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Overburdened: Health care workers more likely to die by suicide
This transcript has been edited for clarity.
Welcome to Impact Factor, your weekly dose of commentary on a new medical study.
If you run into a health care provider these days and ask, “How are you doing?” you’re likely to get a response like this one: “You know, hanging in there.” You smile and move on. But it may be time to go a step further. If you ask that next question – “No, really, how are you doing?” Well, you might need to carve out some time.
It’s been a rough few years for those of us in the health care professions. Our lives, dominated by COVID-related concerns at home, were equally dominated by COVID concerns at work. On the job, there were fewer and fewer of us around as exploitation and COVID-related stressors led doctors, nurses, and others to leave the profession entirely or take early retirement. Even now, I’m not sure we’ve recovered. Staffing in the hospitals is still a huge problem, and the persistence of impersonal meetings via teleconference – which not only prevent any sort of human connection but, audaciously, run from one into another without a break – robs us of even the subtle joy of walking from one hallway to another for 5 minutes of reflection before sitting down to view the next hastily cobbled together PowerPoint.
I’m speaking in generalities, of course.
I’m talking about how bad things are now because, in truth, they’ve never been great. And that may be why health care workers – people with jobs focused on serving others – are nevertheless at substantially increased risk for suicide.
Analyses through the years have shown that physicians tend to have higher rates of death from suicide than the general population. There are reasons for this that may not entirely be because of work-related stress. Doctors’ suicide attempts are more often lethal – we know what is likely to work, after all.
And, according to this paper in JAMA, it is those people who may be suffering most of all.
The study is a nationally representative sample based on the 2008 American Community Survey. Records were linked to the National Death Index through 2019.
Survey respondents were classified into five categories of health care worker, as you can see here. And 1,666,000 non–health care workers served as the control group.
Let’s take a look at the numbers.
I’m showing you age- and sex-standardized rates of death from suicide, starting with non–health care workers. In this study, physicians have similar rates of death from suicide to the general population. Nurses have higher rates, but health care support workers – nurses’ aides, home health aides – have rates nearly twice that of the general population.
Only social and behavioral health workers had rates lower than those in the general population, perhaps because they know how to access life-saving resources.
Of course, these groups differ in a lot of ways – education and income, for example. But even after adjustment for these factors as well as for sex, race, and marital status, the results persist. The only group with even a trend toward lower suicide rates are social and behavioral health workers.
There has been much hand-wringing about rates of physician suicide in the past. It is still a very real problem. But this paper finally highlights that there is a lot more to the health care profession than physicians. It’s time we acknowledge and support the people in our profession who seem to be suffering more than any of us: the aides, the techs, the support staff – the overworked and underpaid who have to deal with all the stresses that physicians like me face and then some.
There’s more to suicide risk than just your job; I know that. Family matters. Relationships matter. Medical and psychiatric illnesses matter. But to ignore this problem when it is right here, in our own house so to speak, can’t continue.
Might I suggest we start by asking someone in our profession – whether doctor, nurse, aide, or tech – how they are doing. How they are really doing. And when we are done listening, we use what we hear to advocate for real change.
Dr. Wilson is associate professor of medicine and public health and director of the Clinical and Translational Research Accelerator at Yale University, New Haven, Conn. He has disclosed no relevant financial relationships.
A version of this article appeared on Medscape.com.
This transcript has been edited for clarity.
Welcome to Impact Factor, your weekly dose of commentary on a new medical study.
If you run into a health care provider these days and ask, “How are you doing?” you’re likely to get a response like this one: “You know, hanging in there.” You smile and move on. But it may be time to go a step further. If you ask that next question – “No, really, how are you doing?” Well, you might need to carve out some time.
It’s been a rough few years for those of us in the health care professions. Our lives, dominated by COVID-related concerns at home, were equally dominated by COVID concerns at work. On the job, there were fewer and fewer of us around as exploitation and COVID-related stressors led doctors, nurses, and others to leave the profession entirely or take early retirement. Even now, I’m not sure we’ve recovered. Staffing in the hospitals is still a huge problem, and the persistence of impersonal meetings via teleconference – which not only prevent any sort of human connection but, audaciously, run from one into another without a break – robs us of even the subtle joy of walking from one hallway to another for 5 minutes of reflection before sitting down to view the next hastily cobbled together PowerPoint.
I’m speaking in generalities, of course.
I’m talking about how bad things are now because, in truth, they’ve never been great. And that may be why health care workers – people with jobs focused on serving others – are nevertheless at substantially increased risk for suicide.
Analyses through the years have shown that physicians tend to have higher rates of death from suicide than the general population. There are reasons for this that may not entirely be because of work-related stress. Doctors’ suicide attempts are more often lethal – we know what is likely to work, after all.
And, according to this paper in JAMA, it is those people who may be suffering most of all.
The study is a nationally representative sample based on the 2008 American Community Survey. Records were linked to the National Death Index through 2019.
Survey respondents were classified into five categories of health care worker, as you can see here. And 1,666,000 non–health care workers served as the control group.
Let’s take a look at the numbers.
I’m showing you age- and sex-standardized rates of death from suicide, starting with non–health care workers. In this study, physicians have similar rates of death from suicide to the general population. Nurses have higher rates, but health care support workers – nurses’ aides, home health aides – have rates nearly twice that of the general population.
Only social and behavioral health workers had rates lower than those in the general population, perhaps because they know how to access life-saving resources.
Of course, these groups differ in a lot of ways – education and income, for example. But even after adjustment for these factors as well as for sex, race, and marital status, the results persist. The only group with even a trend toward lower suicide rates are social and behavioral health workers.
There has been much hand-wringing about rates of physician suicide in the past. It is still a very real problem. But this paper finally highlights that there is a lot more to the health care profession than physicians. It’s time we acknowledge and support the people in our profession who seem to be suffering more than any of us: the aides, the techs, the support staff – the overworked and underpaid who have to deal with all the stresses that physicians like me face and then some.
There’s more to suicide risk than just your job; I know that. Family matters. Relationships matter. Medical and psychiatric illnesses matter. But to ignore this problem when it is right here, in our own house so to speak, can’t continue.
Might I suggest we start by asking someone in our profession – whether doctor, nurse, aide, or tech – how they are doing. How they are really doing. And when we are done listening, we use what we hear to advocate for real change.
Dr. Wilson is associate professor of medicine and public health and director of the Clinical and Translational Research Accelerator at Yale University, New Haven, Conn. He has disclosed no relevant financial relationships.
A version of this article appeared on Medscape.com.
This transcript has been edited for clarity.
Welcome to Impact Factor, your weekly dose of commentary on a new medical study.
If you run into a health care provider these days and ask, “How are you doing?” you’re likely to get a response like this one: “You know, hanging in there.” You smile and move on. But it may be time to go a step further. If you ask that next question – “No, really, how are you doing?” Well, you might need to carve out some time.
It’s been a rough few years for those of us in the health care professions. Our lives, dominated by COVID-related concerns at home, were equally dominated by COVID concerns at work. On the job, there were fewer and fewer of us around as exploitation and COVID-related stressors led doctors, nurses, and others to leave the profession entirely or take early retirement. Even now, I’m not sure we’ve recovered. Staffing in the hospitals is still a huge problem, and the persistence of impersonal meetings via teleconference – which not only prevent any sort of human connection but, audaciously, run from one into another without a break – robs us of even the subtle joy of walking from one hallway to another for 5 minutes of reflection before sitting down to view the next hastily cobbled together PowerPoint.
I’m speaking in generalities, of course.
I’m talking about how bad things are now because, in truth, they’ve never been great. And that may be why health care workers – people with jobs focused on serving others – are nevertheless at substantially increased risk for suicide.
Analyses through the years have shown that physicians tend to have higher rates of death from suicide than the general population. There are reasons for this that may not entirely be because of work-related stress. Doctors’ suicide attempts are more often lethal – we know what is likely to work, after all.
And, according to this paper in JAMA, it is those people who may be suffering most of all.
The study is a nationally representative sample based on the 2008 American Community Survey. Records were linked to the National Death Index through 2019.
Survey respondents were classified into five categories of health care worker, as you can see here. And 1,666,000 non–health care workers served as the control group.
Let’s take a look at the numbers.
I’m showing you age- and sex-standardized rates of death from suicide, starting with non–health care workers. In this study, physicians have similar rates of death from suicide to the general population. Nurses have higher rates, but health care support workers – nurses’ aides, home health aides – have rates nearly twice that of the general population.
Only social and behavioral health workers had rates lower than those in the general population, perhaps because they know how to access life-saving resources.
Of course, these groups differ in a lot of ways – education and income, for example. But even after adjustment for these factors as well as for sex, race, and marital status, the results persist. The only group with even a trend toward lower suicide rates are social and behavioral health workers.
There has been much hand-wringing about rates of physician suicide in the past. It is still a very real problem. But this paper finally highlights that there is a lot more to the health care profession than physicians. It’s time we acknowledge and support the people in our profession who seem to be suffering more than any of us: the aides, the techs, the support staff – the overworked and underpaid who have to deal with all the stresses that physicians like me face and then some.
There’s more to suicide risk than just your job; I know that. Family matters. Relationships matter. Medical and psychiatric illnesses matter. But to ignore this problem when it is right here, in our own house so to speak, can’t continue.
Might I suggest we start by asking someone in our profession – whether doctor, nurse, aide, or tech – how they are doing. How they are really doing. And when we are done listening, we use what we hear to advocate for real change.
Dr. Wilson is associate professor of medicine and public health and director of the Clinical and Translational Research Accelerator at Yale University, New Haven, Conn. He has disclosed no relevant financial relationships.
A version of this article appeared on Medscape.com.
The unappreciated healing power of awe
I’m standing atop the Klein Matterhorn, staring out at the Alps, their moonscape peaks forming a jagged, terrifying, glorious white horizon.
I am small. But the emotions are huge. The joy: I get to be a part of all this today. The fear: It could kill me. More than kill me, it could consume me.
That’s what I always used to feel when training in Zermatt, Switzerland.
I was lucky. As a former U.S. Ski Team athlete, I was regularly able to experience such magnificent scenescapes – and feel the tactile insanity of it, too, the rise and fall of helicopters or trams taking us up the mountains, the slicing, frigid air at the summit, and the lurking on-edge feeling that you, tiny human, really aren’t meant to be standing where you are standing.
“Awe puts things in perspective,” said Craig Anderson, PhD, postdoctoral scholar at Washington University at St. Louis, and researcher of emotions and behavior. “It’s about feeling connected with people and part of the larger collective – and that makes it okay to feel small.”
Our modern world is at odds with awe. We tend to shrink into our daily lives, our problems, our devices, and the real-time emotional reactions to those things, especially anger.
It doesn’t have to be that way.
‘In the upper reaches of pleasure and on the boundary of fear’
That’s how New York University ethical leadership professor Jonathan Haidt, PhD, and psychology professor Dacher Keltner, PhD, of the University of California, Berkeley, defined awe in a seminal report from 2003.
The feeling is composed of two elements: perceived vastness (sensing something larger than ourselves) and accommodation (our need to process and understand that vastness). The researchers also wrote that awe could “change the course of life in profound and permanent ways.”
“There’s a correlation between people who are happier and those who report more feelings of awe,” said David Yaden, PhD, assistant professor in the department of psychiatry and behavioral sciences at Johns Hopkins University, Baltimore, and coauthor of “The Varieties of Spiritual Experience.” “It’s unclear, though, which way the causality runs. Is it that having more awe experiences makes people happier? Or that happy people have more awe. But there is a correlation.”
One aspect about awe that’s clear: When people experience it, they report feeling more connected. And that sense of connection can lead to prosocial behavior – such as serving others and engaging with one’s community.
“Feelings of isolation are quite difficult, and we’re social creatures, so when we feel connected, we can benefit from it,” Dr. Yaden said.
A 2022 study published in the Journal of Personality and Social Psychology revealed that awe “awakens self-transcendence, which in turn invigorates pursuit of the authentic self.”
While these effects can be seen as one individual’s benefits, the researchers posited that they also lead to prosocial behaviors. Another study conducted by the same scientists showed that awe led to greater-good behavior during the pandemic, to the tune of an increased willingness to donate blood. In this study, researchers also cited a correlation between feelings of awe and increased empathy.
The awe experience
Dr. Yaden joined Dr. Keltner and other researchers in creating a scale for the “awe experience,” and found six related factors: a feeling that time momentarily slows; a sense of self-diminishment (your sense of self becomes smaller); a sense of connectedness; feeling in the presence of something grand; the need to mentally process the experience; and physical changes, like goosebumps or feeling your jaw slightly drop.
“Any of these factors can be large or small,” Dr. Yaden noted, adding that awe can also feel positive or negative. A hurricane can instill awe, for example, and the experience might not be pleasant.
However, “it’s more common for the awe experience to be positive,” Dr. Yaden said.
How your brain processes awe
Functional MRI, by which brain activity is measured through blood flow, allows researchers to see what’s happening in the brain after an awe experience.
One study that was conducted in the Netherlands and was published in the journal Human Brain Mapping suggested that certain parts of the brain that are responsible for self-reflection were less “activated” when participants watched awe-inspiring videos.
The researchers posit that the “captivating nature of awe stimuli” could be responsible for such reductions, meaning participants’ brains were geared more toward feelings of connection with others or something greater – and a smaller sense of self.
Another study published in the journal Emotion revealed a link between awe and lower levels of inflammatory cytokines, so awe could have positive and potentially protective health benefits, as well.
And of course there are the physical and emotional benefits of nature, as dozens of studies reveal. Dr. Anderson’s research in the journal Emotion showed that nature “experiences” led to more feelings of awe and that the effects of nature also reduced stress and increased well-being.
Why we turn away from awe
The world we inhabit day to day isn’t conducive to experiencing awe – indoors, seated, reacting negatively to work or social media. The mentalities we forge because of this sometimes work against experiencing any form of awe.
Example: Some people don’t like to feel small. That requires a capacity for humility.
“That [feeling] can be threatening,” noted Dr. Anderson, who earned his doctorate studying as part of Dr. Keltner’s “Project Awe” research team at UC Berkeley.
The pandemic and politics and rise in angry Internet culture also contribute. And if you didn’t know, humans have a “negativity bias.”
“Our responses to stress tend to be stronger in magnitude than responses to positive things,” Dr. Anderson said. “Browsing the Internet and seeing negative things can hijack our responses. Anger really narrows our attention on what makes us angry.”
In that sense, anger is the antithesis of awe. As Dr. Anderson puts it: Awe broadens our attention to the world and “opens us up to other people and possibilities,” he said. “When we’re faced with daily hassles, when we experience something vast and awe-inspiring, those other problems aren’t as big of a deal.”
We crave awe in spite of ourselves
An awful lot of us are out there seeking awe, knowingly or not.
People have been stopping at scenic overlooks and climbing local peaks since forever, but let’s start with record-setting attendance at the most basic and accessible source of natural awe we have in the United States: national parks.
In 2022, 68% of the 312 million visitors sought out nature-based or recreational park activities (as opposed to historical or cultural activities). Even though a rise in national park visits in 2021 and 2022 could be attributed to pandemic-related behavior (the need for social distancing and/or the desire to get outside), people were flocking to parks prior to COVID-19. In fact, 33 parks set visitation records in 2019; 12 did so in 2022.
We also seek awe in man-made spectacle. Consider annual visitor numbers for the following:
- Golden Gate Bridge: 10 million
- : 4 million
- : 1.62 million
And what about the most awe-inducing experience ever manufactured: Space tourism. While catering to the wealthy for now, flying to space allows untrained people to enjoy something only a chosen few astronauts have been able to feel: the “overview effect,” a term coined by author Frank White for the shift in perspective that occurs in people who see Earth from space.
Upon his return from his Blue Origin flight, actor William Shatner was candid about his emotional experience. “I was crying,” he told NPR. “I didn’t know what I was crying about. It was the death that I saw in space and the lifeforce that I saw coming from the planet – the blue, the beige, and the white. And I realized one was death and the other was life.”
We want awe. We want to feel this way.
Adding everyday awe to your life
It may seem counterintuitive: Most awe-inspiring places are special occasion destinations, but in truth it’s possible to find awe each day. Outdoors and indoors.
Park Rx America, led by Robert Zarr, MD, MPH, boasts a network of nearly 1500 healthcare providers ready to “prescribe” walks or time in nature as part of healing. “Our growing community of ‘nature prescribers’ incorporate nature as a treatment option for their willing clients and patients,” Dr. Zarr said.
He also noted that awe is all about where you look, including in small places.
“Something as simple as going for a walk and stopping to notice the complexity of fractal patterns in the leaves, for example, leaves me with a sense of awe,” he said. “Although difficult to measure, there is no doubt that an important part of our health is intricately linked to these daily awe-filled moments.”
Nature is not the only way. Dr. Yaden suggested that going to a museum to see art or sporting events is also a way to experience the feeling.
An unexpected source of man-made awe: Screens. A study published in Nature showed that immersive video experiences (in this case, one achieved by virtual reality) were effective in eliciting an awe response in participants.
While virtual reality isn’t ubiquitous, immersive film experiences are. IMAX screens were created for just this purpose (as anyone who saw the Avatar films in this format can attest).
Is it perfect? No. But whether you’re witnessing a birth, hiking an autumn trail bathed in orange, or letting off a little gasp when you see Oppenheimer’s nuclear explosion in 70 mm, it all counts.
Because it’s not about the thing. It’s about your openness to be awed by the thing.
I’m a little like Dr. Zarr in that I can find wonder in the crystalline structures of a snowflake. And I also love to hike and inhale expansive views. If you can get to Switzerland, and specifically Zermatt, take the old red tram to the top. I highly recommend it.
A version of this article appeared on Medscape.com.
I’m standing atop the Klein Matterhorn, staring out at the Alps, their moonscape peaks forming a jagged, terrifying, glorious white horizon.
I am small. But the emotions are huge. The joy: I get to be a part of all this today. The fear: It could kill me. More than kill me, it could consume me.
That’s what I always used to feel when training in Zermatt, Switzerland.
I was lucky. As a former U.S. Ski Team athlete, I was regularly able to experience such magnificent scenescapes – and feel the tactile insanity of it, too, the rise and fall of helicopters or trams taking us up the mountains, the slicing, frigid air at the summit, and the lurking on-edge feeling that you, tiny human, really aren’t meant to be standing where you are standing.
“Awe puts things in perspective,” said Craig Anderson, PhD, postdoctoral scholar at Washington University at St. Louis, and researcher of emotions and behavior. “It’s about feeling connected with people and part of the larger collective – and that makes it okay to feel small.”
Our modern world is at odds with awe. We tend to shrink into our daily lives, our problems, our devices, and the real-time emotional reactions to those things, especially anger.
It doesn’t have to be that way.
‘In the upper reaches of pleasure and on the boundary of fear’
That’s how New York University ethical leadership professor Jonathan Haidt, PhD, and psychology professor Dacher Keltner, PhD, of the University of California, Berkeley, defined awe in a seminal report from 2003.
The feeling is composed of two elements: perceived vastness (sensing something larger than ourselves) and accommodation (our need to process and understand that vastness). The researchers also wrote that awe could “change the course of life in profound and permanent ways.”
“There’s a correlation between people who are happier and those who report more feelings of awe,” said David Yaden, PhD, assistant professor in the department of psychiatry and behavioral sciences at Johns Hopkins University, Baltimore, and coauthor of “The Varieties of Spiritual Experience.” “It’s unclear, though, which way the causality runs. Is it that having more awe experiences makes people happier? Or that happy people have more awe. But there is a correlation.”
One aspect about awe that’s clear: When people experience it, they report feeling more connected. And that sense of connection can lead to prosocial behavior – such as serving others and engaging with one’s community.
“Feelings of isolation are quite difficult, and we’re social creatures, so when we feel connected, we can benefit from it,” Dr. Yaden said.
A 2022 study published in the Journal of Personality and Social Psychology revealed that awe “awakens self-transcendence, which in turn invigorates pursuit of the authentic self.”
While these effects can be seen as one individual’s benefits, the researchers posited that they also lead to prosocial behaviors. Another study conducted by the same scientists showed that awe led to greater-good behavior during the pandemic, to the tune of an increased willingness to donate blood. In this study, researchers also cited a correlation between feelings of awe and increased empathy.
The awe experience
Dr. Yaden joined Dr. Keltner and other researchers in creating a scale for the “awe experience,” and found six related factors: a feeling that time momentarily slows; a sense of self-diminishment (your sense of self becomes smaller); a sense of connectedness; feeling in the presence of something grand; the need to mentally process the experience; and physical changes, like goosebumps or feeling your jaw slightly drop.
“Any of these factors can be large or small,” Dr. Yaden noted, adding that awe can also feel positive or negative. A hurricane can instill awe, for example, and the experience might not be pleasant.
However, “it’s more common for the awe experience to be positive,” Dr. Yaden said.
How your brain processes awe
Functional MRI, by which brain activity is measured through blood flow, allows researchers to see what’s happening in the brain after an awe experience.
One study that was conducted in the Netherlands and was published in the journal Human Brain Mapping suggested that certain parts of the brain that are responsible for self-reflection were less “activated” when participants watched awe-inspiring videos.
The researchers posit that the “captivating nature of awe stimuli” could be responsible for such reductions, meaning participants’ brains were geared more toward feelings of connection with others or something greater – and a smaller sense of self.
Another study published in the journal Emotion revealed a link between awe and lower levels of inflammatory cytokines, so awe could have positive and potentially protective health benefits, as well.
And of course there are the physical and emotional benefits of nature, as dozens of studies reveal. Dr. Anderson’s research in the journal Emotion showed that nature “experiences” led to more feelings of awe and that the effects of nature also reduced stress and increased well-being.
Why we turn away from awe
The world we inhabit day to day isn’t conducive to experiencing awe – indoors, seated, reacting negatively to work or social media. The mentalities we forge because of this sometimes work against experiencing any form of awe.
Example: Some people don’t like to feel small. That requires a capacity for humility.
“That [feeling] can be threatening,” noted Dr. Anderson, who earned his doctorate studying as part of Dr. Keltner’s “Project Awe” research team at UC Berkeley.
The pandemic and politics and rise in angry Internet culture also contribute. And if you didn’t know, humans have a “negativity bias.”
“Our responses to stress tend to be stronger in magnitude than responses to positive things,” Dr. Anderson said. “Browsing the Internet and seeing negative things can hijack our responses. Anger really narrows our attention on what makes us angry.”
In that sense, anger is the antithesis of awe. As Dr. Anderson puts it: Awe broadens our attention to the world and “opens us up to other people and possibilities,” he said. “When we’re faced with daily hassles, when we experience something vast and awe-inspiring, those other problems aren’t as big of a deal.”
We crave awe in spite of ourselves
An awful lot of us are out there seeking awe, knowingly or not.
People have been stopping at scenic overlooks and climbing local peaks since forever, but let’s start with record-setting attendance at the most basic and accessible source of natural awe we have in the United States: national parks.
In 2022, 68% of the 312 million visitors sought out nature-based or recreational park activities (as opposed to historical or cultural activities). Even though a rise in national park visits in 2021 and 2022 could be attributed to pandemic-related behavior (the need for social distancing and/or the desire to get outside), people were flocking to parks prior to COVID-19. In fact, 33 parks set visitation records in 2019; 12 did so in 2022.
We also seek awe in man-made spectacle. Consider annual visitor numbers for the following:
- Golden Gate Bridge: 10 million
- : 4 million
- : 1.62 million
And what about the most awe-inducing experience ever manufactured: Space tourism. While catering to the wealthy for now, flying to space allows untrained people to enjoy something only a chosen few astronauts have been able to feel: the “overview effect,” a term coined by author Frank White for the shift in perspective that occurs in people who see Earth from space.
Upon his return from his Blue Origin flight, actor William Shatner was candid about his emotional experience. “I was crying,” he told NPR. “I didn’t know what I was crying about. It was the death that I saw in space and the lifeforce that I saw coming from the planet – the blue, the beige, and the white. And I realized one was death and the other was life.”
We want awe. We want to feel this way.
Adding everyday awe to your life
It may seem counterintuitive: Most awe-inspiring places are special occasion destinations, but in truth it’s possible to find awe each day. Outdoors and indoors.
Park Rx America, led by Robert Zarr, MD, MPH, boasts a network of nearly 1500 healthcare providers ready to “prescribe” walks or time in nature as part of healing. “Our growing community of ‘nature prescribers’ incorporate nature as a treatment option for their willing clients and patients,” Dr. Zarr said.
He also noted that awe is all about where you look, including in small places.
“Something as simple as going for a walk and stopping to notice the complexity of fractal patterns in the leaves, for example, leaves me with a sense of awe,” he said. “Although difficult to measure, there is no doubt that an important part of our health is intricately linked to these daily awe-filled moments.”
Nature is not the only way. Dr. Yaden suggested that going to a museum to see art or sporting events is also a way to experience the feeling.
An unexpected source of man-made awe: Screens. A study published in Nature showed that immersive video experiences (in this case, one achieved by virtual reality) were effective in eliciting an awe response in participants.
While virtual reality isn’t ubiquitous, immersive film experiences are. IMAX screens were created for just this purpose (as anyone who saw the Avatar films in this format can attest).
Is it perfect? No. But whether you’re witnessing a birth, hiking an autumn trail bathed in orange, or letting off a little gasp when you see Oppenheimer’s nuclear explosion in 70 mm, it all counts.
Because it’s not about the thing. It’s about your openness to be awed by the thing.
I’m a little like Dr. Zarr in that I can find wonder in the crystalline structures of a snowflake. And I also love to hike and inhale expansive views. If you can get to Switzerland, and specifically Zermatt, take the old red tram to the top. I highly recommend it.
A version of this article appeared on Medscape.com.
I’m standing atop the Klein Matterhorn, staring out at the Alps, their moonscape peaks forming a jagged, terrifying, glorious white horizon.
I am small. But the emotions are huge. The joy: I get to be a part of all this today. The fear: It could kill me. More than kill me, it could consume me.
That’s what I always used to feel when training in Zermatt, Switzerland.
I was lucky. As a former U.S. Ski Team athlete, I was regularly able to experience such magnificent scenescapes – and feel the tactile insanity of it, too, the rise and fall of helicopters or trams taking us up the mountains, the slicing, frigid air at the summit, and the lurking on-edge feeling that you, tiny human, really aren’t meant to be standing where you are standing.
“Awe puts things in perspective,” said Craig Anderson, PhD, postdoctoral scholar at Washington University at St. Louis, and researcher of emotions and behavior. “It’s about feeling connected with people and part of the larger collective – and that makes it okay to feel small.”
Our modern world is at odds with awe. We tend to shrink into our daily lives, our problems, our devices, and the real-time emotional reactions to those things, especially anger.
It doesn’t have to be that way.
‘In the upper reaches of pleasure and on the boundary of fear’
That’s how New York University ethical leadership professor Jonathan Haidt, PhD, and psychology professor Dacher Keltner, PhD, of the University of California, Berkeley, defined awe in a seminal report from 2003.
The feeling is composed of two elements: perceived vastness (sensing something larger than ourselves) and accommodation (our need to process and understand that vastness). The researchers also wrote that awe could “change the course of life in profound and permanent ways.”
“There’s a correlation between people who are happier and those who report more feelings of awe,” said David Yaden, PhD, assistant professor in the department of psychiatry and behavioral sciences at Johns Hopkins University, Baltimore, and coauthor of “The Varieties of Spiritual Experience.” “It’s unclear, though, which way the causality runs. Is it that having more awe experiences makes people happier? Or that happy people have more awe. But there is a correlation.”
One aspect about awe that’s clear: When people experience it, they report feeling more connected. And that sense of connection can lead to prosocial behavior – such as serving others and engaging with one’s community.
“Feelings of isolation are quite difficult, and we’re social creatures, so when we feel connected, we can benefit from it,” Dr. Yaden said.
A 2022 study published in the Journal of Personality and Social Psychology revealed that awe “awakens self-transcendence, which in turn invigorates pursuit of the authentic self.”
While these effects can be seen as one individual’s benefits, the researchers posited that they also lead to prosocial behaviors. Another study conducted by the same scientists showed that awe led to greater-good behavior during the pandemic, to the tune of an increased willingness to donate blood. In this study, researchers also cited a correlation between feelings of awe and increased empathy.
The awe experience
Dr. Yaden joined Dr. Keltner and other researchers in creating a scale for the “awe experience,” and found six related factors: a feeling that time momentarily slows; a sense of self-diminishment (your sense of self becomes smaller); a sense of connectedness; feeling in the presence of something grand; the need to mentally process the experience; and physical changes, like goosebumps or feeling your jaw slightly drop.
“Any of these factors can be large or small,” Dr. Yaden noted, adding that awe can also feel positive or negative. A hurricane can instill awe, for example, and the experience might not be pleasant.
However, “it’s more common for the awe experience to be positive,” Dr. Yaden said.
How your brain processes awe
Functional MRI, by which brain activity is measured through blood flow, allows researchers to see what’s happening in the brain after an awe experience.
One study that was conducted in the Netherlands and was published in the journal Human Brain Mapping suggested that certain parts of the brain that are responsible for self-reflection were less “activated” when participants watched awe-inspiring videos.
The researchers posit that the “captivating nature of awe stimuli” could be responsible for such reductions, meaning participants’ brains were geared more toward feelings of connection with others or something greater – and a smaller sense of self.
Another study published in the journal Emotion revealed a link between awe and lower levels of inflammatory cytokines, so awe could have positive and potentially protective health benefits, as well.
And of course there are the physical and emotional benefits of nature, as dozens of studies reveal. Dr. Anderson’s research in the journal Emotion showed that nature “experiences” led to more feelings of awe and that the effects of nature also reduced stress and increased well-being.
Why we turn away from awe
The world we inhabit day to day isn’t conducive to experiencing awe – indoors, seated, reacting negatively to work or social media. The mentalities we forge because of this sometimes work against experiencing any form of awe.
Example: Some people don’t like to feel small. That requires a capacity for humility.
“That [feeling] can be threatening,” noted Dr. Anderson, who earned his doctorate studying as part of Dr. Keltner’s “Project Awe” research team at UC Berkeley.
The pandemic and politics and rise in angry Internet culture also contribute. And if you didn’t know, humans have a “negativity bias.”
“Our responses to stress tend to be stronger in magnitude than responses to positive things,” Dr. Anderson said. “Browsing the Internet and seeing negative things can hijack our responses. Anger really narrows our attention on what makes us angry.”
In that sense, anger is the antithesis of awe. As Dr. Anderson puts it: Awe broadens our attention to the world and “opens us up to other people and possibilities,” he said. “When we’re faced with daily hassles, when we experience something vast and awe-inspiring, those other problems aren’t as big of a deal.”
We crave awe in spite of ourselves
An awful lot of us are out there seeking awe, knowingly or not.
People have been stopping at scenic overlooks and climbing local peaks since forever, but let’s start with record-setting attendance at the most basic and accessible source of natural awe we have in the United States: national parks.
In 2022, 68% of the 312 million visitors sought out nature-based or recreational park activities (as opposed to historical or cultural activities). Even though a rise in national park visits in 2021 and 2022 could be attributed to pandemic-related behavior (the need for social distancing and/or the desire to get outside), people were flocking to parks prior to COVID-19. In fact, 33 parks set visitation records in 2019; 12 did so in 2022.
We also seek awe in man-made spectacle. Consider annual visitor numbers for the following:
- Golden Gate Bridge: 10 million
- : 4 million
- : 1.62 million
And what about the most awe-inducing experience ever manufactured: Space tourism. While catering to the wealthy for now, flying to space allows untrained people to enjoy something only a chosen few astronauts have been able to feel: the “overview effect,” a term coined by author Frank White for the shift in perspective that occurs in people who see Earth from space.
Upon his return from his Blue Origin flight, actor William Shatner was candid about his emotional experience. “I was crying,” he told NPR. “I didn’t know what I was crying about. It was the death that I saw in space and the lifeforce that I saw coming from the planet – the blue, the beige, and the white. And I realized one was death and the other was life.”
We want awe. We want to feel this way.
Adding everyday awe to your life
It may seem counterintuitive: Most awe-inspiring places are special occasion destinations, but in truth it’s possible to find awe each day. Outdoors and indoors.
Park Rx America, led by Robert Zarr, MD, MPH, boasts a network of nearly 1500 healthcare providers ready to “prescribe” walks or time in nature as part of healing. “Our growing community of ‘nature prescribers’ incorporate nature as a treatment option for their willing clients and patients,” Dr. Zarr said.
He also noted that awe is all about where you look, including in small places.
“Something as simple as going for a walk and stopping to notice the complexity of fractal patterns in the leaves, for example, leaves me with a sense of awe,” he said. “Although difficult to measure, there is no doubt that an important part of our health is intricately linked to these daily awe-filled moments.”
Nature is not the only way. Dr. Yaden suggested that going to a museum to see art or sporting events is also a way to experience the feeling.
An unexpected source of man-made awe: Screens. A study published in Nature showed that immersive video experiences (in this case, one achieved by virtual reality) were effective in eliciting an awe response in participants.
While virtual reality isn’t ubiquitous, immersive film experiences are. IMAX screens were created for just this purpose (as anyone who saw the Avatar films in this format can attest).
Is it perfect? No. But whether you’re witnessing a birth, hiking an autumn trail bathed in orange, or letting off a little gasp when you see Oppenheimer’s nuclear explosion in 70 mm, it all counts.
Because it’s not about the thing. It’s about your openness to be awed by the thing.
I’m a little like Dr. Zarr in that I can find wonder in the crystalline structures of a snowflake. And I also love to hike and inhale expansive views. If you can get to Switzerland, and specifically Zermatt, take the old red tram to the top. I highly recommend it.
A version of this article appeared on Medscape.com.
Gastroenterology Data Trends 2023
GI&Hepatology News and the American Gastroenterological Association present the 2023 issue of Gastroenterology Data Trends, a special report on hot topics in gastroenterology told through original infographics and visual storytelling.
In this issue:
- Gastroenterology and Climate Change: Assessing and Mitigating Impacts
Swapna Gayam, MD, FACG - MASLD/MASH and Weight Loss
Arpan Mohanty, MD, MSc - Digital Tools in the Management of IBS/Functional GI Disorders
Eric D. Shah, MD, MBA, FACG - Long COVID and the Gastrointestinal System: Emerging Evidence
Daniel E. Freedberg, MD, MS, and Lin Chang, MD, AGAF - Germline Genetic Testing in CRC: Implications for Familial and Population-Based Testing
Fay Kastrinos, MD, MPH - Evolution of Targeted Therapies for C difficile
Sahil Khanna, MBBS, MS, FACG, AGAF - Harnessing the Power of AI to Enhance Endoscopy: Promises and Pitfalls
Eugenia Uche-Anya, MD, MPH - The Evolving Role of Surgery for IBD
Julie K.M. Thacker, MD, FACS, FASCRS
GI&Hepatology News and the American Gastroenterological Association present the 2023 issue of Gastroenterology Data Trends, a special report on hot topics in gastroenterology told through original infographics and visual storytelling.
In this issue:
- Gastroenterology and Climate Change: Assessing and Mitigating Impacts
Swapna Gayam, MD, FACG - MASLD/MASH and Weight Loss
Arpan Mohanty, MD, MSc - Digital Tools in the Management of IBS/Functional GI Disorders
Eric D. Shah, MD, MBA, FACG - Long COVID and the Gastrointestinal System: Emerging Evidence
Daniel E. Freedberg, MD, MS, and Lin Chang, MD, AGAF - Germline Genetic Testing in CRC: Implications for Familial and Population-Based Testing
Fay Kastrinos, MD, MPH - Evolution of Targeted Therapies for C difficile
Sahil Khanna, MBBS, MS, FACG, AGAF - Harnessing the Power of AI to Enhance Endoscopy: Promises and Pitfalls
Eugenia Uche-Anya, MD, MPH - The Evolving Role of Surgery for IBD
Julie K.M. Thacker, MD, FACS, FASCRS
GI&Hepatology News and the American Gastroenterological Association present the 2023 issue of Gastroenterology Data Trends, a special report on hot topics in gastroenterology told through original infographics and visual storytelling.
In this issue:
- Gastroenterology and Climate Change: Assessing and Mitigating Impacts
Swapna Gayam, MD, FACG - MASLD/MASH and Weight Loss
Arpan Mohanty, MD, MSc - Digital Tools in the Management of IBS/Functional GI Disorders
Eric D. Shah, MD, MBA, FACG - Long COVID and the Gastrointestinal System: Emerging Evidence
Daniel E. Freedberg, MD, MS, and Lin Chang, MD, AGAF - Germline Genetic Testing in CRC: Implications for Familial and Population-Based Testing
Fay Kastrinos, MD, MPH - Evolution of Targeted Therapies for C difficile
Sahil Khanna, MBBS, MS, FACG, AGAF - Harnessing the Power of AI to Enhance Endoscopy: Promises and Pitfalls
Eugenia Uche-Anya, MD, MPH - The Evolving Role of Surgery for IBD
Julie K.M. Thacker, MD, FACS, FASCRS
Cancer incidence has increased in patients under age 50
Recent data suggest that the incidence of early-onset cancer, defined as cancer diagnosed in people younger than 50 years, is on the rise in several countries. Two recent studies confirm this trend, including one published in early September in BMJ Oncology that presents worldwide data on the matter.
Early-onset cancer
Among them, early-onset breast cancer had the highest incidence (13.7) and mortality (3.5 per 100k) rates in the global population.
Tracheal (nasopharyngeal) and prostate cancer have increased the most rapidly since 1990, with annual percentage changes estimated at 2.28% and 2.23%, respectively. At the other end of the scale, cases of early-onset liver cancer dropped by around 2.88% year on year.
Increase in deaths
There were more than a million (1.06) cancer deaths among patients younger than 50 years in 2019, which is an increase of slightly less than 28% compared with the figures from 1990.
The top four early-onset cancers with the highest mortality and disability-adjusted life year rates among young adults in 2019 were early-onset breast; tracheal, bronchus and lung; stomach; and colorectal cancers. The mortality rates of early-onset kidney cancer and ovarian cancer showed the fastest increasing trends.
“These results contrast with a more traditionally held view of ‘typical’ cancers in adults aged under 50 years,” Ashleigh C. Hamilton, MD, an academic clinical lecturer, and Helen G. Coleman, PhD, a professor, both at Queen’s University Belfast’s Centre for Public Health in the United Kingdom, explained in an accompanying editorial. An important aspect of this study is that it tackled the issue of increasing cancer rates among young people on a global scale, they added. Here, the researchers made use of 2019 data from the Global Burden of Disease database for 29 types of cancer in 204 countries and regions.
Industrialized countries
The highest rates of early-onset cancer in 2019 were reported in North America, Australasia, and Western Europe. However, the burden of early-onset cancers in low- to middle-income countries is also of major public health concern. The highest death rates among patients younger than 50 years were in Oceania, Eastern Europe, and Central Asia.
In low- or middle-income regions, early-onset cancer had a significantly higher impact on women than on men in terms of mortality and disease burden, the researchers reported.
On the basis of trends observed over the past 30 years, they estimate that the global incidence and deaths of early-onset cancer would increase by 31% and 21% in 2030, respectively, with 40-year-olds being the most affected.
Hypotheses and limitations
How can this increase in the incidence of cancer among patients younger than 50 years be explained? For the authors, genetic factors likely play a role. But dietary risk factors (diet high in red meat, low in fruits, high in sodium, and low in milk, etc.), alcohol consumption, and tobacco use are the main risk factors underlying early-onset cancers in patients under age 50 years. Physical inactivity, excess weight, and hyperglycemia were shown to be contributing factors.
The researchers recognized several limitations to their conclusions. First, the accuracy of Global Burden of Disease data was compromised by the quality of cancer registry data in different countries, which may have led to underreporting and underdiagnosis. Also, questions remain about how screening and early exposure to environmental factors can affect the observed trends.
For the authors of the editorial, “Full understanding of the reasons driving the observed trends remains elusive, although lifestyle factors are likely contributing, and novel areas of research such as antibiotic usage, the gut microbiome, outdoor air pollution, and early life exposures are being explored.”
They concluded, “Prevention and early detection measures are urgently required, along with identifying optimal treatment strategies for early-onset cancers, which should include a holistic approach addressing the unique supportive care needs of younger patients.”
The authors added, “It is worth exploring whether early screening and prevention programs for early-onset cancer should be expanded to include individuals aged 40-44 and 45-49, but further systematic studies and randomized trials are necessary to make a definitive determination.”
Trend in the United States
Between 2010 and 2019, although the incidence of cancer dropped in people over age 50 years in the United States, a study published in JAMA Network Open in August showed that the standardized incidence rate of early-onset cancer increased overall. More specifically, the rate increased in women but decreased in men.
In 2019, most early-onset cancer cases involved breast cancer. Between 2010 and 2019, gastrointestinal cancers saw the fastest rise. And among gastrointestinal cancers, those whose incidence rate increased the most rapidly were those affecting the appendix, the intrahepatic bile ducts, and the pancreas.
This article was translated from the Medscape French Edition. A version of this article appeared on Medscape.com.
Recent data suggest that the incidence of early-onset cancer, defined as cancer diagnosed in people younger than 50 years, is on the rise in several countries. Two recent studies confirm this trend, including one published in early September in BMJ Oncology that presents worldwide data on the matter.
Early-onset cancer
Among them, early-onset breast cancer had the highest incidence (13.7) and mortality (3.5 per 100k) rates in the global population.
Tracheal (nasopharyngeal) and prostate cancer have increased the most rapidly since 1990, with annual percentage changes estimated at 2.28% and 2.23%, respectively. At the other end of the scale, cases of early-onset liver cancer dropped by around 2.88% year on year.
Increase in deaths
There were more than a million (1.06) cancer deaths among patients younger than 50 years in 2019, which is an increase of slightly less than 28% compared with the figures from 1990.
The top four early-onset cancers with the highest mortality and disability-adjusted life year rates among young adults in 2019 were early-onset breast; tracheal, bronchus and lung; stomach; and colorectal cancers. The mortality rates of early-onset kidney cancer and ovarian cancer showed the fastest increasing trends.
“These results contrast with a more traditionally held view of ‘typical’ cancers in adults aged under 50 years,” Ashleigh C. Hamilton, MD, an academic clinical lecturer, and Helen G. Coleman, PhD, a professor, both at Queen’s University Belfast’s Centre for Public Health in the United Kingdom, explained in an accompanying editorial. An important aspect of this study is that it tackled the issue of increasing cancer rates among young people on a global scale, they added. Here, the researchers made use of 2019 data from the Global Burden of Disease database for 29 types of cancer in 204 countries and regions.
Industrialized countries
The highest rates of early-onset cancer in 2019 were reported in North America, Australasia, and Western Europe. However, the burden of early-onset cancers in low- to middle-income countries is also of major public health concern. The highest death rates among patients younger than 50 years were in Oceania, Eastern Europe, and Central Asia.
In low- or middle-income regions, early-onset cancer had a significantly higher impact on women than on men in terms of mortality and disease burden, the researchers reported.
On the basis of trends observed over the past 30 years, they estimate that the global incidence and deaths of early-onset cancer would increase by 31% and 21% in 2030, respectively, with 40-year-olds being the most affected.
Hypotheses and limitations
How can this increase in the incidence of cancer among patients younger than 50 years be explained? For the authors, genetic factors likely play a role. But dietary risk factors (diet high in red meat, low in fruits, high in sodium, and low in milk, etc.), alcohol consumption, and tobacco use are the main risk factors underlying early-onset cancers in patients under age 50 years. Physical inactivity, excess weight, and hyperglycemia were shown to be contributing factors.
The researchers recognized several limitations to their conclusions. First, the accuracy of Global Burden of Disease data was compromised by the quality of cancer registry data in different countries, which may have led to underreporting and underdiagnosis. Also, questions remain about how screening and early exposure to environmental factors can affect the observed trends.
For the authors of the editorial, “Full understanding of the reasons driving the observed trends remains elusive, although lifestyle factors are likely contributing, and novel areas of research such as antibiotic usage, the gut microbiome, outdoor air pollution, and early life exposures are being explored.”
They concluded, “Prevention and early detection measures are urgently required, along with identifying optimal treatment strategies for early-onset cancers, which should include a holistic approach addressing the unique supportive care needs of younger patients.”
The authors added, “It is worth exploring whether early screening and prevention programs for early-onset cancer should be expanded to include individuals aged 40-44 and 45-49, but further systematic studies and randomized trials are necessary to make a definitive determination.”
Trend in the United States
Between 2010 and 2019, although the incidence of cancer dropped in people over age 50 years in the United States, a study published in JAMA Network Open in August showed that the standardized incidence rate of early-onset cancer increased overall. More specifically, the rate increased in women but decreased in men.
In 2019, most early-onset cancer cases involved breast cancer. Between 2010 and 2019, gastrointestinal cancers saw the fastest rise. And among gastrointestinal cancers, those whose incidence rate increased the most rapidly were those affecting the appendix, the intrahepatic bile ducts, and the pancreas.
This article was translated from the Medscape French Edition. A version of this article appeared on Medscape.com.
Recent data suggest that the incidence of early-onset cancer, defined as cancer diagnosed in people younger than 50 years, is on the rise in several countries. Two recent studies confirm this trend, including one published in early September in BMJ Oncology that presents worldwide data on the matter.
Early-onset cancer
Among them, early-onset breast cancer had the highest incidence (13.7) and mortality (3.5 per 100k) rates in the global population.
Tracheal (nasopharyngeal) and prostate cancer have increased the most rapidly since 1990, with annual percentage changes estimated at 2.28% and 2.23%, respectively. At the other end of the scale, cases of early-onset liver cancer dropped by around 2.88% year on year.
Increase in deaths
There were more than a million (1.06) cancer deaths among patients younger than 50 years in 2019, which is an increase of slightly less than 28% compared with the figures from 1990.
The top four early-onset cancers with the highest mortality and disability-adjusted life year rates among young adults in 2019 were early-onset breast; tracheal, bronchus and lung; stomach; and colorectal cancers. The mortality rates of early-onset kidney cancer and ovarian cancer showed the fastest increasing trends.
“These results contrast with a more traditionally held view of ‘typical’ cancers in adults aged under 50 years,” Ashleigh C. Hamilton, MD, an academic clinical lecturer, and Helen G. Coleman, PhD, a professor, both at Queen’s University Belfast’s Centre for Public Health in the United Kingdom, explained in an accompanying editorial. An important aspect of this study is that it tackled the issue of increasing cancer rates among young people on a global scale, they added. Here, the researchers made use of 2019 data from the Global Burden of Disease database for 29 types of cancer in 204 countries and regions.
Industrialized countries
The highest rates of early-onset cancer in 2019 were reported in North America, Australasia, and Western Europe. However, the burden of early-onset cancers in low- to middle-income countries is also of major public health concern. The highest death rates among patients younger than 50 years were in Oceania, Eastern Europe, and Central Asia.
In low- or middle-income regions, early-onset cancer had a significantly higher impact on women than on men in terms of mortality and disease burden, the researchers reported.
On the basis of trends observed over the past 30 years, they estimate that the global incidence and deaths of early-onset cancer would increase by 31% and 21% in 2030, respectively, with 40-year-olds being the most affected.
Hypotheses and limitations
How can this increase in the incidence of cancer among patients younger than 50 years be explained? For the authors, genetic factors likely play a role. But dietary risk factors (diet high in red meat, low in fruits, high in sodium, and low in milk, etc.), alcohol consumption, and tobacco use are the main risk factors underlying early-onset cancers in patients under age 50 years. Physical inactivity, excess weight, and hyperglycemia were shown to be contributing factors.
The researchers recognized several limitations to their conclusions. First, the accuracy of Global Burden of Disease data was compromised by the quality of cancer registry data in different countries, which may have led to underreporting and underdiagnosis. Also, questions remain about how screening and early exposure to environmental factors can affect the observed trends.
For the authors of the editorial, “Full understanding of the reasons driving the observed trends remains elusive, although lifestyle factors are likely contributing, and novel areas of research such as antibiotic usage, the gut microbiome, outdoor air pollution, and early life exposures are being explored.”
They concluded, “Prevention and early detection measures are urgently required, along with identifying optimal treatment strategies for early-onset cancers, which should include a holistic approach addressing the unique supportive care needs of younger patients.”
The authors added, “It is worth exploring whether early screening and prevention programs for early-onset cancer should be expanded to include individuals aged 40-44 and 45-49, but further systematic studies and randomized trials are necessary to make a definitive determination.”
Trend in the United States
Between 2010 and 2019, although the incidence of cancer dropped in people over age 50 years in the United States, a study published in JAMA Network Open in August showed that the standardized incidence rate of early-onset cancer increased overall. More specifically, the rate increased in women but decreased in men.
In 2019, most early-onset cancer cases involved breast cancer. Between 2010 and 2019, gastrointestinal cancers saw the fastest rise. And among gastrointestinal cancers, those whose incidence rate increased the most rapidly were those affecting the appendix, the intrahepatic bile ducts, and the pancreas.
This article was translated from the Medscape French Edition. A version of this article appeared on Medscape.com.
from bmj oncology
Have early-onset cancer cases soared? Not so fast, experts say
In early September, startling cancer research findings hit the news.
A study press release headline touted a “global surge” in new cancer cases among younger people over the past 3 decades.
Many major news outlets parroted the “striking” finding. “Cancer cases in under-50s worldwide up nearly 80% in 3 decades, study finds,” The Guardian reported.
The analysis, published in BMJ Oncology, plumbed data from the Global Burden of Disease 2019 study to determine changes in cancer incidence and deaths among people aged 15-49 years across 204 countries.
The team found that, between 1990 and 2019, global cancer cases in this younger group had increased by almost 80% and cancer deaths had risen by nearly 28%. The authors flagged diet, alcohol, and tobacco as “the main risk factors” underlying the early-onset cancer trend.
But
The global population has increased by 46% between 1990 and 2019, but the study calculations are “based on absolute numbers rather than age-standardized rates,” said Montserrat García-Closas, MD, MPH, PhD, professor of epidemiology at the Institute of Cancer Research, London, who weighed in on the findings via the U.K.-based Science Media Centre. That means “these numbers do not account for changes in demographics such as increases in population size or aging of the population.”
The study researchers reported 1.82 million early-onset cancer cases in 1990 and 3.26 million global cases in 2019, which led to the reported increase of 79.1%.
Similarly, the authors calculated the change in cancer deaths globally using absolute, not population or age-adjusted, numbers: 0.83 million cancer deaths in 1990 and 1.06 million in 2019 led to the reported increase of 27.7%.
But when population growth is considered, the story changes dramatically. The population-adjusted calculations indicate that the global incidence of early-onset cancers only rose about 6% over the past 30 years while cancer deaths actually fell 25% in that time, according to calculations done by Medscape using the study’s supplemental data.
Experts commenting via the BMJ website also noted the flawed calculations. “Epidemic news, but no epidemic of cancer,” Henrik Møller, MD, lead epidemiologist for the Danish Clinical Registries, and colleagues wrote, highlighting the “misleading” 79% figure. When accounting for population growth in Nordic countries, Dr. Møller and colleagues found a 1% average annual increase in the cancer incidence rate and a 2.5% decrease in the cancer mortality rate.
This news organization reached out to the study’s corresponding authors, Kefeng Ding and Xue Li, to ask why they used absolute numbers instead of population-adjusted numbers for their calculations, but they did not respond in time for publication.
In their analysis, however, the researchers did note that “the study still has several limitations” that could affect the results, such as variations in the quality and availability of data provided by different countries.
The study, for instance, compared the Solomon Islands with the other 203 nations and concluded that the Solomons had the highest age-standardized death rate for early-onset cancer (82.9 per 100,000). However, this tiny South Pacific nation, whose population is scattered across 350 islands, did not start collecting cancer data until 2008 and founded its first oncology unit in 2019.
The authors also reported the “sharpest increases” in cancer cases diagnosed between 1990 and 2019 in the United Arab Emirates (1,127.6%), Qatar (1,089.5%), and Saudi Arabia (896.0%); however, those numbers do not seem possible, given population growth during that time, and may instead reflect reporting or other changes in those countries.
Although the overarching conclusion may be misleading, some of the numbers ring true, especially for breast cancer. The researchers found that the incidence of early breast cancer increased nearly 18% – from 11.2 to 13.2 per 100,000 – between 1990 and 2019.
This increase is “consistent with what is happening” in the United Kingdom, said Stephen Duffy of Queen Mary University of London, also weighing in via the Science Media Centre. Since the United Kingdom does not routinely screen women under 50, this rise “is not due to increased diagnostic activity.”
Darren Brenner, MD, associate professor in oncology at the University of Calgary (Alta.), said in an interview he agreed that the breast cancer trends look accurate.
In a 2020 study, Brenner and colleagues found that breast cancer diagnoses in women under 40 had increased significantly between 2000 and 2015, at a rate of 0.66% per year. “Given that breast cancer at a younger age is associated with worse outcomes, the results are troubling,” Brenner and colleagues concluded at the time.
The experts commenting via Science Media Centre reported no conflicts of interest.
A version of this article first appeared on Medscape.com.
In early September, startling cancer research findings hit the news.
A study press release headline touted a “global surge” in new cancer cases among younger people over the past 3 decades.
Many major news outlets parroted the “striking” finding. “Cancer cases in under-50s worldwide up nearly 80% in 3 decades, study finds,” The Guardian reported.
The analysis, published in BMJ Oncology, plumbed data from the Global Burden of Disease 2019 study to determine changes in cancer incidence and deaths among people aged 15-49 years across 204 countries.
The team found that, between 1990 and 2019, global cancer cases in this younger group had increased by almost 80% and cancer deaths had risen by nearly 28%. The authors flagged diet, alcohol, and tobacco as “the main risk factors” underlying the early-onset cancer trend.
But
The global population has increased by 46% between 1990 and 2019, but the study calculations are “based on absolute numbers rather than age-standardized rates,” said Montserrat García-Closas, MD, MPH, PhD, professor of epidemiology at the Institute of Cancer Research, London, who weighed in on the findings via the U.K.-based Science Media Centre. That means “these numbers do not account for changes in demographics such as increases in population size or aging of the population.”
The study researchers reported 1.82 million early-onset cancer cases in 1990 and 3.26 million global cases in 2019, which led to the reported increase of 79.1%.
Similarly, the authors calculated the change in cancer deaths globally using absolute, not population or age-adjusted, numbers: 0.83 million cancer deaths in 1990 and 1.06 million in 2019 led to the reported increase of 27.7%.
But when population growth is considered, the story changes dramatically. The population-adjusted calculations indicate that the global incidence of early-onset cancers only rose about 6% over the past 30 years while cancer deaths actually fell 25% in that time, according to calculations done by Medscape using the study’s supplemental data.
Experts commenting via the BMJ website also noted the flawed calculations. “Epidemic news, but no epidemic of cancer,” Henrik Møller, MD, lead epidemiologist for the Danish Clinical Registries, and colleagues wrote, highlighting the “misleading” 79% figure. When accounting for population growth in Nordic countries, Dr. Møller and colleagues found a 1% average annual increase in the cancer incidence rate and a 2.5% decrease in the cancer mortality rate.
This news organization reached out to the study’s corresponding authors, Kefeng Ding and Xue Li, to ask why they used absolute numbers instead of population-adjusted numbers for their calculations, but they did not respond in time for publication.
In their analysis, however, the researchers did note that “the study still has several limitations” that could affect the results, such as variations in the quality and availability of data provided by different countries.
The study, for instance, compared the Solomon Islands with the other 203 nations and concluded that the Solomons had the highest age-standardized death rate for early-onset cancer (82.9 per 100,000). However, this tiny South Pacific nation, whose population is scattered across 350 islands, did not start collecting cancer data until 2008 and founded its first oncology unit in 2019.
The authors also reported the “sharpest increases” in cancer cases diagnosed between 1990 and 2019 in the United Arab Emirates (1,127.6%), Qatar (1,089.5%), and Saudi Arabia (896.0%); however, those numbers do not seem possible, given population growth during that time, and may instead reflect reporting or other changes in those countries.
Although the overarching conclusion may be misleading, some of the numbers ring true, especially for breast cancer. The researchers found that the incidence of early breast cancer increased nearly 18% – from 11.2 to 13.2 per 100,000 – between 1990 and 2019.
This increase is “consistent with what is happening” in the United Kingdom, said Stephen Duffy of Queen Mary University of London, also weighing in via the Science Media Centre. Since the United Kingdom does not routinely screen women under 50, this rise “is not due to increased diagnostic activity.”
Darren Brenner, MD, associate professor in oncology at the University of Calgary (Alta.), said in an interview he agreed that the breast cancer trends look accurate.
In a 2020 study, Brenner and colleagues found that breast cancer diagnoses in women under 40 had increased significantly between 2000 and 2015, at a rate of 0.66% per year. “Given that breast cancer at a younger age is associated with worse outcomes, the results are troubling,” Brenner and colleagues concluded at the time.
The experts commenting via Science Media Centre reported no conflicts of interest.
A version of this article first appeared on Medscape.com.
In early September, startling cancer research findings hit the news.
A study press release headline touted a “global surge” in new cancer cases among younger people over the past 3 decades.
Many major news outlets parroted the “striking” finding. “Cancer cases in under-50s worldwide up nearly 80% in 3 decades, study finds,” The Guardian reported.
The analysis, published in BMJ Oncology, plumbed data from the Global Burden of Disease 2019 study to determine changes in cancer incidence and deaths among people aged 15-49 years across 204 countries.
The team found that, between 1990 and 2019, global cancer cases in this younger group had increased by almost 80% and cancer deaths had risen by nearly 28%. The authors flagged diet, alcohol, and tobacco as “the main risk factors” underlying the early-onset cancer trend.
But
The global population has increased by 46% between 1990 and 2019, but the study calculations are “based on absolute numbers rather than age-standardized rates,” said Montserrat García-Closas, MD, MPH, PhD, professor of epidemiology at the Institute of Cancer Research, London, who weighed in on the findings via the U.K.-based Science Media Centre. That means “these numbers do not account for changes in demographics such as increases in population size or aging of the population.”
The study researchers reported 1.82 million early-onset cancer cases in 1990 and 3.26 million global cases in 2019, which led to the reported increase of 79.1%.
Similarly, the authors calculated the change in cancer deaths globally using absolute, not population or age-adjusted, numbers: 0.83 million cancer deaths in 1990 and 1.06 million in 2019 led to the reported increase of 27.7%.
But when population growth is considered, the story changes dramatically. The population-adjusted calculations indicate that the global incidence of early-onset cancers only rose about 6% over the past 30 years while cancer deaths actually fell 25% in that time, according to calculations done by Medscape using the study’s supplemental data.
Experts commenting via the BMJ website also noted the flawed calculations. “Epidemic news, but no epidemic of cancer,” Henrik Møller, MD, lead epidemiologist for the Danish Clinical Registries, and colleagues wrote, highlighting the “misleading” 79% figure. When accounting for population growth in Nordic countries, Dr. Møller and colleagues found a 1% average annual increase in the cancer incidence rate and a 2.5% decrease in the cancer mortality rate.
This news organization reached out to the study’s corresponding authors, Kefeng Ding and Xue Li, to ask why they used absolute numbers instead of population-adjusted numbers for their calculations, but they did not respond in time for publication.
In their analysis, however, the researchers did note that “the study still has several limitations” that could affect the results, such as variations in the quality and availability of data provided by different countries.
The study, for instance, compared the Solomon Islands with the other 203 nations and concluded that the Solomons had the highest age-standardized death rate for early-onset cancer (82.9 per 100,000). However, this tiny South Pacific nation, whose population is scattered across 350 islands, did not start collecting cancer data until 2008 and founded its first oncology unit in 2019.
The authors also reported the “sharpest increases” in cancer cases diagnosed between 1990 and 2019 in the United Arab Emirates (1,127.6%), Qatar (1,089.5%), and Saudi Arabia (896.0%); however, those numbers do not seem possible, given population growth during that time, and may instead reflect reporting or other changes in those countries.
Although the overarching conclusion may be misleading, some of the numbers ring true, especially for breast cancer. The researchers found that the incidence of early breast cancer increased nearly 18% – from 11.2 to 13.2 per 100,000 – between 1990 and 2019.
This increase is “consistent with what is happening” in the United Kingdom, said Stephen Duffy of Queen Mary University of London, also weighing in via the Science Media Centre. Since the United Kingdom does not routinely screen women under 50, this rise “is not due to increased diagnostic activity.”
Darren Brenner, MD, associate professor in oncology at the University of Calgary (Alta.), said in an interview he agreed that the breast cancer trends look accurate.
In a 2020 study, Brenner and colleagues found that breast cancer diagnoses in women under 40 had increased significantly between 2000 and 2015, at a rate of 0.66% per year. “Given that breast cancer at a younger age is associated with worse outcomes, the results are troubling,” Brenner and colleagues concluded at the time.
The experts commenting via Science Media Centre reported no conflicts of interest.
A version of this article first appeared on Medscape.com.
FROM BMJ ONCOLOGY
Worm pulled from woman’s brain in case that ‘stunned’
When they started the open biopsy, surgeons didn’t know what they were going to find, but they certainly didn’t expect this.
The stringlike worm was five-sixteenths of an inch long, was alive, and wiggled.
“It stunned everyone in that operating theater,” Sanjaya Senanayake, MBBS, an associate professor of infectious disease at Australian National University, Canberra, and senior author of the case report, said in an interview. “When you operate on a brain, you don’t expect to find anything alive.”
The parasitic worm was about half the width of a dime. Helminths like it can usually be seen with the naked eye but are often found in the intestines after being transmitted by soil and infecting the gastrointestinal tract. But this one made it into a woman’s brain in a first-of-its-kind case reported in the journal Emerging Infectious Diseases).
“We weren’t suspecting a worm at all,” Dr. Senanayake said. “There was something abnormal there. Was it going to be granulomatous lesion? Was it going to be cancer? Who knows, but it needed to be biopsied, and a worm was the last thing at the back of anyone’s mind,” he said.
A year of inexplicable symptoms
The 64-year-old woman was diagnosed with pneumonia and had a high white blood cell count, low hemoglobin, high platelets, and a very high C-reactive protein of 102 mg/L.
She hadn’t fully recovered from her illness when the abdominal pain and diarrhea started. And then she had a dry cough and night sweats.
After 3 weeks of discomfort, she was admitted to the hospital. She had a history of diabetes, hypothyroidism, and depression, and doctors began looking for answers to her acute illness.
They tested for autoimmune diseases and parasitic infections and prescribed prednisolone to help ease symptoms.
But 3 weeks later, her fever and cough persisted, and she was readmitted to the hospital. Doctors ordered more tests, and her eosinophils were still high, plus there were lesions on her liver, spleen, and lungs.
But tests were negative for bacterial, fungal, and mycobacterial cultures. Her stools showed no evidence of parasites.
She was prescribed mycophenolate and then ivermectin in case her tests for roundworm were a false negative. Doctors suspected Strongyloides, but lesions remained on her spleen even as the liver and lung lesions improved.
Reducing the prednisolone dose affected respiratory symptoms, so by January 2022, a year after initial symptoms began, the medical team added the monoclonal antibody mepolizumab. But her symptoms worsened, and she developed forgetfulness and more depression.
The specimen was Ophidascaris robertsi, the intestinal roundworm typically of the carpet python. Never before seen in a human, the only other animals in its life cycle are small marsupials or mammals consumed by pythons.
A snake’s bug
Although this is the first case of an Ophidascaris infection in a human, other cases could occur, warn the doctors in their case report.
The best guess for how the patient contracted the infection was by inadvertently consuming larval eggs on wild vegetation that she collected near her home to eat. She lived near a lake known to be home to carpet pythons, so the eggs could have been on the plants she collected or on her hands or kitchen equipment.
“If you’re foraging or using native grasses or plants in recipes, it would be a good idea to cook those instead of having a salad,” Dr. Senanayake said. “That would make the chance of getting something really rare even less likely.”
It’s unclear how or why the worm, which usually stays in the gut, made its way into the patient’s brain, but her long course of immunosuppressing drugs may have played a role, the team points out. “If the normal immune barriers are reduced, then it’s easier for the parasite to move around between organ systems,” Dr. Senanayake said.
Doctors also wondered if she may have been getting re-infected when she went home between hospital admissions. After removing the worm, she received 4 weeks of treatment with albendazole to eliminate any other possible larvae in other organs, especially since Ophidascaris larvae have been known to survive for long periods – more than 4 years in laboratory rats. “The hope is that she’s been cured of this parasitic infection,” Dr. Senanayake said.
As people around the world contend with the global COVID pandemic, they might not realize that new infections are arising around the world every year, he explained.
Novel parasitic infections
“The reality is that 30 new infections appeared in the last 30 years, and three-quarters of them are zoonotic, animal infections spilling over into the human world,” Dr. Senanayake said.
Though some of that number is the result of improved surveillance and diagnostics, a real increase has been occurring as human settlements continue expanding.
“This is just a reflection of how burgeoning human populations are encroaching upon animal habitats, and we’re getting more interactions between humans and wild animals, domestic animals and wild animals, and humans and natural flora, which is increasing the risk of this type of infection being recognized,” he explained.
The Ophidascaris worm found in this instance is in other snake species in different continents around the world, too. “Awareness of this case will hopefully lead to the diagnosis and treatment of other cases,” Dr. Senanayake added.
Though it’s certainly surprising to find this particular parasite in a human, finding a zoonotic organism in a person isn’t that strange, according to Janet Foley, DVM, PhD, a professor of veterinary medicine at the University of California, Davis. This is especially true if the usual host is closely related to humans, like primates, or spends a lot of time around them, like rats.
“There are still a lot of parasites and diseases out there in wildlife that haven’t been discovered, and we don’t know the risk,” said Dr. Foley. “But still, the risk would have to be low, generally, or we would see more human cases.”
In the United States, the roundworm common in raccoon feces is Baylisascaris procyonis and can be dangerous for people. “There have been deaths in people exposed to these worms, which do seem to prefer to travel to a human brain,” Dr. Foley said.
A 2016 Centers for Disease Control and Prevention report described seven U.S. cases identified between May 2013 and December 2015, including six that caused central nervous system disease. Another case report in 2018 involved a toddler who had eaten dirt and animal feces in his backyard.
And this past June, an Emerging Infectious Diseases case report described a B. procyonis infection in a 7-year-old with autism spectrum disorder and a history of pica. He had put material in his mouth from the ground near a tree where epidemiologists later found raccoon feces.
Still, Dr. Senanayake cautions against people jumping to conclusions about parasitic infections when they experience symptoms that aren’t otherwise immediately explainable.
The typical person who develops forgetfulness, depression, and a fever probably doesn’t have a worm in their brain or need an immediate MRI, he pointed out. “There may be other cases out there, but common things happen commonly, and this is likely to be rare,” Dr. Senanayake said.
This case demonstrates the challenge in picking a course of treatment when the differential diagnoses for hypereosinophilic syndromes is so broad.
Tricky hypereosinophilic syndromes
One of those differentials for the syndromes is parasitic infections, for which treatment would be antiparasitic agents, but another differential is an autoimmune condition that would call for immunosuppression.
“Obviously, as with this case, you don’t want to give someone immunosuppressive treatment if they’ve got a parasite, so you want to look really hard for a parasite before you start them on immunosuppressive treatment for an immunological condition,” Dr. Senanayake said.
But all the blood tests for different antibodies came back negative for parasites, “and this parasite was simply difficult to find until they pulled it from her brain,” he said.
Infectious disease physicians are always looking for the unusual and exotic, Dr. Senanayake explained. But it’s important to exclude the common, easy things first, he added. It’s after exhausting all the likely culprits that “you have to start really thinking laterally and putting resources into unusual tests.”
A version of this article first appeared on Medscape.com.
When they started the open biopsy, surgeons didn’t know what they were going to find, but they certainly didn’t expect this.
The stringlike worm was five-sixteenths of an inch long, was alive, and wiggled.
“It stunned everyone in that operating theater,” Sanjaya Senanayake, MBBS, an associate professor of infectious disease at Australian National University, Canberra, and senior author of the case report, said in an interview. “When you operate on a brain, you don’t expect to find anything alive.”
The parasitic worm was about half the width of a dime. Helminths like it can usually be seen with the naked eye but are often found in the intestines after being transmitted by soil and infecting the gastrointestinal tract. But this one made it into a woman’s brain in a first-of-its-kind case reported in the journal Emerging Infectious Diseases).
“We weren’t suspecting a worm at all,” Dr. Senanayake said. “There was something abnormal there. Was it going to be granulomatous lesion? Was it going to be cancer? Who knows, but it needed to be biopsied, and a worm was the last thing at the back of anyone’s mind,” he said.
A year of inexplicable symptoms
The 64-year-old woman was diagnosed with pneumonia and had a high white blood cell count, low hemoglobin, high platelets, and a very high C-reactive protein of 102 mg/L.
She hadn’t fully recovered from her illness when the abdominal pain and diarrhea started. And then she had a dry cough and night sweats.
After 3 weeks of discomfort, she was admitted to the hospital. She had a history of diabetes, hypothyroidism, and depression, and doctors began looking for answers to her acute illness.
They tested for autoimmune diseases and parasitic infections and prescribed prednisolone to help ease symptoms.
But 3 weeks later, her fever and cough persisted, and she was readmitted to the hospital. Doctors ordered more tests, and her eosinophils were still high, plus there were lesions on her liver, spleen, and lungs.
But tests were negative for bacterial, fungal, and mycobacterial cultures. Her stools showed no evidence of parasites.
She was prescribed mycophenolate and then ivermectin in case her tests for roundworm were a false negative. Doctors suspected Strongyloides, but lesions remained on her spleen even as the liver and lung lesions improved.
Reducing the prednisolone dose affected respiratory symptoms, so by January 2022, a year after initial symptoms began, the medical team added the monoclonal antibody mepolizumab. But her symptoms worsened, and she developed forgetfulness and more depression.
The specimen was Ophidascaris robertsi, the intestinal roundworm typically of the carpet python. Never before seen in a human, the only other animals in its life cycle are small marsupials or mammals consumed by pythons.
A snake’s bug
Although this is the first case of an Ophidascaris infection in a human, other cases could occur, warn the doctors in their case report.
The best guess for how the patient contracted the infection was by inadvertently consuming larval eggs on wild vegetation that she collected near her home to eat. She lived near a lake known to be home to carpet pythons, so the eggs could have been on the plants she collected or on her hands or kitchen equipment.
“If you’re foraging or using native grasses or plants in recipes, it would be a good idea to cook those instead of having a salad,” Dr. Senanayake said. “That would make the chance of getting something really rare even less likely.”
It’s unclear how or why the worm, which usually stays in the gut, made its way into the patient’s brain, but her long course of immunosuppressing drugs may have played a role, the team points out. “If the normal immune barriers are reduced, then it’s easier for the parasite to move around between organ systems,” Dr. Senanayake said.
Doctors also wondered if she may have been getting re-infected when she went home between hospital admissions. After removing the worm, she received 4 weeks of treatment with albendazole to eliminate any other possible larvae in other organs, especially since Ophidascaris larvae have been known to survive for long periods – more than 4 years in laboratory rats. “The hope is that she’s been cured of this parasitic infection,” Dr. Senanayake said.
As people around the world contend with the global COVID pandemic, they might not realize that new infections are arising around the world every year, he explained.
Novel parasitic infections
“The reality is that 30 new infections appeared in the last 30 years, and three-quarters of them are zoonotic, animal infections spilling over into the human world,” Dr. Senanayake said.
Though some of that number is the result of improved surveillance and diagnostics, a real increase has been occurring as human settlements continue expanding.
“This is just a reflection of how burgeoning human populations are encroaching upon animal habitats, and we’re getting more interactions between humans and wild animals, domestic animals and wild animals, and humans and natural flora, which is increasing the risk of this type of infection being recognized,” he explained.
The Ophidascaris worm found in this instance is in other snake species in different continents around the world, too. “Awareness of this case will hopefully lead to the diagnosis and treatment of other cases,” Dr. Senanayake added.
Though it’s certainly surprising to find this particular parasite in a human, finding a zoonotic organism in a person isn’t that strange, according to Janet Foley, DVM, PhD, a professor of veterinary medicine at the University of California, Davis. This is especially true if the usual host is closely related to humans, like primates, or spends a lot of time around them, like rats.
“There are still a lot of parasites and diseases out there in wildlife that haven’t been discovered, and we don’t know the risk,” said Dr. Foley. “But still, the risk would have to be low, generally, or we would see more human cases.”
In the United States, the roundworm common in raccoon feces is Baylisascaris procyonis and can be dangerous for people. “There have been deaths in people exposed to these worms, which do seem to prefer to travel to a human brain,” Dr. Foley said.
A 2016 Centers for Disease Control and Prevention report described seven U.S. cases identified between May 2013 and December 2015, including six that caused central nervous system disease. Another case report in 2018 involved a toddler who had eaten dirt and animal feces in his backyard.
And this past June, an Emerging Infectious Diseases case report described a B. procyonis infection in a 7-year-old with autism spectrum disorder and a history of pica. He had put material in his mouth from the ground near a tree where epidemiologists later found raccoon feces.
Still, Dr. Senanayake cautions against people jumping to conclusions about parasitic infections when they experience symptoms that aren’t otherwise immediately explainable.
The typical person who develops forgetfulness, depression, and a fever probably doesn’t have a worm in their brain or need an immediate MRI, he pointed out. “There may be other cases out there, but common things happen commonly, and this is likely to be rare,” Dr. Senanayake said.
This case demonstrates the challenge in picking a course of treatment when the differential diagnoses for hypereosinophilic syndromes is so broad.
Tricky hypereosinophilic syndromes
One of those differentials for the syndromes is parasitic infections, for which treatment would be antiparasitic agents, but another differential is an autoimmune condition that would call for immunosuppression.
“Obviously, as with this case, you don’t want to give someone immunosuppressive treatment if they’ve got a parasite, so you want to look really hard for a parasite before you start them on immunosuppressive treatment for an immunological condition,” Dr. Senanayake said.
But all the blood tests for different antibodies came back negative for parasites, “and this parasite was simply difficult to find until they pulled it from her brain,” he said.
Infectious disease physicians are always looking for the unusual and exotic, Dr. Senanayake explained. But it’s important to exclude the common, easy things first, he added. It’s after exhausting all the likely culprits that “you have to start really thinking laterally and putting resources into unusual tests.”
A version of this article first appeared on Medscape.com.
When they started the open biopsy, surgeons didn’t know what they were going to find, but they certainly didn’t expect this.
The stringlike worm was five-sixteenths of an inch long, was alive, and wiggled.
“It stunned everyone in that operating theater,” Sanjaya Senanayake, MBBS, an associate professor of infectious disease at Australian National University, Canberra, and senior author of the case report, said in an interview. “When you operate on a brain, you don’t expect to find anything alive.”
The parasitic worm was about half the width of a dime. Helminths like it can usually be seen with the naked eye but are often found in the intestines after being transmitted by soil and infecting the gastrointestinal tract. But this one made it into a woman’s brain in a first-of-its-kind case reported in the journal Emerging Infectious Diseases).
“We weren’t suspecting a worm at all,” Dr. Senanayake said. “There was something abnormal there. Was it going to be granulomatous lesion? Was it going to be cancer? Who knows, but it needed to be biopsied, and a worm was the last thing at the back of anyone’s mind,” he said.
A year of inexplicable symptoms
The 64-year-old woman was diagnosed with pneumonia and had a high white blood cell count, low hemoglobin, high platelets, and a very high C-reactive protein of 102 mg/L.
She hadn’t fully recovered from her illness when the abdominal pain and diarrhea started. And then she had a dry cough and night sweats.
After 3 weeks of discomfort, she was admitted to the hospital. She had a history of diabetes, hypothyroidism, and depression, and doctors began looking for answers to her acute illness.
They tested for autoimmune diseases and parasitic infections and prescribed prednisolone to help ease symptoms.
But 3 weeks later, her fever and cough persisted, and she was readmitted to the hospital. Doctors ordered more tests, and her eosinophils were still high, plus there were lesions on her liver, spleen, and lungs.
But tests were negative for bacterial, fungal, and mycobacterial cultures. Her stools showed no evidence of parasites.
She was prescribed mycophenolate and then ivermectin in case her tests for roundworm were a false negative. Doctors suspected Strongyloides, but lesions remained on her spleen even as the liver and lung lesions improved.
Reducing the prednisolone dose affected respiratory symptoms, so by January 2022, a year after initial symptoms began, the medical team added the monoclonal antibody mepolizumab. But her symptoms worsened, and she developed forgetfulness and more depression.
The specimen was Ophidascaris robertsi, the intestinal roundworm typically of the carpet python. Never before seen in a human, the only other animals in its life cycle are small marsupials or mammals consumed by pythons.
A snake’s bug
Although this is the first case of an Ophidascaris infection in a human, other cases could occur, warn the doctors in their case report.
The best guess for how the patient contracted the infection was by inadvertently consuming larval eggs on wild vegetation that she collected near her home to eat. She lived near a lake known to be home to carpet pythons, so the eggs could have been on the plants she collected or on her hands or kitchen equipment.
“If you’re foraging or using native grasses or plants in recipes, it would be a good idea to cook those instead of having a salad,” Dr. Senanayake said. “That would make the chance of getting something really rare even less likely.”
It’s unclear how or why the worm, which usually stays in the gut, made its way into the patient’s brain, but her long course of immunosuppressing drugs may have played a role, the team points out. “If the normal immune barriers are reduced, then it’s easier for the parasite to move around between organ systems,” Dr. Senanayake said.
Doctors also wondered if she may have been getting re-infected when she went home between hospital admissions. After removing the worm, she received 4 weeks of treatment with albendazole to eliminate any other possible larvae in other organs, especially since Ophidascaris larvae have been known to survive for long periods – more than 4 years in laboratory rats. “The hope is that she’s been cured of this parasitic infection,” Dr. Senanayake said.
As people around the world contend with the global COVID pandemic, they might not realize that new infections are arising around the world every year, he explained.
Novel parasitic infections
“The reality is that 30 new infections appeared in the last 30 years, and three-quarters of them are zoonotic, animal infections spilling over into the human world,” Dr. Senanayake said.
Though some of that number is the result of improved surveillance and diagnostics, a real increase has been occurring as human settlements continue expanding.
“This is just a reflection of how burgeoning human populations are encroaching upon animal habitats, and we’re getting more interactions between humans and wild animals, domestic animals and wild animals, and humans and natural flora, which is increasing the risk of this type of infection being recognized,” he explained.
The Ophidascaris worm found in this instance is in other snake species in different continents around the world, too. “Awareness of this case will hopefully lead to the diagnosis and treatment of other cases,” Dr. Senanayake added.
Though it’s certainly surprising to find this particular parasite in a human, finding a zoonotic organism in a person isn’t that strange, according to Janet Foley, DVM, PhD, a professor of veterinary medicine at the University of California, Davis. This is especially true if the usual host is closely related to humans, like primates, or spends a lot of time around them, like rats.
“There are still a lot of parasites and diseases out there in wildlife that haven’t been discovered, and we don’t know the risk,” said Dr. Foley. “But still, the risk would have to be low, generally, or we would see more human cases.”
In the United States, the roundworm common in raccoon feces is Baylisascaris procyonis and can be dangerous for people. “There have been deaths in people exposed to these worms, which do seem to prefer to travel to a human brain,” Dr. Foley said.
A 2016 Centers for Disease Control and Prevention report described seven U.S. cases identified between May 2013 and December 2015, including six that caused central nervous system disease. Another case report in 2018 involved a toddler who had eaten dirt and animal feces in his backyard.
And this past June, an Emerging Infectious Diseases case report described a B. procyonis infection in a 7-year-old with autism spectrum disorder and a history of pica. He had put material in his mouth from the ground near a tree where epidemiologists later found raccoon feces.
Still, Dr. Senanayake cautions against people jumping to conclusions about parasitic infections when they experience symptoms that aren’t otherwise immediately explainable.
The typical person who develops forgetfulness, depression, and a fever probably doesn’t have a worm in their brain or need an immediate MRI, he pointed out. “There may be other cases out there, but common things happen commonly, and this is likely to be rare,” Dr. Senanayake said.
This case demonstrates the challenge in picking a course of treatment when the differential diagnoses for hypereosinophilic syndromes is so broad.
Tricky hypereosinophilic syndromes
One of those differentials for the syndromes is parasitic infections, for which treatment would be antiparasitic agents, but another differential is an autoimmune condition that would call for immunosuppression.
“Obviously, as with this case, you don’t want to give someone immunosuppressive treatment if they’ve got a parasite, so you want to look really hard for a parasite before you start them on immunosuppressive treatment for an immunological condition,” Dr. Senanayake said.
But all the blood tests for different antibodies came back negative for parasites, “and this parasite was simply difficult to find until they pulled it from her brain,” he said.
Infectious disease physicians are always looking for the unusual and exotic, Dr. Senanayake explained. But it’s important to exclude the common, easy things first, he added. It’s after exhausting all the likely culprits that “you have to start really thinking laterally and putting resources into unusual tests.”
A version of this article first appeared on Medscape.com.
FROM EMERGING INFECTIOUS DISEASES
Which factors predict primary nonadherence to medications?
Poor adherence to medication is a real challenge in health care. Despite evidence indicating therapeutic benefit from adhering to a prescribed regimen, it is estimated that around 50% of patients around the world don’t take their medication as it is prescribed – and some simply don’t take them at all.
Nonadherence to medication can be primary or secondary. Primary medication nonadherence occurs when a new medication is prescribed for a patient, but the patient does not obtain the medication or an appropriate alternative within an acceptable period after it was prescribed. Secondary nonadherence measures prescription refills among patients who previously filled their first prescriptions. With most medication adherence research to date focused on secondary nonadherence, PMN has been identified as a major research gap.
Growth in electronic prescribing has partially resolved this issue, and new measures have emerged linking electronic prescribing databases with pharmacy dispensing databases. and which drugs could be at greatest risk of primary nonadherence when prescribed by a primary care physician
Adherence measures
Measuring medication adherence is challenging but can be done using various approaches. It comprises the following approaches:
- Subjective measurements obtained by asking patients, family members, caregivers, and physicians about the patient’s medication use
- Objective measurements obtained by counting pills, examining pharmacy refill records, or using electronic medication event monitoring systems
- Biochemical measurements obtained by adding a nontoxic marker to the medication and detecting its presence in blood or urine or measurement of serum drug levels.
Determining factors
A myriad of factors contributes to poor medication adherence. Some are related to patients (e.g., suboptimal health literacy and lack of involvement in the treatment decision-making process), others are related to physicians (e.g., prescription of complex drug regimens, communication barriers, ineffective communication of information about adverse effects, and provision of care by multiple physicians), and still others are related to health care systems (e.g., office visit time limitations, limited access to care, and lack of health information technology).
Primary nonadherence
The literature has reported substantial variation in primary nonadherence, with estimates ranging from as little as 1.9% of incident prescriptions never filled to as much as 75%.
Investigators for the Canadian study estimated the rate of primary nonadherence, defined as failure to dispense a new medication or its equivalent within 6 months of the prescription date, using data from 150,565 new prescriptions issued to 34,243 patients.
Rate of nonadherence
The following patterns of primary nonadherence were observed:
- Primary nonadherence was lowest for prescriptions issued by prescribers aged 35 years or younger (17.1%) and male prescribers (15.1%).
- It was similar among patients of both sexes.
- It was lowest in the oldest subjects, decreasing with age (odds ratio, 0.91 for each additional 10 years).
- It was highest for drugs prescribed mostly on an as-needed basis, including topical corticosteroids (35.1%) and antihistamines (23.4%).
Predictors of nonadherence
The odds of primary nonadherence exhibited the following patterns:
- Lower for prescriptions issued by male clinicians (OR, 0.66)
- Significantly greater, compared with anti-infectives, for dermatological agents (OR, 1.36) and lowest for cardiovascular agents (OR, 0.46).
- Lower across therapeutic drug categories (except for respiratory agents) for those aged 65 years and older than for those younger than age 65.
In conclusion, in a general medicine setting, the odds of primary nonadherence were higher for younger patients, those who received primary care services from female prescribers, and older patients who were prescribed more medications. Across therapeutic categories, the odds of primary nonadherence were lowest for cardiovascular system agents and highest for dermatological agents.
To date, the lack of a standardized terminology, operational definition, and measurement methods of primary nonadherence has limited our understanding of the extent to which patients do not avail themselves of prescriber-ordered pharmaceutical treatment. These results reaffirm the need to compare the prevalence of such nonadherence in different health care settings.
This article was translated from Univadis Italy. A version appeared on Medscape.com.
Poor adherence to medication is a real challenge in health care. Despite evidence indicating therapeutic benefit from adhering to a prescribed regimen, it is estimated that around 50% of patients around the world don’t take their medication as it is prescribed – and some simply don’t take them at all.
Nonadherence to medication can be primary or secondary. Primary medication nonadherence occurs when a new medication is prescribed for a patient, but the patient does not obtain the medication or an appropriate alternative within an acceptable period after it was prescribed. Secondary nonadherence measures prescription refills among patients who previously filled their first prescriptions. With most medication adherence research to date focused on secondary nonadherence, PMN has been identified as a major research gap.
Growth in electronic prescribing has partially resolved this issue, and new measures have emerged linking electronic prescribing databases with pharmacy dispensing databases. and which drugs could be at greatest risk of primary nonadherence when prescribed by a primary care physician
Adherence measures
Measuring medication adherence is challenging but can be done using various approaches. It comprises the following approaches:
- Subjective measurements obtained by asking patients, family members, caregivers, and physicians about the patient’s medication use
- Objective measurements obtained by counting pills, examining pharmacy refill records, or using electronic medication event monitoring systems
- Biochemical measurements obtained by adding a nontoxic marker to the medication and detecting its presence in blood or urine or measurement of serum drug levels.
Determining factors
A myriad of factors contributes to poor medication adherence. Some are related to patients (e.g., suboptimal health literacy and lack of involvement in the treatment decision-making process), others are related to physicians (e.g., prescription of complex drug regimens, communication barriers, ineffective communication of information about adverse effects, and provision of care by multiple physicians), and still others are related to health care systems (e.g., office visit time limitations, limited access to care, and lack of health information technology).
Primary nonadherence
The literature has reported substantial variation in primary nonadherence, with estimates ranging from as little as 1.9% of incident prescriptions never filled to as much as 75%.
Investigators for the Canadian study estimated the rate of primary nonadherence, defined as failure to dispense a new medication or its equivalent within 6 months of the prescription date, using data from 150,565 new prescriptions issued to 34,243 patients.
Rate of nonadherence
The following patterns of primary nonadherence were observed:
- Primary nonadherence was lowest for prescriptions issued by prescribers aged 35 years or younger (17.1%) and male prescribers (15.1%).
- It was similar among patients of both sexes.
- It was lowest in the oldest subjects, decreasing with age (odds ratio, 0.91 for each additional 10 years).
- It was highest for drugs prescribed mostly on an as-needed basis, including topical corticosteroids (35.1%) and antihistamines (23.4%).
Predictors of nonadherence
The odds of primary nonadherence exhibited the following patterns:
- Lower for prescriptions issued by male clinicians (OR, 0.66)
- Significantly greater, compared with anti-infectives, for dermatological agents (OR, 1.36) and lowest for cardiovascular agents (OR, 0.46).
- Lower across therapeutic drug categories (except for respiratory agents) for those aged 65 years and older than for those younger than age 65.
In conclusion, in a general medicine setting, the odds of primary nonadherence were higher for younger patients, those who received primary care services from female prescribers, and older patients who were prescribed more medications. Across therapeutic categories, the odds of primary nonadherence were lowest for cardiovascular system agents and highest for dermatological agents.
To date, the lack of a standardized terminology, operational definition, and measurement methods of primary nonadherence has limited our understanding of the extent to which patients do not avail themselves of prescriber-ordered pharmaceutical treatment. These results reaffirm the need to compare the prevalence of such nonadherence in different health care settings.
This article was translated from Univadis Italy. A version appeared on Medscape.com.
Poor adherence to medication is a real challenge in health care. Despite evidence indicating therapeutic benefit from adhering to a prescribed regimen, it is estimated that around 50% of patients around the world don’t take their medication as it is prescribed – and some simply don’t take them at all.
Nonadherence to medication can be primary or secondary. Primary medication nonadherence occurs when a new medication is prescribed for a patient, but the patient does not obtain the medication or an appropriate alternative within an acceptable period after it was prescribed. Secondary nonadherence measures prescription refills among patients who previously filled their first prescriptions. With most medication adherence research to date focused on secondary nonadherence, PMN has been identified as a major research gap.
Growth in electronic prescribing has partially resolved this issue, and new measures have emerged linking electronic prescribing databases with pharmacy dispensing databases. and which drugs could be at greatest risk of primary nonadherence when prescribed by a primary care physician
Adherence measures
Measuring medication adherence is challenging but can be done using various approaches. It comprises the following approaches:
- Subjective measurements obtained by asking patients, family members, caregivers, and physicians about the patient’s medication use
- Objective measurements obtained by counting pills, examining pharmacy refill records, or using electronic medication event monitoring systems
- Biochemical measurements obtained by adding a nontoxic marker to the medication and detecting its presence in blood or urine or measurement of serum drug levels.
Determining factors
A myriad of factors contributes to poor medication adherence. Some are related to patients (e.g., suboptimal health literacy and lack of involvement in the treatment decision-making process), others are related to physicians (e.g., prescription of complex drug regimens, communication barriers, ineffective communication of information about adverse effects, and provision of care by multiple physicians), and still others are related to health care systems (e.g., office visit time limitations, limited access to care, and lack of health information technology).
Primary nonadherence
The literature has reported substantial variation in primary nonadherence, with estimates ranging from as little as 1.9% of incident prescriptions never filled to as much as 75%.
Investigators for the Canadian study estimated the rate of primary nonadherence, defined as failure to dispense a new medication or its equivalent within 6 months of the prescription date, using data from 150,565 new prescriptions issued to 34,243 patients.
Rate of nonadherence
The following patterns of primary nonadherence were observed:
- Primary nonadherence was lowest for prescriptions issued by prescribers aged 35 years or younger (17.1%) and male prescribers (15.1%).
- It was similar among patients of both sexes.
- It was lowest in the oldest subjects, decreasing with age (odds ratio, 0.91 for each additional 10 years).
- It was highest for drugs prescribed mostly on an as-needed basis, including topical corticosteroids (35.1%) and antihistamines (23.4%).
Predictors of nonadherence
The odds of primary nonadherence exhibited the following patterns:
- Lower for prescriptions issued by male clinicians (OR, 0.66)
- Significantly greater, compared with anti-infectives, for dermatological agents (OR, 1.36) and lowest for cardiovascular agents (OR, 0.46).
- Lower across therapeutic drug categories (except for respiratory agents) for those aged 65 years and older than for those younger than age 65.
In conclusion, in a general medicine setting, the odds of primary nonadherence were higher for younger patients, those who received primary care services from female prescribers, and older patients who were prescribed more medications. Across therapeutic categories, the odds of primary nonadherence were lowest for cardiovascular system agents and highest for dermatological agents.
To date, the lack of a standardized terminology, operational definition, and measurement methods of primary nonadherence has limited our understanding of the extent to which patients do not avail themselves of prescriber-ordered pharmaceutical treatment. These results reaffirm the need to compare the prevalence of such nonadherence in different health care settings.
This article was translated from Univadis Italy. A version appeared on Medscape.com.
Glaucoma: A hidden threat to vision health rising swiftly
A silent disorder is rising among older people worldwide, as millions unknowingly grapple with glaucoma, ophthalmologists warn.
“That’s a lot of people with a blinding disease who don’t know they have it,” said Joel S. Schuman, MD, professor of ophthalmology and codirector of the Glaucoma Service at Wills Eye Hospital in Philadelphia. “Late in the disease, people may notice they’re tripping over the curb, or walking into things they didn’t see. It really is only in very advanced disease that people notice there’s anything wrong.”
Glaucoma is the second leading cause of blindness worldwide, affecting 3 million people in the United States, and yet half of those affected are unaware, according to the Centers for Disease Control and Prevention.
Recent research at the University of Gothenburg in Sweden underscores glaucoma’s stealthy nature: Five percent of 560 70-year-olds had the disease, and half of those did not know they had it before they took part in the study.
“Living with glaucoma, especially without realizing it, can be very isolating,” said Lena Havstam Johansson, a PhD student at the University of Gothenburg and a specialist nurse at Sahlgrenska University Hospital, who did the study. “It may lead people to stay at home to avoid the trouble.”
Once symptoms arise, some may notice patchy blind spots in their peripheral vision, and in their central vision in late stages.
While many people assume they are getting clumsier with age, Dr. Schuman said, they often have a condition that can be slowed with the right treatment.
Though there are various types of the disease, about 9 in 10 people in the United States have primary open-angle glaucoma (POAG).
It is most common among people over the age of 60, those with a family history of glaucoma, and people who have diabetes. It disproportionately affects Black people, who are six times more likely than are White people to have advanced vision loss from the disease.
More than 120,000 people in the United States are blind from glaucoma, accounting for 9%-12% of all cases of blindness. Glaucoma treatments range from eye drops to laser treatments to surgery, all of which aim to reduce eye pressure. Some doctors will recommend oral medication along with eye drops.
“We have a lot of treatment options, and they work pretty well,” Dr. Schuman said. “But the first step is the person knowing they have glaucoma, and the second step is that person seeking care.
Rarer types of glaucoma include normal-tension glaucoma, which is more common among people of Japanese ancestry, and congenital glaucoma, which affects about 1 in 10,000 babies born in the United States.
The best way to ensure early detection and treatment is to get regular eye exams – every 2-4 years for adults under the age of 55, and annually thereafter, said Annie Wu, MD, clinical assistant professor of ophthalmology at the Kellogg Eye Center at the University of Michigan.
The fact that glaucoma’s symptoms are slow to develop, coupled with a lack of access to eye specialists many Americans face, makes the disease even more dangerous.
The University of Pennsylvania is among those trying to change that. The Philadelphia school has hosted free glaucoma screening programs for Black residents.
There are a number of organizations that offer access to free glaucoma screening.
A version of this article first appeared on WebMD.com.
A silent disorder is rising among older people worldwide, as millions unknowingly grapple with glaucoma, ophthalmologists warn.
“That’s a lot of people with a blinding disease who don’t know they have it,” said Joel S. Schuman, MD, professor of ophthalmology and codirector of the Glaucoma Service at Wills Eye Hospital in Philadelphia. “Late in the disease, people may notice they’re tripping over the curb, or walking into things they didn’t see. It really is only in very advanced disease that people notice there’s anything wrong.”
Glaucoma is the second leading cause of blindness worldwide, affecting 3 million people in the United States, and yet half of those affected are unaware, according to the Centers for Disease Control and Prevention.
Recent research at the University of Gothenburg in Sweden underscores glaucoma’s stealthy nature: Five percent of 560 70-year-olds had the disease, and half of those did not know they had it before they took part in the study.
“Living with glaucoma, especially without realizing it, can be very isolating,” said Lena Havstam Johansson, a PhD student at the University of Gothenburg and a specialist nurse at Sahlgrenska University Hospital, who did the study. “It may lead people to stay at home to avoid the trouble.”
Once symptoms arise, some may notice patchy blind spots in their peripheral vision, and in their central vision in late stages.
While many people assume they are getting clumsier with age, Dr. Schuman said, they often have a condition that can be slowed with the right treatment.
Though there are various types of the disease, about 9 in 10 people in the United States have primary open-angle glaucoma (POAG).
It is most common among people over the age of 60, those with a family history of glaucoma, and people who have diabetes. It disproportionately affects Black people, who are six times more likely than are White people to have advanced vision loss from the disease.
More than 120,000 people in the United States are blind from glaucoma, accounting for 9%-12% of all cases of blindness. Glaucoma treatments range from eye drops to laser treatments to surgery, all of which aim to reduce eye pressure. Some doctors will recommend oral medication along with eye drops.
“We have a lot of treatment options, and they work pretty well,” Dr. Schuman said. “But the first step is the person knowing they have glaucoma, and the second step is that person seeking care.
Rarer types of glaucoma include normal-tension glaucoma, which is more common among people of Japanese ancestry, and congenital glaucoma, which affects about 1 in 10,000 babies born in the United States.
The best way to ensure early detection and treatment is to get regular eye exams – every 2-4 years for adults under the age of 55, and annually thereafter, said Annie Wu, MD, clinical assistant professor of ophthalmology at the Kellogg Eye Center at the University of Michigan.
The fact that glaucoma’s symptoms are slow to develop, coupled with a lack of access to eye specialists many Americans face, makes the disease even more dangerous.
The University of Pennsylvania is among those trying to change that. The Philadelphia school has hosted free glaucoma screening programs for Black residents.
There are a number of organizations that offer access to free glaucoma screening.
A version of this article first appeared on WebMD.com.
A silent disorder is rising among older people worldwide, as millions unknowingly grapple with glaucoma, ophthalmologists warn.
“That’s a lot of people with a blinding disease who don’t know they have it,” said Joel S. Schuman, MD, professor of ophthalmology and codirector of the Glaucoma Service at Wills Eye Hospital in Philadelphia. “Late in the disease, people may notice they’re tripping over the curb, or walking into things they didn’t see. It really is only in very advanced disease that people notice there’s anything wrong.”
Glaucoma is the second leading cause of blindness worldwide, affecting 3 million people in the United States, and yet half of those affected are unaware, according to the Centers for Disease Control and Prevention.
Recent research at the University of Gothenburg in Sweden underscores glaucoma’s stealthy nature: Five percent of 560 70-year-olds had the disease, and half of those did not know they had it before they took part in the study.
“Living with glaucoma, especially without realizing it, can be very isolating,” said Lena Havstam Johansson, a PhD student at the University of Gothenburg and a specialist nurse at Sahlgrenska University Hospital, who did the study. “It may lead people to stay at home to avoid the trouble.”
Once symptoms arise, some may notice patchy blind spots in their peripheral vision, and in their central vision in late stages.
While many people assume they are getting clumsier with age, Dr. Schuman said, they often have a condition that can be slowed with the right treatment.
Though there are various types of the disease, about 9 in 10 people in the United States have primary open-angle glaucoma (POAG).
It is most common among people over the age of 60, those with a family history of glaucoma, and people who have diabetes. It disproportionately affects Black people, who are six times more likely than are White people to have advanced vision loss from the disease.
More than 120,000 people in the United States are blind from glaucoma, accounting for 9%-12% of all cases of blindness. Glaucoma treatments range from eye drops to laser treatments to surgery, all of which aim to reduce eye pressure. Some doctors will recommend oral medication along with eye drops.
“We have a lot of treatment options, and they work pretty well,” Dr. Schuman said. “But the first step is the person knowing they have glaucoma, and the second step is that person seeking care.
Rarer types of glaucoma include normal-tension glaucoma, which is more common among people of Japanese ancestry, and congenital glaucoma, which affects about 1 in 10,000 babies born in the United States.
The best way to ensure early detection and treatment is to get regular eye exams – every 2-4 years for adults under the age of 55, and annually thereafter, said Annie Wu, MD, clinical assistant professor of ophthalmology at the Kellogg Eye Center at the University of Michigan.
The fact that glaucoma’s symptoms are slow to develop, coupled with a lack of access to eye specialists many Americans face, makes the disease even more dangerous.
The University of Pennsylvania is among those trying to change that. The Philadelphia school has hosted free glaucoma screening programs for Black residents.
There are a number of organizations that offer access to free glaucoma screening.
A version of this article first appeared on WebMD.com.
Artificial sweeteners in processed foods tied to increased depression risk
new data from the Nurses Health Study II (NHS II) suggest.
Nurses who consumed more than eight servings daily had about a 50% higher risk of developing depression than nurses who consumed four or fewer servings daily.
However, in a secondary analysis, in which the researchers tried to tease out specific foods that may be associated with increased risk, only artificial sweeteners and artificially sweetened beverages were associated with an increased risk of depression.
“Animal studies have shown that artificial sweeteners may trigger the transmission of particular signaling molecules in the brain that are important for mood,” study investigator Andrew T. Chan, MD, MPH, of the clinical and translational epidemiology unit at Massachusetts General Hospital, Boston, said in an interview.
“Given this potential association between ultraprocessed food and multiple adverse health conditions, wherever possible individuals may wish to limit their intake of such foods. This may be a lifestyle change that could have important benefits, particularly for those who struggle with mental health,” Dr. Chan said.
The study was published online in JAMA Network Open.
Multiple potential mechanisms
The findings are based on 31,712 mostly non-Hispanic White women who were free of depression at baseline. The mean age of the patients at baseline was 52 years. As part of the NHS II, the women provided information on diet every 4 years using validated food frequency questionnaires.
Compared with women with low UPF intake, those with high UPF intake had greater body mass index (BMI). In addition, they were apt to smoke and have diabetes, hypertension, and dyslipidemia, and they were less apt to exercise regularly.
During the study period, there were 2,122 incident cases of depression, as determined using a strict definition that required self-reported clinician-diagnosed depression and regular antidepressant use. There were 4,840 incident cases, as determined using a broad definition that required clinical diagnosis and/or antidepressant use.
Compared with women in the lowest quintile of UPF consumption (fewer than four daily servings), those in the highest quintile (more than 8.8 daily servings) had an increased risk of depression.
This was noted for both the strict depression definition (hazard ratio, 1.49; 95% confidence interval, 1.26-1.76; P < .001) and the broad one (HR, 1.34; 95% CI, 1.20-1.50; P < .001).
“Models were not materially altered after inclusion of potential confounders. We did not observe differential associations in subgroups defined by age, BMI, physical activity, or smoking,” the researchers reported.
In secondary analyses, they classified UPF into their components, including ultraprocessed grain foods, sweet snacks, ready-to-eat meals, fats, sauces, ultraprocessed dairy products, savory snacks, processed meat, beverages, and artificial sweeteners.
Comparing the highest with the lowest quintiles, only high intake of artificially sweetened beverages (HR, 1.37; 95% CI, 1.19-1.57; P < .001) and artificial sweeteners (HR, 1.26; 95% CI, 1.10-1.43; P < .001) was associated with greater risk of depression and after multivariable regression.
In an exploratory analysis, women who reduced their UPF intake by at least three servings per day were at lower risk of depression (strict definition: HR, 0.84; 95% CI, 0.71-0.99), compared with those with relatively stable intake in each 4-year period.
“Ultraprocessed foods have been associated with several different health outcomes which may reflect an effect on common pathways that underlie chronic conditions,” said Dr. Chan.
For example, UPF intake has been associated with chronic inflammation, which in turns leads to multiple potential adverse health effects, including depression, he explained.
There is also a link between UPF and disruption of the gut microbiome.
“This is an important potential mechanism linking ultraprocessed food to depression since there is emerging evidence that microbes in the gut have been linked with mood through their role in metabolizing and producing proteins that have activity in the brain,” Dr. Chan said.
Association, not causation
Several experts weighed in on the study results in a statement from the U.K. nonprofit organization, Science Media Centre.
Gunter Kuhnle, PhD, professor of nutrition and food science, University of Reading (England), cautioned that the study only offers information on association – not causation.
“It is very possible that people with depression change their diet and might decide to consume foods that are easier to prepare – which would often be foods considered to be ultraprocessed,” Dr. Kuhnle said.
What’s most interesting is that the association between UPF intake and depression was driven by a single factor – artificial sweeteners.
“This supports one of the main criticisms of the UPF concept, that it combines a wide range of different foods and thereby makes it difficult to identify underlying causes,” Dr. Kuhnle added.
“There are currently no data that link artificial sweetener use to mental health, despite most of them having been available for some time. It is also important to note that there are a wide range of different artificial sweeteners that are metabolized very differently and that there might be reverse causality,” Dr. Kuhnle commented.
Paul Keedwell, MBChB, PhD, consultant psychiatrist and fellow of the Royal College of Psychiatrists, said this is an “interesting and important finding, but one that raises more questions. At this stage, we cannot say how big an effect diet has on depression risk compared to other risk factors, like family history of depression, stress levels, and having a supportive social network.”
Dr. Keedwell noted that the investigators carefully excluded the possibility that the effect is mediated by obesity or lack of exercise.
“However, an important consideration is that a diet based on ready meals and artificially sweetened drinks might indicate a hectic lifestyle or one with shift work. In other words, a fast-food diet could be an indirect marker of chronic stress. Prolonged stress probably remains the main risk factor for depression,” Dr. Keedwell said.
Keith Frayn, PhD, professor emeritus of human metabolism, University of Oxford (England), noted that the relationship between artificial sweeteners and depression “stands out clearly” even after adjusting for multiple confounding factors, including BMI, smoking, and exercise.
“This adds to growing concerns about artificial sweeteners and cardiometabolic health. The link with depression needs confirmation and further research to suggest how it might be brought about,” Dr. Frayn cautioned.
The NHS II was funded by a grant from the National Cancer Institute. Dr. Chan reported receiving grants from Bayer and Zoe and personal fees from Boehringer Ingelheim, Pfizer, and Freenome outside this work. Dr. Keedwell and Dr. Kuhnle disclosed no relevant financial relationships. Dr. Frayn is an author of books on nutrition and metabolism.
A version of this article first appeared on Medscape.com.
new data from the Nurses Health Study II (NHS II) suggest.
Nurses who consumed more than eight servings daily had about a 50% higher risk of developing depression than nurses who consumed four or fewer servings daily.
However, in a secondary analysis, in which the researchers tried to tease out specific foods that may be associated with increased risk, only artificial sweeteners and artificially sweetened beverages were associated with an increased risk of depression.
“Animal studies have shown that artificial sweeteners may trigger the transmission of particular signaling molecules in the brain that are important for mood,” study investigator Andrew T. Chan, MD, MPH, of the clinical and translational epidemiology unit at Massachusetts General Hospital, Boston, said in an interview.
“Given this potential association between ultraprocessed food and multiple adverse health conditions, wherever possible individuals may wish to limit their intake of such foods. This may be a lifestyle change that could have important benefits, particularly for those who struggle with mental health,” Dr. Chan said.
The study was published online in JAMA Network Open.
Multiple potential mechanisms
The findings are based on 31,712 mostly non-Hispanic White women who were free of depression at baseline. The mean age of the patients at baseline was 52 years. As part of the NHS II, the women provided information on diet every 4 years using validated food frequency questionnaires.
Compared with women with low UPF intake, those with high UPF intake had greater body mass index (BMI). In addition, they were apt to smoke and have diabetes, hypertension, and dyslipidemia, and they were less apt to exercise regularly.
During the study period, there were 2,122 incident cases of depression, as determined using a strict definition that required self-reported clinician-diagnosed depression and regular antidepressant use. There were 4,840 incident cases, as determined using a broad definition that required clinical diagnosis and/or antidepressant use.
Compared with women in the lowest quintile of UPF consumption (fewer than four daily servings), those in the highest quintile (more than 8.8 daily servings) had an increased risk of depression.
This was noted for both the strict depression definition (hazard ratio, 1.49; 95% confidence interval, 1.26-1.76; P < .001) and the broad one (HR, 1.34; 95% CI, 1.20-1.50; P < .001).
“Models were not materially altered after inclusion of potential confounders. We did not observe differential associations in subgroups defined by age, BMI, physical activity, or smoking,” the researchers reported.
In secondary analyses, they classified UPF into their components, including ultraprocessed grain foods, sweet snacks, ready-to-eat meals, fats, sauces, ultraprocessed dairy products, savory snacks, processed meat, beverages, and artificial sweeteners.
Comparing the highest with the lowest quintiles, only high intake of artificially sweetened beverages (HR, 1.37; 95% CI, 1.19-1.57; P < .001) and artificial sweeteners (HR, 1.26; 95% CI, 1.10-1.43; P < .001) was associated with greater risk of depression and after multivariable regression.
In an exploratory analysis, women who reduced their UPF intake by at least three servings per day were at lower risk of depression (strict definition: HR, 0.84; 95% CI, 0.71-0.99), compared with those with relatively stable intake in each 4-year period.
“Ultraprocessed foods have been associated with several different health outcomes which may reflect an effect on common pathways that underlie chronic conditions,” said Dr. Chan.
For example, UPF intake has been associated with chronic inflammation, which in turns leads to multiple potential adverse health effects, including depression, he explained.
There is also a link between UPF and disruption of the gut microbiome.
“This is an important potential mechanism linking ultraprocessed food to depression since there is emerging evidence that microbes in the gut have been linked with mood through their role in metabolizing and producing proteins that have activity in the brain,” Dr. Chan said.
Association, not causation
Several experts weighed in on the study results in a statement from the U.K. nonprofit organization, Science Media Centre.
Gunter Kuhnle, PhD, professor of nutrition and food science, University of Reading (England), cautioned that the study only offers information on association – not causation.
“It is very possible that people with depression change their diet and might decide to consume foods that are easier to prepare – which would often be foods considered to be ultraprocessed,” Dr. Kuhnle said.
What’s most interesting is that the association between UPF intake and depression was driven by a single factor – artificial sweeteners.
“This supports one of the main criticisms of the UPF concept, that it combines a wide range of different foods and thereby makes it difficult to identify underlying causes,” Dr. Kuhnle added.
“There are currently no data that link artificial sweetener use to mental health, despite most of them having been available for some time. It is also important to note that there are a wide range of different artificial sweeteners that are metabolized very differently and that there might be reverse causality,” Dr. Kuhnle commented.
Paul Keedwell, MBChB, PhD, consultant psychiatrist and fellow of the Royal College of Psychiatrists, said this is an “interesting and important finding, but one that raises more questions. At this stage, we cannot say how big an effect diet has on depression risk compared to other risk factors, like family history of depression, stress levels, and having a supportive social network.”
Dr. Keedwell noted that the investigators carefully excluded the possibility that the effect is mediated by obesity or lack of exercise.
“However, an important consideration is that a diet based on ready meals and artificially sweetened drinks might indicate a hectic lifestyle or one with shift work. In other words, a fast-food diet could be an indirect marker of chronic stress. Prolonged stress probably remains the main risk factor for depression,” Dr. Keedwell said.
Keith Frayn, PhD, professor emeritus of human metabolism, University of Oxford (England), noted that the relationship between artificial sweeteners and depression “stands out clearly” even after adjusting for multiple confounding factors, including BMI, smoking, and exercise.
“This adds to growing concerns about artificial sweeteners and cardiometabolic health. The link with depression needs confirmation and further research to suggest how it might be brought about,” Dr. Frayn cautioned.
The NHS II was funded by a grant from the National Cancer Institute. Dr. Chan reported receiving grants from Bayer and Zoe and personal fees from Boehringer Ingelheim, Pfizer, and Freenome outside this work. Dr. Keedwell and Dr. Kuhnle disclosed no relevant financial relationships. Dr. Frayn is an author of books on nutrition and metabolism.
A version of this article first appeared on Medscape.com.
new data from the Nurses Health Study II (NHS II) suggest.
Nurses who consumed more than eight servings daily had about a 50% higher risk of developing depression than nurses who consumed four or fewer servings daily.
However, in a secondary analysis, in which the researchers tried to tease out specific foods that may be associated with increased risk, only artificial sweeteners and artificially sweetened beverages were associated with an increased risk of depression.
“Animal studies have shown that artificial sweeteners may trigger the transmission of particular signaling molecules in the brain that are important for mood,” study investigator Andrew T. Chan, MD, MPH, of the clinical and translational epidemiology unit at Massachusetts General Hospital, Boston, said in an interview.
“Given this potential association between ultraprocessed food and multiple adverse health conditions, wherever possible individuals may wish to limit their intake of such foods. This may be a lifestyle change that could have important benefits, particularly for those who struggle with mental health,” Dr. Chan said.
The study was published online in JAMA Network Open.
Multiple potential mechanisms
The findings are based on 31,712 mostly non-Hispanic White women who were free of depression at baseline. The mean age of the patients at baseline was 52 years. As part of the NHS II, the women provided information on diet every 4 years using validated food frequency questionnaires.
Compared with women with low UPF intake, those with high UPF intake had greater body mass index (BMI). In addition, they were apt to smoke and have diabetes, hypertension, and dyslipidemia, and they were less apt to exercise regularly.
During the study period, there were 2,122 incident cases of depression, as determined using a strict definition that required self-reported clinician-diagnosed depression and regular antidepressant use. There were 4,840 incident cases, as determined using a broad definition that required clinical diagnosis and/or antidepressant use.
Compared with women in the lowest quintile of UPF consumption (fewer than four daily servings), those in the highest quintile (more than 8.8 daily servings) had an increased risk of depression.
This was noted for both the strict depression definition (hazard ratio, 1.49; 95% confidence interval, 1.26-1.76; P < .001) and the broad one (HR, 1.34; 95% CI, 1.20-1.50; P < .001).
“Models were not materially altered after inclusion of potential confounders. We did not observe differential associations in subgroups defined by age, BMI, physical activity, or smoking,” the researchers reported.
In secondary analyses, they classified UPF into their components, including ultraprocessed grain foods, sweet snacks, ready-to-eat meals, fats, sauces, ultraprocessed dairy products, savory snacks, processed meat, beverages, and artificial sweeteners.
Comparing the highest with the lowest quintiles, only high intake of artificially sweetened beverages (HR, 1.37; 95% CI, 1.19-1.57; P < .001) and artificial sweeteners (HR, 1.26; 95% CI, 1.10-1.43; P < .001) was associated with greater risk of depression and after multivariable regression.
In an exploratory analysis, women who reduced their UPF intake by at least three servings per day were at lower risk of depression (strict definition: HR, 0.84; 95% CI, 0.71-0.99), compared with those with relatively stable intake in each 4-year period.
“Ultraprocessed foods have been associated with several different health outcomes which may reflect an effect on common pathways that underlie chronic conditions,” said Dr. Chan.
For example, UPF intake has been associated with chronic inflammation, which in turns leads to multiple potential adverse health effects, including depression, he explained.
There is also a link between UPF and disruption of the gut microbiome.
“This is an important potential mechanism linking ultraprocessed food to depression since there is emerging evidence that microbes in the gut have been linked with mood through their role in metabolizing and producing proteins that have activity in the brain,” Dr. Chan said.
Association, not causation
Several experts weighed in on the study results in a statement from the U.K. nonprofit organization, Science Media Centre.
Gunter Kuhnle, PhD, professor of nutrition and food science, University of Reading (England), cautioned that the study only offers information on association – not causation.
“It is very possible that people with depression change their diet and might decide to consume foods that are easier to prepare – which would often be foods considered to be ultraprocessed,” Dr. Kuhnle said.
What’s most interesting is that the association between UPF intake and depression was driven by a single factor – artificial sweeteners.
“This supports one of the main criticisms of the UPF concept, that it combines a wide range of different foods and thereby makes it difficult to identify underlying causes,” Dr. Kuhnle added.
“There are currently no data that link artificial sweetener use to mental health, despite most of them having been available for some time. It is also important to note that there are a wide range of different artificial sweeteners that are metabolized very differently and that there might be reverse causality,” Dr. Kuhnle commented.
Paul Keedwell, MBChB, PhD, consultant psychiatrist and fellow of the Royal College of Psychiatrists, said this is an “interesting and important finding, but one that raises more questions. At this stage, we cannot say how big an effect diet has on depression risk compared to other risk factors, like family history of depression, stress levels, and having a supportive social network.”
Dr. Keedwell noted that the investigators carefully excluded the possibility that the effect is mediated by obesity or lack of exercise.
“However, an important consideration is that a diet based on ready meals and artificially sweetened drinks might indicate a hectic lifestyle or one with shift work. In other words, a fast-food diet could be an indirect marker of chronic stress. Prolonged stress probably remains the main risk factor for depression,” Dr. Keedwell said.
Keith Frayn, PhD, professor emeritus of human metabolism, University of Oxford (England), noted that the relationship between artificial sweeteners and depression “stands out clearly” even after adjusting for multiple confounding factors, including BMI, smoking, and exercise.
“This adds to growing concerns about artificial sweeteners and cardiometabolic health. The link with depression needs confirmation and further research to suggest how it might be brought about,” Dr. Frayn cautioned.
The NHS II was funded by a grant from the National Cancer Institute. Dr. Chan reported receiving grants from Bayer and Zoe and personal fees from Boehringer Ingelheim, Pfizer, and Freenome outside this work. Dr. Keedwell and Dr. Kuhnle disclosed no relevant financial relationships. Dr. Frayn is an author of books on nutrition and metabolism.
A version of this article first appeared on Medscape.com.
FROM JAMA NETWORK OPEN
Progressive pulmonary fibrosis: treatment and support
MILAN – Numerous unresolved questions surround progressive pulmonary fibrosis (PPF) treatment, according to Elisabeth Bendstrup, MD, PhD, a researcher and clinical professor in the department of clinical medicine – department of respiratory diseases and allergy, Aarhus (Denmark) University, Denmark. These questions regard the optimal timing for treatment initiation, the role of available medications, either as monotherapy or in combination, and nonpharmacologic support options.
What’s in the toolbox?
Pulmonologists who manage PPF have a range of treatment options at their disposal. This includes careful patient observation, with treatment initiation based on clinical necessity. The therapeutic arsenal comprises immunomodulatory treatments, antifibrotic agents, palliative and supportive care, and, for a minority of patients, lung transplantation.
“Once a patient is diagnosed with PPF, it is important to remember that the diagnostic criteria from the guidelines are not exactly the same of those accepted for the reimbursement of antifibrotic treatments in different countries,” Dr. Bendstrup said, suggesting that nonclinical considerations could also potentially influence the treatment choice. She spoke at the annual congress of the European Respiratory Society.
Michael Kreuter, MD, director of the Lung Center at the University Hospital in Mainz, Germany, provided insight into the introduction of antifibrotic drugs for the treatment of PPF. Drawing from nearly a decade ago when the first antifibrotic medication was approved for idiopathic pulmonary fibrosis (IPF), Dr. Kreuter noted its effectiveness in slowing disease progression, although it does not reverse it. Subsequently, the discovery that non-IPF diseases, such as rheumatoid arthritis, exhibited IPF-like behavior led to the exploration of the use of the same drugs for similar conditions, even if not IPF.
“That’s how antifibrotic treatments came into place. Now we have more trials and data to be discussed in the future,” Dr. Kreuter added. He highlighted that antifibrotic drugs are effective for several diseases. Most of those diseases are treated with different anti-inflammatory drugs, which makes it difficult to decide when to start antifibrotic therapy and how to eventually combine it with different pharmacologic approaches.
A pivotal starting point
a question only partially addressed by existing guidelines. Dr. Bendstrup advocated for a comprehensive baseline evaluation. Factors to be considered include symptom burden, the severity of lung decline, radiologic characteristics, signs of alveolar inflammation, progression risk factors, quality of life, patient preferences, and medical history. “All these should be best discussed in a multidisciplinary team, including pulmonologists, nurses, experts in palliative care, occupational physicians, and more,” she said.
Current guidelines recommend nintedanib for PPF treatment for patients who have failed standard management for fibrotic interstitial lung disease (ILD) other than IPF. However, the definition of “standard management” remains a topic of debate, and it is acknowledged that evidence-based guidance for a standard of care varies among patients. Dr. Bendstrup pointed out the limited guidance clinicians receive from these guidelines. “As clinicians, we are not left with very much help from here.”
Choosing the right approach
Dr. Bendstrup delved into the factors influencing the choice between antifibrotic and anti-inflammatory therapies. This decision hinges on whether the patient presents with a predominantly inflammatory or a fibrotic progressive phenotype. Certain clinical characteristics contribute to the decision. Factors such as younger age, female gender, and the presence of connective tissue disease lean toward an inflammatory phenotype. Radiologic patterns, such as organized pneumonia, hypersensitivity pneumonia, or usual interstitial pneumonia–like patterns also provide valuable clues. Additionally, genetics plays a role, with shorter telomeres indicating a more fibrotic phenotype and an increased risk of immunomodulatory treatment side effects in non-IPF ILDs.
Bendstrup referred to a recent position paper on treatment recommendations and many other studies that support the use of different treatments for patients with PPF. The authors highlighted limited evidence for immunomodulation in fibrotic ILD, though such treatment is generally used except for ILD associated with systemic sclerosis. Moreover, the guidelines conditionally recommend nintedanib and call for further research on pirfenidone in PPF.
“We need intelligent, well-designed trials looking at subgroups of patients at higher risk, maybe based on molecular identification. We also need to have good biomarkers to better classify our patients based on disease behavior and treatment response. There’s a lot of discussion of biomarkers for progression, much less – if any – on biomarkers for the response to treatment. And we need them as well,” Dr. Bendstrup said in an interview.
The role of supportive care
Effective PPF treatment extends beyond pharmacologic interventions. It encompasses symptom management, patient education on vaccination and smoking cessation, and fostering social support networks. Psychological support, supplemental oxygen therapy, and pulmonary rehabilitation are integral components of care.
Elisabeth Robertson, a PPF patient representative from the United Kingdom, emphasized the importance of palliative care, not just in end-of-life scenarios but throughout the patient’s journey. Palliative care encompasses symptom alleviation, enabling patients to stay at home when possible, addressing mental health, and preparing for the end of life. Such holistic care can significantly enhance the patient’s quality of life.
The cochair of the session, Marlies S. Wijsenbeek, MD, PhD, pulmonary physician and head of the ILD Centre at the Erasmus University Medical Centre, Rotterdam, the Netherlands, underscored that palliative care begins at diagnosis and involves managing symptom burdens. “Supportive care also includes nurses, as they are precious for the patients while answering their questions and can help save time for the doctors,” she said in an interview.
In the discussion on treatment decisions, experts agreed on the pivotal role of patients in decision-making. However, Dr. Kreuter highlighted two critical factors that influence successful patient-doctor interactions: the cultural backgrounds of patients and their relatives, and the attitudes of health care providers.
Dr. Bendstrup has received honoraria or consultation fees from Boehringer Ingelheim, Roche, Astra Zeneca, Chiesi, and Daiichi Sankyo. Ms. Robertson disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
MILAN – Numerous unresolved questions surround progressive pulmonary fibrosis (PPF) treatment, according to Elisabeth Bendstrup, MD, PhD, a researcher and clinical professor in the department of clinical medicine – department of respiratory diseases and allergy, Aarhus (Denmark) University, Denmark. These questions regard the optimal timing for treatment initiation, the role of available medications, either as monotherapy or in combination, and nonpharmacologic support options.
What’s in the toolbox?
Pulmonologists who manage PPF have a range of treatment options at their disposal. This includes careful patient observation, with treatment initiation based on clinical necessity. The therapeutic arsenal comprises immunomodulatory treatments, antifibrotic agents, palliative and supportive care, and, for a minority of patients, lung transplantation.
“Once a patient is diagnosed with PPF, it is important to remember that the diagnostic criteria from the guidelines are not exactly the same of those accepted for the reimbursement of antifibrotic treatments in different countries,” Dr. Bendstrup said, suggesting that nonclinical considerations could also potentially influence the treatment choice. She spoke at the annual congress of the European Respiratory Society.
Michael Kreuter, MD, director of the Lung Center at the University Hospital in Mainz, Germany, provided insight into the introduction of antifibrotic drugs for the treatment of PPF. Drawing from nearly a decade ago when the first antifibrotic medication was approved for idiopathic pulmonary fibrosis (IPF), Dr. Kreuter noted its effectiveness in slowing disease progression, although it does not reverse it. Subsequently, the discovery that non-IPF diseases, such as rheumatoid arthritis, exhibited IPF-like behavior led to the exploration of the use of the same drugs for similar conditions, even if not IPF.
“That’s how antifibrotic treatments came into place. Now we have more trials and data to be discussed in the future,” Dr. Kreuter added. He highlighted that antifibrotic drugs are effective for several diseases. Most of those diseases are treated with different anti-inflammatory drugs, which makes it difficult to decide when to start antifibrotic therapy and how to eventually combine it with different pharmacologic approaches.
A pivotal starting point
a question only partially addressed by existing guidelines. Dr. Bendstrup advocated for a comprehensive baseline evaluation. Factors to be considered include symptom burden, the severity of lung decline, radiologic characteristics, signs of alveolar inflammation, progression risk factors, quality of life, patient preferences, and medical history. “All these should be best discussed in a multidisciplinary team, including pulmonologists, nurses, experts in palliative care, occupational physicians, and more,” she said.
Current guidelines recommend nintedanib for PPF treatment for patients who have failed standard management for fibrotic interstitial lung disease (ILD) other than IPF. However, the definition of “standard management” remains a topic of debate, and it is acknowledged that evidence-based guidance for a standard of care varies among patients. Dr. Bendstrup pointed out the limited guidance clinicians receive from these guidelines. “As clinicians, we are not left with very much help from here.”
Choosing the right approach
Dr. Bendstrup delved into the factors influencing the choice between antifibrotic and anti-inflammatory therapies. This decision hinges on whether the patient presents with a predominantly inflammatory or a fibrotic progressive phenotype. Certain clinical characteristics contribute to the decision. Factors such as younger age, female gender, and the presence of connective tissue disease lean toward an inflammatory phenotype. Radiologic patterns, such as organized pneumonia, hypersensitivity pneumonia, or usual interstitial pneumonia–like patterns also provide valuable clues. Additionally, genetics plays a role, with shorter telomeres indicating a more fibrotic phenotype and an increased risk of immunomodulatory treatment side effects in non-IPF ILDs.
Bendstrup referred to a recent position paper on treatment recommendations and many other studies that support the use of different treatments for patients with PPF. The authors highlighted limited evidence for immunomodulation in fibrotic ILD, though such treatment is generally used except for ILD associated with systemic sclerosis. Moreover, the guidelines conditionally recommend nintedanib and call for further research on pirfenidone in PPF.
“We need intelligent, well-designed trials looking at subgroups of patients at higher risk, maybe based on molecular identification. We also need to have good biomarkers to better classify our patients based on disease behavior and treatment response. There’s a lot of discussion of biomarkers for progression, much less – if any – on biomarkers for the response to treatment. And we need them as well,” Dr. Bendstrup said in an interview.
The role of supportive care
Effective PPF treatment extends beyond pharmacologic interventions. It encompasses symptom management, patient education on vaccination and smoking cessation, and fostering social support networks. Psychological support, supplemental oxygen therapy, and pulmonary rehabilitation are integral components of care.
Elisabeth Robertson, a PPF patient representative from the United Kingdom, emphasized the importance of palliative care, not just in end-of-life scenarios but throughout the patient’s journey. Palliative care encompasses symptom alleviation, enabling patients to stay at home when possible, addressing mental health, and preparing for the end of life. Such holistic care can significantly enhance the patient’s quality of life.
The cochair of the session, Marlies S. Wijsenbeek, MD, PhD, pulmonary physician and head of the ILD Centre at the Erasmus University Medical Centre, Rotterdam, the Netherlands, underscored that palliative care begins at diagnosis and involves managing symptom burdens. “Supportive care also includes nurses, as they are precious for the patients while answering their questions and can help save time for the doctors,” she said in an interview.
In the discussion on treatment decisions, experts agreed on the pivotal role of patients in decision-making. However, Dr. Kreuter highlighted two critical factors that influence successful patient-doctor interactions: the cultural backgrounds of patients and their relatives, and the attitudes of health care providers.
Dr. Bendstrup has received honoraria or consultation fees from Boehringer Ingelheim, Roche, Astra Zeneca, Chiesi, and Daiichi Sankyo. Ms. Robertson disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
MILAN – Numerous unresolved questions surround progressive pulmonary fibrosis (PPF) treatment, according to Elisabeth Bendstrup, MD, PhD, a researcher and clinical professor in the department of clinical medicine – department of respiratory diseases and allergy, Aarhus (Denmark) University, Denmark. These questions regard the optimal timing for treatment initiation, the role of available medications, either as monotherapy or in combination, and nonpharmacologic support options.
What’s in the toolbox?
Pulmonologists who manage PPF have a range of treatment options at their disposal. This includes careful patient observation, with treatment initiation based on clinical necessity. The therapeutic arsenal comprises immunomodulatory treatments, antifibrotic agents, palliative and supportive care, and, for a minority of patients, lung transplantation.
“Once a patient is diagnosed with PPF, it is important to remember that the diagnostic criteria from the guidelines are not exactly the same of those accepted for the reimbursement of antifibrotic treatments in different countries,” Dr. Bendstrup said, suggesting that nonclinical considerations could also potentially influence the treatment choice. She spoke at the annual congress of the European Respiratory Society.
Michael Kreuter, MD, director of the Lung Center at the University Hospital in Mainz, Germany, provided insight into the introduction of antifibrotic drugs for the treatment of PPF. Drawing from nearly a decade ago when the first antifibrotic medication was approved for idiopathic pulmonary fibrosis (IPF), Dr. Kreuter noted its effectiveness in slowing disease progression, although it does not reverse it. Subsequently, the discovery that non-IPF diseases, such as rheumatoid arthritis, exhibited IPF-like behavior led to the exploration of the use of the same drugs for similar conditions, even if not IPF.
“That’s how antifibrotic treatments came into place. Now we have more trials and data to be discussed in the future,” Dr. Kreuter added. He highlighted that antifibrotic drugs are effective for several diseases. Most of those diseases are treated with different anti-inflammatory drugs, which makes it difficult to decide when to start antifibrotic therapy and how to eventually combine it with different pharmacologic approaches.
A pivotal starting point
a question only partially addressed by existing guidelines. Dr. Bendstrup advocated for a comprehensive baseline evaluation. Factors to be considered include symptom burden, the severity of lung decline, radiologic characteristics, signs of alveolar inflammation, progression risk factors, quality of life, patient preferences, and medical history. “All these should be best discussed in a multidisciplinary team, including pulmonologists, nurses, experts in palliative care, occupational physicians, and more,” she said.
Current guidelines recommend nintedanib for PPF treatment for patients who have failed standard management for fibrotic interstitial lung disease (ILD) other than IPF. However, the definition of “standard management” remains a topic of debate, and it is acknowledged that evidence-based guidance for a standard of care varies among patients. Dr. Bendstrup pointed out the limited guidance clinicians receive from these guidelines. “As clinicians, we are not left with very much help from here.”
Choosing the right approach
Dr. Bendstrup delved into the factors influencing the choice between antifibrotic and anti-inflammatory therapies. This decision hinges on whether the patient presents with a predominantly inflammatory or a fibrotic progressive phenotype. Certain clinical characteristics contribute to the decision. Factors such as younger age, female gender, and the presence of connective tissue disease lean toward an inflammatory phenotype. Radiologic patterns, such as organized pneumonia, hypersensitivity pneumonia, or usual interstitial pneumonia–like patterns also provide valuable clues. Additionally, genetics plays a role, with shorter telomeres indicating a more fibrotic phenotype and an increased risk of immunomodulatory treatment side effects in non-IPF ILDs.
Bendstrup referred to a recent position paper on treatment recommendations and many other studies that support the use of different treatments for patients with PPF. The authors highlighted limited evidence for immunomodulation in fibrotic ILD, though such treatment is generally used except for ILD associated with systemic sclerosis. Moreover, the guidelines conditionally recommend nintedanib and call for further research on pirfenidone in PPF.
“We need intelligent, well-designed trials looking at subgroups of patients at higher risk, maybe based on molecular identification. We also need to have good biomarkers to better classify our patients based on disease behavior and treatment response. There’s a lot of discussion of biomarkers for progression, much less – if any – on biomarkers for the response to treatment. And we need them as well,” Dr. Bendstrup said in an interview.
The role of supportive care
Effective PPF treatment extends beyond pharmacologic interventions. It encompasses symptom management, patient education on vaccination and smoking cessation, and fostering social support networks. Psychological support, supplemental oxygen therapy, and pulmonary rehabilitation are integral components of care.
Elisabeth Robertson, a PPF patient representative from the United Kingdom, emphasized the importance of palliative care, not just in end-of-life scenarios but throughout the patient’s journey. Palliative care encompasses symptom alleviation, enabling patients to stay at home when possible, addressing mental health, and preparing for the end of life. Such holistic care can significantly enhance the patient’s quality of life.
The cochair of the session, Marlies S. Wijsenbeek, MD, PhD, pulmonary physician and head of the ILD Centre at the Erasmus University Medical Centre, Rotterdam, the Netherlands, underscored that palliative care begins at diagnosis and involves managing symptom burdens. “Supportive care also includes nurses, as they are precious for the patients while answering their questions and can help save time for the doctors,” she said in an interview.
In the discussion on treatment decisions, experts agreed on the pivotal role of patients in decision-making. However, Dr. Kreuter highlighted two critical factors that influence successful patient-doctor interactions: the cultural backgrounds of patients and their relatives, and the attitudes of health care providers.
Dr. Bendstrup has received honoraria or consultation fees from Boehringer Ingelheim, Roche, Astra Zeneca, Chiesi, and Daiichi Sankyo. Ms. Robertson disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
AT ERS 2023