% were opioid-naive at baseline and 27% were users. At 1 year after procedure, overall use dropped slightly to 24%. However, 905 patients – 8.8% of the initial opioid-native group – were new and persistent opioid users.
According to Dr. Carlin, this is almost 50% higher than in patients after general surgical procedures.
These users were significantly more likely to be black (OR 1.67), less likely to have private insurance (0.76 OR), more likely to have income under $25,000 (OR 1.43), and more likely to have a mobility limitation (OR 1.78).
The researchers also found evidence linking a higher risk of new and persistent opioid use to lack of unemployment, depression, musculoskeletal disorders, tobacco use and gastric bypass procedures.
Why might bariatric patients in general be more susceptible to new and persistent opioid use? “We don’t know that answer,” Dr. Carlin said. “Maybe there’s some addiction transfer. Or maybe it’s something physiologic. We’re doing an operation on the gut, and that could have an impact on absorption.”
As for solutions, Dr. Carlin says “prescribe less, prescribe differently, be more patient-specific. We’re looking at different modalities to treat the pain such as nerve blocks during surgery, anti-inflammatories and muscle relaxants.”
And if patients aren’t using opioids in the hospital and not having that much pain, he said, physicians don’t send any pills home with them.
The next steps should include research into links between opioids and perioperative complications and surgical outcomes, the researchers suggested.
Dr. Carlin and Dr. Mohanty report no relevant disclosures.
AT THE ACS CLINICAL CONGRESS
Key clinical point: It’s common for opioid-naive bariatric patients to begin using opioids after surgery and continuing at 1 year.
Major finding: At 1 year after surgery, 8.8% of the 73% of bariatric patients who were opioid-naive were new and persistent opioid users.
Data source: 14,063 Michigan bariatric patients tracked from 2006-2017.
Disclosures: The study authors report no relevant disclosures.