Federal Practitioner

The rising national suicide rate is being driven by increases among younger people and among people of color, according to a new report. 

Significant increases in suicide occurred among Native American, Black and Hispanic people, with a startling rise among young Black people. Meanwhile, the rate of suicide among older people declined between 2018 and 2021, the Centers for Disease Control and Prevention has reported.

In 2021, 48,183 people died by suicide in the United States, which equates to a suicide rate of 14.1 per 100,000 people. That level equals the 2018 suicide rate, which had seen a peak that was followed by declines associated with the pandemic.

Experts said rebounding suicide rates are common following times of crisis, such as the COVID-19 pandemic. Suicide declines have also occurred during times of war and natural disaster, when psychological resilience tends to increase and people work together to overcome shared adversity.

“That will wane, and then you will see rebounding in suicide rates. That is, in fact, what we feared would happen. And it has happened, at least in 2021,” Christine Moutier, MD, chief medical officer of the American Foundation for Suicide Prevention, told the New York Times.

The new CDC report found that the largest increase was among Black people aged 10-24 years, who experienced a 36.6% increase in suicide rate between 2018 and 2021. While Black people experience mental illness at the same rates as that of the general population, historically they have disproportionately limited access to mental health care, according to the American Psychiatric Association.

CDC report authors noted that some of the biggest increases in suicide rates occurred among groups most affected by the pandemic. 

From 2018 to 2021, the suicide rate for people aged 25-44 increased among Native Americans by 33.7% and among Black people by 22.9%. Suicide increased among multiracial people by 20.6% and among Hispanic or Latinx people by 19.4%. Among White people of all ages, the suicide rate declined or remained steady.

“As the nation continues to respond to the short- and long-term impacts of the COVID-19 pandemic, remaining vigilant in prevention efforts is critical, especially among disproportionately affected populations where longer-term impacts might compound preexisting inequities in suicide risk,” the CDC researchers wrote.

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

The rising national suicide rate is being driven by increases among younger people and among people of color, according to a new report. 

Significant increases in suicide occurred among Native American, Black and Hispanic people, with a startling rise among young Black people. Meanwhile, the rate of suicide among older people declined between 2018 and 2021, the Centers for Disease Control and Prevention has reported.

In 2021, 48,183 people died by suicide in the United States, which equates to a suicide rate of 14.1 per 100,000 people. That level equals the 2018 suicide rate, which had seen a peak that was followed by declines associated with the pandemic.

Experts said rebounding suicide rates are common following times of crisis, such as the COVID-19 pandemic. Suicide declines have also occurred during times of war and natural disaster, when psychological resilience tends to increase and people work together to overcome shared adversity.

“That will wane, and then you will see rebounding in suicide rates. That is, in fact, what we feared would happen. And it has happened, at least in 2021,” Christine Moutier, MD, chief medical officer of the American Foundation for Suicide Prevention, told the New York Times.

The new CDC report found that the largest increase was among Black people aged 10-24 years, who experienced a 36.6% increase in suicide rate between 2018 and 2021. While Black people experience mental illness at the same rates as that of the general population, historically they have disproportionately limited access to mental health care, according to the American Psychiatric Association.

CDC report authors noted that some of the biggest increases in suicide rates occurred among groups most affected by the pandemic. 

From 2018 to 2021, the suicide rate for people aged 25-44 increased among Native Americans by 33.7% and among Black people by 22.9%. Suicide increased among multiracial people by 20.6% and among Hispanic or Latinx people by 19.4%. Among White people of all ages, the suicide rate declined or remained steady.

“As the nation continues to respond to the short- and long-term impacts of the COVID-19 pandemic, remaining vigilant in prevention efforts is critical, especially among disproportionately affected populations where longer-term impacts might compound preexisting inequities in suicide risk,” the CDC researchers wrote.

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

The rising national suicide rate is being driven by increases among younger people and among people of color, according to a new report. 

Significant increases in suicide occurred among Native American, Black and Hispanic people, with a startling rise among young Black people. Meanwhile, the rate of suicide among older people declined between 2018 and 2021, the Centers for Disease Control and Prevention has reported.

In 2021, 48,183 people died by suicide in the United States, which equates to a suicide rate of 14.1 per 100,000 people. That level equals the 2018 suicide rate, which had seen a peak that was followed by declines associated with the pandemic.

Experts said rebounding suicide rates are common following times of crisis, such as the COVID-19 pandemic. Suicide declines have also occurred during times of war and natural disaster, when psychological resilience tends to increase and people work together to overcome shared adversity.

“That will wane, and then you will see rebounding in suicide rates. That is, in fact, what we feared would happen. And it has happened, at least in 2021,” Christine Moutier, MD, chief medical officer of the American Foundation for Suicide Prevention, told the New York Times.

The new CDC report found that the largest increase was among Black people aged 10-24 years, who experienced a 36.6% increase in suicide rate between 2018 and 2021. While Black people experience mental illness at the same rates as that of the general population, historically they have disproportionately limited access to mental health care, according to the American Psychiatric Association.

CDC report authors noted that some of the biggest increases in suicide rates occurred among groups most affected by the pandemic. 

From 2018 to 2021, the suicide rate for people aged 25-44 increased among Native Americans by 33.7% and among Black people by 22.9%. Suicide increased among multiracial people by 20.6% and among Hispanic or Latinx people by 19.4%. Among White people of all ages, the suicide rate declined or remained steady.

“As the nation continues to respond to the short- and long-term impacts of the COVID-19 pandemic, remaining vigilant in prevention efforts is critical, especially among disproportionately affected populations where longer-term impacts might compound preexisting inequities in suicide risk,” the CDC researchers wrote.

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

Asymptomatic adults, teens, and pregnant women with no known history or symptoms of herpes infection need not undergo routine screening, according to the latest recommendation from the U.S. Preventive Services Task Force.

The 2023 recommendation reaffirms the conclusion from 2016, wrote Carol M. Mangione, MD, of the University of California, Los Angeles, and members of the task force.

“Currently, routine serologic screening for genital herpes is limited by the low predictive value of the widely available serologic screening tests and the expected high rate of false-positive results likely to occur with routine screening of asymptomatic persons in the U.S.,” the authors said.

In the recommendation, published in JAMA, the authors affirmed with moderate certainty and a grade D recommendation that the risks of routine screening for herpes simplex virus (HSV) in asymptomatic individuals outweigh the benefits.

The task force found no new evidence on the accuracy of serologic screening tests, the benefits of early detection and treatment, or on the harms of screening and treatment since the 2016 review of 17 studies in 19 publications, with data from more than 9,000 individuals.

Studies of the accuracy of serologic screening for herpes simplex virus-2 in the 2016 report mainly reflect populations with higher HSV-2 prevalence and are of limited applicability to the U.S. primary care population, the authors wrote. Evidence from the 2016 review also showed limited and inconsistent support for the early identification and treatment of HSV-2 in asymptomatic individuals, including those who were pregnant.

No new evidence has emerged since 2016 regarding harms of screening or treating genital herpes in asymptomatic individuals, the authors noted. “Based on previous evidence, the USPSTF estimated that using the widely available serologic tests for HSV-2, nearly 1 of every 2 diagnoses in the general U.S. primary care population could be false,” they said. The task force also concluded that the low accuracy of the current tests could prompt unnecessary treatment for individuals with false-positive diagnoses, as well as social and emotional harm for these individuals.

During a period of public comment from Aug. 16, 2022, to Sept. 12, 2022, individuals expressed concerns that the recommendation against routine screening showed a disinclination to take herpes seriously, and concerns that asymptomatic individuals could transmit the infection to sexual partners, the authors said. However, the estimated seroprevalence of HSV-1 and HSV-2 has declined in recent decades, and other comments supported the USPSTF’s analysis of the evidence and noted their consistency with current clinical practice.

The task force noted that research gaps remain and recognized the need to improve screening and treatment of genital herpes to prevent symptomatic episodes and transmission. Specifically, the USPSTF recommendation calls for more research to assess the accuracy of screening tests, to enroll more study participants from populations disproportionately affected by HSV, to examine the effect of behavioral counseling, and to clarify associations between HSV and pregnancy outcomes. In addition, the task force called for research to create an effective vaccine to prevent genital HSV infection and to develop a cure.
 

Targeted screening makes sense for now

“Given the frequency and severity of the range of diseases seen with HSV and the large proportion of persons who are asymptomatic, identifying carriers through type-specific serologic screening has long been considered a plausible strategy,” Mark D. Pearlman, MD, of the University of Michigan, Ann Arbor, wrote in an accompanying editorial.

However, accuracy of the currently available serology screening tests is low, and the adverse social and psychological effects and the impact on relationships for many asymptomatic individuals who test positive and may be incorrectly identified as infected remains a concern, said Dr. Pearlman.

Although some may be disagree about the value of routine serotesting for HSV-2 in asymptomatic individuals, other strategies can reduce the spread of infection and help those infected, he said.

Many experts continue to recommend targeted serotesting to high-risk populations, such as pregnant women whose nonpregnant partner is known to have genital or oral herpes and whose own infection status or serostatus is uncertain, said Dr. Pearlman. Other targeted strategies include screening individuals with recurrent or atypical genital symptoms and negative polymerase chain reaction assay or culture results, a clinical herpes diagnosis without laboratory confirmation, or those at increased risk because of a high number of sexual partners or a history of HIV infection, he said.

“Of note, the current CDC STI guidelines and ACOG both concur with the USPSTF that routine screening in the general population or routine screening during pregnancy are not recommended,” Dr. Pearlman said. Meanwhile, research efforts continue to help reduce the impact of HSV disease and development of a more effective testing methodology “might tip the balance in favor of routine screening” in the future, he emphasized.

The recommendations were supported by the Agency for Healthcare Research and Quality. The members of the task force received reimbursement for travel and an honorarium but had no other relevant financial conflicts to disclose. Dr. Pearlman had no financial conflicts to disclose.

Asymptomatic adults, teens, and pregnant women with no known history or symptoms of herpes infection need not undergo routine screening, according to the latest recommendation from the U.S. Preventive Services Task Force.

The 2023 recommendation reaffirms the conclusion from 2016, wrote Carol M. Mangione, MD, of the University of California, Los Angeles, and members of the task force.

“Currently, routine serologic screening for genital herpes is limited by the low predictive value of the widely available serologic screening tests and the expected high rate of false-positive results likely to occur with routine screening of asymptomatic persons in the U.S.,” the authors said.

In the recommendation, published in JAMA, the authors affirmed with moderate certainty and a grade D recommendation that the risks of routine screening for herpes simplex virus (HSV) in asymptomatic individuals outweigh the benefits.

The task force found no new evidence on the accuracy of serologic screening tests, the benefits of early detection and treatment, or on the harms of screening and treatment since the 2016 review of 17 studies in 19 publications, with data from more than 9,000 individuals.

Studies of the accuracy of serologic screening for herpes simplex virus-2 in the 2016 report mainly reflect populations with higher HSV-2 prevalence and are of limited applicability to the U.S. primary care population, the authors wrote. Evidence from the 2016 review also showed limited and inconsistent support for the early identification and treatment of HSV-2 in asymptomatic individuals, including those who were pregnant.

No new evidence has emerged since 2016 regarding harms of screening or treating genital herpes in asymptomatic individuals, the authors noted. “Based on previous evidence, the USPSTF estimated that using the widely available serologic tests for HSV-2, nearly 1 of every 2 diagnoses in the general U.S. primary care population could be false,” they said. The task force also concluded that the low accuracy of the current tests could prompt unnecessary treatment for individuals with false-positive diagnoses, as well as social and emotional harm for these individuals.

During a period of public comment from Aug. 16, 2022, to Sept. 12, 2022, individuals expressed concerns that the recommendation against routine screening showed a disinclination to take herpes seriously, and concerns that asymptomatic individuals could transmit the infection to sexual partners, the authors said. However, the estimated seroprevalence of HSV-1 and HSV-2 has declined in recent decades, and other comments supported the USPSTF’s analysis of the evidence and noted their consistency with current clinical practice.

The task force noted that research gaps remain and recognized the need to improve screening and treatment of genital herpes to prevent symptomatic episodes and transmission. Specifically, the USPSTF recommendation calls for more research to assess the accuracy of screening tests, to enroll more study participants from populations disproportionately affected by HSV, to examine the effect of behavioral counseling, and to clarify associations between HSV and pregnancy outcomes. In addition, the task force called for research to create an effective vaccine to prevent genital HSV infection and to develop a cure.
 

Targeted screening makes sense for now

“Given the frequency and severity of the range of diseases seen with HSV and the large proportion of persons who are asymptomatic, identifying carriers through type-specific serologic screening has long been considered a plausible strategy,” Mark D. Pearlman, MD, of the University of Michigan, Ann Arbor, wrote in an accompanying editorial.

However, accuracy of the currently available serology screening tests is low, and the adverse social and psychological effects and the impact on relationships for many asymptomatic individuals who test positive and may be incorrectly identified as infected remains a concern, said Dr. Pearlman.

Although some may be disagree about the value of routine serotesting for HSV-2 in asymptomatic individuals, other strategies can reduce the spread of infection and help those infected, he said.

Many experts continue to recommend targeted serotesting to high-risk populations, such as pregnant women whose nonpregnant partner is known to have genital or oral herpes and whose own infection status or serostatus is uncertain, said Dr. Pearlman. Other targeted strategies include screening individuals with recurrent or atypical genital symptoms and negative polymerase chain reaction assay or culture results, a clinical herpes diagnosis without laboratory confirmation, or those at increased risk because of a high number of sexual partners or a history of HIV infection, he said.

“Of note, the current CDC STI guidelines and ACOG both concur with the USPSTF that routine screening in the general population or routine screening during pregnancy are not recommended,” Dr. Pearlman said. Meanwhile, research efforts continue to help reduce the impact of HSV disease and development of a more effective testing methodology “might tip the balance in favor of routine screening” in the future, he emphasized.

The recommendations were supported by the Agency for Healthcare Research and Quality. The members of the task force received reimbursement for travel and an honorarium but had no other relevant financial conflicts to disclose. Dr. Pearlman had no financial conflicts to disclose.

Asymptomatic adults, teens, and pregnant women with no known history or symptoms of herpes infection need not undergo routine screening, according to the latest recommendation from the U.S. Preventive Services Task Force.

The 2023 recommendation reaffirms the conclusion from 2016, wrote Carol M. Mangione, MD, of the University of California, Los Angeles, and members of the task force.

“Currently, routine serologic screening for genital herpes is limited by the low predictive value of the widely available serologic screening tests and the expected high rate of false-positive results likely to occur with routine screening of asymptomatic persons in the U.S.,” the authors said.

In the recommendation, published in JAMA, the authors affirmed with moderate certainty and a grade D recommendation that the risks of routine screening for herpes simplex virus (HSV) in asymptomatic individuals outweigh the benefits.

The task force found no new evidence on the accuracy of serologic screening tests, the benefits of early detection and treatment, or on the harms of screening and treatment since the 2016 review of 17 studies in 19 publications, with data from more than 9,000 individuals.

Studies of the accuracy of serologic screening for herpes simplex virus-2 in the 2016 report mainly reflect populations with higher HSV-2 prevalence and are of limited applicability to the U.S. primary care population, the authors wrote. Evidence from the 2016 review also showed limited and inconsistent support for the early identification and treatment of HSV-2 in asymptomatic individuals, including those who were pregnant.

No new evidence has emerged since 2016 regarding harms of screening or treating genital herpes in asymptomatic individuals, the authors noted. “Based on previous evidence, the USPSTF estimated that using the widely available serologic tests for HSV-2, nearly 1 of every 2 diagnoses in the general U.S. primary care population could be false,” they said. The task force also concluded that the low accuracy of the current tests could prompt unnecessary treatment for individuals with false-positive diagnoses, as well as social and emotional harm for these individuals.

During a period of public comment from Aug. 16, 2022, to Sept. 12, 2022, individuals expressed concerns that the recommendation against routine screening showed a disinclination to take herpes seriously, and concerns that asymptomatic individuals could transmit the infection to sexual partners, the authors said. However, the estimated seroprevalence of HSV-1 and HSV-2 has declined in recent decades, and other comments supported the USPSTF’s analysis of the evidence and noted their consistency with current clinical practice.

The task force noted that research gaps remain and recognized the need to improve screening and treatment of genital herpes to prevent symptomatic episodes and transmission. Specifically, the USPSTF recommendation calls for more research to assess the accuracy of screening tests, to enroll more study participants from populations disproportionately affected by HSV, to examine the effect of behavioral counseling, and to clarify associations between HSV and pregnancy outcomes. In addition, the task force called for research to create an effective vaccine to prevent genital HSV infection and to develop a cure.
 

Targeted screening makes sense for now

“Given the frequency and severity of the range of diseases seen with HSV and the large proportion of persons who are asymptomatic, identifying carriers through type-specific serologic screening has long been considered a plausible strategy,” Mark D. Pearlman, MD, of the University of Michigan, Ann Arbor, wrote in an accompanying editorial.

However, accuracy of the currently available serology screening tests is low, and the adverse social and psychological effects and the impact on relationships for many asymptomatic individuals who test positive and may be incorrectly identified as infected remains a concern, said Dr. Pearlman.

Although some may be disagree about the value of routine serotesting for HSV-2 in asymptomatic individuals, other strategies can reduce the spread of infection and help those infected, he said.

Many experts continue to recommend targeted serotesting to high-risk populations, such as pregnant women whose nonpregnant partner is known to have genital or oral herpes and whose own infection status or serostatus is uncertain, said Dr. Pearlman. Other targeted strategies include screening individuals with recurrent or atypical genital symptoms and negative polymerase chain reaction assay or culture results, a clinical herpes diagnosis without laboratory confirmation, or those at increased risk because of a high number of sexual partners or a history of HIV infection, he said.

“Of note, the current CDC STI guidelines and ACOG both concur with the USPSTF that routine screening in the general population or routine screening during pregnancy are not recommended,” Dr. Pearlman said. Meanwhile, research efforts continue to help reduce the impact of HSV disease and development of a more effective testing methodology “might tip the balance in favor of routine screening” in the future, he emphasized.

The recommendations were supported by the Agency for Healthcare Research and Quality. The members of the task force received reimbursement for travel and an honorarium but had no other relevant financial conflicts to disclose. Dr. Pearlman had no financial conflicts to disclose.

Repetitive transcranial magnetic stimulation (rTMS) is associated with reduced symptom severity in patients with comorbid major depressive disorder (MDD) and substance use disorders (SUDs), new research suggests.

In a retrospective observational study, participants receiving 20-30 rTMS sessions delivered over a course of 4-6 weeks showed significant reductions in both craving and depression symptom scores.

In addition, the researchers found that the number of rTMS sessions significantly predicted the number of days of drug abstinence, even after controlling for confounders.

“For each additional TMS session, there was an additional 10 days of abstinence in the community,” principal investigator Wael Foad, MD, medical director, Erada Center for Treatment and Rehabilitation, Dubai, United Arab Emirates, told this news organization.

However, Dr. Foad noted that he would need to construct a randomized controlled trial to further explore that “interesting” finding.

The results were published in the Annals of Clinical Psychiatry.
 

Inpatient program

The researchers retrospectively analyzed medical records of men admitted to the inpatient unit at the Erada Center between June 2019 and September 2020. The vast majority were native to the UAE.

The inpatient program focuses on treating patients with SUDs and is the only dedicated addiction rehabilitation service in Dubai, the investigators noted.

They analyzed outcomes for 55 men with mild to moderate MDD who received rTMS as standard treatment.

Participants were excluded from the data analysis if they had another comorbid diagnosis from the DSM-5 other than SUD or MDD. They were also excluded if they used an illicit substance 2 weeks before the study or used certain medications, including antipsychotics, benzodiazepines, or mood stabilizers.

When patients first arrived on the unit, they were detoxed for a period of time before they began receiving rTMS sessions.

The 55 men received 20-30 high-frequency rTMS sessions over the course of 4-6 weeks in the area of the dorsolateral prefrontal cortex. Each session consisted of 3,000 pulses delivered over a period of 37.5 minutes.  Severity of depression was measured with the Clinical Global Impression–Severity Scale (CGI-S), which uses a 7-point Likert scale.

In addition, participants’ scores were tracked on the Brief Substance Craving Scale (BSCS), a self-report scale that measures craving for primary and secondary substances of abuse over a 24-hr period.

Of all participants, 47% said opiates and 35% said methamphetamine were their primary substances of abuse.
 

Significant improvement

Results showed a statistically significant improvement (P < .05) between baseline and post-rTMS treatment scores in severity of depression and drug craving, as measured by the BSCS and the CGI-S.

The researchers noted that eight participants dropped out of the study after their first rTMS session for various reasons.

Dr. Foad explained that investigators contracted with study participants to receive 20 rTMS sessions; if the sessions were not fully completed during the inpatient stay, the rTMS sessions were continued on an outpatient basis. A study clinician closely monitored patients until they finished their sessions.

For each additional rTMS session the patients completed beyond 20 sessions, there was an associated excess of 10 more days of abstinence from the primary drug in the community.

The investigators speculated that rTMS may reduce drug craving by increasing dopaminergic binding in the striatum, or by releasing dopamine in the caudate nucleus.

Study limitations cited include the lack of a control group and the fact that the study sample was limited to male inpatients, which limits generalizability of the findings to other populations.
 

Promising intervention

Commenting on the study, Colleen Ann Hanlon, PhD, noted that, from years of work using TMS for depression, “we know that more sessions of TMS during the acute treatment phase tends to lead to stronger and possibly more durable results long-term.”

Dr. Hanlon, who was not involved with the current research, formerly headed a clinical neuromodulation lab at Wake Forest University, Winston-Salem, N.C. She is now vice president of medical affairs at BrainsWay, an international health technology company specializing in Deep TMS.

She noted that Deep TMS was approved by the Food and Drug Administration for smoking cessation in 2020, “which was a tremendous win for our field at large, and requires only 15 acute sessions followed by 3 weekly sessions” of deep TMS.

“I suspect this is just the beginning of a new era in neuromodulation-based therapeutics for people struggling with drug and alcohol use disorders,” Dr. Hanlon said. 

The study behind the FDA approval for smoking approval was a large double-blind, sham-controlled multisite clinical trial where investigators used an H4 coil – a TMS coil that modulates multiple brain areas involved in addictive behaviors simultaneously.

Results from that study showed that 15 sessions of deep TMS significantly improved smoking cessation rates relative to sham (10 Hz, 120% motor threshold, H4 coil, 1,800 pulses/session).

“The difference in cigarette consumption and craving was significant as early as 2 weeks after treatment initiation,” said Dr. Hanlon. “I am looking forward to the future of this field for all people suffering from drug and alcohol use disorders.”

The study and services provided through the Erada Center were funded by the government of Dubai. The investigators reported no relevant financial relationships.

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

Repetitive transcranial magnetic stimulation (rTMS) is associated with reduced symptom severity in patients with comorbid major depressive disorder (MDD) and substance use disorders (SUDs), new research suggests.

In a retrospective observational study, participants receiving 20-30 rTMS sessions delivered over a course of 4-6 weeks showed significant reductions in both craving and depression symptom scores.

In addition, the researchers found that the number of rTMS sessions significantly predicted the number of days of drug abstinence, even after controlling for confounders.

“For each additional TMS session, there was an additional 10 days of abstinence in the community,” principal investigator Wael Foad, MD, medical director, Erada Center for Treatment and Rehabilitation, Dubai, United Arab Emirates, told this news organization.

However, Dr. Foad noted that he would need to construct a randomized controlled trial to further explore that “interesting” finding.

The results were published in the Annals of Clinical Psychiatry.
 

Inpatient program

The researchers retrospectively analyzed medical records of men admitted to the inpatient unit at the Erada Center between June 2019 and September 2020. The vast majority were native to the UAE.

The inpatient program focuses on treating patients with SUDs and is the only dedicated addiction rehabilitation service in Dubai, the investigators noted.

They analyzed outcomes for 55 men with mild to moderate MDD who received rTMS as standard treatment.

Participants were excluded from the data analysis if they had another comorbid diagnosis from the DSM-5 other than SUD or MDD. They were also excluded if they used an illicit substance 2 weeks before the study or used certain medications, including antipsychotics, benzodiazepines, or mood stabilizers.

When patients first arrived on the unit, they were detoxed for a period of time before they began receiving rTMS sessions.

The 55 men received 20-30 high-frequency rTMS sessions over the course of 4-6 weeks in the area of the dorsolateral prefrontal cortex. Each session consisted of 3,000 pulses delivered over a period of 37.5 minutes.  Severity of depression was measured with the Clinical Global Impression–Severity Scale (CGI-S), which uses a 7-point Likert scale.

In addition, participants’ scores were tracked on the Brief Substance Craving Scale (BSCS), a self-report scale that measures craving for primary and secondary substances of abuse over a 24-hr period.

Of all participants, 47% said opiates and 35% said methamphetamine were their primary substances of abuse.
 

Significant improvement

Results showed a statistically significant improvement (P < .05) between baseline and post-rTMS treatment scores in severity of depression and drug craving, as measured by the BSCS and the CGI-S.

The researchers noted that eight participants dropped out of the study after their first rTMS session for various reasons.

Dr. Foad explained that investigators contracted with study participants to receive 20 rTMS sessions; if the sessions were not fully completed during the inpatient stay, the rTMS sessions were continued on an outpatient basis. A study clinician closely monitored patients until they finished their sessions.

For each additional rTMS session the patients completed beyond 20 sessions, there was an associated excess of 10 more days of abstinence from the primary drug in the community.

The investigators speculated that rTMS may reduce drug craving by increasing dopaminergic binding in the striatum, or by releasing dopamine in the caudate nucleus.

Study limitations cited include the lack of a control group and the fact that the study sample was limited to male inpatients, which limits generalizability of the findings to other populations.
 

Promising intervention

Commenting on the study, Colleen Ann Hanlon, PhD, noted that, from years of work using TMS for depression, “we know that more sessions of TMS during the acute treatment phase tends to lead to stronger and possibly more durable results long-term.”

Dr. Hanlon, who was not involved with the current research, formerly headed a clinical neuromodulation lab at Wake Forest University, Winston-Salem, N.C. She is now vice president of medical affairs at BrainsWay, an international health technology company specializing in Deep TMS.

She noted that Deep TMS was approved by the Food and Drug Administration for smoking cessation in 2020, “which was a tremendous win for our field at large, and requires only 15 acute sessions followed by 3 weekly sessions” of deep TMS.

“I suspect this is just the beginning of a new era in neuromodulation-based therapeutics for people struggling with drug and alcohol use disorders,” Dr. Hanlon said. 

The study behind the FDA approval for smoking approval was a large double-blind, sham-controlled multisite clinical trial where investigators used an H4 coil – a TMS coil that modulates multiple brain areas involved in addictive behaviors simultaneously.

Results from that study showed that 15 sessions of deep TMS significantly improved smoking cessation rates relative to sham (10 Hz, 120% motor threshold, H4 coil, 1,800 pulses/session).

“The difference in cigarette consumption and craving was significant as early as 2 weeks after treatment initiation,” said Dr. Hanlon. “I am looking forward to the future of this field for all people suffering from drug and alcohol use disorders.”

The study and services provided through the Erada Center were funded by the government of Dubai. The investigators reported no relevant financial relationships.

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

Repetitive transcranial magnetic stimulation (rTMS) is associated with reduced symptom severity in patients with comorbid major depressive disorder (MDD) and substance use disorders (SUDs), new research suggests.

In a retrospective observational study, participants receiving 20-30 rTMS sessions delivered over a course of 4-6 weeks showed significant reductions in both craving and depression symptom scores.

In addition, the researchers found that the number of rTMS sessions significantly predicted the number of days of drug abstinence, even after controlling for confounders.

“For each additional TMS session, there was an additional 10 days of abstinence in the community,” principal investigator Wael Foad, MD, medical director, Erada Center for Treatment and Rehabilitation, Dubai, United Arab Emirates, told this news organization.

However, Dr. Foad noted that he would need to construct a randomized controlled trial to further explore that “interesting” finding.

The results were published in the Annals of Clinical Psychiatry.
 

Inpatient program

The researchers retrospectively analyzed medical records of men admitted to the inpatient unit at the Erada Center between June 2019 and September 2020. The vast majority were native to the UAE.

The inpatient program focuses on treating patients with SUDs and is the only dedicated addiction rehabilitation service in Dubai, the investigators noted.

They analyzed outcomes for 55 men with mild to moderate MDD who received rTMS as standard treatment.

Participants were excluded from the data analysis if they had another comorbid diagnosis from the DSM-5 other than SUD or MDD. They were also excluded if they used an illicit substance 2 weeks before the study or used certain medications, including antipsychotics, benzodiazepines, or mood stabilizers.

When patients first arrived on the unit, they were detoxed for a period of time before they began receiving rTMS sessions.

The 55 men received 20-30 high-frequency rTMS sessions over the course of 4-6 weeks in the area of the dorsolateral prefrontal cortex. Each session consisted of 3,000 pulses delivered over a period of 37.5 minutes.  Severity of depression was measured with the Clinical Global Impression–Severity Scale (CGI-S), which uses a 7-point Likert scale.

In addition, participants’ scores were tracked on the Brief Substance Craving Scale (BSCS), a self-report scale that measures craving for primary and secondary substances of abuse over a 24-hr period.

Of all participants, 47% said opiates and 35% said methamphetamine were their primary substances of abuse.
 

Significant improvement

Results showed a statistically significant improvement (P < .05) between baseline and post-rTMS treatment scores in severity of depression and drug craving, as measured by the BSCS and the CGI-S.

The researchers noted that eight participants dropped out of the study after their first rTMS session for various reasons.

Dr. Foad explained that investigators contracted with study participants to receive 20 rTMS sessions; if the sessions were not fully completed during the inpatient stay, the rTMS sessions were continued on an outpatient basis. A study clinician closely monitored patients until they finished their sessions.

For each additional rTMS session the patients completed beyond 20 sessions, there was an associated excess of 10 more days of abstinence from the primary drug in the community.

The investigators speculated that rTMS may reduce drug craving by increasing dopaminergic binding in the striatum, or by releasing dopamine in the caudate nucleus.

Study limitations cited include the lack of a control group and the fact that the study sample was limited to male inpatients, which limits generalizability of the findings to other populations.
 

Promising intervention

Commenting on the study, Colleen Ann Hanlon, PhD, noted that, from years of work using TMS for depression, “we know that more sessions of TMS during the acute treatment phase tends to lead to stronger and possibly more durable results long-term.”

Dr. Hanlon, who was not involved with the current research, formerly headed a clinical neuromodulation lab at Wake Forest University, Winston-Salem, N.C. She is now vice president of medical affairs at BrainsWay, an international health technology company specializing in Deep TMS.

She noted that Deep TMS was approved by the Food and Drug Administration for smoking cessation in 2020, “which was a tremendous win for our field at large, and requires only 15 acute sessions followed by 3 weekly sessions” of deep TMS.

“I suspect this is just the beginning of a new era in neuromodulation-based therapeutics for people struggling with drug and alcohol use disorders,” Dr. Hanlon said. 

The study behind the FDA approval for smoking approval was a large double-blind, sham-controlled multisite clinical trial where investigators used an H4 coil – a TMS coil that modulates multiple brain areas involved in addictive behaviors simultaneously.

Results from that study showed that 15 sessions of deep TMS significantly improved smoking cessation rates relative to sham (10 Hz, 120% motor threshold, H4 coil, 1,800 pulses/session).

“The difference in cigarette consumption and craving was significant as early as 2 weeks after treatment initiation,” said Dr. Hanlon. “I am looking forward to the future of this field for all people suffering from drug and alcohol use disorders.”

The study and services provided through the Erada Center were funded by the government of Dubai. The investigators reported no relevant financial relationships.

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

SAN DIEGO – According to the latest American Cancer Society (ACS) data, cutaneous melanoma was the 5th most common cancer in 2022, with an estimated 99,780 new cases and 7,650 deaths, following cancer of the colorectal area, lung and bronchus, prostate, and breast.

“The incidence of melanoma seems to have continued to go up since the early 1990s,” David E. Kent, MD, a dermatologist who practices in Macon, Ga., said at the annual Cutaneous Malignancy Update. “The death rates have been flat and may have slightly decreased.”

In 2023, the ACS estimates that about 97,610 new melanomas will be diagnosed in the United States (58,120 men and 39,490 women), and about 7,990 people are expected to die of melanoma (5,420 men and 2,570 women). In addition, ACS data from 2017-2019 project that about 2.1% of men and women will be diagnosed with cutaneous melanoma in their lifetime. To date, more than 1.3 million people in the United States live with cutaneous melanoma, and the overall 5-year survival is 93.7%.

Epidemiologic studies show an increase in melanoma incidence, primarily among White populations. “This is believed to be due primarily to sun exposure and to changing recreational behaviors and tanning bed exposures,” said Dr. Kent, who holds a faculty position in the department of dermatology at the Medical College of Georgia, Augusta. Increased surveillance and diagnosis also play a role. In the medical literature, annual increases in melanoma incidence vary from 3% to 7% per year, “which translates into a doubling of rates every 10-20 years,” he said, noting that annual melanoma costs are approximately $3.3 billion.

While incidence rates are lower in non-White, non-Hispanic populations, poor outcomes are disproportionately higher in persons of color. Blacks present at diagnosis with more advanced stage disease and are 1.5 times more likely to die from melanoma, he said, while Hispanics are 2.4 times more likely to present with stage III disease and 3.6 times more likely to have distant metastases. Persons of color also have higher rates of mucosal, acral lentiginous, and subungual melanoma.

Known genetic risk factors for melanoma include having skin types I and II, particularly those with light hair, light eyes, and freckling, and those with a family history have a twofold increased risk. Also, up to 40% of genetic cases are from inherited mutations in CDKN2A, CDK4, BAP1, and MCR1. Other genetic-related risk factors include the number and size of nevi, having atypical nevus syndrome, DNA repair defects, large congenital nevi, and a personal history of melanoma.

The main environmental risk factor for melanoma is exposure to ultraviolet radiation. “You can break it down in terms of whether this exposure is lifetime, intermittent intense UV exposure, from the use of tanning beds, or due to sunburns during childhood,” Dr. Kent said at the meeting, which was hosted by Scripps MD Anderson Cancer Center. Other environmental risk factors include distance from the equator, having a high socioeconomic status, being immunosuppressed, and exposure to heavy metals, insecticides, or hormones.

In a recently published study, researchers investigated the risk factors associated with first and second primary melanomas in 38,845 patients who were followed in Australia between 2011 and 2018. During a median follow-up of 7.4 years, 1,212 patients (3.1%) had a single primary melanoma diagnosis and 245 (0.6%) had a secondary primary melanoma diagnosis. The researchers found that second melanomas were more likely than were first melanomas to be in situ; for invasive tumors, second melanomas were more likely to be thin (defined as 1 mm or less) than were first melanomas.

In addition, having many self-reported moles at age 21 years was more strongly associated with second melanomas compared with first melanomas (hazard ratio [HR], 6.36 vs. 3.46, respectively; P = .01), as was having a high genetic predisposition (HR, 3.28 vs. 2.06; P = .03).

Second melanomas were also more strongly associated with a history of multiple skin cancer excisions than were first melanomas (HR, 2.63 vs. 1.86; P = .05). “Interestingly, there were no differences in UV exposure between the first primary and second primary melanoma groups,” said Dr. Kent, who was not involved with the study.

He noted that while sunscreen use protects against melanoma, a National Ambulatory Medical Care Survey (NAMCS) found that internists and pediatricians mentioned sunscreen at fewer than 0.1% of visits – even those with patients who have a diagnosis of skin disease. “Physicians need to do better,” he said. “We as dermatologists have work to do to help educate them.”

Dr. Kent reported having no relevant disclosures.

SAN DIEGO – According to the latest American Cancer Society (ACS) data, cutaneous melanoma was the 5th most common cancer in 2022, with an estimated 99,780 new cases and 7,650 deaths, following cancer of the colorectal area, lung and bronchus, prostate, and breast.

“The incidence of melanoma seems to have continued to go up since the early 1990s,” David E. Kent, MD, a dermatologist who practices in Macon, Ga., said at the annual Cutaneous Malignancy Update. “The death rates have been flat and may have slightly decreased.”

In 2023, the ACS estimates that about 97,610 new melanomas will be diagnosed in the United States (58,120 men and 39,490 women), and about 7,990 people are expected to die of melanoma (5,420 men and 2,570 women). In addition, ACS data from 2017-2019 project that about 2.1% of men and women will be diagnosed with cutaneous melanoma in their lifetime. To date, more than 1.3 million people in the United States live with cutaneous melanoma, and the overall 5-year survival is 93.7%.

Epidemiologic studies show an increase in melanoma incidence, primarily among White populations. “This is believed to be due primarily to sun exposure and to changing recreational behaviors and tanning bed exposures,” said Dr. Kent, who holds a faculty position in the department of dermatology at the Medical College of Georgia, Augusta. Increased surveillance and diagnosis also play a role. In the medical literature, annual increases in melanoma incidence vary from 3% to 7% per year, “which translates into a doubling of rates every 10-20 years,” he said, noting that annual melanoma costs are approximately $3.3 billion.

While incidence rates are lower in non-White, non-Hispanic populations, poor outcomes are disproportionately higher in persons of color. Blacks present at diagnosis with more advanced stage disease and are 1.5 times more likely to die from melanoma, he said, while Hispanics are 2.4 times more likely to present with stage III disease and 3.6 times more likely to have distant metastases. Persons of color also have higher rates of mucosal, acral lentiginous, and subungual melanoma.

Known genetic risk factors for melanoma include having skin types I and II, particularly those with light hair, light eyes, and freckling, and those with a family history have a twofold increased risk. Also, up to 40% of genetic cases are from inherited mutations in CDKN2A, CDK4, BAP1, and MCR1. Other genetic-related risk factors include the number and size of nevi, having atypical nevus syndrome, DNA repair defects, large congenital nevi, and a personal history of melanoma.

The main environmental risk factor for melanoma is exposure to ultraviolet radiation. “You can break it down in terms of whether this exposure is lifetime, intermittent intense UV exposure, from the use of tanning beds, or due to sunburns during childhood,” Dr. Kent said at the meeting, which was hosted by Scripps MD Anderson Cancer Center. Other environmental risk factors include distance from the equator, having a high socioeconomic status, being immunosuppressed, and exposure to heavy metals, insecticides, or hormones.

In a recently published study, researchers investigated the risk factors associated with first and second primary melanomas in 38,845 patients who were followed in Australia between 2011 and 2018. During a median follow-up of 7.4 years, 1,212 patients (3.1%) had a single primary melanoma diagnosis and 245 (0.6%) had a secondary primary melanoma diagnosis. The researchers found that second melanomas were more likely than were first melanomas to be in situ; for invasive tumors, second melanomas were more likely to be thin (defined as 1 mm or less) than were first melanomas.

In addition, having many self-reported moles at age 21 years was more strongly associated with second melanomas compared with first melanomas (hazard ratio [HR], 6.36 vs. 3.46, respectively; P = .01), as was having a high genetic predisposition (HR, 3.28 vs. 2.06; P = .03).

Second melanomas were also more strongly associated with a history of multiple skin cancer excisions than were first melanomas (HR, 2.63 vs. 1.86; P = .05). “Interestingly, there were no differences in UV exposure between the first primary and second primary melanoma groups,” said Dr. Kent, who was not involved with the study.

He noted that while sunscreen use protects against melanoma, a National Ambulatory Medical Care Survey (NAMCS) found that internists and pediatricians mentioned sunscreen at fewer than 0.1% of visits – even those with patients who have a diagnosis of skin disease. “Physicians need to do better,” he said. “We as dermatologists have work to do to help educate them.”

Dr. Kent reported having no relevant disclosures.

SAN DIEGO – According to the latest American Cancer Society (ACS) data, cutaneous melanoma was the 5th most common cancer in 2022, with an estimated 99,780 new cases and 7,650 deaths, following cancer of the colorectal area, lung and bronchus, prostate, and breast.

“The incidence of melanoma seems to have continued to go up since the early 1990s,” David E. Kent, MD, a dermatologist who practices in Macon, Ga., said at the annual Cutaneous Malignancy Update. “The death rates have been flat and may have slightly decreased.”

In 2023, the ACS estimates that about 97,610 new melanomas will be diagnosed in the United States (58,120 men and 39,490 women), and about 7,990 people are expected to die of melanoma (5,420 men and 2,570 women). In addition, ACS data from 2017-2019 project that about 2.1% of men and women will be diagnosed with cutaneous melanoma in their lifetime. To date, more than 1.3 million people in the United States live with cutaneous melanoma, and the overall 5-year survival is 93.7%.

Epidemiologic studies show an increase in melanoma incidence, primarily among White populations. “This is believed to be due primarily to sun exposure and to changing recreational behaviors and tanning bed exposures,” said Dr. Kent, who holds a faculty position in the department of dermatology at the Medical College of Georgia, Augusta. Increased surveillance and diagnosis also play a role. In the medical literature, annual increases in melanoma incidence vary from 3% to 7% per year, “which translates into a doubling of rates every 10-20 years,” he said, noting that annual melanoma costs are approximately $3.3 billion.

While incidence rates are lower in non-White, non-Hispanic populations, poor outcomes are disproportionately higher in persons of color. Blacks present at diagnosis with more advanced stage disease and are 1.5 times more likely to die from melanoma, he said, while Hispanics are 2.4 times more likely to present with stage III disease and 3.6 times more likely to have distant metastases. Persons of color also have higher rates of mucosal, acral lentiginous, and subungual melanoma.

Known genetic risk factors for melanoma include having skin types I and II, particularly those with light hair, light eyes, and freckling, and those with a family history have a twofold increased risk. Also, up to 40% of genetic cases are from inherited mutations in CDKN2A, CDK4, BAP1, and MCR1. Other genetic-related risk factors include the number and size of nevi, having atypical nevus syndrome, DNA repair defects, large congenital nevi, and a personal history of melanoma.

The main environmental risk factor for melanoma is exposure to ultraviolet radiation. “You can break it down in terms of whether this exposure is lifetime, intermittent intense UV exposure, from the use of tanning beds, or due to sunburns during childhood,” Dr. Kent said at the meeting, which was hosted by Scripps MD Anderson Cancer Center. Other environmental risk factors include distance from the equator, having a high socioeconomic status, being immunosuppressed, and exposure to heavy metals, insecticides, or hormones.

In a recently published study, researchers investigated the risk factors associated with first and second primary melanomas in 38,845 patients who were followed in Australia between 2011 and 2018. During a median follow-up of 7.4 years, 1,212 patients (3.1%) had a single primary melanoma diagnosis and 245 (0.6%) had a secondary primary melanoma diagnosis. The researchers found that second melanomas were more likely than were first melanomas to be in situ; for invasive tumors, second melanomas were more likely to be thin (defined as 1 mm or less) than were first melanomas.

In addition, having many self-reported moles at age 21 years was more strongly associated with second melanomas compared with first melanomas (hazard ratio [HR], 6.36 vs. 3.46, respectively; P = .01), as was having a high genetic predisposition (HR, 3.28 vs. 2.06; P = .03).

Second melanomas were also more strongly associated with a history of multiple skin cancer excisions than were first melanomas (HR, 2.63 vs. 1.86; P = .05). “Interestingly, there were no differences in UV exposure between the first primary and second primary melanoma groups,” said Dr. Kent, who was not involved with the study.

He noted that while sunscreen use protects against melanoma, a National Ambulatory Medical Care Survey (NAMCS) found that internists and pediatricians mentioned sunscreen at fewer than 0.1% of visits – even those with patients who have a diagnosis of skin disease. “Physicians need to do better,” he said. “We as dermatologists have work to do to help educate them.”

Dr. Kent reported having no relevant disclosures.

Pounding heart, sweating, insomnia. Surges of dopamine, norepinephrine, and adrenaline. All symptoms of a very common yet frustrating condition: Falling in love.

The prognosis is vague. A prescription pad and knowledge of biochemistry aren’t helpful when it comes to relationships.

Medical training can consume decades when others are exploring relationships and starting families. There are few recent data on this, but a 2012 longitudinal study of more than 20,000 physicians by the UK Medical Careers Research Group found that, by age 25, the rate of doctors who were in partnerships was far lower than in the general population.

But there is hope! By age 36, the number of doctors in long-term relationships had overtaken everyone else by more than 10% for women and 20% for men. The Medscape 2022 Physician Happiness & Lifestyle Report found that 83% were in committed relationships, and even better, happy ones. At least three-quarters of doctors in every specialty described their partnerships as “very good” or “good.”

How should a single medical student, resident, or attending physician find happiness ever after in 2023? Sometimes Mr./Ms. Right can be found in the anatomy lab or hospital, with sparks flying between students or colleagues. But for many in health care, along with millions of others looking for love, the solution is dating apps.
 

When ‘MD’ is a turnoff

Dr. M, a psychiatry resident in California who prefers not to give her name, hadn’t found a life partner during college, grad school, or medical school. When she passed her final Step 3 board exam, she decided it was time to take the plunge. She signed up for popular dating apps like Hinge, Bumble, and Coffee Meets Bagel, but her dates seemed to follow a disappointing pattern.

“I met lots of guys, but it was incredibly rare to find another physician,” said Dr. M. “I found myself always wanting to talk about my life as a resident. More often than not, the guys would give me this blank stare as I complained about being on call or spoke about spending 12 hours a day studying for a board exam, or even the process of The Match and how I ended up in California.”

Both of Dr. M’s parents are physicians, and she grew up watching how they supported each other through residency, exams, and exhausting schedules. A relationship with another physician, her parents told her, would give both partners the best chance to understand each other’s lives. The problem was how to find one.

That was when Dr. M saw an ad for a dating app with a cute medical name: DownToDate, a play on the clinical evidence resource UpToDate. “I thought it was a meme,” she said. “It was this doctors-only app. I remember thinking, ‘this has to be a joke,’ but then it was very real.”

She signed up and was required to provide a photo of her ID and her NPI number. Immediately, men began “requesting a consult,” the app’s form of “liking” her profile, and sending her “pages” (messages).

DownToDate was created by another physician, Robin Boyer, MD, MBA, a pediatrics resident in Loma Linda, Calif. The inspiration came in 2020 during the initial COVID crisis. Exhausted from long and often heartbreaking shifts, Dr. Boyer was grateful for her husband’s unwavering support. But many of her coresidents weren’t so lucky. The women in particular talked about their dating struggles, and there was a recurring theme. They didn’t feel confident putting “physician” on a dating site profile.

“If you’re male and you tell people you’re a doctor, it seems like it really attracts people,” Dr. Boyer said. “But if you’re female, it brings up a lot of stereotypes where you’re perceived as too intimidating either as the breadwinner, being more educated, or having a [demanding] career. It does make it more difficult.”

Dr. Boyer met her husband in high school, and she had never used a dating app. She convinced a coresident, Celestine Odigwe, MD, to pursue the idea as partners. They began researching the market within their network and heard from over a thousand interested physicians, both men and women, heterosexual and LGBTQ+. They even created fake accounts on other sites to gauge how easy it is to falsify a profile. From these insights, the app took shape. It launched in 2021 and currently has more than 5000 verified users.
 

Branches from the same tree

Around the same time that DownToDate began, Shivani Shah, DO, a pediatric neurology resident at Duke University, Durham, N.C., and her brother, Sagar Shah, an entrepreneur, had a similar idea.

At the time, Dr. Shah was a fourth-year medical student about to move from New Jersey to North Carolina. Friends who were internal medicine residents described the grueling reality of the early COVID pandemic.

“It was just horrible,” said Dr. Shah. “You were isolated from your family, your support system, everything. ... I think the pandemic really pushed us into realizing that this is a very important need, and sometimes it feels like community is lacking in the health care field.”

The sibling duo developed ForeverX, an app for health care workers to find meaningful and long-term romantic connections. It launched in 2021.

Concerned that the medical field was “siloed,” the Shahs chose to open the app to physicians, dentists, nurses, physical therapists, and other health care professionals. “Opening up the doors to more communication” between the health care branches was a priority.

To prevent catfishing, the app uses a twofold vetting system. Each user submits a photo of their driver’s license and a selfie that must match. There is also health care verification through an NPI number, nurse’s ID, or a manual process for those without either. None of the information is stored.

Through personal experience with dating apps, Dr. Shah hopes ForeverX can improve on some of their flaws, particularly the problem of matches being overly filtered by preferences. The “natural way” of meeting people is not filtered. And while most people have a dating checklist in mind, meeting someone face to face might send some of those prerequisites “out the window.”

“You can’t really put into words how you feel with someone ... the vibe,” Dr. Shah said. That is why her goal is to get people off the app and on an actual date IRL. “Something we’ve discussed internally is, how do we make this experience that’s virtual more human?”

She acknowledged that certain requirements, like a desire for children, might be crucial to some users. Many female doctors in their 30’s feel the “time crunch” of a ticking biological clock.
 

Optimize your date-ability

“I think people either love or hate dating apps, and I love them,” said Kevin Jubbal, MD. “I get to meet cool people and schedule dates from the comfort of my home.”

Dr. Jubbal, a former plastic surgery resident who left medicine to become an entrepreneur, is the founder of Med School Insiders, a tutoring and advising resource for premeds, medical students, and residents. His YouTube channel has more than 1.5 million subscribers, and he often receives questions about whether dating is feasible in medical school and how to balance a personal and academic/professional life.

Those who hate dating apps or receive few matches would do well to look inward instead of blaming the process, he said. It helps to view the experience as a learning tool that provides feedback very quickly.

“If you want to find a really amazing person, then you need to be what you want to find,” said Dr. Jubbal. “If you want to find someone who’s fit and intelligent and well read and well traveled, you need to be that. Otherwise, you’re probably not going to attract that person.”
 

An app designed to help single female MDs

Ifie Williams, MD, a psychiatrist in Washington, D.C., believes a wider dating pool is key – provided everyone understands the situation up front. When Dr. Williams started residency in 2014, she was “as single as can be.” She tried many dating apps, but they were extremely time consuming. Even when she set specific preferences, she found herself sifting through “matches” that didn’t fit her criteria.

“Dating nowadays has become almost like a second job,” said Dr. Williams. “Just the amount of time that people are having to spend on apps, swiping left and right and then meeting people. You think they’re interested and then you deal with all these games.”

By 2017, Dr. Williams had invented Miss Doctor, a dating app that would connect female physicians and other doctoral-level professionals with men or women on a similar achievement level.

By definition, these people would not be intimidated by ambitious, busy women. They would be heavily screened and vetted. And one other proviso: they would have to pay for “likes.”

Most dating apps charge a subscription fee. Users are allowed to “like” numerous profiles and perhaps not bother responding to many matches. By contrast, Miss Doctor accounts are free and include a limited number of “likes” to indicate interest. Beyond that, there’s a price.

“We wanted to find a way to make people a little more intentional with how they like people on the app, so they give a little more thought to it,” Dr. Williams said. “So, we monetize it and use that to change behavior.”

After an initial launch in 2017, the app had to take a back seat while Dr. Williams started her psychiatry practice and got married herself. She plans to relaunch it in spring 2023.

Male or female, there is general agreement that finding time to date as a young physician isn’t easy. While DownToDate has had “doctor meets doctor” success stories, many users are still searching for “the one.”

Dr. Boyer believes that career challenges are not a reason to give up. “There are so many single and available people out there,” she said. “And everyone’s deserving of love. Even if you only have an hour a week.”

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

Pounding heart, sweating, insomnia. Surges of dopamine, norepinephrine, and adrenaline. All symptoms of a very common yet frustrating condition: Falling in love.

The prognosis is vague. A prescription pad and knowledge of biochemistry aren’t helpful when it comes to relationships.

Medical training can consume decades when others are exploring relationships and starting families. There are few recent data on this, but a 2012 longitudinal study of more than 20,000 physicians by the UK Medical Careers Research Group found that, by age 25, the rate of doctors who were in partnerships was far lower than in the general population.

But there is hope! By age 36, the number of doctors in long-term relationships had overtaken everyone else by more than 10% for women and 20% for men. The Medscape 2022 Physician Happiness & Lifestyle Report found that 83% were in committed relationships, and even better, happy ones. At least three-quarters of doctors in every specialty described their partnerships as “very good” or “good.”

How should a single medical student, resident, or attending physician find happiness ever after in 2023? Sometimes Mr./Ms. Right can be found in the anatomy lab or hospital, with sparks flying between students or colleagues. But for many in health care, along with millions of others looking for love, the solution is dating apps.
 

When ‘MD’ is a turnoff

Dr. M, a psychiatry resident in California who prefers not to give her name, hadn’t found a life partner during college, grad school, or medical school. When she passed her final Step 3 board exam, she decided it was time to take the plunge. She signed up for popular dating apps like Hinge, Bumble, and Coffee Meets Bagel, but her dates seemed to follow a disappointing pattern.

“I met lots of guys, but it was incredibly rare to find another physician,” said Dr. M. “I found myself always wanting to talk about my life as a resident. More often than not, the guys would give me this blank stare as I complained about being on call or spoke about spending 12 hours a day studying for a board exam, or even the process of The Match and how I ended up in California.”

Both of Dr. M’s parents are physicians, and she grew up watching how they supported each other through residency, exams, and exhausting schedules. A relationship with another physician, her parents told her, would give both partners the best chance to understand each other’s lives. The problem was how to find one.

That was when Dr. M saw an ad for a dating app with a cute medical name: DownToDate, a play on the clinical evidence resource UpToDate. “I thought it was a meme,” she said. “It was this doctors-only app. I remember thinking, ‘this has to be a joke,’ but then it was very real.”

She signed up and was required to provide a photo of her ID and her NPI number. Immediately, men began “requesting a consult,” the app’s form of “liking” her profile, and sending her “pages” (messages).

DownToDate was created by another physician, Robin Boyer, MD, MBA, a pediatrics resident in Loma Linda, Calif. The inspiration came in 2020 during the initial COVID crisis. Exhausted from long and often heartbreaking shifts, Dr. Boyer was grateful for her husband’s unwavering support. But many of her coresidents weren’t so lucky. The women in particular talked about their dating struggles, and there was a recurring theme. They didn’t feel confident putting “physician” on a dating site profile.

“If you’re male and you tell people you’re a doctor, it seems like it really attracts people,” Dr. Boyer said. “But if you’re female, it brings up a lot of stereotypes where you’re perceived as too intimidating either as the breadwinner, being more educated, or having a [demanding] career. It does make it more difficult.”

Dr. Boyer met her husband in high school, and she had never used a dating app. She convinced a coresident, Celestine Odigwe, MD, to pursue the idea as partners. They began researching the market within their network and heard from over a thousand interested physicians, both men and women, heterosexual and LGBTQ+. They even created fake accounts on other sites to gauge how easy it is to falsify a profile. From these insights, the app took shape. It launched in 2021 and currently has more than 5000 verified users.
 

Branches from the same tree

Around the same time that DownToDate began, Shivani Shah, DO, a pediatric neurology resident at Duke University, Durham, N.C., and her brother, Sagar Shah, an entrepreneur, had a similar idea.

At the time, Dr. Shah was a fourth-year medical student about to move from New Jersey to North Carolina. Friends who were internal medicine residents described the grueling reality of the early COVID pandemic.

“It was just horrible,” said Dr. Shah. “You were isolated from your family, your support system, everything. ... I think the pandemic really pushed us into realizing that this is a very important need, and sometimes it feels like community is lacking in the health care field.”

The sibling duo developed ForeverX, an app for health care workers to find meaningful and long-term romantic connections. It launched in 2021.

Concerned that the medical field was “siloed,” the Shahs chose to open the app to physicians, dentists, nurses, physical therapists, and other health care professionals. “Opening up the doors to more communication” between the health care branches was a priority.

To prevent catfishing, the app uses a twofold vetting system. Each user submits a photo of their driver’s license and a selfie that must match. There is also health care verification through an NPI number, nurse’s ID, or a manual process for those without either. None of the information is stored.

Through personal experience with dating apps, Dr. Shah hopes ForeverX can improve on some of their flaws, particularly the problem of matches being overly filtered by preferences. The “natural way” of meeting people is not filtered. And while most people have a dating checklist in mind, meeting someone face to face might send some of those prerequisites “out the window.”

“You can’t really put into words how you feel with someone ... the vibe,” Dr. Shah said. That is why her goal is to get people off the app and on an actual date IRL. “Something we’ve discussed internally is, how do we make this experience that’s virtual more human?”

She acknowledged that certain requirements, like a desire for children, might be crucial to some users. Many female doctors in their 30’s feel the “time crunch” of a ticking biological clock.
 

Optimize your date-ability

“I think people either love or hate dating apps, and I love them,” said Kevin Jubbal, MD. “I get to meet cool people and schedule dates from the comfort of my home.”

Dr. Jubbal, a former plastic surgery resident who left medicine to become an entrepreneur, is the founder of Med School Insiders, a tutoring and advising resource for premeds, medical students, and residents. His YouTube channel has more than 1.5 million subscribers, and he often receives questions about whether dating is feasible in medical school and how to balance a personal and academic/professional life.

Those who hate dating apps or receive few matches would do well to look inward instead of blaming the process, he said. It helps to view the experience as a learning tool that provides feedback very quickly.

“If you want to find a really amazing person, then you need to be what you want to find,” said Dr. Jubbal. “If you want to find someone who’s fit and intelligent and well read and well traveled, you need to be that. Otherwise, you’re probably not going to attract that person.”
 

An app designed to help single female MDs

Ifie Williams, MD, a psychiatrist in Washington, D.C., believes a wider dating pool is key – provided everyone understands the situation up front. When Dr. Williams started residency in 2014, she was “as single as can be.” She tried many dating apps, but they were extremely time consuming. Even when she set specific preferences, she found herself sifting through “matches” that didn’t fit her criteria.

“Dating nowadays has become almost like a second job,” said Dr. Williams. “Just the amount of time that people are having to spend on apps, swiping left and right and then meeting people. You think they’re interested and then you deal with all these games.”

By 2017, Dr. Williams had invented Miss Doctor, a dating app that would connect female physicians and other doctoral-level professionals with men or women on a similar achievement level.

By definition, these people would not be intimidated by ambitious, busy women. They would be heavily screened and vetted. And one other proviso: they would have to pay for “likes.”

Most dating apps charge a subscription fee. Users are allowed to “like” numerous profiles and perhaps not bother responding to many matches. By contrast, Miss Doctor accounts are free and include a limited number of “likes” to indicate interest. Beyond that, there’s a price.

“We wanted to find a way to make people a little more intentional with how they like people on the app, so they give a little more thought to it,” Dr. Williams said. “So, we monetize it and use that to change behavior.”

After an initial launch in 2017, the app had to take a back seat while Dr. Williams started her psychiatry practice and got married herself. She plans to relaunch it in spring 2023.

Male or female, there is general agreement that finding time to date as a young physician isn’t easy. While DownToDate has had “doctor meets doctor” success stories, many users are still searching for “the one.”

Dr. Boyer believes that career challenges are not a reason to give up. “There are so many single and available people out there,” she said. “And everyone’s deserving of love. Even if you only have an hour a week.”

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

Pounding heart, sweating, insomnia. Surges of dopamine, norepinephrine, and adrenaline. All symptoms of a very common yet frustrating condition: Falling in love.

The prognosis is vague. A prescription pad and knowledge of biochemistry aren’t helpful when it comes to relationships.

Medical training can consume decades when others are exploring relationships and starting families. There are few recent data on this, but a 2012 longitudinal study of more than 20,000 physicians by the UK Medical Careers Research Group found that, by age 25, the rate of doctors who were in partnerships was far lower than in the general population.

But there is hope! By age 36, the number of doctors in long-term relationships had overtaken everyone else by more than 10% for women and 20% for men. The Medscape 2022 Physician Happiness & Lifestyle Report found that 83% were in committed relationships, and even better, happy ones. At least three-quarters of doctors in every specialty described their partnerships as “very good” or “good.”

How should a single medical student, resident, or attending physician find happiness ever after in 2023? Sometimes Mr./Ms. Right can be found in the anatomy lab or hospital, with sparks flying between students or colleagues. But for many in health care, along with millions of others looking for love, the solution is dating apps.
 

When ‘MD’ is a turnoff

Dr. M, a psychiatry resident in California who prefers not to give her name, hadn’t found a life partner during college, grad school, or medical school. When she passed her final Step 3 board exam, she decided it was time to take the plunge. She signed up for popular dating apps like Hinge, Bumble, and Coffee Meets Bagel, but her dates seemed to follow a disappointing pattern.

“I met lots of guys, but it was incredibly rare to find another physician,” said Dr. M. “I found myself always wanting to talk about my life as a resident. More often than not, the guys would give me this blank stare as I complained about being on call or spoke about spending 12 hours a day studying for a board exam, or even the process of The Match and how I ended up in California.”

Both of Dr. M’s parents are physicians, and she grew up watching how they supported each other through residency, exams, and exhausting schedules. A relationship with another physician, her parents told her, would give both partners the best chance to understand each other’s lives. The problem was how to find one.

That was when Dr. M saw an ad for a dating app with a cute medical name: DownToDate, a play on the clinical evidence resource UpToDate. “I thought it was a meme,” she said. “It was this doctors-only app. I remember thinking, ‘this has to be a joke,’ but then it was very real.”

She signed up and was required to provide a photo of her ID and her NPI number. Immediately, men began “requesting a consult,” the app’s form of “liking” her profile, and sending her “pages” (messages).

DownToDate was created by another physician, Robin Boyer, MD, MBA, a pediatrics resident in Loma Linda, Calif. The inspiration came in 2020 during the initial COVID crisis. Exhausted from long and often heartbreaking shifts, Dr. Boyer was grateful for her husband’s unwavering support. But many of her coresidents weren’t so lucky. The women in particular talked about their dating struggles, and there was a recurring theme. They didn’t feel confident putting “physician” on a dating site profile.

“If you’re male and you tell people you’re a doctor, it seems like it really attracts people,” Dr. Boyer said. “But if you’re female, it brings up a lot of stereotypes where you’re perceived as too intimidating either as the breadwinner, being more educated, or having a [demanding] career. It does make it more difficult.”

Dr. Boyer met her husband in high school, and she had never used a dating app. She convinced a coresident, Celestine Odigwe, MD, to pursue the idea as partners. They began researching the market within their network and heard from over a thousand interested physicians, both men and women, heterosexual and LGBTQ+. They even created fake accounts on other sites to gauge how easy it is to falsify a profile. From these insights, the app took shape. It launched in 2021 and currently has more than 5000 verified users.
 

Branches from the same tree

Around the same time that DownToDate began, Shivani Shah, DO, a pediatric neurology resident at Duke University, Durham, N.C., and her brother, Sagar Shah, an entrepreneur, had a similar idea.

At the time, Dr. Shah was a fourth-year medical student about to move from New Jersey to North Carolina. Friends who were internal medicine residents described the grueling reality of the early COVID pandemic.

“It was just horrible,” said Dr. Shah. “You were isolated from your family, your support system, everything. ... I think the pandemic really pushed us into realizing that this is a very important need, and sometimes it feels like community is lacking in the health care field.”

The sibling duo developed ForeverX, an app for health care workers to find meaningful and long-term romantic connections. It launched in 2021.

Concerned that the medical field was “siloed,” the Shahs chose to open the app to physicians, dentists, nurses, physical therapists, and other health care professionals. “Opening up the doors to more communication” between the health care branches was a priority.

To prevent catfishing, the app uses a twofold vetting system. Each user submits a photo of their driver’s license and a selfie that must match. There is also health care verification through an NPI number, nurse’s ID, or a manual process for those without either. None of the information is stored.

Through personal experience with dating apps, Dr. Shah hopes ForeverX can improve on some of their flaws, particularly the problem of matches being overly filtered by preferences. The “natural way” of meeting people is not filtered. And while most people have a dating checklist in mind, meeting someone face to face might send some of those prerequisites “out the window.”

“You can’t really put into words how you feel with someone ... the vibe,” Dr. Shah said. That is why her goal is to get people off the app and on an actual date IRL. “Something we’ve discussed internally is, how do we make this experience that’s virtual more human?”

She acknowledged that certain requirements, like a desire for children, might be crucial to some users. Many female doctors in their 30’s feel the “time crunch” of a ticking biological clock.
 

Optimize your date-ability

“I think people either love or hate dating apps, and I love them,” said Kevin Jubbal, MD. “I get to meet cool people and schedule dates from the comfort of my home.”

Dr. Jubbal, a former plastic surgery resident who left medicine to become an entrepreneur, is the founder of Med School Insiders, a tutoring and advising resource for premeds, medical students, and residents. His YouTube channel has more than 1.5 million subscribers, and he often receives questions about whether dating is feasible in medical school and how to balance a personal and academic/professional life.

Those who hate dating apps or receive few matches would do well to look inward instead of blaming the process, he said. It helps to view the experience as a learning tool that provides feedback very quickly.

“If you want to find a really amazing person, then you need to be what you want to find,” said Dr. Jubbal. “If you want to find someone who’s fit and intelligent and well read and well traveled, you need to be that. Otherwise, you’re probably not going to attract that person.”
 

An app designed to help single female MDs

Ifie Williams, MD, a psychiatrist in Washington, D.C., believes a wider dating pool is key – provided everyone understands the situation up front. When Dr. Williams started residency in 2014, she was “as single as can be.” She tried many dating apps, but they were extremely time consuming. Even when she set specific preferences, she found herself sifting through “matches” that didn’t fit her criteria.

“Dating nowadays has become almost like a second job,” said Dr. Williams. “Just the amount of time that people are having to spend on apps, swiping left and right and then meeting people. You think they’re interested and then you deal with all these games.”

By 2017, Dr. Williams had invented Miss Doctor, a dating app that would connect female physicians and other doctoral-level professionals with men or women on a similar achievement level.

By definition, these people would not be intimidated by ambitious, busy women. They would be heavily screened and vetted. And one other proviso: they would have to pay for “likes.”

Most dating apps charge a subscription fee. Users are allowed to “like” numerous profiles and perhaps not bother responding to many matches. By contrast, Miss Doctor accounts are free and include a limited number of “likes” to indicate interest. Beyond that, there’s a price.

“We wanted to find a way to make people a little more intentional with how they like people on the app, so they give a little more thought to it,” Dr. Williams said. “So, we monetize it and use that to change behavior.”

After an initial launch in 2017, the app had to take a back seat while Dr. Williams started her psychiatry practice and got married herself. She plans to relaunch it in spring 2023.

Male or female, there is general agreement that finding time to date as a young physician isn’t easy. While DownToDate has had “doctor meets doctor” success stories, many users are still searching for “the one.”

Dr. Boyer believes that career challenges are not a reason to give up. “There are so many single and available people out there,” she said. “And everyone’s deserving of love. Even if you only have an hour a week.”

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

A new vibrating pill shown to help relieve constipation is now available. 

The drug-free solution is designed for daily use. In a trial, the pill produced at least one additional weekly bowel movement for 41% of participants, compared with at least one additional bowel movement for 23% of participants who took a placebo pill. 

Vibrant was approved by the Food and Drug Administration in August but is just now becoming available for doctors to prescribe, the company announced Wednesday. 

Because it is not a drug, Vibrant is considered a class 2 medical device by the FDA, which is the same class as contact lenses.

Here’s how it works: Around bedtime, the pill is inserted in a pod to activate it, then swallowed. It travels the digestive tract and reaches the large intestine about 14 hours later. 

“Then it goes to work,” the company explained in a news release. “After it’s swallowed, it is active for about 2 hours, goes quiet for around 6, hours and then activates again for another 2 hours.”

“There are little vibrations for 3 seconds on, 3 seconds off,” said Cathy Collis, chief commercial officer for Israel-based Vibrant Gastro, in a statement.

The vibrations help trigger peristalsis, the wave-like muscle contractions that move food through the gastrointestinal tract, the company said. Decreased peristalsis is a cause of constipation, which is defined as having less than three bowel movements per week, according to the Cleveland Clinic. 

About 2.5 million people see their doctor each year for constipation. The pills are made of what the company called “medical-grade material” that is the same as what’s used to make gastroenterology cameras.

In the trial, most people did not report feeling the pill inside of them.

“A minority could feel it,” said Eamonn Quigley, MD, chief of gastroenterology at Houston Methodist Hospital, in a statement. “None of them felt it was being uncomfortable. And none of them stopped taking it because of that.”

Dr. Quigley helped test the capsules and does not have a financial stake in the company, according to Vibrant.

The pills do not dissolve inside a person’s body. Rather, “after they’ve done their job, the person’s body poops them out, and they’re flushed away,” the company said.  

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

A new vibrating pill shown to help relieve constipation is now available. 

The drug-free solution is designed for daily use. In a trial, the pill produced at least one additional weekly bowel movement for 41% of participants, compared with at least one additional bowel movement for 23% of participants who took a placebo pill. 

Vibrant was approved by the Food and Drug Administration in August but is just now becoming available for doctors to prescribe, the company announced Wednesday. 

Because it is not a drug, Vibrant is considered a class 2 medical device by the FDA, which is the same class as contact lenses.

Here’s how it works: Around bedtime, the pill is inserted in a pod to activate it, then swallowed. It travels the digestive tract and reaches the large intestine about 14 hours later. 

“Then it goes to work,” the company explained in a news release. “After it’s swallowed, it is active for about 2 hours, goes quiet for around 6, hours and then activates again for another 2 hours.”

“There are little vibrations for 3 seconds on, 3 seconds off,” said Cathy Collis, chief commercial officer for Israel-based Vibrant Gastro, in a statement.

The vibrations help trigger peristalsis, the wave-like muscle contractions that move food through the gastrointestinal tract, the company said. Decreased peristalsis is a cause of constipation, which is defined as having less than three bowel movements per week, according to the Cleveland Clinic. 

About 2.5 million people see their doctor each year for constipation. The pills are made of what the company called “medical-grade material” that is the same as what’s used to make gastroenterology cameras.

In the trial, most people did not report feeling the pill inside of them.

“A minority could feel it,” said Eamonn Quigley, MD, chief of gastroenterology at Houston Methodist Hospital, in a statement. “None of them felt it was being uncomfortable. And none of them stopped taking it because of that.”

Dr. Quigley helped test the capsules and does not have a financial stake in the company, according to Vibrant.

The pills do not dissolve inside a person’s body. Rather, “after they’ve done their job, the person’s body poops them out, and they’re flushed away,” the company said.  

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

A new vibrating pill shown to help relieve constipation is now available. 

The drug-free solution is designed for daily use. In a trial, the pill produced at least one additional weekly bowel movement for 41% of participants, compared with at least one additional bowel movement for 23% of participants who took a placebo pill. 

Vibrant was approved by the Food and Drug Administration in August but is just now becoming available for doctors to prescribe, the company announced Wednesday. 

Because it is not a drug, Vibrant is considered a class 2 medical device by the FDA, which is the same class as contact lenses.

Here’s how it works: Around bedtime, the pill is inserted in a pod to activate it, then swallowed. It travels the digestive tract and reaches the large intestine about 14 hours later. 

“Then it goes to work,” the company explained in a news release. “After it’s swallowed, it is active for about 2 hours, goes quiet for around 6, hours and then activates again for another 2 hours.”

“There are little vibrations for 3 seconds on, 3 seconds off,” said Cathy Collis, chief commercial officer for Israel-based Vibrant Gastro, in a statement.

The vibrations help trigger peristalsis, the wave-like muscle contractions that move food through the gastrointestinal tract, the company said. Decreased peristalsis is a cause of constipation, which is defined as having less than three bowel movements per week, according to the Cleveland Clinic. 

About 2.5 million people see their doctor each year for constipation. The pills are made of what the company called “medical-grade material” that is the same as what’s used to make gastroenterology cameras.

In the trial, most people did not report feeling the pill inside of them.

“A minority could feel it,” said Eamonn Quigley, MD, chief of gastroenterology at Houston Methodist Hospital, in a statement. “None of them felt it was being uncomfortable. And none of them stopped taking it because of that.”

Dr. Quigley helped test the capsules and does not have a financial stake in the company, according to Vibrant.

The pills do not dissolve inside a person’s body. Rather, “after they’ve done their job, the person’s body poops them out, and they’re flushed away,” the company said.  

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

Outpatient COVID-19 treatment with monoclonal antibodies or antiretroviral medications such as nirmatrelvir-ritonavir (Paxlovid) administered to patients with systemic autoimmune rheumatic disease led to lower odds of having severe outcomes when compared with similar patients who received no outpatient treatment in a real-world, retrospective analysis of cases.

The investigators found that there were nine hospitalizations or deaths (2.1%) among 426 patients who received outpatient treatment, compared with 49 (17.6%) among 278 who did not receive outpatient treatment, yielding an odds ratio of 0.12 (95% confidence interval, 0.05-0.25), after adjusting for age, sex, race, comorbidities, and kidney function. The study was published in Lancet Rheumatology.

“Across the board, there was a really strong association with receiving outpatient treatment and lower risk of severe COVID-19,” senior author Jeffrey A. Sparks, MD, MMSc, assistant professor of medicine, Harvard Medical School and Brigham and Women’s Hospital, Boston, said in an interview. “It is pretty powerful evidence that, in this high-risk group, that treatment still matters related to preventing severe COVID. We found almost all patients who had severe COVID-19, either hospitalized or who had died, were in the untreated group.”
 

Early outpatient treatment an important tool in patients with rheumatic disease

Dr. Sparks noted that he and his coinvestigators conducted the study because the benefit of outpatient COVID-19 treatments in individuals with systemic autoimmune rheumatic disease was not adequately determined in clinical trials because they had infrequent enrollment of such patients.

The analysis included 704 patients with a mean age of 58.4 years who were seen at Mass General Brigham Integrated Health Care System, a multicenter health care system that includes 14 hospitals and primary care or specialty outpatient centers in the Boston area. A majority were female (76%) and White (84%). Nearly half had rheumatoid arthritis. Of the 704, 426 (61%) received outpatient treatment, which included nirmatrelvir-ritonavir (n = 307), monoclonal antibodies (n = 105), molnupiravir (n = 5), remdesivir (n = 3), and combination treatment (n = 6).

The findings underline the need to individualize approaches to outpatient treatment in those who test positive for SARS-CoV-2 to fend off severe COVID-19, according to Dr. Sparks. “It seems if you are vaccinated and in the general population that you are way less likely to have severe COVID-19 in the current environment, but that doesn’t necessarily apply to some high-risk groups like patients on immunosuppression. There are still patients at risk of severe COVID-19, and some of them are in this group of rheumatic patients. This should be part of the discussion related to deciding whether or not to treat.”

Dr. Sparks noted that vaccination against COVID-19 confers protection against developing severe COVID-19 in patients with rheumatic disease as it does in the general population, but patients with rheumatic diseases remain at increased risk for severe presentation. “Certainly, the vaccines really help our patients too, but there’s still a bit of a gap between the risk for our patients with rheumatic diseases and the general population” in developing severe COVID-19.

Dr. Sparks said he hopes the results represent a “call to action” that even among vaccinated patients there are still some who have poor outcomes, and that early outpatient treatment appears to be an important tool in the fight against poor outcomes from SARS-CoV-2 infection.
 

COVID-19 rebound

The study also reported on the phenomenon of COVID-19 rebound (recurrence of symptoms and test positivity after regimen completion) after oral outpatient SARS-CoV-2 treatment. “This [COVID-19 rebound] is a downside to treatment,” he said. COVID rebound was not infrequent: A total of 25 (8%) of 318 patients who received oral outpatient treatment had documented COVID-19 rebound.

“It was reassuring because we found no one who had rebound progressed to have severe COVID-19,” Dr. Sparks said. “On the other hand, [rebound] happened pretty frequently in our data, as 8% of patients are documented to have it.”

Dr. Sparks said he and coinvestigators speculate that more patients in the cohort may have experienced COVID-19 rebound but did not communicate this to their health care providers, and, as such, it was not documented in the medical record. The potential development of COVID-19 rebound “is something to counsel your patients about.” COVID-19 rebound is a phenomenon that is being most commonly observed with nirmatrelvir-ritonavir as outpatient treatment.
 

Possible confounding factors in study

Katie Bechman, MBChB, clinical lecturer in rheumatology at King’s College London, who coauthored an accompanying editorial about the study and its findings, pointed out that the study is limited by its observational design.

“With any study that looks at the efficacy of treatment, especially in an observational cohort, you’re going to have to consider the unmeasured confounding and the difference between these two groups,” Dr. Bechman said. “I know that they did try to adjust for that in this study, but there’s always going to be factors that we can’t [control for]. That is something that needs to be considered. I think that’s always something we need to consider when we’re looking at observational data.”

In lieu of a randomized, controlled trial, Dr. Bechman noted that the study and its associated findings serve as “the best data we have,” and she described the results as “very informative and positive.”

She added that the large number of patients represents a strength of the study, as does the robust method employed for identifying which patients had COVID-19.

The learnings from this study with respect to outpatient treatment can be applied to more common illnesses that patients with rheumatic disease may develop, such as the flu, according to Dr. Bechman.

“One of the positive aspects from this pandemic is that we’ve learned a huge amount about how best to treat certain viruses and prevent them in patients,” she said. “It would be worth thinking towards the future, what we can do for illnesses that we see very commonly in these populations. There may be treatment regimens that we haven’t really considered until now. You could hypothesize that in the next couple of years, if we have an influenza breakout, that we should be providing some prehospital antiviral treatment to patients, especially the ones that are at high risk.”

The study was conducted without outside funding. Dr. Sparks has received research support from Bristol-Myers Squibb and consulted for AbbVie, Amgen, Boehringer Ingelheim, Bristol-Myers Squibb, Gilead, Inova Diagnostics, Janssen, Optum, and Pfizer unrelated to this work. Dr. Bechman reported no relevant financial relationships.

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

Outpatient COVID-19 treatment with monoclonal antibodies or antiretroviral medications such as nirmatrelvir-ritonavir (Paxlovid) administered to patients with systemic autoimmune rheumatic disease led to lower odds of having severe outcomes when compared with similar patients who received no outpatient treatment in a real-world, retrospective analysis of cases.

The investigators found that there were nine hospitalizations or deaths (2.1%) among 426 patients who received outpatient treatment, compared with 49 (17.6%) among 278 who did not receive outpatient treatment, yielding an odds ratio of 0.12 (95% confidence interval, 0.05-0.25), after adjusting for age, sex, race, comorbidities, and kidney function. The study was published in Lancet Rheumatology.

“Across the board, there was a really strong association with receiving outpatient treatment and lower risk of severe COVID-19,” senior author Jeffrey A. Sparks, MD, MMSc, assistant professor of medicine, Harvard Medical School and Brigham and Women’s Hospital, Boston, said in an interview. “It is pretty powerful evidence that, in this high-risk group, that treatment still matters related to preventing severe COVID. We found almost all patients who had severe COVID-19, either hospitalized or who had died, were in the untreated group.”
 

Early outpatient treatment an important tool in patients with rheumatic disease

Dr. Sparks noted that he and his coinvestigators conducted the study because the benefit of outpatient COVID-19 treatments in individuals with systemic autoimmune rheumatic disease was not adequately determined in clinical trials because they had infrequent enrollment of such patients.

The analysis included 704 patients with a mean age of 58.4 years who were seen at Mass General Brigham Integrated Health Care System, a multicenter health care system that includes 14 hospitals and primary care or specialty outpatient centers in the Boston area. A majority were female (76%) and White (84%). Nearly half had rheumatoid arthritis. Of the 704, 426 (61%) received outpatient treatment, which included nirmatrelvir-ritonavir (n = 307), monoclonal antibodies (n = 105), molnupiravir (n = 5), remdesivir (n = 3), and combination treatment (n = 6).

The findings underline the need to individualize approaches to outpatient treatment in those who test positive for SARS-CoV-2 to fend off severe COVID-19, according to Dr. Sparks. “It seems if you are vaccinated and in the general population that you are way less likely to have severe COVID-19 in the current environment, but that doesn’t necessarily apply to some high-risk groups like patients on immunosuppression. There are still patients at risk of severe COVID-19, and some of them are in this group of rheumatic patients. This should be part of the discussion related to deciding whether or not to treat.”

Dr. Sparks noted that vaccination against COVID-19 confers protection against developing severe COVID-19 in patients with rheumatic disease as it does in the general population, but patients with rheumatic diseases remain at increased risk for severe presentation. “Certainly, the vaccines really help our patients too, but there’s still a bit of a gap between the risk for our patients with rheumatic diseases and the general population” in developing severe COVID-19.

Dr. Sparks said he hopes the results represent a “call to action” that even among vaccinated patients there are still some who have poor outcomes, and that early outpatient treatment appears to be an important tool in the fight against poor outcomes from SARS-CoV-2 infection.
 

COVID-19 rebound

The study also reported on the phenomenon of COVID-19 rebound (recurrence of symptoms and test positivity after regimen completion) after oral outpatient SARS-CoV-2 treatment. “This [COVID-19 rebound] is a downside to treatment,” he said. COVID rebound was not infrequent: A total of 25 (8%) of 318 patients who received oral outpatient treatment had documented COVID-19 rebound.

“It was reassuring because we found no one who had rebound progressed to have severe COVID-19,” Dr. Sparks said. “On the other hand, [rebound] happened pretty frequently in our data, as 8% of patients are documented to have it.”

Dr. Sparks said he and coinvestigators speculate that more patients in the cohort may have experienced COVID-19 rebound but did not communicate this to their health care providers, and, as such, it was not documented in the medical record. The potential development of COVID-19 rebound “is something to counsel your patients about.” COVID-19 rebound is a phenomenon that is being most commonly observed with nirmatrelvir-ritonavir as outpatient treatment.
 

Possible confounding factors in study

Katie Bechman, MBChB, clinical lecturer in rheumatology at King’s College London, who coauthored an accompanying editorial about the study and its findings, pointed out that the study is limited by its observational design.

“With any study that looks at the efficacy of treatment, especially in an observational cohort, you’re going to have to consider the unmeasured confounding and the difference between these two groups,” Dr. Bechman said. “I know that they did try to adjust for that in this study, but there’s always going to be factors that we can’t [control for]. That is something that needs to be considered. I think that’s always something we need to consider when we’re looking at observational data.”

In lieu of a randomized, controlled trial, Dr. Bechman noted that the study and its associated findings serve as “the best data we have,” and she described the results as “very informative and positive.”

She added that the large number of patients represents a strength of the study, as does the robust method employed for identifying which patients had COVID-19.

The learnings from this study with respect to outpatient treatment can be applied to more common illnesses that patients with rheumatic disease may develop, such as the flu, according to Dr. Bechman.

“One of the positive aspects from this pandemic is that we’ve learned a huge amount about how best to treat certain viruses and prevent them in patients,” she said. “It would be worth thinking towards the future, what we can do for illnesses that we see very commonly in these populations. There may be treatment regimens that we haven’t really considered until now. You could hypothesize that in the next couple of years, if we have an influenza breakout, that we should be providing some prehospital antiviral treatment to patients, especially the ones that are at high risk.”

The study was conducted without outside funding. Dr. Sparks has received research support from Bristol-Myers Squibb and consulted for AbbVie, Amgen, Boehringer Ingelheim, Bristol-Myers Squibb, Gilead, Inova Diagnostics, Janssen, Optum, and Pfizer unrelated to this work. Dr. Bechman reported no relevant financial relationships.

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

Outpatient COVID-19 treatment with monoclonal antibodies or antiretroviral medications such as nirmatrelvir-ritonavir (Paxlovid) administered to patients with systemic autoimmune rheumatic disease led to lower odds of having severe outcomes when compared with similar patients who received no outpatient treatment in a real-world, retrospective analysis of cases.

The investigators found that there were nine hospitalizations or deaths (2.1%) among 426 patients who received outpatient treatment, compared with 49 (17.6%) among 278 who did not receive outpatient treatment, yielding an odds ratio of 0.12 (95% confidence interval, 0.05-0.25), after adjusting for age, sex, race, comorbidities, and kidney function. The study was published in Lancet Rheumatology.

“Across the board, there was a really strong association with receiving outpatient treatment and lower risk of severe COVID-19,” senior author Jeffrey A. Sparks, MD, MMSc, assistant professor of medicine, Harvard Medical School and Brigham and Women’s Hospital, Boston, said in an interview. “It is pretty powerful evidence that, in this high-risk group, that treatment still matters related to preventing severe COVID. We found almost all patients who had severe COVID-19, either hospitalized or who had died, were in the untreated group.”
 

Early outpatient treatment an important tool in patients with rheumatic disease

Dr. Sparks noted that he and his coinvestigators conducted the study because the benefit of outpatient COVID-19 treatments in individuals with systemic autoimmune rheumatic disease was not adequately determined in clinical trials because they had infrequent enrollment of such patients.

The analysis included 704 patients with a mean age of 58.4 years who were seen at Mass General Brigham Integrated Health Care System, a multicenter health care system that includes 14 hospitals and primary care or specialty outpatient centers in the Boston area. A majority were female (76%) and White (84%). Nearly half had rheumatoid arthritis. Of the 704, 426 (61%) received outpatient treatment, which included nirmatrelvir-ritonavir (n = 307), monoclonal antibodies (n = 105), molnupiravir (n = 5), remdesivir (n = 3), and combination treatment (n = 6).

The findings underline the need to individualize approaches to outpatient treatment in those who test positive for SARS-CoV-2 to fend off severe COVID-19, according to Dr. Sparks. “It seems if you are vaccinated and in the general population that you are way less likely to have severe COVID-19 in the current environment, but that doesn’t necessarily apply to some high-risk groups like patients on immunosuppression. There are still patients at risk of severe COVID-19, and some of them are in this group of rheumatic patients. This should be part of the discussion related to deciding whether or not to treat.”

Dr. Sparks noted that vaccination against COVID-19 confers protection against developing severe COVID-19 in patients with rheumatic disease as it does in the general population, but patients with rheumatic diseases remain at increased risk for severe presentation. “Certainly, the vaccines really help our patients too, but there’s still a bit of a gap between the risk for our patients with rheumatic diseases and the general population” in developing severe COVID-19.

Dr. Sparks said he hopes the results represent a “call to action” that even among vaccinated patients there are still some who have poor outcomes, and that early outpatient treatment appears to be an important tool in the fight against poor outcomes from SARS-CoV-2 infection.
 

COVID-19 rebound

The study also reported on the phenomenon of COVID-19 rebound (recurrence of symptoms and test positivity after regimen completion) after oral outpatient SARS-CoV-2 treatment. “This [COVID-19 rebound] is a downside to treatment,” he said. COVID rebound was not infrequent: A total of 25 (8%) of 318 patients who received oral outpatient treatment had documented COVID-19 rebound.

“It was reassuring because we found no one who had rebound progressed to have severe COVID-19,” Dr. Sparks said. “On the other hand, [rebound] happened pretty frequently in our data, as 8% of patients are documented to have it.”

Dr. Sparks said he and coinvestigators speculate that more patients in the cohort may have experienced COVID-19 rebound but did not communicate this to their health care providers, and, as such, it was not documented in the medical record. The potential development of COVID-19 rebound “is something to counsel your patients about.” COVID-19 rebound is a phenomenon that is being most commonly observed with nirmatrelvir-ritonavir as outpatient treatment.
 

Possible confounding factors in study

Katie Bechman, MBChB, clinical lecturer in rheumatology at King’s College London, who coauthored an accompanying editorial about the study and its findings, pointed out that the study is limited by its observational design.

“With any study that looks at the efficacy of treatment, especially in an observational cohort, you’re going to have to consider the unmeasured confounding and the difference between these two groups,” Dr. Bechman said. “I know that they did try to adjust for that in this study, but there’s always going to be factors that we can’t [control for]. That is something that needs to be considered. I think that’s always something we need to consider when we’re looking at observational data.”

In lieu of a randomized, controlled trial, Dr. Bechman noted that the study and its associated findings serve as “the best data we have,” and she described the results as “very informative and positive.”

She added that the large number of patients represents a strength of the study, as does the robust method employed for identifying which patients had COVID-19.

The learnings from this study with respect to outpatient treatment can be applied to more common illnesses that patients with rheumatic disease may develop, such as the flu, according to Dr. Bechman.

“One of the positive aspects from this pandemic is that we’ve learned a huge amount about how best to treat certain viruses and prevent them in patients,” she said. “It would be worth thinking towards the future, what we can do for illnesses that we see very commonly in these populations. There may be treatment regimens that we haven’t really considered until now. You could hypothesize that in the next couple of years, if we have an influenza breakout, that we should be providing some prehospital antiviral treatment to patients, especially the ones that are at high risk.”

The study was conducted without outside funding. Dr. Sparks has received research support from Bristol-Myers Squibb and consulted for AbbVie, Amgen, Boehringer Ingelheim, Bristol-Myers Squibb, Gilead, Inova Diagnostics, Janssen, Optum, and Pfizer unrelated to this work. Dr. Bechman reported no relevant financial relationships.

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

Middle-aged White women who had higher levels of some breakdown products of phthalates – a class of endocrine disrupting chemicals (EDCs), or “forever chemicals,” that act as plasticizers – had a significantly greater risk of developing type 2 diabetes over a 6-year period compared with other similar women.

However, this association was not seen among Black or Asian middle-aged women.

These findings from the Study of Women’s Health Across the Nation – Multipollutant Study (SWAN-MPS), by Mia Q. Peng, PhD, MPH, and colleagues, have been published online in the Journal of Clinical Endocrinology & Metabolism.

“Overall, our study has added some evidence to support the potential diabetogenic effects of phthalates, but it also highlights that much is still unknown about the metabolic effects of these chemicals,” the group noted.

“The apparent racial/ethnic differences in the associations between phthalates and incident diabetes should be investigated in future studies,” they cautioned.

Recruiting younger participants and observing them longer, they suggested, “will also help us understand the effects of phthalates on different stages of the diabetogenic process, including whether body fat gain is an important mediator.”
 

Phthalates are all around us

Low-molecular-weight phthalates are frequently added to personal care products, such as fragrance, nail polish, and some feminine hygiene products, as solvents, plasticizers, and fixatives, the researchers explained.

And high-molecular-weight phthalates are frequently added to polyvinyl chloride plastic products, such as plastic food packaging, clothing, and vinyl flooring, as plasticizers.

Phthalates have been hypothesized to contribute to the development of diabetes, but longitudinal evidence in humans was limited.

“Given widespread exposure to phthalates and the enormous costs of diabetes to individuals and societies, ongoing investments in the research on phthalates’ metabolic effects are warranted,” the researchers concluded.
 

Racial differences in phthalates and incident diabetes

“A new finding is that we observed some phthalates are associated with a higher risk of diabetes development, especially in White women [that] were not seen in Black or Asian women,” senior author Sung Kyun Park, ScD, MPH, of the University of Michigan, Ann Arbor, told this news organization.

“We were surprised to see the racial/ethnic differences,” added Dr. Peng, formerly of the University of Michigan and now at Lifecourse Epidemiology of Adiposity and Diabetes Center, University of Colorado Anschutz Medical Campus.

A possible explanation is that “compared to White women, Black women develop diabetes at a younger age and are exposed to higher levels of several phthalates,” and this study excluded women who already had diabetes by midlife, she noted.

“Although our study was conducted in a cohort of women,” Dr. Park stressed, “we hope that our findings are not interpreted that only women should be concerned of phthalates. Our findings add to the current literature that phthalates may be a potential risk factor for type 2 diabetes.

“Certain phthalates are prohibited in children’s toys and child care articles,” Dr. Peng noted, as explained by the U.S. Consumer Product Safety Commission. In addition, a bill has been introduced in Congress to ban phthalates in food contact substances.

“If phthalates are removed from plastics and other consumer products,” she cautioned, “we do have to be careful in the process to avoid replacing them with some other potentially harmful chemicals.”

A well-known example of this type of “regrettable substitution,” Dr. Park added, “is ‘BPA-free’ plastics that replaced bisphenol A with other bisphenols such as bisphenol-F (BPF) or bisphenol-S (BPS). The product has a label of ‘BPA-free’, but those replaced chemicals turned out to be equally toxic. Science is slow to determine if a new chemical introduced to the market is safe and can replace a regulated chemical.”

And studies have shown that a diet rich in meat, fat, and ultraprocessed foods is associated with increased exposures to some phthalates, especially when the foods are obtained away from home, such as fast foods, Dr. Peng observed. In addition, some phthalates are added to personal care products such as fragrance.

“As a first step,” she said, “I think reducing consumption of ultraprocessed foods packaged in plastics may help reduce phthalate exposure.”

A 2020 report from the Endocrine Society and the International Pollutants Elimination Network (IPEN), titled, “Plastics, EDCs, and Health,” summarizes research on bisphenol A, per- and polyfluoroalkyl substances (PFAS), phthalates, and other EDCs that leach from plastics. The Endocrine Society website also has a link to a 2-page summary.  
 

Levels of 12 phthalate metabolites

Previously, the researchers reported how another class of “forever chemicals,” PFAS, were associated with risk of hypertension in a 17-year follow-up of middle-aged women in the SWAN study.

In the current study, they analyzed data from 1,308 women in SWAN-MPS who had been recruited at five study sites (Oakland, Calif; Los Angeles; Detroit; Pittsburgh; and Boston).

The women were between ages 42 and 52 years in 1996-1997 and self-identified as White, Black, Chinese, or Japanese.

They did not have diabetes in 1999-2000 and had sufficient urine samples for phthalate assessment then and midway through a 6-year follow-up.

The women were a median age of 49 years in 1999-2000. About half were White, 20% were Black, 13% were Chinese, and 15% were Japanese.

Researchers analyzed levels of 12 metabolites, chosen because their parent phthalates have been widely used in industry and commerce, and exposure to these phthalates is a national biomonitoring priority.

The measured phthalates were:

Three metabolites of low-molecular-weight phthalates:

• mono-ethyl phthalate (MEP)
• mono-n-butyl phthalate (MnBP)
• mono-isobutyl phthalate (MiBP)

Four metabolites of the high-molecular-weight phthalate di(2-ethylhexyl) phthalate (DEHP), which is of particular public health interest:

• mono(2-ethylhexyl) phthalate (MEHP)
• mono(2-ethyl-5-hydroxyhexyl) phthalate (MEHHP)
• mono(2-ethyl-5-oxohexyl) phthalate (MEOHP)
• mono(2-ethyl-5-carboxypentyl) phthalate (MECPP)

Five metabolites of other high-molecular-weight phthalates:

• monobenzyl phthalate (MBzP)
• monoisononyl phthalate (MiNP)
• mono-carboxyoctyl phthalate (MCOP)
• mono-carboxy-isononyl phthalate (MCNP)
• mono(3-carboxypropyl) phthalate (MCPP)

The researchers excluded MiNP from all analyses because it was detected in less than 1% of urine samples.

The different phthalate metabolites were detected in 84.8% of samples (MEHP) to 100% of samples (MnBP and MECPP).

Women who were younger, Black, current smokers, or obese generally had higher concentrations of phthalate metabolites.

Over 6 years, 61 women developed diabetes (an incidence rate of 8.1 per 1000 person-years).

Compared with other women, those with incident diabetes had significantly higher concentrations of all phthalate metabolites except DEHP metabolites and MCPP. 

Phthalates were not associated with incident diabetes in Black or Asian women.

However, among White women, each doubling of the concentrations of MiBP, MBzP, MCOP, MCNP, and MCCP was associated with a 30% to 63% higher incidence of diabetes (HR 1.30 for MCNP; HR 1.63 for MiBP).

The SWAN study was supported by the National Institutes of Health, Department of Health & Human Services, National Institute on Aging, National Institute of Nursing Research, NIH Office of Research on Women’s Health, and SWAN Repository. The current study was supported by the National Center for Research Resources, National Center for Advancing Translational Sciences, NIH, National Institute of Environmental Health, and Centers for Disease Control and Prevention/National Institute for Occupational Safety and Health. Dr. Peng was supported by an Interdisciplinary Research Training on Health and Aging grant from the NIA. The authors have reported no relevant financial relationships.

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

Middle-aged White women who had higher levels of some breakdown products of phthalates – a class of endocrine disrupting chemicals (EDCs), or “forever chemicals,” that act as plasticizers – had a significantly greater risk of developing type 2 diabetes over a 6-year period compared with other similar women.

However, this association was not seen among Black or Asian middle-aged women.

These findings from the Study of Women’s Health Across the Nation – Multipollutant Study (SWAN-MPS), by Mia Q. Peng, PhD, MPH, and colleagues, have been published online in the Journal of Clinical Endocrinology & Metabolism.

“Overall, our study has added some evidence to support the potential diabetogenic effects of phthalates, but it also highlights that much is still unknown about the metabolic effects of these chemicals,” the group noted.

“The apparent racial/ethnic differences in the associations between phthalates and incident diabetes should be investigated in future studies,” they cautioned.

Recruiting younger participants and observing them longer, they suggested, “will also help us understand the effects of phthalates on different stages of the diabetogenic process, including whether body fat gain is an important mediator.”
 

Phthalates are all around us

Low-molecular-weight phthalates are frequently added to personal care products, such as fragrance, nail polish, and some feminine hygiene products, as solvents, plasticizers, and fixatives, the researchers explained.

And high-molecular-weight phthalates are frequently added to polyvinyl chloride plastic products, such as plastic food packaging, clothing, and vinyl flooring, as plasticizers.

Phthalates have been hypothesized to contribute to the development of diabetes, but longitudinal evidence in humans was limited.

“Given widespread exposure to phthalates and the enormous costs of diabetes to individuals and societies, ongoing investments in the research on phthalates’ metabolic effects are warranted,” the researchers concluded.
 

Racial differences in phthalates and incident diabetes

“A new finding is that we observed some phthalates are associated with a higher risk of diabetes development, especially in White women [that] were not seen in Black or Asian women,” senior author Sung Kyun Park, ScD, MPH, of the University of Michigan, Ann Arbor, told this news organization.

“We were surprised to see the racial/ethnic differences,” added Dr. Peng, formerly of the University of Michigan and now at Lifecourse Epidemiology of Adiposity and Diabetes Center, University of Colorado Anschutz Medical Campus.

A possible explanation is that “compared to White women, Black women develop diabetes at a younger age and are exposed to higher levels of several phthalates,” and this study excluded women who already had diabetes by midlife, she noted.

“Although our study was conducted in a cohort of women,” Dr. Park stressed, “we hope that our findings are not interpreted that only women should be concerned of phthalates. Our findings add to the current literature that phthalates may be a potential risk factor for type 2 diabetes.

“Certain phthalates are prohibited in children’s toys and child care articles,” Dr. Peng noted, as explained by the U.S. Consumer Product Safety Commission. In addition, a bill has been introduced in Congress to ban phthalates in food contact substances.

“If phthalates are removed from plastics and other consumer products,” she cautioned, “we do have to be careful in the process to avoid replacing them with some other potentially harmful chemicals.”

A well-known example of this type of “regrettable substitution,” Dr. Park added, “is ‘BPA-free’ plastics that replaced bisphenol A with other bisphenols such as bisphenol-F (BPF) or bisphenol-S (BPS). The product has a label of ‘BPA-free’, but those replaced chemicals turned out to be equally toxic. Science is slow to determine if a new chemical introduced to the market is safe and can replace a regulated chemical.”

And studies have shown that a diet rich in meat, fat, and ultraprocessed foods is associated with increased exposures to some phthalates, especially when the foods are obtained away from home, such as fast foods, Dr. Peng observed. In addition, some phthalates are added to personal care products such as fragrance.

“As a first step,” she said, “I think reducing consumption of ultraprocessed foods packaged in plastics may help reduce phthalate exposure.”

A 2020 report from the Endocrine Society and the International Pollutants Elimination Network (IPEN), titled, “Plastics, EDCs, and Health,” summarizes research on bisphenol A, per- and polyfluoroalkyl substances (PFAS), phthalates, and other EDCs that leach from plastics. The Endocrine Society website also has a link to a 2-page summary.  
 

Levels of 12 phthalate metabolites

Previously, the researchers reported how another class of “forever chemicals,” PFAS, were associated with risk of hypertension in a 17-year follow-up of middle-aged women in the SWAN study.

In the current study, they analyzed data from 1,308 women in SWAN-MPS who had been recruited at five study sites (Oakland, Calif; Los Angeles; Detroit; Pittsburgh; and Boston).

The women were between ages 42 and 52 years in 1996-1997 and self-identified as White, Black, Chinese, or Japanese.

They did not have diabetes in 1999-2000 and had sufficient urine samples for phthalate assessment then and midway through a 6-year follow-up.

The women were a median age of 49 years in 1999-2000. About half were White, 20% were Black, 13% were Chinese, and 15% were Japanese.

Researchers analyzed levels of 12 metabolites, chosen because their parent phthalates have been widely used in industry and commerce, and exposure to these phthalates is a national biomonitoring priority.

The measured phthalates were:

Three metabolites of low-molecular-weight phthalates:

• mono-ethyl phthalate (MEP)
• mono-n-butyl phthalate (MnBP)
• mono-isobutyl phthalate (MiBP)

Four metabolites of the high-molecular-weight phthalate di(2-ethylhexyl) phthalate (DEHP), which is of particular public health interest:

• mono(2-ethylhexyl) phthalate (MEHP)
• mono(2-ethyl-5-hydroxyhexyl) phthalate (MEHHP)
• mono(2-ethyl-5-oxohexyl) phthalate (MEOHP)
• mono(2-ethyl-5-carboxypentyl) phthalate (MECPP)

Five metabolites of other high-molecular-weight phthalates:

• monobenzyl phthalate (MBzP)
• monoisononyl phthalate (MiNP)
• mono-carboxyoctyl phthalate (MCOP)
• mono-carboxy-isononyl phthalate (MCNP)
• mono(3-carboxypropyl) phthalate (MCPP)

The researchers excluded MiNP from all analyses because it was detected in less than 1% of urine samples.

The different phthalate metabolites were detected in 84.8% of samples (MEHP) to 100% of samples (MnBP and MECPP).

Women who were younger, Black, current smokers, or obese generally had higher concentrations of phthalate metabolites.

Over 6 years, 61 women developed diabetes (an incidence rate of 8.1 per 1000 person-years).

Compared with other women, those with incident diabetes had significantly higher concentrations of all phthalate metabolites except DEHP metabolites and MCPP. 

Phthalates were not associated with incident diabetes in Black or Asian women.

However, among White women, each doubling of the concentrations of MiBP, MBzP, MCOP, MCNP, and MCCP was associated with a 30% to 63% higher incidence of diabetes (HR 1.30 for MCNP; HR 1.63 for MiBP).

The SWAN study was supported by the National Institutes of Health, Department of Health & Human Services, National Institute on Aging, National Institute of Nursing Research, NIH Office of Research on Women’s Health, and SWAN Repository. The current study was supported by the National Center for Research Resources, National Center for Advancing Translational Sciences, NIH, National Institute of Environmental Health, and Centers for Disease Control and Prevention/National Institute for Occupational Safety and Health. Dr. Peng was supported by an Interdisciplinary Research Training on Health and Aging grant from the NIA. The authors have reported no relevant financial relationships.

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

Middle-aged White women who had higher levels of some breakdown products of phthalates – a class of endocrine disrupting chemicals (EDCs), or “forever chemicals,” that act as plasticizers – had a significantly greater risk of developing type 2 diabetes over a 6-year period compared with other similar women.

However, this association was not seen among Black or Asian middle-aged women.

These findings from the Study of Women’s Health Across the Nation – Multipollutant Study (SWAN-MPS), by Mia Q. Peng, PhD, MPH, and colleagues, have been published online in the Journal of Clinical Endocrinology & Metabolism.

“Overall, our study has added some evidence to support the potential diabetogenic effects of phthalates, but it also highlights that much is still unknown about the metabolic effects of these chemicals,” the group noted.

“The apparent racial/ethnic differences in the associations between phthalates and incident diabetes should be investigated in future studies,” they cautioned.

Recruiting younger participants and observing them longer, they suggested, “will also help us understand the effects of phthalates on different stages of the diabetogenic process, including whether body fat gain is an important mediator.”
 

Phthalates are all around us

Low-molecular-weight phthalates are frequently added to personal care products, such as fragrance, nail polish, and some feminine hygiene products, as solvents, plasticizers, and fixatives, the researchers explained.

And high-molecular-weight phthalates are frequently added to polyvinyl chloride plastic products, such as plastic food packaging, clothing, and vinyl flooring, as plasticizers.

Phthalates have been hypothesized to contribute to the development of diabetes, but longitudinal evidence in humans was limited.

“Given widespread exposure to phthalates and the enormous costs of diabetes to individuals and societies, ongoing investments in the research on phthalates’ metabolic effects are warranted,” the researchers concluded.
 

Racial differences in phthalates and incident diabetes

“A new finding is that we observed some phthalates are associated with a higher risk of diabetes development, especially in White women [that] were not seen in Black or Asian women,” senior author Sung Kyun Park, ScD, MPH, of the University of Michigan, Ann Arbor, told this news organization.

“We were surprised to see the racial/ethnic differences,” added Dr. Peng, formerly of the University of Michigan and now at Lifecourse Epidemiology of Adiposity and Diabetes Center, University of Colorado Anschutz Medical Campus.

A possible explanation is that “compared to White women, Black women develop diabetes at a younger age and are exposed to higher levels of several phthalates,” and this study excluded women who already had diabetes by midlife, she noted.

“Although our study was conducted in a cohort of women,” Dr. Park stressed, “we hope that our findings are not interpreted that only women should be concerned of phthalates. Our findings add to the current literature that phthalates may be a potential risk factor for type 2 diabetes.

“Certain phthalates are prohibited in children’s toys and child care articles,” Dr. Peng noted, as explained by the U.S. Consumer Product Safety Commission. In addition, a bill has been introduced in Congress to ban phthalates in food contact substances.

“If phthalates are removed from plastics and other consumer products,” she cautioned, “we do have to be careful in the process to avoid replacing them with some other potentially harmful chemicals.”

A well-known example of this type of “regrettable substitution,” Dr. Park added, “is ‘BPA-free’ plastics that replaced bisphenol A with other bisphenols such as bisphenol-F (BPF) or bisphenol-S (BPS). The product has a label of ‘BPA-free’, but those replaced chemicals turned out to be equally toxic. Science is slow to determine if a new chemical introduced to the market is safe and can replace a regulated chemical.”

And studies have shown that a diet rich in meat, fat, and ultraprocessed foods is associated with increased exposures to some phthalates, especially when the foods are obtained away from home, such as fast foods, Dr. Peng observed. In addition, some phthalates are added to personal care products such as fragrance.

“As a first step,” she said, “I think reducing consumption of ultraprocessed foods packaged in plastics may help reduce phthalate exposure.”

A 2020 report from the Endocrine Society and the International Pollutants Elimination Network (IPEN), titled, “Plastics, EDCs, and Health,” summarizes research on bisphenol A, per- and polyfluoroalkyl substances (PFAS), phthalates, and other EDCs that leach from plastics. The Endocrine Society website also has a link to a 2-page summary.  
 

Levels of 12 phthalate metabolites

Previously, the researchers reported how another class of “forever chemicals,” PFAS, were associated with risk of hypertension in a 17-year follow-up of middle-aged women in the SWAN study.

In the current study, they analyzed data from 1,308 women in SWAN-MPS who had been recruited at five study sites (Oakland, Calif; Los Angeles; Detroit; Pittsburgh; and Boston).

The women were between ages 42 and 52 years in 1996-1997 and self-identified as White, Black, Chinese, or Japanese.

They did not have diabetes in 1999-2000 and had sufficient urine samples for phthalate assessment then and midway through a 6-year follow-up.

The women were a median age of 49 years in 1999-2000. About half were White, 20% were Black, 13% were Chinese, and 15% were Japanese.

Researchers analyzed levels of 12 metabolites, chosen because their parent phthalates have been widely used in industry and commerce, and exposure to these phthalates is a national biomonitoring priority.

The measured phthalates were:

Three metabolites of low-molecular-weight phthalates:

• mono-ethyl phthalate (MEP)
• mono-n-butyl phthalate (MnBP)
• mono-isobutyl phthalate (MiBP)

Four metabolites of the high-molecular-weight phthalate di(2-ethylhexyl) phthalate (DEHP), which is of particular public health interest:

• mono(2-ethylhexyl) phthalate (MEHP)
• mono(2-ethyl-5-hydroxyhexyl) phthalate (MEHHP)
• mono(2-ethyl-5-oxohexyl) phthalate (MEOHP)
• mono(2-ethyl-5-carboxypentyl) phthalate (MECPP)

Five metabolites of other high-molecular-weight phthalates:

• monobenzyl phthalate (MBzP)
• monoisononyl phthalate (MiNP)
• mono-carboxyoctyl phthalate (MCOP)
• mono-carboxy-isononyl phthalate (MCNP)
• mono(3-carboxypropyl) phthalate (MCPP)

The researchers excluded MiNP from all analyses because it was detected in less than 1% of urine samples.

The different phthalate metabolites were detected in 84.8% of samples (MEHP) to 100% of samples (MnBP and MECPP).

Women who were younger, Black, current smokers, or obese generally had higher concentrations of phthalate metabolites.

Over 6 years, 61 women developed diabetes (an incidence rate of 8.1 per 1000 person-years).

Compared with other women, those with incident diabetes had significantly higher concentrations of all phthalate metabolites except DEHP metabolites and MCPP. 

Phthalates were not associated with incident diabetes in Black or Asian women.

However, among White women, each doubling of the concentrations of MiBP, MBzP, MCOP, MCNP, and MCCP was associated with a 30% to 63% higher incidence of diabetes (HR 1.30 for MCNP; HR 1.63 for MiBP).

The SWAN study was supported by the National Institutes of Health, Department of Health & Human Services, National Institute on Aging, National Institute of Nursing Research, NIH Office of Research on Women’s Health, and SWAN Repository. The current study was supported by the National Center for Research Resources, National Center for Advancing Translational Sciences, NIH, National Institute of Environmental Health, and Centers for Disease Control and Prevention/National Institute for Occupational Safety and Health. Dr. Peng was supported by an Interdisciplinary Research Training on Health and Aging grant from the NIA. The authors have reported no relevant financial relationships.

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

In the STROKE AF study, among patients who had a stroke presumably caused by atherosclerosis, the rate of atrial fibrillation (AFib) was almost 22% at 3 years, as detected by continuous monitoring.

The 3-year results from the study were presented by Lee H. Schwamm, MD, of Massachusetts General Hospital, Boston, at the International Stroke Conference presented by the American Stroke Association, a division of the American Heart Association.

Dr. Schwamm said the high rate of AFib detection in this study suggests that continuous monitoring for AFib should be considered for a larger population of stroke patients, rather than just those with cryptogenic stroke.

“We found a much higher rate of AF[ib] than we expected in this population of patients who have had an atherosclerotic stroke,” Dr. Schwamm said in an interview.

“These AF[ib] occurrences were found by a device, so they are known as ‘device-documented AF[ib].’ The patient is not generally aware of symptoms, but 67% of the AF[ib] episodes lasted for more than 1 hour, showing that this is not trivial AF[ib]. This is meaningful AF[ib],” he said.

Dr. Schwamm said the major question is whether these cases of AFib that are detected with a device warrant treatment with anticoagulation. He noted that, in this study, clinicians decided to provide anticoagulation to 70%-80% of patients in whom AFib was detected.

“If we think it deserves treatment, then we have to look for it. And if we care about finding AF[ib], we have no choice but to monitor continuously,” he said.

“If this data doesn’t convince you that AF[ib] is present in this population, I don’t think any data will. Because it is consistent, it accumulates over time and looks remarkably similar to a set of data that we have all become very comfortable with – the CRYSTAL-AF study in patients with cryptogenic stroke,” he stated.

Dr. Schwamm noted that the STROKE AF trial was not based on the cause of the index stroke; rather, it was asking whether there are risk factors that could contribute to the 25% stroke recurrence rate in this population that are not covered in current guidelines.

“I’m really trying to move away from the anchor that I was trained in, which is to figure out the cause of the last stroke to help decide how to prevent the next stroke, towards more of a probabilistic model – of what is all the information I have at my disposal and how do I act on it to prevent the next stroke? We have to start thinking differently about building models for future stroke risk and determining therapy based on that,” he commented.
 

Changing practice

ISC 2023 program chair Tudor Jovin, MD, Cooper Neurological Institute, Cherry Hill, N.J., and moderator of the session at which the results were presented, discussed the STROKE AF results in a highlights presentation.

“To me as clinician, these results are even more relevant than those at 12 months,” Dr. Jovin said. “The lesson I took is that AF[ib] is even more prevalent than we thought. The burden of AF[ib] is significant in these patients, and it doesn’t seem to be limited to a particular time. These are very thought-provoking results which are going to change clinical practice. I think the threshold for long-term monitoring will be lower.”

Comoderator Lauren Sansing, MD, Yale University, New Haven, Conn., added: “This study shows that the longer we monitor, the more patients with AF[ib] we are likely to pick up. And because in two-thirds of patients with AF[ib], it lasted longer than 1 hour, I do believe this was clinically relevant AF[ib]. The question now is, do we monitor everyone? I think it puts the burden on us to search for AF[ib] in our patients.”

In his presentation, Dr. Schwamm explained that, on the basis of the CRYSTAL-AF study, insertable cardiac monitoring devices are frequently used to identify poststroke AFib in patients with cryptogenic stroke. In the device-monitored arm of that study, AFib was detected in 12.4% of patients over 12 months versus 2.0% in the control arm.

“However, we don’t know how often AF[ib] is detected in other presumed stroke types – largely those due to atherosclerosis,” he said.

He pointed out that, at present, long-term monitoring post stroke for the detection of AFib is not currently recommended for patients with ischemic stroke, owing to presumed small-vessel occlusion or large-artery atherosclerosis.

“In these patients, we are not suspecting AF[ib] because we believe the cause of the stroke was not embolic. But we wanted to investigate what the AF[ib] risk is in these patients, who often have multiple stroke risk factors,” he said.

The trial enrolled 496 patients at 33 centers in the United States. Eligible patients were aged 60 years or older or aged 50-59 years with at least one additional stroke risk factor and had an index stroke that was attributed to large-artery or small-vessel disease. Patients were randomly assigned either to continuous monitoring with the Reveal LINQ device (Medtronic) or to the control arm following site-specific standard of care for AFib detection.

Dr. Schwamm noted that usual care for these patients normally involves monitoring for just a few days while in hospital, but this picks up less than 5% of AFib occurrences.

Baseline characteristics of patients in the STROKE AF study showed that the enrolled population was at high risk for stroke, with a CHADSVASC score of 5. But the index strokes were generally small; the median National Institutes of Health Stroke Scale score was 2.

Results at 12 months, reported 2 years ago, showed a 12.5% incidence of AFib with continuous monitoring versus 1.8% with standard of care (hazard ratio, 7.7; P < .001), rates similar to that found in the CRYSTAL-AF study.

By 3 years, the rate of detected AFib had risen to 21.7% in the continuous monitoring arm versus 2.4% in the control arm (HR, 10.0; P < .001).

“At 12 months, we were seven times more likely to detect AF[ib] with continuous monitoring in these patients, and by 3 years, it was 10 times more likely that AF would be detected with continuous monitoring. I think we’ve settled the question of the best way to find AF[ib] in these patients – it is with an inserted device,” Dr. Schwamm said.

“We have also shown that this is not a transient rise in AFib after the stroke which then diminishes over the next few years. It is a continuous and progressive detection of AF[ib].”

Dr. Schwamm pointed out that 88% of the recorded AFib episodes were asymptomatic. “So relying on patients self-reporting symptoms when deciding who to monitor is unreliable and not a sensible strategy.”

The median time to the first adjudicated AFib episode at 12-month follow-up was 99 days; at the 3-year follow-up, it was 284 days.

“This shows that 30 days of monitoring with an external patch is not sufficient to exclude the presence of AF[ib]. And this really argues for a strategy of immediate insertion of cardiac monitor placement if your goal is to look for AF[ib],” Dr. Schwamm commented.
 

Is this clinically relevant AFib?

Dr. Schwamm acknowledged that there is a question of whether device-detected AFib should be thought about in the same way as clinically detected AFib with respect to future stroke risk.

He noted that, in this study, 67.4% of patients for whom AFib was detected by continuous monitoring (31 of 46 patients) had at least one episode of AFib that lasted more than 1 hour.

“This is not a trivial little squiggle of something on an EKG which then goes away. This is of significant duration that the cardiologist who adjudicated these rhythm strips felt confident was AF[ib].”

He added: “AF[ib] lasting more than 1 hour crosses the threshold for most practitioners I know to feel confident in treating the patient with anticoagulation. If it was symptomatic AF, this wouldn’t even be a question.”

Dr. Schwamm made the point that device-detected A AFib F has been accepted as worthy of treatment in patients after cryptogenic stroke.

“If we are honest with ourselves and if we have no hesitation in starting anticoagulation in a patient with cryptogenic stroke who has had device-detected AF 6 months later, should we decide that if the patient has had a lacunar stroke, we can ignore that same device-detected fibrillation?”

He put forward the idea that, at some level, all stroke is cryptogenic. “We never know for sure what the cause was. We have hypotheses, we have associations, but we don’t really know. So how much should we weigh that presumptive etiology in terms of how we interpret a rhythm disturbance of fibrillation?”

When looking for predictors of AFib in this study, the investigators found that patients were more likely to have an episode of AFib detected if they had one of the four following risk factors: congestive heart failure, left atrial enlargement, obesity, or QRS prolongation.

“In patients with any one of those four factors, 30% of those had device-detected AF[ib]. These are same predictors of AF[ib] that we are all accustomed to,” Dr. Schwamm said.
 

Shared decision-making

Dr. Schwamm said in an interview that, in his practice, for these patients, the decision as to whether to use continuous monitoring is made with the patient through shared decision-making.

“We discuss the chance that they could have AF[ib], and I suggest that it might be worth looking for it, but there are factors to be considered. There is a cost to the device, and reimbursement may depend on insurance coverage. Also, some patients may have strong feelings about having the chip implanted in their body.”

He says implanting the chip is easy. “It takes longer to check in at the front desk than to put the device in. It is injected under the skin. It just needs two stitches and a Band-Aid.” The device connects with a smartphone, and the results are interpreted by a cardiologist.

Dr. Schwamm pointed out that the optimal antithrombotic regimen for these patients in whom AFib is detected remains uncertain and should be the focus of future research.

“Do we just stick to antiplatelet therapy or advance to anticoagulation? In moving to an anticoagulant, are we providing less effective prevention for the atherosclerotic stroke risk at the expense of reducing the AF[ib]-related stroke risk? That may be a reasonable trade-off because we know the disability from AF[ib]-associated stroke is much higher.

“Or perhaps the optimal therapy is aspirin plus low-dose anticoagulant? Or left atrial appendage closure and an antiplatelet for patients at a higher risk of bleeding?” he said. “These are the really important questions we need to start asking.”

He added that he hopes a future study will address these questions, but he noted that it would have to be a large study, that it would have to first identify these patients and then randomly assign them to anticoagulation or to no treatment. “That is quite a major undertaking.”

In the highlights presentation, Dr. Jovin said he was uncertain of which of these patients in whom AFib is detected would benefit from anticoagulation. He said he would also like to see a randomized trial on this. But he added: “This would be challenging, as there is the issue of whether there would be equipoise to allow us to randomize to a placebo.”

Dr. Sansing agreed. “I think it would be a hard sell. I would have to think carefully about randomizing a patient to anticoagulation therapy or no therapy who has been found to have AF[ib].”

Dr. Schwamm noted that the current STROKE-AF study was not designed or powered to detect differences in stroke recurrence rates and that there was no difference in stroke recurrence rates between the two arms. There was also no randomization with regard to treatment; choice of medication was left to the discretion of the treating physician.

But he noted that only for 3 of the 34 patients with recurrent stroke in the continuous-monitor arm was AFib detected prior to the recurrent stroke, and only one of those three was receiving anticoagulation at the time of the recurrent stroke.

“These strokes were occurring in patients who did not have device-detected AF[ib],” Dr. Schwamm said. “This is because the population in this study were loaded with stroke risk factors and are at risk of recurrent stroke, but we don’t have the opportunity in this study to really understand the significance of the recurrent strokes.”

The STROKE AF trial was funded by Medtronic. Dr. Schwamm is a consultant to Medtronic.

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