The number of U.S. patients diagnosed with Parkinson’s disease each year is about 50% higher than previously thought, according to new research that investigators say highlights the growing strain on clinical services and the need for more research funding.

In an analysis of five databases and more than 15 million people, about 60,000-90,000 individuals older than 45 years are estimated to be diagnosed with Parkinson’s disease each year – which is far more than the previous estimate of around 40,000-60,000 new cases annually.

This is the latest study to update decades-old epidemiologic data on Parkinson’s disease incidence and prevalence. Previous incidence rates came from small, single-population studies that are now more than 25 years old.

“In the advocacy community, we’ve been earnest about the impact of people living with Parkinson’s disease, and what we really lacked was sufficient data to be able to demonstrate the urgency of our need,” said study coinvestigator James Beck, PhD, chief scientific officer at the Parkinson’s Foundation, New York.

“We wanted to revise these numbers, highlight that they are larger than people anticipated, and use it as a call to action to change the approach we have toward Parkinson’s,” Dr. Beck said.

The findings were published online in NPJ Parkinson’s Disease.
 

Updating an outdated model

The study builds on the Parkinson’s Prevalence Project, a 2018 initiative that used a new model to calculate Parkinson’s disease prevalence. Before then, federal prevalence data was based on a 40-year-old study of just 26 Parkinson’s disease cases in one small county in rural Mississippi.

Dr. Beck and others used a more sophisticated model, using data from five separate cohort studies. They estimated the total number of patients living with Parkinson’s disease in the United States to be 930,000, which is far higher than the 650,000 the old model predicted.

Researchers then moved on to the current project, developing a new method to estimate Parkinson’s disease incidence.

The project included 2012 data on more than 15 million individuals in the United States and Canada. The investigators drew from three large insurance databases (Kaiser Permanente Northern California, Ontario Health Care, and Medicare) and two long-term epidemiologic studies (the Honolulu-Asia Aging Study and the Rochester Epidemiology Project).

On the basis of their analysis, the investigators proposed a working Parkinson’s disease incident rate estimate of 47-77 cases per 100,000 people aged 45 years or older. Limiting the analysis to those aged 65 or older raised the incidence to 108-212 per 100,000 people.

That translates to 60,000-95,000 new cases each year among adults aged 45 years or older. Using the Medicare administrative database alone for this same time period suggests an annual incidence of nearly 90,000 for individuals aged 65 or older.

“The numbers we’re proposing are conservative,” Dr. Beck said. “The true numbers are probably north of 90,000.”

Incidence rates increased with age and were higher in men. The researchers also identified clusters of counties with higher incidence rates in parts of the country called the “Parkinson’s belt.”

That geographic area mirrors the Rust Belt and includes parts of the Northeastern and Midwestern United States with a long history of industrial manufacturing that used heavy metals and industrial solvents, which are environmental factors linked to risk for Parkinson’s disease.

Cases were also higher in southern California, southeastern Texas, and Florida – agricultural regions with high pesticide use, which is also a risk factor for Parkinson’s disease. Central Pennsylvania also had higher incidence rates.
 

Why the increase?

The increase in cases could be the result of the more comprehensive estimation model used, the researchers noted. Or it could be improved detection, the aging population, a rise in sedentary lifestyles, increased exposure to environmental risk factors, or even the sharp decline in smoking in the United States, as some studies have shown that smokers have a lower Parkinson’s disease risk.

“The short answer is, we don’t know; and the long answer is, it’s all the above,” Dr. Beck said.

Although about 15% of Parkinson’s disease cases have a genetic basis, the cause is unknown in the majority of cases. In addition, diagnosis is difficult because there is no blood test or scan that detects the disease.

“Diagnosis requires a skilled clinician with real familiarity with Parkinson’s. And we have a real shortage of neurologists in this country to not only be able to diagnose but also to treat the condition,” Dr. Beck said.

That was one motivation for doing the study: to highlight what experts say is a pending clinical crisis for patients with Parkinson’s disease, he added.

The investigators also wanted to raise awareness about the scope of the disorder – not just about prevalence and incidence but also what those data mean for the health care industry, research aims, drug development and health care coverage, and policies.

In a 2020 study, the same researchers calculated a cost of $52 billion per year for medical and nonmedical costs related to Parkinson’s disease, which works out to about $26,000 per year per patient. That figure is expected to surpass $79 billion by 2030.

“This is an urgent condition for many people who live with the disease. And to the extent we can get our country to recognize that and really make the investment now, this is an area where a stitch in time saves nine,” Dr. Beck said.

“If we can invest some money now, we have a chance to really make a difference in the future,” he added.
 

‘Groundbreaking’ findings

Commenting on the findings, Jori Fleisher, MD, MSCE, associate professor of neurological sciences at Rush University Medical Center, Chicago, called the results “groundbreaking” and said that they validate what clinicians have been seeing in real-world practice.

“The findings reflect what a lot of us in practice have been appreciating anecdotally, which is that it seems that Parkinson’s is being diagnosed more frequently and that the incidence has been rising,” said Dr. Fleisher, who was not involved with the study.

She noted that the use of multiple datasets is one element of the methodology that makes the data so significant.

“There has been great work out of individual centers; but no matter how good your study methods are within that one population, you’re drawing conclusions based on that one population,” Dr. Fleisher said.

This research, together with the previous work by the group on prevalence data, could go a long way toward raising awareness about the scope of Parkinson’s disease in the United States – which could lead to earlier diagnosis, more research funding, and increased attention on the need for more clinicians who specialize in movement disorders, she added.

“This should increase research funding across the spectrum, including everything from the basic science to translational research, clinical research and implementation, and health services research,” Dr. Fleisher said.

The study was supported by the Parkinson’s Foundation, The Michael J. Fox Foundation for Parkinson’s Research, and the Institute for Clinical Evaluative Sciences. Dr. Beck and Dr. Fleisher reported no relevant financial relationships.

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

The number of U.S. patients diagnosed with Parkinson’s disease each year is about 50% higher than previously thought, according to new research that investigators say highlights the growing strain on clinical services and the need for more research funding.

In an analysis of five databases and more than 15 million people, about 60,000-90,000 individuals older than 45 years are estimated to be diagnosed with Parkinson’s disease each year – which is far more than the previous estimate of around 40,000-60,000 new cases annually.

This is the latest study to update decades-old epidemiologic data on Parkinson’s disease incidence and prevalence. Previous incidence rates came from small, single-population studies that are now more than 25 years old.

“In the advocacy community, we’ve been earnest about the impact of people living with Parkinson’s disease, and what we really lacked was sufficient data to be able to demonstrate the urgency of our need,” said study coinvestigator James Beck, PhD, chief scientific officer at the Parkinson’s Foundation, New York.

“We wanted to revise these numbers, highlight that they are larger than people anticipated, and use it as a call to action to change the approach we have toward Parkinson’s,” Dr. Beck said.

The findings were published online in NPJ Parkinson’s Disease.
 

Updating an outdated model

The study builds on the Parkinson’s Prevalence Project, a 2018 initiative that used a new model to calculate Parkinson’s disease prevalence. Before then, federal prevalence data was based on a 40-year-old study of just 26 Parkinson’s disease cases in one small county in rural Mississippi.

Dr. Beck and others used a more sophisticated model, using data from five separate cohort studies. They estimated the total number of patients living with Parkinson’s disease in the United States to be 930,000, which is far higher than the 650,000 the old model predicted.

Researchers then moved on to the current project, developing a new method to estimate Parkinson’s disease incidence.

The project included 2012 data on more than 15 million individuals in the United States and Canada. The investigators drew from three large insurance databases (Kaiser Permanente Northern California, Ontario Health Care, and Medicare) and two long-term epidemiologic studies (the Honolulu-Asia Aging Study and the Rochester Epidemiology Project).

On the basis of their analysis, the investigators proposed a working Parkinson’s disease incident rate estimate of 47-77 cases per 100,000 people aged 45 years or older. Limiting the analysis to those aged 65 or older raised the incidence to 108-212 per 100,000 people.

That translates to 60,000-95,000 new cases each year among adults aged 45 years or older. Using the Medicare administrative database alone for this same time period suggests an annual incidence of nearly 90,000 for individuals aged 65 or older.

“The numbers we’re proposing are conservative,” Dr. Beck said. “The true numbers are probably north of 90,000.”

Incidence rates increased with age and were higher in men. The researchers also identified clusters of counties with higher incidence rates in parts of the country called the “Parkinson’s belt.”

That geographic area mirrors the Rust Belt and includes parts of the Northeastern and Midwestern United States with a long history of industrial manufacturing that used heavy metals and industrial solvents, which are environmental factors linked to risk for Parkinson’s disease.

Cases were also higher in southern California, southeastern Texas, and Florida – agricultural regions with high pesticide use, which is also a risk factor for Parkinson’s disease. Central Pennsylvania also had higher incidence rates.
 

Why the increase?

The increase in cases could be the result of the more comprehensive estimation model used, the researchers noted. Or it could be improved detection, the aging population, a rise in sedentary lifestyles, increased exposure to environmental risk factors, or even the sharp decline in smoking in the United States, as some studies have shown that smokers have a lower Parkinson’s disease risk.

“The short answer is, we don’t know; and the long answer is, it’s all the above,” Dr. Beck said.

Although about 15% of Parkinson’s disease cases have a genetic basis, the cause is unknown in the majority of cases. In addition, diagnosis is difficult because there is no blood test or scan that detects the disease.

“Diagnosis requires a skilled clinician with real familiarity with Parkinson’s. And we have a real shortage of neurologists in this country to not only be able to diagnose but also to treat the condition,” Dr. Beck said.

That was one motivation for doing the study: to highlight what experts say is a pending clinical crisis for patients with Parkinson’s disease, he added.

The investigators also wanted to raise awareness about the scope of the disorder – not just about prevalence and incidence but also what those data mean for the health care industry, research aims, drug development and health care coverage, and policies.

In a 2020 study, the same researchers calculated a cost of $52 billion per year for medical and nonmedical costs related to Parkinson’s disease, which works out to about $26,000 per year per patient. That figure is expected to surpass $79 billion by 2030.

“This is an urgent condition for many people who live with the disease. And to the extent we can get our country to recognize that and really make the investment now, this is an area where a stitch in time saves nine,” Dr. Beck said.

“If we can invest some money now, we have a chance to really make a difference in the future,” he added.
 

‘Groundbreaking’ findings

Commenting on the findings, Jori Fleisher, MD, MSCE, associate professor of neurological sciences at Rush University Medical Center, Chicago, called the results “groundbreaking” and said that they validate what clinicians have been seeing in real-world practice.

“The findings reflect what a lot of us in practice have been appreciating anecdotally, which is that it seems that Parkinson’s is being diagnosed more frequently and that the incidence has been rising,” said Dr. Fleisher, who was not involved with the study.

She noted that the use of multiple datasets is one element of the methodology that makes the data so significant.

“There has been great work out of individual centers; but no matter how good your study methods are within that one population, you’re drawing conclusions based on that one population,” Dr. Fleisher said.

This research, together with the previous work by the group on prevalence data, could go a long way toward raising awareness about the scope of Parkinson’s disease in the United States – which could lead to earlier diagnosis, more research funding, and increased attention on the need for more clinicians who specialize in movement disorders, she added.

“This should increase research funding across the spectrum, including everything from the basic science to translational research, clinical research and implementation, and health services research,” Dr. Fleisher said.

The study was supported by the Parkinson’s Foundation, The Michael J. Fox Foundation for Parkinson’s Research, and the Institute for Clinical Evaluative Sciences. Dr. Beck and Dr. Fleisher reported no relevant financial relationships.

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

The number of U.S. patients diagnosed with Parkinson’s disease each year is about 50% higher than previously thought, according to new research that investigators say highlights the growing strain on clinical services and the need for more research funding.

In an analysis of five databases and more than 15 million people, about 60,000-90,000 individuals older than 45 years are estimated to be diagnosed with Parkinson’s disease each year – which is far more than the previous estimate of around 40,000-60,000 new cases annually.

This is the latest study to update decades-old epidemiologic data on Parkinson’s disease incidence and prevalence. Previous incidence rates came from small, single-population studies that are now more than 25 years old.

“In the advocacy community, we’ve been earnest about the impact of people living with Parkinson’s disease, and what we really lacked was sufficient data to be able to demonstrate the urgency of our need,” said study coinvestigator James Beck, PhD, chief scientific officer at the Parkinson’s Foundation, New York.

“We wanted to revise these numbers, highlight that they are larger than people anticipated, and use it as a call to action to change the approach we have toward Parkinson’s,” Dr. Beck said.

The findings were published online in NPJ Parkinson’s Disease.
 

Updating an outdated model

The study builds on the Parkinson’s Prevalence Project, a 2018 initiative that used a new model to calculate Parkinson’s disease prevalence. Before then, federal prevalence data was based on a 40-year-old study of just 26 Parkinson’s disease cases in one small county in rural Mississippi.

Dr. Beck and others used a more sophisticated model, using data from five separate cohort studies. They estimated the total number of patients living with Parkinson’s disease in the United States to be 930,000, which is far higher than the 650,000 the old model predicted.

Researchers then moved on to the current project, developing a new method to estimate Parkinson’s disease incidence.

The project included 2012 data on more than 15 million individuals in the United States and Canada. The investigators drew from three large insurance databases (Kaiser Permanente Northern California, Ontario Health Care, and Medicare) and two long-term epidemiologic studies (the Honolulu-Asia Aging Study and the Rochester Epidemiology Project).

On the basis of their analysis, the investigators proposed a working Parkinson’s disease incident rate estimate of 47-77 cases per 100,000 people aged 45 years or older. Limiting the analysis to those aged 65 or older raised the incidence to 108-212 per 100,000 people.

That translates to 60,000-95,000 new cases each year among adults aged 45 years or older. Using the Medicare administrative database alone for this same time period suggests an annual incidence of nearly 90,000 for individuals aged 65 or older.

“The numbers we’re proposing are conservative,” Dr. Beck said. “The true numbers are probably north of 90,000.”

Incidence rates increased with age and were higher in men. The researchers also identified clusters of counties with higher incidence rates in parts of the country called the “Parkinson’s belt.”

That geographic area mirrors the Rust Belt and includes parts of the Northeastern and Midwestern United States with a long history of industrial manufacturing that used heavy metals and industrial solvents, which are environmental factors linked to risk for Parkinson’s disease.

Cases were also higher in southern California, southeastern Texas, and Florida – agricultural regions with high pesticide use, which is also a risk factor for Parkinson’s disease. Central Pennsylvania also had higher incidence rates.
 

Why the increase?

The increase in cases could be the result of the more comprehensive estimation model used, the researchers noted. Or it could be improved detection, the aging population, a rise in sedentary lifestyles, increased exposure to environmental risk factors, or even the sharp decline in smoking in the United States, as some studies have shown that smokers have a lower Parkinson’s disease risk.

“The short answer is, we don’t know; and the long answer is, it’s all the above,” Dr. Beck said.

Although about 15% of Parkinson’s disease cases have a genetic basis, the cause is unknown in the majority of cases. In addition, diagnosis is difficult because there is no blood test or scan that detects the disease.

“Diagnosis requires a skilled clinician with real familiarity with Parkinson’s. And we have a real shortage of neurologists in this country to not only be able to diagnose but also to treat the condition,” Dr. Beck said.

That was one motivation for doing the study: to highlight what experts say is a pending clinical crisis for patients with Parkinson’s disease, he added.

The investigators also wanted to raise awareness about the scope of the disorder – not just about prevalence and incidence but also what those data mean for the health care industry, research aims, drug development and health care coverage, and policies.

In a 2020 study, the same researchers calculated a cost of $52 billion per year for medical and nonmedical costs related to Parkinson’s disease, which works out to about $26,000 per year per patient. That figure is expected to surpass $79 billion by 2030.

“This is an urgent condition for many people who live with the disease. And to the extent we can get our country to recognize that and really make the investment now, this is an area where a stitch in time saves nine,” Dr. Beck said.

“If we can invest some money now, we have a chance to really make a difference in the future,” he added.
 

‘Groundbreaking’ findings

Commenting on the findings, Jori Fleisher, MD, MSCE, associate professor of neurological sciences at Rush University Medical Center, Chicago, called the results “groundbreaking” and said that they validate what clinicians have been seeing in real-world practice.

“The findings reflect what a lot of us in practice have been appreciating anecdotally, which is that it seems that Parkinson’s is being diagnosed more frequently and that the incidence has been rising,” said Dr. Fleisher, who was not involved with the study.

She noted that the use of multiple datasets is one element of the methodology that makes the data so significant.

“There has been great work out of individual centers; but no matter how good your study methods are within that one population, you’re drawing conclusions based on that one population,” Dr. Fleisher said.

This research, together with the previous work by the group on prevalence data, could go a long way toward raising awareness about the scope of Parkinson’s disease in the United States – which could lead to earlier diagnosis, more research funding, and increased attention on the need for more clinicians who specialize in movement disorders, she added.

“This should increase research funding across the spectrum, including everything from the basic science to translational research, clinical research and implementation, and health services research,” Dr. Fleisher said.

The study was supported by the Parkinson’s Foundation, The Michael J. Fox Foundation for Parkinson’s Research, and the Institute for Clinical Evaluative Sciences. Dr. Beck and Dr. Fleisher reported no relevant financial relationships.

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

Weak handgrip in older adults is linked to a higher risk for depression – while a stronger handgrip may have protective benefits, new research suggests.
 

In a study of more than 115,000 adults, there was a significant association between stronger handgrip, up to 40 kg in men and 27 kg in women, and lower depression risk.

Investigators add that there was a “dose-response” association between physical strength and risk for depression.

“Being physically strong may serve as a preventive factor for depression in older adults, but this is limited to a maximum specific threshold for men and women,” Ruben Lopez-Bueno, PhD, of the department of physical medicine and nursing, University of Zaragoza, Spain, and colleagues write.

The findings were published online in the British Journal of Psychiatry.
 

Easy, fast, reliable

Depression is a major public health problem, and studies “aimed at examining preventive factors to tackle the increase in depression are required,” the investigators write.

They add that a “growing body of research” is examining the link between depression and muscle strength, with handgrip as an estimator, in healthy middle-aged and older adults.

Handgrip strength is an “easy-to-use, fast and reliable indicator of both sarcopenia (age-related loss of muscle mass) and dynapenia (age-related loss of muscle strength), both of which have been associated with depression,” the researchers note.

It is plausible that there is a “regulatory role of skeletal muscle on brain function affecting this condition,” they add.

They note that exercise seems to play a “key role” because it can improve muscle strength as well as muscle mass, downregulate systemic inflammation, and improve neuroplasticity, neuroendocrine, and oxidative stress responses.

Previous studies have relied either on cross-sectional or prospective cohort models and have focused mostly on a specific country, “not accounting for time-varying changes of both handgrip strength and relevant covariables.”

Moreover, previous evidence has been mixed regarding the “extent to which handgrip strength levels may associate with lower risk of depression, with study results ranging from weak to strong associations,” the investigators write.

So “higher-quality research with representative samples from different countries is required to better clarify the strength of such an association and to confirm directionality,” they add.
 

SHARE data

To fill this gap, the researchers turned to data from waves 1, 2, 4, 5, 6, and 7 of the Survey of Health, Ageing and Retirement in Europe (SHARE). This encompassed 115,601 individuals aged 50 years and older (mean age, 64.3 years; 54.3% women) residing in European countries and Israel (24 countries total).

Data from wave 3 were not used because handgrip measures were not used in that wave. In the other waves, a handheld dynamometer was used to measure handgrip strength.

The participants were divided into tertiles of handgrip strength, with the “first third” being the lowest tertile of strength and the “final third” representing the highest strength.

All participants were followed for a median of 7.3 years (792,459 person-years), during which 26.1% experienced a risk for depression, as reflected by scores on the EURO-D 12-item scale.

The investigators set the time scale as the months from study entry until either a first depression onset or the end of follow-up.

Covariates that the researchers accounted for included gender, age, education, country, body mass index, physical inactivity, smoking, alcohol consumption, whether living with a partner, wave of inclusion, chronic diseases, consumption of prescribed drugs, and fruit and vegetable consumption.

The researchers used two models: the first adjusted for gender and age at time of the interview, and the second adjusted for all confounders.

In the model that was adjusted only for gender and age, greater handgrip strength was associated with a significantly reduced risk for depression among participants in the second, third, and the final third in comparison with the first third (hazard ratio, 0.65; 95% confidence interval, 0.63-0.68; and HR, 0.50; 95% CI, 0.48-0.53, respectively).

The associations remained consistent in the fully adjusted model, although risk for depression was slightly attenuated in the second and final thirds compared with the first third (HR, 0.76; 95% CI, 0.71-0.81; and HR, 0.64; 95% CI, 0.59-0.69, respectively).

When the researchers conducted analyses using restricted cubic spline modeling, they found a significant association for each kilogram increase of handgrip strength and depression, up to 40 kg in men and 27 kg in women (HR, 1.39; 95% CI, 1.08-1.71; and HR, 1.28; 95% CI, 1.05-1.55, respectively).

There was no greater reduction in depression risk in those with handgrip strength above those values.
 

Potential depression screen

The investigators suggest several explanations for their findings. For example, handgrip strength has “been used as an overall indicator of health status, including sarcopenia,” they write.

Adults with sarcopenia have been found to be at greater risk for depression because of reduced muscle strength, since neurotrophins are produced by skeletal muscle, among other tissues, and are associated with improvement in mood.

From a psychological point of view, “being physically strong may lead to a sensation of psychological wellbeing,” the researchers write.

Moreover, being physically active “across the lifespan also promotes structural and functional changes in the brain, benefiting cognitive functioning and reducing the risk of neurodegeneration,” they write.

This can be important because aging adults with cognitive impairments can also experience neuromuscular impairments that “presumably will contribute to becoming weaker,” they note.

Overall, the findings “warrant strength training programmes aimed at older adults to reduce depression risk,” the investigators write. Clinicians “may consider using the observed handgrip strength thresholds to screen for potential depression risk in older adults,” they add.
 

Protective factor?

Commenting for this news organization, Julian Mutz, PhD, postdoctoral research associate at the Social, Genetic and Developmental Psychiatry Centre, King’s College, London, said the study “provides further evidence that physical strength may be a protective factor against depression in older adults.”

This confirms a “plethora of cross-sectional and longitudinal studies,” including one recently conducted by Dr. Mutz’s group.

The design of the current study “allowed the authors to address a number of key limitations of previous studies, for example, by including repeated measurements of grip strength and adjustment for potential confounding factors over time,” said Dr. Mutz, who was not involved with the research.

Additionally, “an important contribution of this study is that the authors show that higher grip strength is only associated with a lower risk of depression up to a specific threshold,” he noted.

“The clinical implication of this finding is that only individuals with grip strength below this threshold are at a higher risk of depression. These individuals especially may benefit from interventions aimed at increasing physical strength,” Dr. Mutz said.

The SHARE data collection has been funded by the European Commission and by DG Employment, Social Affairs and Inclusion. Additional funding was obtained from the German Ministry of Education and Research, the Max Planck Society for the Advancement of Science, and the U.S. National Institute on Aging. Dr. Lopez-Bueno is supported by the European Union – Next Generation EU. The other investigators and Dr. Mutz have reported no relevant financial relationships.

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

Weak handgrip in older adults is linked to a higher risk for depression – while a stronger handgrip may have protective benefits, new research suggests.
 

In a study of more than 115,000 adults, there was a significant association between stronger handgrip, up to 40 kg in men and 27 kg in women, and lower depression risk.

Investigators add that there was a “dose-response” association between physical strength and risk for depression.

“Being physically strong may serve as a preventive factor for depression in older adults, but this is limited to a maximum specific threshold for men and women,” Ruben Lopez-Bueno, PhD, of the department of physical medicine and nursing, University of Zaragoza, Spain, and colleagues write.

The findings were published online in the British Journal of Psychiatry.
 

Easy, fast, reliable

Depression is a major public health problem, and studies “aimed at examining preventive factors to tackle the increase in depression are required,” the investigators write.

They add that a “growing body of research” is examining the link between depression and muscle strength, with handgrip as an estimator, in healthy middle-aged and older adults.

Handgrip strength is an “easy-to-use, fast and reliable indicator of both sarcopenia (age-related loss of muscle mass) and dynapenia (age-related loss of muscle strength), both of which have been associated with depression,” the researchers note.

It is plausible that there is a “regulatory role of skeletal muscle on brain function affecting this condition,” they add.

They note that exercise seems to play a “key role” because it can improve muscle strength as well as muscle mass, downregulate systemic inflammation, and improve neuroplasticity, neuroendocrine, and oxidative stress responses.

Previous studies have relied either on cross-sectional or prospective cohort models and have focused mostly on a specific country, “not accounting for time-varying changes of both handgrip strength and relevant covariables.”

Moreover, previous evidence has been mixed regarding the “extent to which handgrip strength levels may associate with lower risk of depression, with study results ranging from weak to strong associations,” the investigators write.

So “higher-quality research with representative samples from different countries is required to better clarify the strength of such an association and to confirm directionality,” they add.
 

SHARE data

To fill this gap, the researchers turned to data from waves 1, 2, 4, 5, 6, and 7 of the Survey of Health, Ageing and Retirement in Europe (SHARE). This encompassed 115,601 individuals aged 50 years and older (mean age, 64.3 years; 54.3% women) residing in European countries and Israel (24 countries total).

Data from wave 3 were not used because handgrip measures were not used in that wave. In the other waves, a handheld dynamometer was used to measure handgrip strength.

The participants were divided into tertiles of handgrip strength, with the “first third” being the lowest tertile of strength and the “final third” representing the highest strength.

All participants were followed for a median of 7.3 years (792,459 person-years), during which 26.1% experienced a risk for depression, as reflected by scores on the EURO-D 12-item scale.

The investigators set the time scale as the months from study entry until either a first depression onset or the end of follow-up.

Covariates that the researchers accounted for included gender, age, education, country, body mass index, physical inactivity, smoking, alcohol consumption, whether living with a partner, wave of inclusion, chronic diseases, consumption of prescribed drugs, and fruit and vegetable consumption.

The researchers used two models: the first adjusted for gender and age at time of the interview, and the second adjusted for all confounders.

In the model that was adjusted only for gender and age, greater handgrip strength was associated with a significantly reduced risk for depression among participants in the second, third, and the final third in comparison with the first third (hazard ratio, 0.65; 95% confidence interval, 0.63-0.68; and HR, 0.50; 95% CI, 0.48-0.53, respectively).

The associations remained consistent in the fully adjusted model, although risk for depression was slightly attenuated in the second and final thirds compared with the first third (HR, 0.76; 95% CI, 0.71-0.81; and HR, 0.64; 95% CI, 0.59-0.69, respectively).

When the researchers conducted analyses using restricted cubic spline modeling, they found a significant association for each kilogram increase of handgrip strength and depression, up to 40 kg in men and 27 kg in women (HR, 1.39; 95% CI, 1.08-1.71; and HR, 1.28; 95% CI, 1.05-1.55, respectively).

There was no greater reduction in depression risk in those with handgrip strength above those values.
 

Potential depression screen

The investigators suggest several explanations for their findings. For example, handgrip strength has “been used as an overall indicator of health status, including sarcopenia,” they write.

Adults with sarcopenia have been found to be at greater risk for depression because of reduced muscle strength, since neurotrophins are produced by skeletal muscle, among other tissues, and are associated with improvement in mood.

From a psychological point of view, “being physically strong may lead to a sensation of psychological wellbeing,” the researchers write.

Moreover, being physically active “across the lifespan also promotes structural and functional changes in the brain, benefiting cognitive functioning and reducing the risk of neurodegeneration,” they write.

This can be important because aging adults with cognitive impairments can also experience neuromuscular impairments that “presumably will contribute to becoming weaker,” they note.

Overall, the findings “warrant strength training programmes aimed at older adults to reduce depression risk,” the investigators write. Clinicians “may consider using the observed handgrip strength thresholds to screen for potential depression risk in older adults,” they add.
 

Protective factor?

Commenting for this news organization, Julian Mutz, PhD, postdoctoral research associate at the Social, Genetic and Developmental Psychiatry Centre, King’s College, London, said the study “provides further evidence that physical strength may be a protective factor against depression in older adults.”

This confirms a “plethora of cross-sectional and longitudinal studies,” including one recently conducted by Dr. Mutz’s group.

The design of the current study “allowed the authors to address a number of key limitations of previous studies, for example, by including repeated measurements of grip strength and adjustment for potential confounding factors over time,” said Dr. Mutz, who was not involved with the research.

Additionally, “an important contribution of this study is that the authors show that higher grip strength is only associated with a lower risk of depression up to a specific threshold,” he noted.

“The clinical implication of this finding is that only individuals with grip strength below this threshold are at a higher risk of depression. These individuals especially may benefit from interventions aimed at increasing physical strength,” Dr. Mutz said.

The SHARE data collection has been funded by the European Commission and by DG Employment, Social Affairs and Inclusion. Additional funding was obtained from the German Ministry of Education and Research, the Max Planck Society for the Advancement of Science, and the U.S. National Institute on Aging. Dr. Lopez-Bueno is supported by the European Union – Next Generation EU. The other investigators and Dr. Mutz have reported no relevant financial relationships.

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

Weak handgrip in older adults is linked to a higher risk for depression – while a stronger handgrip may have protective benefits, new research suggests.
 

In a study of more than 115,000 adults, there was a significant association between stronger handgrip, up to 40 kg in men and 27 kg in women, and lower depression risk.

Investigators add that there was a “dose-response” association between physical strength and risk for depression.

“Being physically strong may serve as a preventive factor for depression in older adults, but this is limited to a maximum specific threshold for men and women,” Ruben Lopez-Bueno, PhD, of the department of physical medicine and nursing, University of Zaragoza, Spain, and colleagues write.

The findings were published online in the British Journal of Psychiatry.
 

Easy, fast, reliable

Depression is a major public health problem, and studies “aimed at examining preventive factors to tackle the increase in depression are required,” the investigators write.

They add that a “growing body of research” is examining the link between depression and muscle strength, with handgrip as an estimator, in healthy middle-aged and older adults.

Handgrip strength is an “easy-to-use, fast and reliable indicator of both sarcopenia (age-related loss of muscle mass) and dynapenia (age-related loss of muscle strength), both of which have been associated with depression,” the researchers note.

It is plausible that there is a “regulatory role of skeletal muscle on brain function affecting this condition,” they add.

They note that exercise seems to play a “key role” because it can improve muscle strength as well as muscle mass, downregulate systemic inflammation, and improve neuroplasticity, neuroendocrine, and oxidative stress responses.

Previous studies have relied either on cross-sectional or prospective cohort models and have focused mostly on a specific country, “not accounting for time-varying changes of both handgrip strength and relevant covariables.”

Moreover, previous evidence has been mixed regarding the “extent to which handgrip strength levels may associate with lower risk of depression, with study results ranging from weak to strong associations,” the investigators write.

So “higher-quality research with representative samples from different countries is required to better clarify the strength of such an association and to confirm directionality,” they add.
 

SHARE data

To fill this gap, the researchers turned to data from waves 1, 2, 4, 5, 6, and 7 of the Survey of Health, Ageing and Retirement in Europe (SHARE). This encompassed 115,601 individuals aged 50 years and older (mean age, 64.3 years; 54.3% women) residing in European countries and Israel (24 countries total).

Data from wave 3 were not used because handgrip measures were not used in that wave. In the other waves, a handheld dynamometer was used to measure handgrip strength.

The participants were divided into tertiles of handgrip strength, with the “first third” being the lowest tertile of strength and the “final third” representing the highest strength.

All participants were followed for a median of 7.3 years (792,459 person-years), during which 26.1% experienced a risk for depression, as reflected by scores on the EURO-D 12-item scale.

The investigators set the time scale as the months from study entry until either a first depression onset or the end of follow-up.

Covariates that the researchers accounted for included gender, age, education, country, body mass index, physical inactivity, smoking, alcohol consumption, whether living with a partner, wave of inclusion, chronic diseases, consumption of prescribed drugs, and fruit and vegetable consumption.

The researchers used two models: the first adjusted for gender and age at time of the interview, and the second adjusted for all confounders.

In the model that was adjusted only for gender and age, greater handgrip strength was associated with a significantly reduced risk for depression among participants in the second, third, and the final third in comparison with the first third (hazard ratio, 0.65; 95% confidence interval, 0.63-0.68; and HR, 0.50; 95% CI, 0.48-0.53, respectively).

The associations remained consistent in the fully adjusted model, although risk for depression was slightly attenuated in the second and final thirds compared with the first third (HR, 0.76; 95% CI, 0.71-0.81; and HR, 0.64; 95% CI, 0.59-0.69, respectively).

When the researchers conducted analyses using restricted cubic spline modeling, they found a significant association for each kilogram increase of handgrip strength and depression, up to 40 kg in men and 27 kg in women (HR, 1.39; 95% CI, 1.08-1.71; and HR, 1.28; 95% CI, 1.05-1.55, respectively).

There was no greater reduction in depression risk in those with handgrip strength above those values.
 

Potential depression screen

The investigators suggest several explanations for their findings. For example, handgrip strength has “been used as an overall indicator of health status, including sarcopenia,” they write.

Adults with sarcopenia have been found to be at greater risk for depression because of reduced muscle strength, since neurotrophins are produced by skeletal muscle, among other tissues, and are associated with improvement in mood.

From a psychological point of view, “being physically strong may lead to a sensation of psychological wellbeing,” the researchers write.

Moreover, being physically active “across the lifespan also promotes structural and functional changes in the brain, benefiting cognitive functioning and reducing the risk of neurodegeneration,” they write.

This can be important because aging adults with cognitive impairments can also experience neuromuscular impairments that “presumably will contribute to becoming weaker,” they note.

Overall, the findings “warrant strength training programmes aimed at older adults to reduce depression risk,” the investigators write. Clinicians “may consider using the observed handgrip strength thresholds to screen for potential depression risk in older adults,” they add.
 

Protective factor?

Commenting for this news organization, Julian Mutz, PhD, postdoctoral research associate at the Social, Genetic and Developmental Psychiatry Centre, King’s College, London, said the study “provides further evidence that physical strength may be a protective factor against depression in older adults.”

This confirms a “plethora of cross-sectional and longitudinal studies,” including one recently conducted by Dr. Mutz’s group.

The design of the current study “allowed the authors to address a number of key limitations of previous studies, for example, by including repeated measurements of grip strength and adjustment for potential confounding factors over time,” said Dr. Mutz, who was not involved with the research.

Additionally, “an important contribution of this study is that the authors show that higher grip strength is only associated with a lower risk of depression up to a specific threshold,” he noted.

“The clinical implication of this finding is that only individuals with grip strength below this threshold are at a higher risk of depression. These individuals especially may benefit from interventions aimed at increasing physical strength,” Dr. Mutz said.

The SHARE data collection has been funded by the European Commission and by DG Employment, Social Affairs and Inclusion. Additional funding was obtained from the German Ministry of Education and Research, the Max Planck Society for the Advancement of Science, and the U.S. National Institute on Aging. Dr. Lopez-Bueno is supported by the European Union – Next Generation EU. The other investigators and Dr. Mutz have reported no relevant financial relationships.

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

This holiday season, I am looking forward to spending some time with family, as I have in the past. As I have chatted with others, many friends are looking forward to events that are potentially larger and potentially returning to prepandemic type gatherings.

Gathering is important and can bring joy, sense of community, and love to the lives of many. Unfortunately, the risks associated with gathering are not over. We are currently facing what many are calling a “tripledemic” as our country faces many cases of respiratory syncytial virus (RSV), COVID-19, and influenza at the same time.

During the first week of December, cases of influenza were rising across the country¹ and were rising faster than in previous years. Although getting the vaccine is an important method of influenza prevention and is recommended for everyone over the age of 6 months with rare exception, many have not gotten their vaccine this year.
 

Influenza

Thus far, “nearly 50% of reported flu-associated hospitalizations in women of childbearing age have been in women who are pregnant.” We are seeing this at a time with lower-than-average uptake of influenza vaccine leaving both the pregnant persons and their babies unprotected. In addition to utilizing vaccines as prevention, isolating when ill, cleaning surfaces, and practicing good hand hygiene can all decrease transmission.

RSV

In addition to rises of influenza, there are currently high rates of RSV in various parts of the country. Prior to 2020, RSV typically started in the fall and peaked in the winter months. However, since the pandemic, the typical seasonal pattern has not returned, and it is unclear when it will. Although RSV hits the very young, the old, and the immunocompromised the most, RSV can infect anyone. Unfortunately, we do not currently have a vaccine for everyone against this virus. Prevention of transmission includes, as with flu, isolating when ill, cleaning surfaces, and washing hands.²

COVID-19

Of course, the effects of the COVID-19 pandemic are also still here as well. During the first week of December, the CDC reported rising cases of COVID across the country. Within the past few months, there have been several developments, though, for protection. There are now bivalent vaccines available as either third doses or booster doses approved for all persons over 6 months of age. As of the first week of December, only 13.5% of those aged 5 and over had received an updated booster.

There is currently wider access to rapid testing, including at-home testing, which can allow individuals to identify if COVID positive. Additionally, there is access to medication to decrease the likelihood of severe disease – though this does not take the place of vaccinations.

If anyone does test positive for COVID, they should follow the most recent quarantine guidelines including wearing a well-fitted mask when they do begin returning to activities.³

With rising cases of all three of these viruses, some may be asking how we can safely gather. There are several things to consider and do to enjoy our events. The first thing everyone can do is to receive updated vaccinations for both influenza and COVID-19 if eligible. Although it may take some time to be effective, vaccination is still one of our most effective methods of disease prevention and is important this winter season. Vaccinations can also help decrease the risk of severe disease.

Although many have stopped masking, as cases rise, it is time to consider masking particularly when community levels of any of these viruses are high. Masks help with preventing and spreading more than just COVID-19. Using them can be especially important for those going places such as stores and to large public gatherings and when riding on buses, planes, or trains.
 

In summary

Preventing exposure by masking can help keep individuals healthy prior to celebrating the holidays with others. With access to rapid testing, it makes sense to consider testing prior to gathering with friends and family. Most importantly, although we all are looking forward to spending time with our loved ones, it is important to stay home if not feeling well. Following these recommendations will allow us to have a safer and more joyful holiday season.

Dr. Wheat is a family physician at Erie Family Health Center and program director of Northwestern University’s McGaw Family Medicine residency program, both in Chicago. Dr. Wheat serves on the editorial advisory board of Family Practice News. You can contact her at fpnews@mdedge.com.

References

1. Centers for Disease Control and Prevention. Influenza (flu). [Online] Dec. 1, 2022. [Cited: 2022 Dec 10.] https://www.cdc.gov/flu/index.htm.

2. Respiratory syncytial virus. Respiratory syncytial virus infection (RSV). [Online] Oct. 28, 2022. [Cited: 2022 Dec 10.] https://www.cdc.gov/rsv/index.html.

3. COVID-19. [Online] Dec. 7, 2022. [Cited: 2022 Dec 10.] https://www.cdc.gov/coronavirus/2019-ncov/index.html.

This holiday season, I am looking forward to spending some time with family, as I have in the past. As I have chatted with others, many friends are looking forward to events that are potentially larger and potentially returning to prepandemic type gatherings.

Gathering is important and can bring joy, sense of community, and love to the lives of many. Unfortunately, the risks associated with gathering are not over. We are currently facing what many are calling a “tripledemic” as our country faces many cases of respiratory syncytial virus (RSV), COVID-19, and influenza at the same time.

During the first week of December, cases of influenza were rising across the country¹ and were rising faster than in previous years. Although getting the vaccine is an important method of influenza prevention and is recommended for everyone over the age of 6 months with rare exception, many have not gotten their vaccine this year.
 

Influenza

Thus far, “nearly 50% of reported flu-associated hospitalizations in women of childbearing age have been in women who are pregnant.” We are seeing this at a time with lower-than-average uptake of influenza vaccine leaving both the pregnant persons and their babies unprotected. In addition to utilizing vaccines as prevention, isolating when ill, cleaning surfaces, and practicing good hand hygiene can all decrease transmission.

RSV

In addition to rises of influenza, there are currently high rates of RSV in various parts of the country. Prior to 2020, RSV typically started in the fall and peaked in the winter months. However, since the pandemic, the typical seasonal pattern has not returned, and it is unclear when it will. Although RSV hits the very young, the old, and the immunocompromised the most, RSV can infect anyone. Unfortunately, we do not currently have a vaccine for everyone against this virus. Prevention of transmission includes, as with flu, isolating when ill, cleaning surfaces, and washing hands.²

COVID-19

Of course, the effects of the COVID-19 pandemic are also still here as well. During the first week of December, the CDC reported rising cases of COVID across the country. Within the past few months, there have been several developments, though, for protection. There are now bivalent vaccines available as either third doses or booster doses approved for all persons over 6 months of age. As of the first week of December, only 13.5% of those aged 5 and over had received an updated booster.

There is currently wider access to rapid testing, including at-home testing, which can allow individuals to identify if COVID positive. Additionally, there is access to medication to decrease the likelihood of severe disease – though this does not take the place of vaccinations.

If anyone does test positive for COVID, they should follow the most recent quarantine guidelines including wearing a well-fitted mask when they do begin returning to activities.³

With rising cases of all three of these viruses, some may be asking how we can safely gather. There are several things to consider and do to enjoy our events. The first thing everyone can do is to receive updated vaccinations for both influenza and COVID-19 if eligible. Although it may take some time to be effective, vaccination is still one of our most effective methods of disease prevention and is important this winter season. Vaccinations can also help decrease the risk of severe disease.

Although many have stopped masking, as cases rise, it is time to consider masking particularly when community levels of any of these viruses are high. Masks help with preventing and spreading more than just COVID-19. Using them can be especially important for those going places such as stores and to large public gatherings and when riding on buses, planes, or trains.
 

In summary

Preventing exposure by masking can help keep individuals healthy prior to celebrating the holidays with others. With access to rapid testing, it makes sense to consider testing prior to gathering with friends and family. Most importantly, although we all are looking forward to spending time with our loved ones, it is important to stay home if not feeling well. Following these recommendations will allow us to have a safer and more joyful holiday season.

Dr. Wheat is a family physician at Erie Family Health Center and program director of Northwestern University’s McGaw Family Medicine residency program, both in Chicago. Dr. Wheat serves on the editorial advisory board of Family Practice News. You can contact her at fpnews@mdedge.com.

References

1. Centers for Disease Control and Prevention. Influenza (flu). [Online] Dec. 1, 2022. [Cited: 2022 Dec 10.] https://www.cdc.gov/flu/index.htm.

2. Respiratory syncytial virus. Respiratory syncytial virus infection (RSV). [Online] Oct. 28, 2022. [Cited: 2022 Dec 10.] https://www.cdc.gov/rsv/index.html.

3. COVID-19. [Online] Dec. 7, 2022. [Cited: 2022 Dec 10.] https://www.cdc.gov/coronavirus/2019-ncov/index.html.

This holiday season, I am looking forward to spending some time with family, as I have in the past. As I have chatted with others, many friends are looking forward to events that are potentially larger and potentially returning to prepandemic type gatherings.

Gathering is important and can bring joy, sense of community, and love to the lives of many. Unfortunately, the risks associated with gathering are not over. We are currently facing what many are calling a “tripledemic” as our country faces many cases of respiratory syncytial virus (RSV), COVID-19, and influenza at the same time.

During the first week of December, cases of influenza were rising across the country¹ and were rising faster than in previous years. Although getting the vaccine is an important method of influenza prevention and is recommended for everyone over the age of 6 months with rare exception, many have not gotten their vaccine this year.
 

Influenza

Thus far, “nearly 50% of reported flu-associated hospitalizations in women of childbearing age have been in women who are pregnant.” We are seeing this at a time with lower-than-average uptake of influenza vaccine leaving both the pregnant persons and their babies unprotected. In addition to utilizing vaccines as prevention, isolating when ill, cleaning surfaces, and practicing good hand hygiene can all decrease transmission.

RSV

In addition to rises of influenza, there are currently high rates of RSV in various parts of the country. Prior to 2020, RSV typically started in the fall and peaked in the winter months. However, since the pandemic, the typical seasonal pattern has not returned, and it is unclear when it will. Although RSV hits the very young, the old, and the immunocompromised the most, RSV can infect anyone. Unfortunately, we do not currently have a vaccine for everyone against this virus. Prevention of transmission includes, as with flu, isolating when ill, cleaning surfaces, and washing hands.²

COVID-19

Of course, the effects of the COVID-19 pandemic are also still here as well. During the first week of December, the CDC reported rising cases of COVID across the country. Within the past few months, there have been several developments, though, for protection. There are now bivalent vaccines available as either third doses or booster doses approved for all persons over 6 months of age. As of the first week of December, only 13.5% of those aged 5 and over had received an updated booster.

There is currently wider access to rapid testing, including at-home testing, which can allow individuals to identify if COVID positive. Additionally, there is access to medication to decrease the likelihood of severe disease – though this does not take the place of vaccinations.

If anyone does test positive for COVID, they should follow the most recent quarantine guidelines including wearing a well-fitted mask when they do begin returning to activities.³

With rising cases of all three of these viruses, some may be asking how we can safely gather. There are several things to consider and do to enjoy our events. The first thing everyone can do is to receive updated vaccinations for both influenza and COVID-19 if eligible. Although it may take some time to be effective, vaccination is still one of our most effective methods of disease prevention and is important this winter season. Vaccinations can also help decrease the risk of severe disease.

Although many have stopped masking, as cases rise, it is time to consider masking particularly when community levels of any of these viruses are high. Masks help with preventing and spreading more than just COVID-19. Using them can be especially important for those going places such as stores and to large public gatherings and when riding on buses, planes, or trains.
 

In summary

Preventing exposure by masking can help keep individuals healthy prior to celebrating the holidays with others. With access to rapid testing, it makes sense to consider testing prior to gathering with friends and family. Most importantly, although we all are looking forward to spending time with our loved ones, it is important to stay home if not feeling well. Following these recommendations will allow us to have a safer and more joyful holiday season.

Dr. Wheat is a family physician at Erie Family Health Center and program director of Northwestern University’s McGaw Family Medicine residency program, both in Chicago. Dr. Wheat serves on the editorial advisory board of Family Practice News. You can contact her at fpnews@mdedge.com.

References

1. Centers for Disease Control and Prevention. Influenza (flu). [Online] Dec. 1, 2022. [Cited: 2022 Dec 10.] https://www.cdc.gov/flu/index.htm.

2. Respiratory syncytial virus. Respiratory syncytial virus infection (RSV). [Online] Oct. 28, 2022. [Cited: 2022 Dec 10.] https://www.cdc.gov/rsv/index.html.

3. COVID-19. [Online] Dec. 7, 2022. [Cited: 2022 Dec 10.] https://www.cdc.gov/coronavirus/2019-ncov/index.html.

The chance of surviving a cardiac arrest varies widely across hospitals in the United States, even when the arrest occurs in the highly controlled setting of a cardiac catheterization lab, a new study indicates.

Among 4,787 patients who arrested in the cath lab at 231 hospitals in the Get With The Guidelines (GWTG) Resuscitation registry, only about one-third survived to discharge. The median risk-adjusted survival rate (RASR) for all hospitals was 36%.

When stratified by RASR tertiles, however, median survival rates were 20%, 36%, and 52% for hospitals in the lowest, middle, and highest tertiles.

The odds of survival differed by 71% in similar patients presenting at two randomly selected hospitals (median odds ratio, 1.71; 95% confidence interval, 1.52-1.87).

“The good news is that cardiac arrests in the cath lab are relatively infrequent, but the bad news is that they still occur and the outcomes are, in general, pretty dismal,” senior author Deepak L. Bhatt, MD, MPH, said in an interview. “So anything that we can do as hospitals [and] health care systems to improve the care of these patients could go a long way.”

Hospital and patient factors

Possible explanations for the wide disparity in survival are the small number of cardiac arrests in the cath lab, the increasing complexity of cases, and the fact that patients are often very sick and may experience a problem during a procedure, or both, Dr. Bhatt suggested. Cath labs also vary in how they handle resuscitative efforts and access to advanced mechanical support devices, such as extracorporeal membrane oxygenation (ECMO).

“It’s not available in every cath lab and, even in hospitals that have it, they may not have a given ECMO circuit available at the exact time the patient’s having a cardiac arrest,” he said. “That’s one example of something that can make, in my opinion, a big difference in whether a patient lives or dies if they’re having a cardiac arrest but may not always be easily deployed.”

When the investigators looked specifically at hospital-level factors, only yearly volume of cardiac arrests in the cath lab was significantly associated with risk-adjusted survival (P < .01), whereas hospital size, rural or urban setting, teaching status, and geographic location were not.

In multivariate adjusted analyses, factors associated with survival to discharge included age (OR, 0.78), Black race (OR, 0.68), respiratory insufficiency (OR, 0.75), and initial cardiac arrest rhythm (OR, 3.32).

The median hospital RASR was 27% higher for ventricular tachycardia or ventricular fibrillation arrests than for arrests with a nonshockable rhythm of asystole and pulseless electrical activity (55% vs. 28%).

Notably, hospitals in the lowest tertile of risk-adjusted survival rates had a higher prevalence of non-White patients, renal and respiratory comorbidity, and arrest with nonshockable rhythm.

“We want to make sure as we’re contemplating whether to resuscitate a patient or how aggressively to resuscitate, that we aren’t letting any of our own biases, whether they have to do with race or potentially sex and gender, interfere with more objective assessments of whether the patient can in fact be saved or not,” Dr. Bhatt said.

Reached for comment, Srihari S. Naidu, MD, who chaired the writing group for the Society for Cardiovascular Angiography and Interventions’ (SCAI) consensus statement on cardiogenic shock and co-authored its document on best practices in the cardiac cath lab, said the findings show that survival in the cath lab is higher than that seen in-hospital. “Still, there’s a lot of room for improvement,” he said.

He was particularly struck by the variability in survival. “Underprivileged individuals, so those who are non-White populations and have respiratory and renal problems, they seem to have a worse survival and that makes sense – patients with comorbidities – but it feeds into the issue of, ‘Are we treating our population similarly in terms of their baseline race and ethnicity as a gap in care?’ ”

Better survival at hospitals with high volumes likely reflects more experience in handling these events, a rapid response and personnel to help with resuscitation, and overall better critical care and cath lab environment, said Dr. Naidu, director of the cardiac cath lab at Westchester Medical Center and professor of medicine at New York Medical College, both in Valhalla, N.Y.

“So that leads into two things,” he said. “One is that probably we should be working on having all high-risk patients go to centers of excellence. So, for example, [for] patients in shock, patients with STEMI, regionalization of care to the high-volume cath labs that are experienced in cardiac arrest and critical care management may be a way to go.”

“Second, if experience counts, can that experience be simulated through drills and simulations in the cath lab?” Dr. Naidu said. “Should all cath labs have drills where we have a cardiac arrest patient, and how would we respond to that? Who’s going to do the compressions? Where’s the mechanical support device? What are the things we need to have a seamless cardiac arrest protocol for arrests during the cath lab?”

Dr. Bhatt and colleagues acknowledge that despite adjustment for many key variables, the study lacked procedural details that may affect survival and information related to resuscitation efforts.

“We really do need to focus more research efforts, potentially more in the way of quality-improvement efforts, to try and help patients get these sorts of patients who are in dire straits to the cath lab but hopefully also through the hospital discharge and back home,” Dr. Bhatt said.

In an editorial accompanying the study, Matthew L. Tomey, MD, Icahn School of Medicine at Mount Sinai, New York, writes that the “findings and limitations of this study together sound a call to action.”

He also signaled the need for more research and for registries and reporting instruments to capture variables particular to in-laboratory cardiac arrest and resuscitation in the cardiac cath lab. “A necessary first step is the development of consensus data elements for supplemental reporting in cases of ILCA,” such as indication for cath lab presentation, timing of arrest relative to procedure, and cause of arrest.

Dr. Bhatt reported numerous relationships with industry. Dr. Naidu and Dr. Tomey report having no relevant financial relationships.

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

The chance of surviving a cardiac arrest varies widely across hospitals in the United States, even when the arrest occurs in the highly controlled setting of a cardiac catheterization lab, a new study indicates.

Among 4,787 patients who arrested in the cath lab at 231 hospitals in the Get With The Guidelines (GWTG) Resuscitation registry, only about one-third survived to discharge. The median risk-adjusted survival rate (RASR) for all hospitals was 36%.

When stratified by RASR tertiles, however, median survival rates were 20%, 36%, and 52% for hospitals in the lowest, middle, and highest tertiles.

The odds of survival differed by 71% in similar patients presenting at two randomly selected hospitals (median odds ratio, 1.71; 95% confidence interval, 1.52-1.87).

“The good news is that cardiac arrests in the cath lab are relatively infrequent, but the bad news is that they still occur and the outcomes are, in general, pretty dismal,” senior author Deepak L. Bhatt, MD, MPH, said in an interview. “So anything that we can do as hospitals [and] health care systems to improve the care of these patients could go a long way.”

Hospital and patient factors

Possible explanations for the wide disparity in survival are the small number of cardiac arrests in the cath lab, the increasing complexity of cases, and the fact that patients are often very sick and may experience a problem during a procedure, or both, Dr. Bhatt suggested. Cath labs also vary in how they handle resuscitative efforts and access to advanced mechanical support devices, such as extracorporeal membrane oxygenation (ECMO).

“It’s not available in every cath lab and, even in hospitals that have it, they may not have a given ECMO circuit available at the exact time the patient’s having a cardiac arrest,” he said. “That’s one example of something that can make, in my opinion, a big difference in whether a patient lives or dies if they’re having a cardiac arrest but may not always be easily deployed.”

When the investigators looked specifically at hospital-level factors, only yearly volume of cardiac arrests in the cath lab was significantly associated with risk-adjusted survival (P < .01), whereas hospital size, rural or urban setting, teaching status, and geographic location were not.

In multivariate adjusted analyses, factors associated with survival to discharge included age (OR, 0.78), Black race (OR, 0.68), respiratory insufficiency (OR, 0.75), and initial cardiac arrest rhythm (OR, 3.32).

The median hospital RASR was 27% higher for ventricular tachycardia or ventricular fibrillation arrests than for arrests with a nonshockable rhythm of asystole and pulseless electrical activity (55% vs. 28%).

Notably, hospitals in the lowest tertile of risk-adjusted survival rates had a higher prevalence of non-White patients, renal and respiratory comorbidity, and arrest with nonshockable rhythm.

“We want to make sure as we’re contemplating whether to resuscitate a patient or how aggressively to resuscitate, that we aren’t letting any of our own biases, whether they have to do with race or potentially sex and gender, interfere with more objective assessments of whether the patient can in fact be saved or not,” Dr. Bhatt said.

Reached for comment, Srihari S. Naidu, MD, who chaired the writing group for the Society for Cardiovascular Angiography and Interventions’ (SCAI) consensus statement on cardiogenic shock and co-authored its document on best practices in the cardiac cath lab, said the findings show that survival in the cath lab is higher than that seen in-hospital. “Still, there’s a lot of room for improvement,” he said.

He was particularly struck by the variability in survival. “Underprivileged individuals, so those who are non-White populations and have respiratory and renal problems, they seem to have a worse survival and that makes sense – patients with comorbidities – but it feeds into the issue of, ‘Are we treating our population similarly in terms of their baseline race and ethnicity as a gap in care?’ ”

Better survival at hospitals with high volumes likely reflects more experience in handling these events, a rapid response and personnel to help with resuscitation, and overall better critical care and cath lab environment, said Dr. Naidu, director of the cardiac cath lab at Westchester Medical Center and professor of medicine at New York Medical College, both in Valhalla, N.Y.

“So that leads into two things,” he said. “One is that probably we should be working on having all high-risk patients go to centers of excellence. So, for example, [for] patients in shock, patients with STEMI, regionalization of care to the high-volume cath labs that are experienced in cardiac arrest and critical care management may be a way to go.”

“Second, if experience counts, can that experience be simulated through drills and simulations in the cath lab?” Dr. Naidu said. “Should all cath labs have drills where we have a cardiac arrest patient, and how would we respond to that? Who’s going to do the compressions? Where’s the mechanical support device? What are the things we need to have a seamless cardiac arrest protocol for arrests during the cath lab?”

Dr. Bhatt and colleagues acknowledge that despite adjustment for many key variables, the study lacked procedural details that may affect survival and information related to resuscitation efforts.

“We really do need to focus more research efforts, potentially more in the way of quality-improvement efforts, to try and help patients get these sorts of patients who are in dire straits to the cath lab but hopefully also through the hospital discharge and back home,” Dr. Bhatt said.

In an editorial accompanying the study, Matthew L. Tomey, MD, Icahn School of Medicine at Mount Sinai, New York, writes that the “findings and limitations of this study together sound a call to action.”

He also signaled the need for more research and for registries and reporting instruments to capture variables particular to in-laboratory cardiac arrest and resuscitation in the cardiac cath lab. “A necessary first step is the development of consensus data elements for supplemental reporting in cases of ILCA,” such as indication for cath lab presentation, timing of arrest relative to procedure, and cause of arrest.

Dr. Bhatt reported numerous relationships with industry. Dr. Naidu and Dr. Tomey report having no relevant financial relationships.

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

The chance of surviving a cardiac arrest varies widely across hospitals in the United States, even when the arrest occurs in the highly controlled setting of a cardiac catheterization lab, a new study indicates.

Among 4,787 patients who arrested in the cath lab at 231 hospitals in the Get With The Guidelines (GWTG) Resuscitation registry, only about one-third survived to discharge. The median risk-adjusted survival rate (RASR) for all hospitals was 36%.

When stratified by RASR tertiles, however, median survival rates were 20%, 36%, and 52% for hospitals in the lowest, middle, and highest tertiles.

The odds of survival differed by 71% in similar patients presenting at two randomly selected hospitals (median odds ratio, 1.71; 95% confidence interval, 1.52-1.87).

“The good news is that cardiac arrests in the cath lab are relatively infrequent, but the bad news is that they still occur and the outcomes are, in general, pretty dismal,” senior author Deepak L. Bhatt, MD, MPH, said in an interview. “So anything that we can do as hospitals [and] health care systems to improve the care of these patients could go a long way.”

Hospital and patient factors

Possible explanations for the wide disparity in survival are the small number of cardiac arrests in the cath lab, the increasing complexity of cases, and the fact that patients are often very sick and may experience a problem during a procedure, or both, Dr. Bhatt suggested. Cath labs also vary in how they handle resuscitative efforts and access to advanced mechanical support devices, such as extracorporeal membrane oxygenation (ECMO).

“It’s not available in every cath lab and, even in hospitals that have it, they may not have a given ECMO circuit available at the exact time the patient’s having a cardiac arrest,” he said. “That’s one example of something that can make, in my opinion, a big difference in whether a patient lives or dies if they’re having a cardiac arrest but may not always be easily deployed.”

When the investigators looked specifically at hospital-level factors, only yearly volume of cardiac arrests in the cath lab was significantly associated with risk-adjusted survival (P < .01), whereas hospital size, rural or urban setting, teaching status, and geographic location were not.

In multivariate adjusted analyses, factors associated with survival to discharge included age (OR, 0.78), Black race (OR, 0.68), respiratory insufficiency (OR, 0.75), and initial cardiac arrest rhythm (OR, 3.32).

The median hospital RASR was 27% higher for ventricular tachycardia or ventricular fibrillation arrests than for arrests with a nonshockable rhythm of asystole and pulseless electrical activity (55% vs. 28%).

Notably, hospitals in the lowest tertile of risk-adjusted survival rates had a higher prevalence of non-White patients, renal and respiratory comorbidity, and arrest with nonshockable rhythm.

“We want to make sure as we’re contemplating whether to resuscitate a patient or how aggressively to resuscitate, that we aren’t letting any of our own biases, whether they have to do with race or potentially sex and gender, interfere with more objective assessments of whether the patient can in fact be saved or not,” Dr. Bhatt said.

Reached for comment, Srihari S. Naidu, MD, who chaired the writing group for the Society for Cardiovascular Angiography and Interventions’ (SCAI) consensus statement on cardiogenic shock and co-authored its document on best practices in the cardiac cath lab, said the findings show that survival in the cath lab is higher than that seen in-hospital. “Still, there’s a lot of room for improvement,” he said.

He was particularly struck by the variability in survival. “Underprivileged individuals, so those who are non-White populations and have respiratory and renal problems, they seem to have a worse survival and that makes sense – patients with comorbidities – but it feeds into the issue of, ‘Are we treating our population similarly in terms of their baseline race and ethnicity as a gap in care?’ ”

Better survival at hospitals with high volumes likely reflects more experience in handling these events, a rapid response and personnel to help with resuscitation, and overall better critical care and cath lab environment, said Dr. Naidu, director of the cardiac cath lab at Westchester Medical Center and professor of medicine at New York Medical College, both in Valhalla, N.Y.

“So that leads into two things,” he said. “One is that probably we should be working on having all high-risk patients go to centers of excellence. So, for example, [for] patients in shock, patients with STEMI, regionalization of care to the high-volume cath labs that are experienced in cardiac arrest and critical care management may be a way to go.”

“Second, if experience counts, can that experience be simulated through drills and simulations in the cath lab?” Dr. Naidu said. “Should all cath labs have drills where we have a cardiac arrest patient, and how would we respond to that? Who’s going to do the compressions? Where’s the mechanical support device? What are the things we need to have a seamless cardiac arrest protocol for arrests during the cath lab?”

Dr. Bhatt and colleagues acknowledge that despite adjustment for many key variables, the study lacked procedural details that may affect survival and information related to resuscitation efforts.

“We really do need to focus more research efforts, potentially more in the way of quality-improvement efforts, to try and help patients get these sorts of patients who are in dire straits to the cath lab but hopefully also through the hospital discharge and back home,” Dr. Bhatt said.

In an editorial accompanying the study, Matthew L. Tomey, MD, Icahn School of Medicine at Mount Sinai, New York, writes that the “findings and limitations of this study together sound a call to action.”

He also signaled the need for more research and for registries and reporting instruments to capture variables particular to in-laboratory cardiac arrest and resuscitation in the cardiac cath lab. “A necessary first step is the development of consensus data elements for supplemental reporting in cases of ILCA,” such as indication for cath lab presentation, timing of arrest relative to procedure, and cause of arrest.

Dr. Bhatt reported numerous relationships with industry. Dr. Naidu and Dr. Tomey report having no relevant financial relationships.

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

Cardiac injury caused by COVID-19 may be much less common than suggested previously, a new study has found.

The study examined cardiac MRI scans in 31 patients before and after having COVID-19 infection and found no new evidence of myocardial injury in the post-COVID scans relative to the pre-COVID scans.

“To the best of our knowledge this is the first cardiac MRI study to assess myocardial injury pre- and post-COVID-19,” the authors stated.

They say that while this study cannot rule out the possibility of rare events of COVID-19–induced myocardial injury, “the complete absence of de novo late gadolinium enhancement lesions after COVID-19 in this cohort indicates that outside special circumstances, COVID-19–induced myocardial injury may be much less common than suggested by previous studies.”

The study was published online in JACC: Cardiovascular Imaging.

Coauthor Till F. Althoff, MD, Cardiovascular Institute, Clínic–University Hospital Barcelona, said in an interview that previous reports have found a high rate of cardiac lesions in patients undergoing imaging after having had COVID-19 infection.

“In some reports, this has been as high as 80% of patients even though they have not had severe COVID disease. These reports have been interpreted as showing the majority of patients have some COVID-induced cardiac damage, which is an alarming message,” he commented.

However, he pointed out that the patients in these reports did not undergo a cardiac MRI scan before they had COVID-19 so it wasn’t known whether these cardiac lesions were present before infection or not.

To try and gain more accurate information, the current study examined cardiac MRI scans in the same patients before and after they had COVID-19.

The researchers, from an arrhythmia unit, made use of the fact that all their patients have cardiac MRI data, so they used their large registry of patients in whom cardiac MRI had been performed, and cross referenced this to a health care database to identify those patients who had confirmed COVID-19 after they obtaining a cardiac scan at the arrhythmia unit. They then conducted another cardiac MRI scan in the 31 patients identified a median of 5 months after their COVID-19 infection.

“These 31 patients had a cardiac MRI scan pre-COVID and post COVID using exactly the same scanner with identical sequences, so the scans were absolutely comparable,” Dr. Althoff noted.

Of these 31 patients, 7 had been hospitalized at the time of acute presentation with COVID-19, of whom 2 required intensive care. Most patients (29) had been symptomatic, but none reported cardiac symptoms.

Results showed that, on the post–COVID-19 scan, late gadolinium enhancement lesions indicative of residual myocardial injury were encountered in 15 of the 31 patients (48%), which the researchers said is in line with previous reports.

However, intraindividual comparison with the pre–COVID-19 cardiac MRI scans showed all these lesions were preexisting with identical localization, pattern, and transmural distribution, and thus not COVID-19 related.

Quantitative analyses, performed independently, detected no increase in the size of individual lesions nor in the global left ventricular late gadolinium enhancement extent.

Comparison of pre- and post COVID-19 imaging sequences did not show any differences in ventricular functional or structural parameters.

“While this study only has 31 patients, the fact that we are conducting intra-individual comparisons, which rules out bias, means that we don’t need a large number of patients for reliable results,” Dr. Althoff said.

“These types of lesions are normal to see. We know that individuals without cardiac disease have these types of lesions, and they are not necessarily an indication of any specific pathology. I was kind of surprised by the interpretation of previous data, which is why we did the current study,” he added.

Dr. Althoff acknowledged that some cardiac injury may have been seen if much larger numbers of patients had been included. “But I think we can say from this data that COVID-induced cardiac damage is much less of an issue than we may have previously thought,” he added.

He also noted that most of the patients in this study had mild COVID-19, so the results cannot be extrapolated to severe COVID-19 infection.

However, Dr. Althoff pointed out that all the patients already had atrial fibrillation, so would have been at higher risk of cardiac injury from COVID-19.

“These patients had preexisting cardiac risk factors, and thus they would have been more susceptible to both a more severe course of COVID and an increased risk of myocardial damage due to COVID. The fact that we don’t find any myocardial injury due to COVID in this group is even more reassuring. The general population will be at even lower risk,” he commented.

“I think we can say that, in COVID patients who do not have any cardiac symptoms, our study suggests that the incidence of cardiac injury is very low,” Dr. Althoff said.

“Even in patients with severe COVID and myocardial involvement reflected by increased troponin levels, I wouldn’t be sure that they have any residual cardiac injury. While it has been reported that cardiac lesions have been found in such patients, pre-COVID MRI scans were not available so we don’t know if they were there before,” he added.

“We do not know the true incidence of cardiac injury after COVID, but I think we can say from this data that it is definitely not anywhere near the 40%-50% or even greater that some of the previous reports have suggested,” he stated.

Dr. Althoff suggested that, based on these data, some of the recommendations based on previous reports such the need for follow-up cardiac scans and caution about partaking in sports again after COVID-19 infection, are probably not necessary.

“Our data suggest that these concerns are unfounded, and we need to step back a bit and stop alarming patients about the risk of cardiac damage after COVID,” he said. “Yes, if patients have cardiac symptoms during or after COVID infection they should get checked out, but I do not think we need to do a cardiac risk assessment in patients without cardiac symptoms in COVID.”

This work is supported in part by grants from Instituto de Salud Carlos III, the Spanish government, Madrid, and Fundació la Marató de TV3 in Catalonia. Dr. Althoff has received research grants for investigator-initiated trials from Biosense Webster.

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

Cardiac injury caused by COVID-19 may be much less common than suggested previously, a new study has found.

The study examined cardiac MRI scans in 31 patients before and after having COVID-19 infection and found no new evidence of myocardial injury in the post-COVID scans relative to the pre-COVID scans.

“To the best of our knowledge this is the first cardiac MRI study to assess myocardial injury pre- and post-COVID-19,” the authors stated.

They say that while this study cannot rule out the possibility of rare events of COVID-19–induced myocardial injury, “the complete absence of de novo late gadolinium enhancement lesions after COVID-19 in this cohort indicates that outside special circumstances, COVID-19–induced myocardial injury may be much less common than suggested by previous studies.”

The study was published online in JACC: Cardiovascular Imaging.

Coauthor Till F. Althoff, MD, Cardiovascular Institute, Clínic–University Hospital Barcelona, said in an interview that previous reports have found a high rate of cardiac lesions in patients undergoing imaging after having had COVID-19 infection.

“In some reports, this has been as high as 80% of patients even though they have not had severe COVID disease. These reports have been interpreted as showing the majority of patients have some COVID-induced cardiac damage, which is an alarming message,” he commented.

However, he pointed out that the patients in these reports did not undergo a cardiac MRI scan before they had COVID-19 so it wasn’t known whether these cardiac lesions were present before infection or not.

To try and gain more accurate information, the current study examined cardiac MRI scans in the same patients before and after they had COVID-19.

The researchers, from an arrhythmia unit, made use of the fact that all their patients have cardiac MRI data, so they used their large registry of patients in whom cardiac MRI had been performed, and cross referenced this to a health care database to identify those patients who had confirmed COVID-19 after they obtaining a cardiac scan at the arrhythmia unit. They then conducted another cardiac MRI scan in the 31 patients identified a median of 5 months after their COVID-19 infection.

“These 31 patients had a cardiac MRI scan pre-COVID and post COVID using exactly the same scanner with identical sequences, so the scans were absolutely comparable,” Dr. Althoff noted.

Of these 31 patients, 7 had been hospitalized at the time of acute presentation with COVID-19, of whom 2 required intensive care. Most patients (29) had been symptomatic, but none reported cardiac symptoms.

Results showed that, on the post–COVID-19 scan, late gadolinium enhancement lesions indicative of residual myocardial injury were encountered in 15 of the 31 patients (48%), which the researchers said is in line with previous reports.

However, intraindividual comparison with the pre–COVID-19 cardiac MRI scans showed all these lesions were preexisting with identical localization, pattern, and transmural distribution, and thus not COVID-19 related.

Quantitative analyses, performed independently, detected no increase in the size of individual lesions nor in the global left ventricular late gadolinium enhancement extent.

Comparison of pre- and post COVID-19 imaging sequences did not show any differences in ventricular functional or structural parameters.

“While this study only has 31 patients, the fact that we are conducting intra-individual comparisons, which rules out bias, means that we don’t need a large number of patients for reliable results,” Dr. Althoff said.

“These types of lesions are normal to see. We know that individuals without cardiac disease have these types of lesions, and they are not necessarily an indication of any specific pathology. I was kind of surprised by the interpretation of previous data, which is why we did the current study,” he added.

Dr. Althoff acknowledged that some cardiac injury may have been seen if much larger numbers of patients had been included. “But I think we can say from this data that COVID-induced cardiac damage is much less of an issue than we may have previously thought,” he added.

He also noted that most of the patients in this study had mild COVID-19, so the results cannot be extrapolated to severe COVID-19 infection.

However, Dr. Althoff pointed out that all the patients already had atrial fibrillation, so would have been at higher risk of cardiac injury from COVID-19.

“These patients had preexisting cardiac risk factors, and thus they would have been more susceptible to both a more severe course of COVID and an increased risk of myocardial damage due to COVID. The fact that we don’t find any myocardial injury due to COVID in this group is even more reassuring. The general population will be at even lower risk,” he commented.

“I think we can say that, in COVID patients who do not have any cardiac symptoms, our study suggests that the incidence of cardiac injury is very low,” Dr. Althoff said.

“Even in patients with severe COVID and myocardial involvement reflected by increased troponin levels, I wouldn’t be sure that they have any residual cardiac injury. While it has been reported that cardiac lesions have been found in such patients, pre-COVID MRI scans were not available so we don’t know if they were there before,” he added.

“We do not know the true incidence of cardiac injury after COVID, but I think we can say from this data that it is definitely not anywhere near the 40%-50% or even greater that some of the previous reports have suggested,” he stated.

Dr. Althoff suggested that, based on these data, some of the recommendations based on previous reports such the need for follow-up cardiac scans and caution about partaking in sports again after COVID-19 infection, are probably not necessary.

“Our data suggest that these concerns are unfounded, and we need to step back a bit and stop alarming patients about the risk of cardiac damage after COVID,” he said. “Yes, if patients have cardiac symptoms during or after COVID infection they should get checked out, but I do not think we need to do a cardiac risk assessment in patients without cardiac symptoms in COVID.”

This work is supported in part by grants from Instituto de Salud Carlos III, the Spanish government, Madrid, and Fundació la Marató de TV3 in Catalonia. Dr. Althoff has received research grants for investigator-initiated trials from Biosense Webster.

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

Cardiac injury caused by COVID-19 may be much less common than suggested previously, a new study has found.

The study examined cardiac MRI scans in 31 patients before and after having COVID-19 infection and found no new evidence of myocardial injury in the post-COVID scans relative to the pre-COVID scans.

“To the best of our knowledge this is the first cardiac MRI study to assess myocardial injury pre- and post-COVID-19,” the authors stated.

They say that while this study cannot rule out the possibility of rare events of COVID-19–induced myocardial injury, “the complete absence of de novo late gadolinium enhancement lesions after COVID-19 in this cohort indicates that outside special circumstances, COVID-19–induced myocardial injury may be much less common than suggested by previous studies.”

The study was published online in JACC: Cardiovascular Imaging.

Coauthor Till F. Althoff, MD, Cardiovascular Institute, Clínic–University Hospital Barcelona, said in an interview that previous reports have found a high rate of cardiac lesions in patients undergoing imaging after having had COVID-19 infection.

“In some reports, this has been as high as 80% of patients even though they have not had severe COVID disease. These reports have been interpreted as showing the majority of patients have some COVID-induced cardiac damage, which is an alarming message,” he commented.

However, he pointed out that the patients in these reports did not undergo a cardiac MRI scan before they had COVID-19 so it wasn’t known whether these cardiac lesions were present before infection or not.

To try and gain more accurate information, the current study examined cardiac MRI scans in the same patients before and after they had COVID-19.

The researchers, from an arrhythmia unit, made use of the fact that all their patients have cardiac MRI data, so they used their large registry of patients in whom cardiac MRI had been performed, and cross referenced this to a health care database to identify those patients who had confirmed COVID-19 after they obtaining a cardiac scan at the arrhythmia unit. They then conducted another cardiac MRI scan in the 31 patients identified a median of 5 months after their COVID-19 infection.

“These 31 patients had a cardiac MRI scan pre-COVID and post COVID using exactly the same scanner with identical sequences, so the scans were absolutely comparable,” Dr. Althoff noted.

Of these 31 patients, 7 had been hospitalized at the time of acute presentation with COVID-19, of whom 2 required intensive care. Most patients (29) had been symptomatic, but none reported cardiac symptoms.

Results showed that, on the post–COVID-19 scan, late gadolinium enhancement lesions indicative of residual myocardial injury were encountered in 15 of the 31 patients (48%), which the researchers said is in line with previous reports.

However, intraindividual comparison with the pre–COVID-19 cardiac MRI scans showed all these lesions were preexisting with identical localization, pattern, and transmural distribution, and thus not COVID-19 related.

Quantitative analyses, performed independently, detected no increase in the size of individual lesions nor in the global left ventricular late gadolinium enhancement extent.

Comparison of pre- and post COVID-19 imaging sequences did not show any differences in ventricular functional or structural parameters.

“While this study only has 31 patients, the fact that we are conducting intra-individual comparisons, which rules out bias, means that we don’t need a large number of patients for reliable results,” Dr. Althoff said.

“These types of lesions are normal to see. We know that individuals without cardiac disease have these types of lesions, and they are not necessarily an indication of any specific pathology. I was kind of surprised by the interpretation of previous data, which is why we did the current study,” he added.

Dr. Althoff acknowledged that some cardiac injury may have been seen if much larger numbers of patients had been included. “But I think we can say from this data that COVID-induced cardiac damage is much less of an issue than we may have previously thought,” he added.

He also noted that most of the patients in this study had mild COVID-19, so the results cannot be extrapolated to severe COVID-19 infection.

However, Dr. Althoff pointed out that all the patients already had atrial fibrillation, so would have been at higher risk of cardiac injury from COVID-19.

“These patients had preexisting cardiac risk factors, and thus they would have been more susceptible to both a more severe course of COVID and an increased risk of myocardial damage due to COVID. The fact that we don’t find any myocardial injury due to COVID in this group is even more reassuring. The general population will be at even lower risk,” he commented.

“I think we can say that, in COVID patients who do not have any cardiac symptoms, our study suggests that the incidence of cardiac injury is very low,” Dr. Althoff said.

“Even in patients with severe COVID and myocardial involvement reflected by increased troponin levels, I wouldn’t be sure that they have any residual cardiac injury. While it has been reported that cardiac lesions have been found in such patients, pre-COVID MRI scans were not available so we don’t know if they were there before,” he added.

“We do not know the true incidence of cardiac injury after COVID, but I think we can say from this data that it is definitely not anywhere near the 40%-50% or even greater that some of the previous reports have suggested,” he stated.

Dr. Althoff suggested that, based on these data, some of the recommendations based on previous reports such the need for follow-up cardiac scans and caution about partaking in sports again after COVID-19 infection, are probably not necessary.

“Our data suggest that these concerns are unfounded, and we need to step back a bit and stop alarming patients about the risk of cardiac damage after COVID,” he said. “Yes, if patients have cardiac symptoms during or after COVID infection they should get checked out, but I do not think we need to do a cardiac risk assessment in patients without cardiac symptoms in COVID.”

This work is supported in part by grants from Instituto de Salud Carlos III, the Spanish government, Madrid, and Fundació la Marató de TV3 in Catalonia. Dr. Althoff has received research grants for investigator-initiated trials from Biosense Webster.

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

Seven former patients have filed malpractice complaints against an interventional cardiologist based in Indianapolis, alleging he performed unnecessary cardiac procedures that led to physical and emotional harm.

The medical records for one patient, 70-year-old John Pflum, of Noblesville, Ind., show that Edward Harlamert, MD, performed 44 heart catheterizations and inserted at least 41 stents between 2004 and 2013, according to an investigation by WTHR 13News in Indianapolis that was published Dec. 14.

The news outlet asked four cardiologists to review and comment on John Pflum’s medical records.

“There is not a single scenario I can think of where doing this level of stents and angiograms would be justified or make sense. I have never seen this happen in the course of my medical training or my medical career,” Payal Kohli, MD, cardiologist and medical director of Cherry Creek Heart in Denver, told 13News.

Sunil Rao, MD, director of interventional cardiology at NYU Langone Health and president of the Society for Cardiovascular Angioplasty and Interventions, who also reviewed Mr. Pflum’s medical records for 13News, said he’s “never seen a patient who has gotten this many procedures.”

Dr. Rao said that on the basis of what he saw in the records and in the images, there were several deviations from the standard of care.

Two other independent cardiologists who spoke with 13News voiced similar opinions.

Mr. Pflum was “getting cathed almost every month. That’s not how it’s done,” Morton Rinder, MD, an interventional cardiologist at St. Luke’s Hospital near St. Louis, told 13News.

Dr. Rinder has been hired as a medical consultant for the attorneys who filed Mr. Pflum’s malpractice complaint against Dr. Harlamert.

Cardiologists who reviewed the catheterization films for 13News said some of Mr. Pflum’s heart blockages met the 70% threshold to warrant consideration of a stent, while others clearly did not. In-stent restenosis occurred in several of the implanted stents, requiring a second open heart surgery.

In a statement, Dr. Harlamert’s attorneys told 13News that Dr. Harlamert has “always been committed to providing quality care to patients” and that he treated his cardiology patients “based on their unique circumstances, his expertise, and the tools available.

“Because of stringent privacy laws and pending litigation, a response to a local news story is not the proper forum to present a picture of any particular treatment decision, especially when that picture may be incomplete at this time,” the statement reads.
 

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

Seven former patients have filed malpractice complaints against an interventional cardiologist based in Indianapolis, alleging he performed unnecessary cardiac procedures that led to physical and emotional harm.

The medical records for one patient, 70-year-old John Pflum, of Noblesville, Ind., show that Edward Harlamert, MD, performed 44 heart catheterizations and inserted at least 41 stents between 2004 and 2013, according to an investigation by WTHR 13News in Indianapolis that was published Dec. 14.

The news outlet asked four cardiologists to review and comment on John Pflum’s medical records.

“There is not a single scenario I can think of where doing this level of stents and angiograms would be justified or make sense. I have never seen this happen in the course of my medical training or my medical career,” Payal Kohli, MD, cardiologist and medical director of Cherry Creek Heart in Denver, told 13News.

Sunil Rao, MD, director of interventional cardiology at NYU Langone Health and president of the Society for Cardiovascular Angioplasty and Interventions, who also reviewed Mr. Pflum’s medical records for 13News, said he’s “never seen a patient who has gotten this many procedures.”

Dr. Rao said that on the basis of what he saw in the records and in the images, there were several deviations from the standard of care.

Two other independent cardiologists who spoke with 13News voiced similar opinions.

Mr. Pflum was “getting cathed almost every month. That’s not how it’s done,” Morton Rinder, MD, an interventional cardiologist at St. Luke’s Hospital near St. Louis, told 13News.

Dr. Rinder has been hired as a medical consultant for the attorneys who filed Mr. Pflum’s malpractice complaint against Dr. Harlamert.

Cardiologists who reviewed the catheterization films for 13News said some of Mr. Pflum’s heart blockages met the 70% threshold to warrant consideration of a stent, while others clearly did not. In-stent restenosis occurred in several of the implanted stents, requiring a second open heart surgery.

In a statement, Dr. Harlamert’s attorneys told 13News that Dr. Harlamert has “always been committed to providing quality care to patients” and that he treated his cardiology patients “based on their unique circumstances, his expertise, and the tools available.

“Because of stringent privacy laws and pending litigation, a response to a local news story is not the proper forum to present a picture of any particular treatment decision, especially when that picture may be incomplete at this time,” the statement reads.
 

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

Seven former patients have filed malpractice complaints against an interventional cardiologist based in Indianapolis, alleging he performed unnecessary cardiac procedures that led to physical and emotional harm.

The medical records for one patient, 70-year-old John Pflum, of Noblesville, Ind., show that Edward Harlamert, MD, performed 44 heart catheterizations and inserted at least 41 stents between 2004 and 2013, according to an investigation by WTHR 13News in Indianapolis that was published Dec. 14.

The news outlet asked four cardiologists to review and comment on John Pflum’s medical records.

“There is not a single scenario I can think of where doing this level of stents and angiograms would be justified or make sense. I have never seen this happen in the course of my medical training or my medical career,” Payal Kohli, MD, cardiologist and medical director of Cherry Creek Heart in Denver, told 13News.

Sunil Rao, MD, director of interventional cardiology at NYU Langone Health and president of the Society for Cardiovascular Angioplasty and Interventions, who also reviewed Mr. Pflum’s medical records for 13News, said he’s “never seen a patient who has gotten this many procedures.”

Dr. Rao said that on the basis of what he saw in the records and in the images, there were several deviations from the standard of care.

Two other independent cardiologists who spoke with 13News voiced similar opinions.

Mr. Pflum was “getting cathed almost every month. That’s not how it’s done,” Morton Rinder, MD, an interventional cardiologist at St. Luke’s Hospital near St. Louis, told 13News.

Dr. Rinder has been hired as a medical consultant for the attorneys who filed Mr. Pflum’s malpractice complaint against Dr. Harlamert.

Cardiologists who reviewed the catheterization films for 13News said some of Mr. Pflum’s heart blockages met the 70% threshold to warrant consideration of a stent, while others clearly did not. In-stent restenosis occurred in several of the implanted stents, requiring a second open heart surgery.

In a statement, Dr. Harlamert’s attorneys told 13News that Dr. Harlamert has “always been committed to providing quality care to patients” and that he treated his cardiology patients “based on their unique circumstances, his expertise, and the tools available.

“Because of stringent privacy laws and pending litigation, a response to a local news story is not the proper forum to present a picture of any particular treatment decision, especially when that picture may be incomplete at this time,” the statement reads.
 

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

AGA members advocate for GI during Alliance of Specialty Medicine fly-in

In December, six AGA members joined more than 100 specialty doctors organized by the Alliance of Specialty Medicine, a coalition that represents specialty physicians, to meet with House and Senate offices and discuss pressing policy priorities.

Members spoke on behalf of GI and stressed the need for Congress to act immediately on the upcoming Medicare cuts, and discussed step therapy protocols, prior authorization reform, and the role of artificial intelligence in the specialty.

Courtesy AGA

Our members represented GI well throughout the day’s meetings!

AGA PAC Board Member and Congressional Advocate Dr. Sadeea Abbasi spoke to House Leader Kevin McCarthy (R-CA) about challenges specialty doctors are facing and petitioned for Congress to mitigate the nearly 10 percent Medicare payment cuts before the end of the 117th Congress.

Additionally, AGA Government Affairs Committee Chair Dr. Rotonya Carr engaged with several members of Congress on issues impacting specialty care and discussed the future of AI in medicine with Rep. Mariannette Miller-Meeks (R-IA), who is an ophthalmologist.

Thank you to all our members who spoke on behalf of GI! We appreciate our AGA leaders who took time to participate!

• Sadeea Abbasi, MD, PhD
• Dawn B. Beaulieu, MD, AGAF
• Brent Burnette, MD
• Rotonya M. Carr, MD, FACP
• Peter S. Margolis, MD, AGAF
• Suzette Rivera MacMurray, MD

Learn how AGA is advocating for you. Visit gastro.org/advocacy.

AGA workshops champion women in GI

At AGA, we’re committed to supporting, empowering, and amplifying women in GI. As part of our ongoing efforts, we were thrilled to host nearly 250 women at four Women in GI regional workshops this fall. These workshops provided women across the country with opportunities to develop their personal and professional networks, participate in leadership development seminars, receive career mentoring, and engage in various wellness practices.

Following the conclusion of the regional workshops, we hosted the AGA Women’s Leadership Collaboration Conference at the AGA national office in Bethesda, Md.

Courtesy AGA

During the two-day conference, 22 delegates discussed workplace experiences, reported on their region’s workshop, and participated in strategy development exercises to further gender equity in GI, which included identifying tactics and ideas for action.

This unique event brought together delegates from each regional workshop, including 2023 Dr. Maria Leo-Lieber scholarship winners Alyssa Parian and Alexandra Livanos, who attended the Northeast workshop. It was a great time of collaboration and connection with the AGA #WomenInGI community!

Thank you to everyone who participated and made the events a success. We look forward to uplifting all women in GI and identifying ways to support the community in the coming year.

AGA thanks Johnson & Johnson Health Care Systems, Inc. for their support of this program.


 

Help move innovation forward at the 2023 AGA Tech Summit

Innovative technologies for endoscopy, advanced imaging, and bariatric care are a few of the topics that will headline the 2023 AGA Tech Summit, March 9-10, 2023, at the Grand Hyatt San Francisco. Registration is now open. Visit techsummit.gastro.org to secure your spot.

The Tech Summit is where GI innovators, clinicians, medical device companies, venture capitalists and regulatory agencies meet to foster the development and adoption of GI technologies. It is the perfect venue for:

• All innovators, entrepreneurs and clinicians who want to build their professional networks in the GI space.
• Early-stage GI companies who want to showcase their technologies and find new ideas for further innovations that will improve patient care.
• GI fellows who want an exclusive and immersive behind-the-scenes look into the MedTech world.

Learn more by visiting techsummit.gastro.org.

AGA members advocate for GI during Alliance of Specialty Medicine fly-in

In December, six AGA members joined more than 100 specialty doctors organized by the Alliance of Specialty Medicine, a coalition that represents specialty physicians, to meet with House and Senate offices and discuss pressing policy priorities.

Members spoke on behalf of GI and stressed the need for Congress to act immediately on the upcoming Medicare cuts, and discussed step therapy protocols, prior authorization reform, and the role of artificial intelligence in the specialty.

Courtesy AGA

Our members represented GI well throughout the day’s meetings!

AGA PAC Board Member and Congressional Advocate Dr. Sadeea Abbasi spoke to House Leader Kevin McCarthy (R-CA) about challenges specialty doctors are facing and petitioned for Congress to mitigate the nearly 10 percent Medicare payment cuts before the end of the 117th Congress.

Additionally, AGA Government Affairs Committee Chair Dr. Rotonya Carr engaged with several members of Congress on issues impacting specialty care and discussed the future of AI in medicine with Rep. Mariannette Miller-Meeks (R-IA), who is an ophthalmologist.

Thank you to all our members who spoke on behalf of GI! We appreciate our AGA leaders who took time to participate!

• Sadeea Abbasi, MD, PhD
• Dawn B. Beaulieu, MD, AGAF
• Brent Burnette, MD
• Rotonya M. Carr, MD, FACP
• Peter S. Margolis, MD, AGAF
• Suzette Rivera MacMurray, MD

Learn how AGA is advocating for you. Visit gastro.org/advocacy.

AGA workshops champion women in GI

At AGA, we’re committed to supporting, empowering, and amplifying women in GI. As part of our ongoing efforts, we were thrilled to host nearly 250 women at four Women in GI regional workshops this fall. These workshops provided women across the country with opportunities to develop their personal and professional networks, participate in leadership development seminars, receive career mentoring, and engage in various wellness practices.

Following the conclusion of the regional workshops, we hosted the AGA Women’s Leadership Collaboration Conference at the AGA national office in Bethesda, Md.

Courtesy AGA

During the two-day conference, 22 delegates discussed workplace experiences, reported on their region’s workshop, and participated in strategy development exercises to further gender equity in GI, which included identifying tactics and ideas for action.

This unique event brought together delegates from each regional workshop, including 2023 Dr. Maria Leo-Lieber scholarship winners Alyssa Parian and Alexandra Livanos, who attended the Northeast workshop. It was a great time of collaboration and connection with the AGA #WomenInGI community!

Thank you to everyone who participated and made the events a success. We look forward to uplifting all women in GI and identifying ways to support the community in the coming year.

AGA thanks Johnson & Johnson Health Care Systems, Inc. for their support of this program.


 

Help move innovation forward at the 2023 AGA Tech Summit

Innovative technologies for endoscopy, advanced imaging, and bariatric care are a few of the topics that will headline the 2023 AGA Tech Summit, March 9-10, 2023, at the Grand Hyatt San Francisco. Registration is now open. Visit techsummit.gastro.org to secure your spot.

The Tech Summit is where GI innovators, clinicians, medical device companies, venture capitalists and regulatory agencies meet to foster the development and adoption of GI technologies. It is the perfect venue for:

• All innovators, entrepreneurs and clinicians who want to build their professional networks in the GI space.
• Early-stage GI companies who want to showcase their technologies and find new ideas for further innovations that will improve patient care.
• GI fellows who want an exclusive and immersive behind-the-scenes look into the MedTech world.

Learn more by visiting techsummit.gastro.org.

AGA members advocate for GI during Alliance of Specialty Medicine fly-in

In December, six AGA members joined more than 100 specialty doctors organized by the Alliance of Specialty Medicine, a coalition that represents specialty physicians, to meet with House and Senate offices and discuss pressing policy priorities.

Members spoke on behalf of GI and stressed the need for Congress to act immediately on the upcoming Medicare cuts, and discussed step therapy protocols, prior authorization reform, and the role of artificial intelligence in the specialty.

Courtesy AGA

Our members represented GI well throughout the day’s meetings!

AGA PAC Board Member and Congressional Advocate Dr. Sadeea Abbasi spoke to House Leader Kevin McCarthy (R-CA) about challenges specialty doctors are facing and petitioned for Congress to mitigate the nearly 10 percent Medicare payment cuts before the end of the 117th Congress.

Additionally, AGA Government Affairs Committee Chair Dr. Rotonya Carr engaged with several members of Congress on issues impacting specialty care and discussed the future of AI in medicine with Rep. Mariannette Miller-Meeks (R-IA), who is an ophthalmologist.

Thank you to all our members who spoke on behalf of GI! We appreciate our AGA leaders who took time to participate!

• Sadeea Abbasi, MD, PhD
• Dawn B. Beaulieu, MD, AGAF
• Brent Burnette, MD
• Rotonya M. Carr, MD, FACP
• Peter S. Margolis, MD, AGAF
• Suzette Rivera MacMurray, MD

Learn how AGA is advocating for you. Visit gastro.org/advocacy.

AGA workshops champion women in GI

At AGA, we’re committed to supporting, empowering, and amplifying women in GI. As part of our ongoing efforts, we were thrilled to host nearly 250 women at four Women in GI regional workshops this fall. These workshops provided women across the country with opportunities to develop their personal and professional networks, participate in leadership development seminars, receive career mentoring, and engage in various wellness practices.

Following the conclusion of the regional workshops, we hosted the AGA Women’s Leadership Collaboration Conference at the AGA national office in Bethesda, Md.

Courtesy AGA

During the two-day conference, 22 delegates discussed workplace experiences, reported on their region’s workshop, and participated in strategy development exercises to further gender equity in GI, which included identifying tactics and ideas for action.

This unique event brought together delegates from each regional workshop, including 2023 Dr. Maria Leo-Lieber scholarship winners Alyssa Parian and Alexandra Livanos, who attended the Northeast workshop. It was a great time of collaboration and connection with the AGA #WomenInGI community!

Thank you to everyone who participated and made the events a success. We look forward to uplifting all women in GI and identifying ways to support the community in the coming year.

AGA thanks Johnson & Johnson Health Care Systems, Inc. for their support of this program.


 

Help move innovation forward at the 2023 AGA Tech Summit

Innovative technologies for endoscopy, advanced imaging, and bariatric care are a few of the topics that will headline the 2023 AGA Tech Summit, March 9-10, 2023, at the Grand Hyatt San Francisco. Registration is now open. Visit techsummit.gastro.org to secure your spot.

The Tech Summit is where GI innovators, clinicians, medical device companies, venture capitalists and regulatory agencies meet to foster the development and adoption of GI technologies. It is the perfect venue for:

• All innovators, entrepreneurs and clinicians who want to build their professional networks in the GI space.
• Early-stage GI companies who want to showcase their technologies and find new ideas for further innovations that will improve patient care.
• GI fellows who want an exclusive and immersive behind-the-scenes look into the MedTech world.

Learn more by visiting techsummit.gastro.org.

This patient's findings are consistent with a diagnosis of malignant mantle cell lymphoma (MCL).

MCL is a rare and aggressive form of non-Hodgkin lymphoma that accounts for approximately 5%-7% of all lymphomas. MCL has a characteristic immunophenotype (ie, CD5+, CD10−, Bcl-2+, Bcl-6−, CD20+), with the t(11;14)(q13;q32) chromosomal translocation, and expression of cyclin D1. The median age at diagnosis is between 60 and 70 years. Approximately 70% of all cases occur in men. 

The clinical presentation of MCL can vary. Patients may have asymptomatic monoclonal MCL type lymphocytosis or nonbulky nodal/extra nodal disease with minimal symptoms, or they may present with significant symptoms, progressive generalized lymphadenopathy, cytopenia, splenomegaly, and extranodal disease, including gastrointestinal involvement (lymphomatous polyposis), kidney involvement, involvement of other organs, or, rarely, central nervous system involvement. Disease involving multiple lymph nodes and other sites of the body is seen in most patients. Approximately 70% of patients present with stage IV disease requiring systemic treatment.

According to 2022 guidelines from the National Comprehensive Cancer Network (NCCN), essential components in the workup for MCL include:

•    Physical examination, with attention to node-bearing areas, including Waldeyer ring, and to size of liver and spleen
•    Assessment of performance status and B symptoms (ie, fever > 100.4°F [may be sporadic], drenching night sweats, unintentional weight loss of > 10% of body weight over 6 months or less)
•    CBC with differential
•    Comprehensive metabolic panel
•    Serum lactate dehydrogenase (LDH) level (an important prognostic marker)
•    PET/CT scan (including neck)
•    Hepatitis B testing if treatment with rituximab is being contemplated
•    Echocardiogram or multigated acquisition (MUGA) scan if anthracycline or anthracenedione-based regimen is indicated
•    Pregnancy testing in women of childbearing age (if chemotherapy or radiation therapy is planned) 

Additional testing may be indicated in specific circumstances, such as colonoscopy/endoscopy. 

MCL remains challenging to treat. While 50%-90% of patients with MCL respond to combination chemotherapy, only 30% achieve a complete response. Median time to treatment failure is < 18 months. 

When selecting systemic treatment for patients with MCL, clinicians should consider the availability of clinical trials for subsets of patients, eligibility for stem cell transplant (SCT), high-risk status (ie, blastoid MCL, high Ki-67% > 30%, or central nervous system involvement), age, and performance status. The addition of radiation to chemotherapy may be beneficial for patients with limited-stage, nonbulky disease, although this has not been confirmed in large, randomized studies. Outside of clinical trials, the usual approach for frontline treatment of MCL is chemoimmunotherapy with/without autologous SCT and with/without maintenance therapy.

Available options for primary MCL therapy in patients who require systemic therapy include: 

•    Single alkylating agents
•    CVP (cyclophosphamide, vincristine, prednisone)
•    CHOP (cyclophosphamide, doxorubicin [hydroxydaunorubicin], vincristine [Oncovin], prednisone)
•    Hyper-CVAD (hyperfractionated cyclophosphamide, vincristine, doxorubicin, dexamethasone) with or without rituximab
•    R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, prednisone)
•    Lenalidomide plus rituximab
•    Hyper-CVAD with autologous SCT

Options for relapsed or refractory MCL include:

•    R-hyper-CVAD
•    Hyper-CVAD with or without rituximab followed by autologous SCT
•    Nucleoside analogues and combinations
•    Salvage chemotherapy combinations followed by autologous SCT
•    Bortezomib 
•    Lenalidomide 
•    Ibrutinib 
•    Radioimmunotherapy
•    Rituximab
•    Rituximab and thalidomide combination
•    Acalabrutinib 
•    High-dose chemotherapy with autologous bone marrow or SCT
•    Brexucabtagene autoleucel 

Timothy J. Voorhees, MD, MSCR, Assistant Professor of Internal Medicine - Clinical, Division of Hematology, The Ohio State University James Comprehensive Cancer Center, Columbus, OH.

Timothy J. Voorhees, MD, MSCR, has disclosed the following relevant financial relationships:
Received research grant from: AstraZeneca; Morphosys; Incyte; Recordati.

Image Quizzes are fictional or fictionalized clinical scenarios intended to provide evidence-based educational takeaways.

This patient's findings are consistent with a diagnosis of malignant mantle cell lymphoma (MCL).

MCL is a rare and aggressive form of non-Hodgkin lymphoma that accounts for approximately 5%-7% of all lymphomas. MCL has a characteristic immunophenotype (ie, CD5+, CD10−, Bcl-2+, Bcl-6−, CD20+), with the t(11;14)(q13;q32) chromosomal translocation, and expression of cyclin D1. The median age at diagnosis is between 60 and 70 years. Approximately 70% of all cases occur in men. 

The clinical presentation of MCL can vary. Patients may have asymptomatic monoclonal MCL type lymphocytosis or nonbulky nodal/extra nodal disease with minimal symptoms, or they may present with significant symptoms, progressive generalized lymphadenopathy, cytopenia, splenomegaly, and extranodal disease, including gastrointestinal involvement (lymphomatous polyposis), kidney involvement, involvement of other organs, or, rarely, central nervous system involvement. Disease involving multiple lymph nodes and other sites of the body is seen in most patients. Approximately 70% of patients present with stage IV disease requiring systemic treatment.

According to 2022 guidelines from the National Comprehensive Cancer Network (NCCN), essential components in the workup for MCL include:

•    Physical examination, with attention to node-bearing areas, including Waldeyer ring, and to size of liver and spleen
•    Assessment of performance status and B symptoms (ie, fever > 100.4°F [may be sporadic], drenching night sweats, unintentional weight loss of > 10% of body weight over 6 months or less)
•    CBC with differential
•    Comprehensive metabolic panel
•    Serum lactate dehydrogenase (LDH) level (an important prognostic marker)
•    PET/CT scan (including neck)
•    Hepatitis B testing if treatment with rituximab is being contemplated
•    Echocardiogram or multigated acquisition (MUGA) scan if anthracycline or anthracenedione-based regimen is indicated
•    Pregnancy testing in women of childbearing age (if chemotherapy or radiation therapy is planned) 

Additional testing may be indicated in specific circumstances, such as colonoscopy/endoscopy. 

MCL remains challenging to treat. While 50%-90% of patients with MCL respond to combination chemotherapy, only 30% achieve a complete response. Median time to treatment failure is < 18 months. 

When selecting systemic treatment for patients with MCL, clinicians should consider the availability of clinical trials for subsets of patients, eligibility for stem cell transplant (SCT), high-risk status (ie, blastoid MCL, high Ki-67% > 30%, or central nervous system involvement), age, and performance status. The addition of radiation to chemotherapy may be beneficial for patients with limited-stage, nonbulky disease, although this has not been confirmed in large, randomized studies. Outside of clinical trials, the usual approach for frontline treatment of MCL is chemoimmunotherapy with/without autologous SCT and with/without maintenance therapy.

Available options for primary MCL therapy in patients who require systemic therapy include: 

•    Single alkylating agents
•    CVP (cyclophosphamide, vincristine, prednisone)
•    CHOP (cyclophosphamide, doxorubicin [hydroxydaunorubicin], vincristine [Oncovin], prednisone)
•    Hyper-CVAD (hyperfractionated cyclophosphamide, vincristine, doxorubicin, dexamethasone) with or without rituximab
•    R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, prednisone)
•    Lenalidomide plus rituximab
•    Hyper-CVAD with autologous SCT

Options for relapsed or refractory MCL include:

•    R-hyper-CVAD
•    Hyper-CVAD with or without rituximab followed by autologous SCT
•    Nucleoside analogues and combinations
•    Salvage chemotherapy combinations followed by autologous SCT
•    Bortezomib 
•    Lenalidomide 
•    Ibrutinib 
•    Radioimmunotherapy
•    Rituximab
•    Rituximab and thalidomide combination
•    Acalabrutinib 
•    High-dose chemotherapy with autologous bone marrow or SCT
•    Brexucabtagene autoleucel 

Timothy J. Voorhees, MD, MSCR, Assistant Professor of Internal Medicine - Clinical, Division of Hematology, The Ohio State University James Comprehensive Cancer Center, Columbus, OH.

Timothy J. Voorhees, MD, MSCR, has disclosed the following relevant financial relationships:
Received research grant from: AstraZeneca; Morphosys; Incyte; Recordati.

Image Quizzes are fictional or fictionalized clinical scenarios intended to provide evidence-based educational takeaways.

This patient's findings are consistent with a diagnosis of malignant mantle cell lymphoma (MCL).

MCL is a rare and aggressive form of non-Hodgkin lymphoma that accounts for approximately 5%-7% of all lymphomas. MCL has a characteristic immunophenotype (ie, CD5+, CD10−, Bcl-2+, Bcl-6−, CD20+), with the t(11;14)(q13;q32) chromosomal translocation, and expression of cyclin D1. The median age at diagnosis is between 60 and 70 years. Approximately 70% of all cases occur in men. 

The clinical presentation of MCL can vary. Patients may have asymptomatic monoclonal MCL type lymphocytosis or nonbulky nodal/extra nodal disease with minimal symptoms, or they may present with significant symptoms, progressive generalized lymphadenopathy, cytopenia, splenomegaly, and extranodal disease, including gastrointestinal involvement (lymphomatous polyposis), kidney involvement, involvement of other organs, or, rarely, central nervous system involvement. Disease involving multiple lymph nodes and other sites of the body is seen in most patients. Approximately 70% of patients present with stage IV disease requiring systemic treatment.

According to 2022 guidelines from the National Comprehensive Cancer Network (NCCN), essential components in the workup for MCL include:

•    Physical examination, with attention to node-bearing areas, including Waldeyer ring, and to size of liver and spleen
•    Assessment of performance status and B symptoms (ie, fever > 100.4°F [may be sporadic], drenching night sweats, unintentional weight loss of > 10% of body weight over 6 months or less)
•    CBC with differential
•    Comprehensive metabolic panel
•    Serum lactate dehydrogenase (LDH) level (an important prognostic marker)
•    PET/CT scan (including neck)
•    Hepatitis B testing if treatment with rituximab is being contemplated
•    Echocardiogram or multigated acquisition (MUGA) scan if anthracycline or anthracenedione-based regimen is indicated
•    Pregnancy testing in women of childbearing age (if chemotherapy or radiation therapy is planned) 

Additional testing may be indicated in specific circumstances, such as colonoscopy/endoscopy. 

MCL remains challenging to treat. While 50%-90% of patients with MCL respond to combination chemotherapy, only 30% achieve a complete response. Median time to treatment failure is < 18 months. 

When selecting systemic treatment for patients with MCL, clinicians should consider the availability of clinical trials for subsets of patients, eligibility for stem cell transplant (SCT), high-risk status (ie, blastoid MCL, high Ki-67% > 30%, or central nervous system involvement), age, and performance status. The addition of radiation to chemotherapy may be beneficial for patients with limited-stage, nonbulky disease, although this has not been confirmed in large, randomized studies. Outside of clinical trials, the usual approach for frontline treatment of MCL is chemoimmunotherapy with/without autologous SCT and with/without maintenance therapy.

Available options for primary MCL therapy in patients who require systemic therapy include: 

•    Single alkylating agents
•    CVP (cyclophosphamide, vincristine, prednisone)
•    CHOP (cyclophosphamide, doxorubicin [hydroxydaunorubicin], vincristine [Oncovin], prednisone)
•    Hyper-CVAD (hyperfractionated cyclophosphamide, vincristine, doxorubicin, dexamethasone) with or without rituximab
•    R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, prednisone)
•    Lenalidomide plus rituximab
•    Hyper-CVAD with autologous SCT

Options for relapsed or refractory MCL include:

•    R-hyper-CVAD
•    Hyper-CVAD with or without rituximab followed by autologous SCT
•    Nucleoside analogues and combinations
•    Salvage chemotherapy combinations followed by autologous SCT
•    Bortezomib 
•    Lenalidomide 
•    Ibrutinib 
•    Radioimmunotherapy
•    Rituximab
•    Rituximab and thalidomide combination
•    Acalabrutinib 
•    High-dose chemotherapy with autologous bone marrow or SCT
•    Brexucabtagene autoleucel 

Timothy J. Voorhees, MD, MSCR, Assistant Professor of Internal Medicine - Clinical, Division of Hematology, The Ohio State University James Comprehensive Cancer Center, Columbus, OH.

Timothy J. Voorhees, MD, MSCR, has disclosed the following relevant financial relationships:
Received research grant from: AstraZeneca; Morphosys; Incyte; Recordati.

Image Quizzes are fictional or fictionalized clinical scenarios intended to provide evidence-based educational takeaways.

SAN DIEGO – When Omar A. Ibrahimi, MD, PhD, opened his own cosmetic dermatology practice in Stamford, Conn., in 2012, he sensed that he had his work cut out for him.

“I was a fellowship-trained Mohs surgeon who wanted to do aesthetics,” Dr. Ibrahimi, medical director of the Connecticut Skin Institute, recalled during the annual Masters of Aesthetics Symposium. “I was in a geographic area that was new to me. I didn’t know any referring doctors, but I started to network and tried to grow my practice.”

Someone once told him that the “three As” of being a medical specialist are “Available, Affable, and Ability,” so he applied that principle as he began to cultivate relationships with physicians in his geographic area. “I told my referring doctors, ‘If you’re kind enough to send me Mohs cases, I’ll help you out if there’s something you don’t like doing, whether it’s a nail biopsy or treating male genital warts,’” he said. “You want to make it easy for doctors to refer to you, but you also want to make their lives easier.”

Dr. Ibrahimi, who is also on the board of directors for the American Society for Dermatologic Surgery and the American Society for Laser Medicine and Surgery, offered nine other recommendations for building and growing a cosmetic dermatology practice. They include:

Know yourself. Do what you love to do, not what you feel like you should do. “Whatever you’re doing in your practice, it should be something that you’re passionate about and excited about,” he said. “I do a mix of Mohs surgery and procedural aesthetic dermatology. Most of my practice is shaped toward energy-based devices and laser procedures. Pick the things that you enjoy doing and try to deliver good results.”

Know your patients. When dermatologists who plan to open their own practice ask Dr. Ibrahimi what kind of laser they should buy, he typically responds by asking them to consider what procedures their patients are asking for. “Depending on where you are geographically and the economic profile of the community in which you practice, it can be a different answer,” Dr. Ibrahimi said. “If you practice in the Northeast and do a lot of medical dermatology, it might mean getting a vascular laser to treat rosacea. If you’re in Southern California, treating pigment might be a bigger concern than treating rosacea.” The annual ASDS Survey on Dermatologic Procedures provides a snapshot of trends and can be useful for decision-making, he said.

Know your practice. “Make sure you are capable of entering the aesthetics field,” he advised. “You cannot have a practice that runs like the DMV, with people waiting 30 to 40 minutes to be seen.” Proper training of staff is also key and representatives from device and injectable companies can provide advice and support. As for marketing, some dermatologists hire a public relations agency, but Dr. Ibrahimi finds that the best source of his referrals is word of mouth. “If I do a good job taking care of patients, they will send their friends and family over to me, but social media is also important,” he said. Taking quality before-and-after photos, and obtaining consent from patients to use them online in educational posts is a good approach, he noted.

Know your market. When Dr. Ibrahimi first opened his practice, offering laser hair removal was not a priority because so many other dermatologists and medical spas in his area were already providing it. With time, though, he added laser hair removal to his menu of treatment offerings because “I knew that if my patients weren’t getting that service from me, they would be getting it from somewhere else,” he said. “Initially it wasn’t important for me, but as my practice matured, I wanted to make sure that I was comprehensive.”

Start cautiously. Think safety first. “I tell people that starting a cosmetic practice is like baseball: don’t try to hit home runs,” Dr. Ibrahimi said. “Just aim for base hits and keep your patients happy. Make sure you deliver safe, good results.” This means knowing everything possible about the devices used in the office, because if the use of a laser is delegated to a staff member and a problem arises, “you have to know everything about how that device works so that you can troubleshoot,” he said. “A lot of problems that arise are from lack of intimacy with your device.”

Seek knowledge. Attend courses in cosmetic dermatology and read literature from journals like Dermatologic Surgery and Lasers in Surgery and Medicine, he advised. “People will see the success, but they won’t know how much hard work it takes to get there,” he said. “You have to develop your reputation to develop the kind of practice that you want.”

Understand the business of aesthetics. Most energy devices carry a steep price tag, and leasing or financing devices come with a monthly payment, he said. “Make sure that what you’re bringing in on that device is going to be sufficient to cover the monthly payment. With something like tissue microcoring, you don’t have to use that five times a day to cover that lease payment. But if you have a vascular laser, you probably need to be treating more than a couple patients per day to make that lease payment. If you can recover the amount the device costs in about a year, that’s going to be a good investment. Many devices come with consumables, so you have to remember that.”

Don’t be afraid to be unique/change directions. Becoming an early adopter of new technologies and procedures can make someone stand out. “Other providers feel more comfortable waiting to allow more data to come out about a new technology before they make a purchase,” he said. “But if you’re established and have a busy practice, that’s an opportunity that can draw people in.”

Have patience and realistic expectations. It’s smart to offer a variety of services, he said, such as medical or surgical dermatology in addition to cosmetic dermatology. “That’s going to help you through any kind of economic downturn,” he said. “Success depends on a lot of factors going right. Make sure you set short- and long-term goals.”

Dr. Ibrahimi disclosed that he is a member of the Advisory Board for Accure Acne, AbbVie, Cutera, Lutronic, Blueberry Therapeutics, Cytrellis, and Quthero. He also holds stock in many device and pharmaceutical companies.

SAN DIEGO – When Omar A. Ibrahimi, MD, PhD, opened his own cosmetic dermatology practice in Stamford, Conn., in 2012, he sensed that he had his work cut out for him.

“I was a fellowship-trained Mohs surgeon who wanted to do aesthetics,” Dr. Ibrahimi, medical director of the Connecticut Skin Institute, recalled during the annual Masters of Aesthetics Symposium. “I was in a geographic area that was new to me. I didn’t know any referring doctors, but I started to network and tried to grow my practice.”

Someone once told him that the “three As” of being a medical specialist are “Available, Affable, and Ability,” so he applied that principle as he began to cultivate relationships with physicians in his geographic area. “I told my referring doctors, ‘If you’re kind enough to send me Mohs cases, I’ll help you out if there’s something you don’t like doing, whether it’s a nail biopsy or treating male genital warts,’” he said. “You want to make it easy for doctors to refer to you, but you also want to make their lives easier.”

Dr. Ibrahimi, who is also on the board of directors for the American Society for Dermatologic Surgery and the American Society for Laser Medicine and Surgery, offered nine other recommendations for building and growing a cosmetic dermatology practice. They include:

Know yourself. Do what you love to do, not what you feel like you should do. “Whatever you’re doing in your practice, it should be something that you’re passionate about and excited about,” he said. “I do a mix of Mohs surgery and procedural aesthetic dermatology. Most of my practice is shaped toward energy-based devices and laser procedures. Pick the things that you enjoy doing and try to deliver good results.”

Know your patients. When dermatologists who plan to open their own practice ask Dr. Ibrahimi what kind of laser they should buy, he typically responds by asking them to consider what procedures their patients are asking for. “Depending on where you are geographically and the economic profile of the community in which you practice, it can be a different answer,” Dr. Ibrahimi said. “If you practice in the Northeast and do a lot of medical dermatology, it might mean getting a vascular laser to treat rosacea. If you’re in Southern California, treating pigment might be a bigger concern than treating rosacea.” The annual ASDS Survey on Dermatologic Procedures provides a snapshot of trends and can be useful for decision-making, he said.

Know your practice. “Make sure you are capable of entering the aesthetics field,” he advised. “You cannot have a practice that runs like the DMV, with people waiting 30 to 40 minutes to be seen.” Proper training of staff is also key and representatives from device and injectable companies can provide advice and support. As for marketing, some dermatologists hire a public relations agency, but Dr. Ibrahimi finds that the best source of his referrals is word of mouth. “If I do a good job taking care of patients, they will send their friends and family over to me, but social media is also important,” he said. Taking quality before-and-after photos, and obtaining consent from patients to use them online in educational posts is a good approach, he noted.

Know your market. When Dr. Ibrahimi first opened his practice, offering laser hair removal was not a priority because so many other dermatologists and medical spas in his area were already providing it. With time, though, he added laser hair removal to his menu of treatment offerings because “I knew that if my patients weren’t getting that service from me, they would be getting it from somewhere else,” he said. “Initially it wasn’t important for me, but as my practice matured, I wanted to make sure that I was comprehensive.”

Start cautiously. Think safety first. “I tell people that starting a cosmetic practice is like baseball: don’t try to hit home runs,” Dr. Ibrahimi said. “Just aim for base hits and keep your patients happy. Make sure you deliver safe, good results.” This means knowing everything possible about the devices used in the office, because if the use of a laser is delegated to a staff member and a problem arises, “you have to know everything about how that device works so that you can troubleshoot,” he said. “A lot of problems that arise are from lack of intimacy with your device.”

Seek knowledge. Attend courses in cosmetic dermatology and read literature from journals like Dermatologic Surgery and Lasers in Surgery and Medicine, he advised. “People will see the success, but they won’t know how much hard work it takes to get there,” he said. “You have to develop your reputation to develop the kind of practice that you want.”

Understand the business of aesthetics. Most energy devices carry a steep price tag, and leasing or financing devices come with a monthly payment, he said. “Make sure that what you’re bringing in on that device is going to be sufficient to cover the monthly payment. With something like tissue microcoring, you don’t have to use that five times a day to cover that lease payment. But if you have a vascular laser, you probably need to be treating more than a couple patients per day to make that lease payment. If you can recover the amount the device costs in about a year, that’s going to be a good investment. Many devices come with consumables, so you have to remember that.”

Don’t be afraid to be unique/change directions. Becoming an early adopter of new technologies and procedures can make someone stand out. “Other providers feel more comfortable waiting to allow more data to come out about a new technology before they make a purchase,” he said. “But if you’re established and have a busy practice, that’s an opportunity that can draw people in.”

Have patience and realistic expectations. It’s smart to offer a variety of services, he said, such as medical or surgical dermatology in addition to cosmetic dermatology. “That’s going to help you through any kind of economic downturn,” he said. “Success depends on a lot of factors going right. Make sure you set short- and long-term goals.”

Dr. Ibrahimi disclosed that he is a member of the Advisory Board for Accure Acne, AbbVie, Cutera, Lutronic, Blueberry Therapeutics, Cytrellis, and Quthero. He also holds stock in many device and pharmaceutical companies.

SAN DIEGO – When Omar A. Ibrahimi, MD, PhD, opened his own cosmetic dermatology practice in Stamford, Conn., in 2012, he sensed that he had his work cut out for him.

“I was a fellowship-trained Mohs surgeon who wanted to do aesthetics,” Dr. Ibrahimi, medical director of the Connecticut Skin Institute, recalled during the annual Masters of Aesthetics Symposium. “I was in a geographic area that was new to me. I didn’t know any referring doctors, but I started to network and tried to grow my practice.”

Someone once told him that the “three As” of being a medical specialist are “Available, Affable, and Ability,” so he applied that principle as he began to cultivate relationships with physicians in his geographic area. “I told my referring doctors, ‘If you’re kind enough to send me Mohs cases, I’ll help you out if there’s something you don’t like doing, whether it’s a nail biopsy or treating male genital warts,’” he said. “You want to make it easy for doctors to refer to you, but you also want to make their lives easier.”

Dr. Ibrahimi, who is also on the board of directors for the American Society for Dermatologic Surgery and the American Society for Laser Medicine and Surgery, offered nine other recommendations for building and growing a cosmetic dermatology practice. They include:

Know yourself. Do what you love to do, not what you feel like you should do. “Whatever you’re doing in your practice, it should be something that you’re passionate about and excited about,” he said. “I do a mix of Mohs surgery and procedural aesthetic dermatology. Most of my practice is shaped toward energy-based devices and laser procedures. Pick the things that you enjoy doing and try to deliver good results.”

Know your patients. When dermatologists who plan to open their own practice ask Dr. Ibrahimi what kind of laser they should buy, he typically responds by asking them to consider what procedures their patients are asking for. “Depending on where you are geographically and the economic profile of the community in which you practice, it can be a different answer,” Dr. Ibrahimi said. “If you practice in the Northeast and do a lot of medical dermatology, it might mean getting a vascular laser to treat rosacea. If you’re in Southern California, treating pigment might be a bigger concern than treating rosacea.” The annual ASDS Survey on Dermatologic Procedures provides a snapshot of trends and can be useful for decision-making, he said.

Know your practice. “Make sure you are capable of entering the aesthetics field,” he advised. “You cannot have a practice that runs like the DMV, with people waiting 30 to 40 minutes to be seen.” Proper training of staff is also key and representatives from device and injectable companies can provide advice and support. As for marketing, some dermatologists hire a public relations agency, but Dr. Ibrahimi finds that the best source of his referrals is word of mouth. “If I do a good job taking care of patients, they will send their friends and family over to me, but social media is also important,” he said. Taking quality before-and-after photos, and obtaining consent from patients to use them online in educational posts is a good approach, he noted.

Know your market. When Dr. Ibrahimi first opened his practice, offering laser hair removal was not a priority because so many other dermatologists and medical spas in his area were already providing it. With time, though, he added laser hair removal to his menu of treatment offerings because “I knew that if my patients weren’t getting that service from me, they would be getting it from somewhere else,” he said. “Initially it wasn’t important for me, but as my practice matured, I wanted to make sure that I was comprehensive.”

Start cautiously. Think safety first. “I tell people that starting a cosmetic practice is like baseball: don’t try to hit home runs,” Dr. Ibrahimi said. “Just aim for base hits and keep your patients happy. Make sure you deliver safe, good results.” This means knowing everything possible about the devices used in the office, because if the use of a laser is delegated to a staff member and a problem arises, “you have to know everything about how that device works so that you can troubleshoot,” he said. “A lot of problems that arise are from lack of intimacy with your device.”

Seek knowledge. Attend courses in cosmetic dermatology and read literature from journals like Dermatologic Surgery and Lasers in Surgery and Medicine, he advised. “People will see the success, but they won’t know how much hard work it takes to get there,” he said. “You have to develop your reputation to develop the kind of practice that you want.”

Understand the business of aesthetics. Most energy devices carry a steep price tag, and leasing or financing devices come with a monthly payment, he said. “Make sure that what you’re bringing in on that device is going to be sufficient to cover the monthly payment. With something like tissue microcoring, you don’t have to use that five times a day to cover that lease payment. But if you have a vascular laser, you probably need to be treating more than a couple patients per day to make that lease payment. If you can recover the amount the device costs in about a year, that’s going to be a good investment. Many devices come with consumables, so you have to remember that.”

Don’t be afraid to be unique/change directions. Becoming an early adopter of new technologies and procedures can make someone stand out. “Other providers feel more comfortable waiting to allow more data to come out about a new technology before they make a purchase,” he said. “But if you’re established and have a busy practice, that’s an opportunity that can draw people in.”

Have patience and realistic expectations. It’s smart to offer a variety of services, he said, such as medical or surgical dermatology in addition to cosmetic dermatology. “That’s going to help you through any kind of economic downturn,” he said. “Success depends on a lot of factors going right. Make sure you set short- and long-term goals.”

Dr. Ibrahimi disclosed that he is a member of the Advisory Board for Accure Acne, AbbVie, Cutera, Lutronic, Blueberry Therapeutics, Cytrellis, and Quthero. He also holds stock in many device and pharmaceutical companies.

The Ohio measles outbreak continues to expand, with cases now totaling 81 – a 37% increase in the course of just 2 weeks.

The lead health official where the outbreak is occurring said the driving force behind the spread is vaccine hesitancy. Most of the children infected were unvaccinated but were old enough to get the measles, mumps, and rubella (MMR) shot, which is 97% effective at preventing measles.

“I think these are individuals who are making a decision not to protect their children against vaccine-preventable diseases, and some of them are making a specific decision not to use the MMR vaccine,” Columbus Public Health Commissioner Mysheika W. Roberts, MD, told JAMA.

She said that parents’ refusal to vaccinate their children was due to a misconception that the vaccine causes autism.

“We’re sounding the alarm that if your child is of age and not vaccinated, they should get vaccinated ASAP,” Dr. Roberts said, noting that she hasn’t seen that happening more.

Health officials have predicted the outbreak, which started in November, will last at least several months. Measles is so contagious that 9 out of 10 unvaccinated people in a room will become infected if exposed.

All of the infections have been in children. According to the Columbus Public Health measles dashboard, of the 81 confirmed cases:

• 29 children have been hospitalized.
• 22 cases are among children under 1 year old.
• No deaths have been reported.

Dr. Roberts said the hospitalized children have had symptoms including dehydration, diarrhea, and pneumonia. Some have had to go to the intensive care unit.

Measles infection causes a rash and a fever that can spike beyond 104° F. Sometimes, the illness can lead to brain swelling, brain damage, and even death, the CDC says.

One of the most recent cases was an infant too young to be vaccinated who lives 45 miles away from where the outbreak began, the Dayton Daily News reported. That’s the first case in Clark County in more than 20 years. At least 10% of kindergartners’ parents in the region’s elementary schools opted out of vaccines because of religious or moral objections.

“We knew this was coming. It was a matter of when, not if,” Yamini Teegala, MD, chief medical officer at Rocking Horse Community Health Center in Springfield, told the Dayton Daily News.

This is the second measles outbreak this year. Minnesota tallied 22 cases since June in an unrelated outbreak, JAMA reported.

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

The Ohio measles outbreak continues to expand, with cases now totaling 81 – a 37% increase in the course of just 2 weeks.

The lead health official where the outbreak is occurring said the driving force behind the spread is vaccine hesitancy. Most of the children infected were unvaccinated but were old enough to get the measles, mumps, and rubella (MMR) shot, which is 97% effective at preventing measles.

“I think these are individuals who are making a decision not to protect their children against vaccine-preventable diseases, and some of them are making a specific decision not to use the MMR vaccine,” Columbus Public Health Commissioner Mysheika W. Roberts, MD, told JAMA.

She said that parents’ refusal to vaccinate their children was due to a misconception that the vaccine causes autism.

“We’re sounding the alarm that if your child is of age and not vaccinated, they should get vaccinated ASAP,” Dr. Roberts said, noting that she hasn’t seen that happening more.

Health officials have predicted the outbreak, which started in November, will last at least several months. Measles is so contagious that 9 out of 10 unvaccinated people in a room will become infected if exposed.

All of the infections have been in children. According to the Columbus Public Health measles dashboard, of the 81 confirmed cases:

• 29 children have been hospitalized.
• 22 cases are among children under 1 year old.
• No deaths have been reported.

Dr. Roberts said the hospitalized children have had symptoms including dehydration, diarrhea, and pneumonia. Some have had to go to the intensive care unit.

Measles infection causes a rash and a fever that can spike beyond 104° F. Sometimes, the illness can lead to brain swelling, brain damage, and even death, the CDC says.

One of the most recent cases was an infant too young to be vaccinated who lives 45 miles away from where the outbreak began, the Dayton Daily News reported. That’s the first case in Clark County in more than 20 years. At least 10% of kindergartners’ parents in the region’s elementary schools opted out of vaccines because of religious or moral objections.

“We knew this was coming. It was a matter of when, not if,” Yamini Teegala, MD, chief medical officer at Rocking Horse Community Health Center in Springfield, told the Dayton Daily News.

This is the second measles outbreak this year. Minnesota tallied 22 cases since June in an unrelated outbreak, JAMA reported.

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

The Ohio measles outbreak continues to expand, with cases now totaling 81 – a 37% increase in the course of just 2 weeks.

The lead health official where the outbreak is occurring said the driving force behind the spread is vaccine hesitancy. Most of the children infected were unvaccinated but were old enough to get the measles, mumps, and rubella (MMR) shot, which is 97% effective at preventing measles.

“I think these are individuals who are making a decision not to protect their children against vaccine-preventable diseases, and some of them are making a specific decision not to use the MMR vaccine,” Columbus Public Health Commissioner Mysheika W. Roberts, MD, told JAMA.

She said that parents’ refusal to vaccinate their children was due to a misconception that the vaccine causes autism.

“We’re sounding the alarm that if your child is of age and not vaccinated, they should get vaccinated ASAP,” Dr. Roberts said, noting that she hasn’t seen that happening more.

Health officials have predicted the outbreak, which started in November, will last at least several months. Measles is so contagious that 9 out of 10 unvaccinated people in a room will become infected if exposed.

All of the infections have been in children. According to the Columbus Public Health measles dashboard, of the 81 confirmed cases:

• 29 children have been hospitalized.
• 22 cases are among children under 1 year old.
• No deaths have been reported.

Dr. Roberts said the hospitalized children have had symptoms including dehydration, diarrhea, and pneumonia. Some have had to go to the intensive care unit.

Measles infection causes a rash and a fever that can spike beyond 104° F. Sometimes, the illness can lead to brain swelling, brain damage, and even death, the CDC says.

One of the most recent cases was an infant too young to be vaccinated who lives 45 miles away from where the outbreak began, the Dayton Daily News reported. That’s the first case in Clark County in more than 20 years. At least 10% of kindergartners’ parents in the region’s elementary schools opted out of vaccines because of religious or moral objections.

“We knew this was coming. It was a matter of when, not if,” Yamini Teegala, MD, chief medical officer at Rocking Horse Community Health Center in Springfield, told the Dayton Daily News.

This is the second measles outbreak this year. Minnesota tallied 22 cases since June in an unrelated outbreak, JAMA reported.

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