A new scanner can provide three-dimensional (3D) photoacoustic images of millimeter-scale veins and arteries in seconds.

The scanner, developed by researchers at University College London (UCL) in England, could help clinicians better visualize and track microvascular changes for a wide range of diseases, including cancer, rheumatoid arthritis (RA), and peripheral vascular disease (PVD).

In exploratory case studies, researchers demonstrated how the scanner visualized vessels with a corkscrew-like structure in patients with suspected PVD and mapped new blood vessel formation driven by inflammation in patients with RA.

The case studies “illustrate potential areas of application that warrant future, more comprehensive clinical studies,” the authors wrote. “Moreover, they demonstrate the feasibility of using the scanner on a real-world patient cohort where imaging is more challenging due to frailty, comorbidity, or pain that may limit their ability to tolerate prolonged scan times.”

The work was published online in Nature Biomedical Engineering.
 

Improving Photoacoustic Imaging

PAT works using the photoacoustic effect, a phenomenon where sound waves are generated when light is absorbed by a material. When pulsed light from a laser is directed at tissue, some of that light is absorbed and causes an increase in heat in the targeted area. This localized heat also increases pressure, which generates ultrasound waves that can be detected by specialized sensors.

While previous PAT scanners translated these sound waves to electric signals directly to generate imaging, UCL engineers developed a sensor in the early 2000s that can detect these ultrasound waves using light. The result was much clearer, 3D images.

“That was great, but the problem was it was very slow, and it would take 5 minutes to get an image,” explained Paul Beard, PhD, professor of biomedical photoacoustics at UCL and senior author of the study. “That’s fine if you’re imaging a dead mouse or an anesthetized mouse, but not so useful for human imaging,” he continued, where motion would blur the image.

In this new paper, Beard and colleagues outlined how they cut scanning times to an order of seconds (or fraction of a second) rather than minutes. While previous iterations could detect only acoustic waves from one point at a time, this new scanner can detect waves from multiple points simultaneously. The scanner can visualize veins and arteries up to 15 mm deep in human tissue and can also provide dynamic, 3D images of “time-varying tissue perfusion and other hemodynamic events,” the authors wrote.

With these types of scanners, there is always a trade-off between imaging quality and imaging speed, explained Srivalleesha Mallidi, PhD, an assistant professor of biomedical engineering at Tufts University in Medford, Massachusetts. She was not involved with the work.

“With the resolution that [the authors] are providing and the depth at which they are seeing the signals, it is one of the fastest systems,” she said.
 

Clinical Utility

Beard and colleagues also tested the scanner to visualize blood vessels in participants with RA, suspected PVD, and skin inflammation. The scanning images “illustrated how vascular abnormalities such as increased vessel tortuosity, which has previously been linked to PVD, and the neovascularization associated with inflammation can be visualized and quantified,” the authors wrote.

The next step, Beard noted, is testing whether these characteristics can be used as a marker for the progression of disease.

Nehal Mehta, MD, a cardiologist and professor of medicine at the George Washington University, Washington, DC, agreed that more longitudinal research is needed to understand how the abnormalities captured in these images can inform detection and diagnosis of various diseases.

“You don’t know whether these images look bad because of reverse causation — the disease is doing this — or true causation — that this is actually detecting the root cause of the disease,” he explained. “Until we have a bank of normal and abnormal scans, we don’t know what any of these things mean.”

Though still some time away from entering the clinic, Mehta likened the technology to the introduction of optical coherence tomography in the 1980s. Before being adapted for clinical use, researchers first needed to visualize differences between normal coronary vasculature and myocardial infarction.

“I think this is an amazingly strong first proof of concept,” Mehta said. “This technology is showing a true promise in the field imaging.”

The work was funded by grants from Cancer Research UK, the Engineering & Physical Sciences Research Council, Wellcome Trust, the European Research Council, and the National Institute for Health and Care Research University College London Hospitals Biomedical Research Centre. Beard and two coauthors are shareholders of DeepColor Imaging to which the intellectual property associated with the new scanner has been licensed, but the company was not involved in any of this research. Mallidi and Mehta had no relevant disclosures.

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

A new scanner can provide three-dimensional (3D) photoacoustic images of millimeter-scale veins and arteries in seconds.

The scanner, developed by researchers at University College London (UCL) in England, could help clinicians better visualize and track microvascular changes for a wide range of diseases, including cancer, rheumatoid arthritis (RA), and peripheral vascular disease (PVD).

In exploratory case studies, researchers demonstrated how the scanner visualized vessels with a corkscrew-like structure in patients with suspected PVD and mapped new blood vessel formation driven by inflammation in patients with RA.

The case studies “illustrate potential areas of application that warrant future, more comprehensive clinical studies,” the authors wrote. “Moreover, they demonstrate the feasibility of using the scanner on a real-world patient cohort where imaging is more challenging due to frailty, comorbidity, or pain that may limit their ability to tolerate prolonged scan times.”

The work was published online in Nature Biomedical Engineering.
 

Improving Photoacoustic Imaging

PAT works using the photoacoustic effect, a phenomenon where sound waves are generated when light is absorbed by a material. When pulsed light from a laser is directed at tissue, some of that light is absorbed and causes an increase in heat in the targeted area. This localized heat also increases pressure, which generates ultrasound waves that can be detected by specialized sensors.

While previous PAT scanners translated these sound waves to electric signals directly to generate imaging, UCL engineers developed a sensor in the early 2000s that can detect these ultrasound waves using light. The result was much clearer, 3D images.

“That was great, but the problem was it was very slow, and it would take 5 minutes to get an image,” explained Paul Beard, PhD, professor of biomedical photoacoustics at UCL and senior author of the study. “That’s fine if you’re imaging a dead mouse or an anesthetized mouse, but not so useful for human imaging,” he continued, where motion would blur the image.

In this new paper, Beard and colleagues outlined how they cut scanning times to an order of seconds (or fraction of a second) rather than minutes. While previous iterations could detect only acoustic waves from one point at a time, this new scanner can detect waves from multiple points simultaneously. The scanner can visualize veins and arteries up to 15 mm deep in human tissue and can also provide dynamic, 3D images of “time-varying tissue perfusion and other hemodynamic events,” the authors wrote.

With these types of scanners, there is always a trade-off between imaging quality and imaging speed, explained Srivalleesha Mallidi, PhD, an assistant professor of biomedical engineering at Tufts University in Medford, Massachusetts. She was not involved with the work.

“With the resolution that [the authors] are providing and the depth at which they are seeing the signals, it is one of the fastest systems,” she said.
 

Clinical Utility

Beard and colleagues also tested the scanner to visualize blood vessels in participants with RA, suspected PVD, and skin inflammation. The scanning images “illustrated how vascular abnormalities such as increased vessel tortuosity, which has previously been linked to PVD, and the neovascularization associated with inflammation can be visualized and quantified,” the authors wrote.

The next step, Beard noted, is testing whether these characteristics can be used as a marker for the progression of disease.

Nehal Mehta, MD, a cardiologist and professor of medicine at the George Washington University, Washington, DC, agreed that more longitudinal research is needed to understand how the abnormalities captured in these images can inform detection and diagnosis of various diseases.

“You don’t know whether these images look bad because of reverse causation — the disease is doing this — or true causation — that this is actually detecting the root cause of the disease,” he explained. “Until we have a bank of normal and abnormal scans, we don’t know what any of these things mean.”

Though still some time away from entering the clinic, Mehta likened the technology to the introduction of optical coherence tomography in the 1980s. Before being adapted for clinical use, researchers first needed to visualize differences between normal coronary vasculature and myocardial infarction.

“I think this is an amazingly strong first proof of concept,” Mehta said. “This technology is showing a true promise in the field imaging.”

The work was funded by grants from Cancer Research UK, the Engineering & Physical Sciences Research Council, Wellcome Trust, the European Research Council, and the National Institute for Health and Care Research University College London Hospitals Biomedical Research Centre. Beard and two coauthors are shareholders of DeepColor Imaging to which the intellectual property associated with the new scanner has been licensed, but the company was not involved in any of this research. Mallidi and Mehta had no relevant disclosures.

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

A new scanner can provide three-dimensional (3D) photoacoustic images of millimeter-scale veins and arteries in seconds.

The scanner, developed by researchers at University College London (UCL) in England, could help clinicians better visualize and track microvascular changes for a wide range of diseases, including cancer, rheumatoid arthritis (RA), and peripheral vascular disease (PVD).

In exploratory case studies, researchers demonstrated how the scanner visualized vessels with a corkscrew-like structure in patients with suspected PVD and mapped new blood vessel formation driven by inflammation in patients with RA.

The case studies “illustrate potential areas of application that warrant future, more comprehensive clinical studies,” the authors wrote. “Moreover, they demonstrate the feasibility of using the scanner on a real-world patient cohort where imaging is more challenging due to frailty, comorbidity, or pain that may limit their ability to tolerate prolonged scan times.”

The work was published online in Nature Biomedical Engineering.
 

Improving Photoacoustic Imaging

PAT works using the photoacoustic effect, a phenomenon where sound waves are generated when light is absorbed by a material. When pulsed light from a laser is directed at tissue, some of that light is absorbed and causes an increase in heat in the targeted area. This localized heat also increases pressure, which generates ultrasound waves that can be detected by specialized sensors.

While previous PAT scanners translated these sound waves to electric signals directly to generate imaging, UCL engineers developed a sensor in the early 2000s that can detect these ultrasound waves using light. The result was much clearer, 3D images.

“That was great, but the problem was it was very slow, and it would take 5 minutes to get an image,” explained Paul Beard, PhD, professor of biomedical photoacoustics at UCL and senior author of the study. “That’s fine if you’re imaging a dead mouse or an anesthetized mouse, but not so useful for human imaging,” he continued, where motion would blur the image.

In this new paper, Beard and colleagues outlined how they cut scanning times to an order of seconds (or fraction of a second) rather than minutes. While previous iterations could detect only acoustic waves from one point at a time, this new scanner can detect waves from multiple points simultaneously. The scanner can visualize veins and arteries up to 15 mm deep in human tissue and can also provide dynamic, 3D images of “time-varying tissue perfusion and other hemodynamic events,” the authors wrote.

With these types of scanners, there is always a trade-off between imaging quality and imaging speed, explained Srivalleesha Mallidi, PhD, an assistant professor of biomedical engineering at Tufts University in Medford, Massachusetts. She was not involved with the work.

“With the resolution that [the authors] are providing and the depth at which they are seeing the signals, it is one of the fastest systems,” she said.
 

Clinical Utility

Beard and colleagues also tested the scanner to visualize blood vessels in participants with RA, suspected PVD, and skin inflammation. The scanning images “illustrated how vascular abnormalities such as increased vessel tortuosity, which has previously been linked to PVD, and the neovascularization associated with inflammation can be visualized and quantified,” the authors wrote.

The next step, Beard noted, is testing whether these characteristics can be used as a marker for the progression of disease.

Nehal Mehta, MD, a cardiologist and professor of medicine at the George Washington University, Washington, DC, agreed that more longitudinal research is needed to understand how the abnormalities captured in these images can inform detection and diagnosis of various diseases.

“You don’t know whether these images look bad because of reverse causation — the disease is doing this — or true causation — that this is actually detecting the root cause of the disease,” he explained. “Until we have a bank of normal and abnormal scans, we don’t know what any of these things mean.”

Though still some time away from entering the clinic, Mehta likened the technology to the introduction of optical coherence tomography in the 1980s. Before being adapted for clinical use, researchers first needed to visualize differences between normal coronary vasculature and myocardial infarction.

“I think this is an amazingly strong first proof of concept,” Mehta said. “This technology is showing a true promise in the field imaging.”

The work was funded by grants from Cancer Research UK, the Engineering & Physical Sciences Research Council, Wellcome Trust, the European Research Council, and the National Institute for Health and Care Research University College London Hospitals Biomedical Research Centre. Beard and two coauthors are shareholders of DeepColor Imaging to which the intellectual property associated with the new scanner has been licensed, but the company was not involved in any of this research. Mallidi and Mehta had no relevant disclosures.

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

TOPLINE:

Cancer survivors who had overweight or obesity at the time of their initial cancer diagnosis have a higher risk for a second primary cancer, particularly an obesity-related cancer, a new analysis found.

METHODOLOGY:

• Cancer survivors have an increased risk for another primary cancer. Studies suggest that lifestyle factors, such as excess body weight, may contribute to the risk for a second cancer; however, prospective long-term data on this association remain limited.
• Researchers evaluated 26,894 participants (mean age at first cancer diagnosis, 72.2 years; 97.6% White) from the Cancer Prevention Study II Nutrition cohort, who were diagnosed with a first nonmetastatic primary cancer between 1992 and 2015.
• Body mass index (BMI) was calculated from self-reported data at the time of the first primary cancer diagnosis; 10,713 participants had a normal BMI (18.5 to < 25.0), 11,497 had overweight (25.0 to < 30.0), and 4684 had obesity (≥ 30.0). Participants were followed through 2017.
• The study outcomes were the incidences of any second primary cancer and obesity-related second cancers.
• The most common first primary cancers were prostate (35.0%), breast (19.1%), and colorectal (9.5%) cancers; almost 40% of all first primary cancers were related to obesity.

TAKEAWAY:

• Overall, 13.9% participants (3749 of 26,894) were diagnosed with a second cancer over a median of 7.9 years; 33.2% of these cancers were related to obesity.
• Compared with participants with a normal BMI, those who had overweight had a 15% higher risk for any second cancer (adjusted hazard ratio [aHR], 1.15) and a 40% higher risk for an obesity-related second cancer (aHR, 1.40). Additionally, those with obesity had a 34% higher risk for any second cancer and a 78% higher risk for an obesity-related second cancer.
• For every 5-unit increase in BMI, the risk for an obesity-related cancer (aHR, 1.28) was considerably higher than the risk for any second cancer (aHR, 1.13).
• Among all survivors, every 5-unit increase in BMI was associated with a 42% increased risk for colorectal cancer as a second cancer (aHR, 1.42) and a 70% higher risk for kidney cancer as a second cancer (aHR, 1.70).

IN PRACTICE:

“In this cohort study of older survivors of nonmetastatic cancer, those who had overweight or obesity at the time of their first cancer diagnosis were at higher risk of developing a second cancer, especially obesity-related cancers,” the authors wrote. “These findings have important public health implications and may inform evidence-based survivorship guidelines to reduce the risk of second primary cancers among cancer survivors.”

SOURCE:

This study, led by Clara Bodelon, PhD, MS, American Cancer Society, Atlanta, was published online in JAMA Network Open.

LIMITATIONS:

The exclusion of multiple primary cancers in the same site could have underestimated the magnitude of the association of excess body weight with the risk for second primary cancers. BMI was used as a measure of excess body fat in this study, which does not differentiate between fat and lean mass. Unmeasured or residual confounding factors might be present.

DISCLOSURES:

The study was supported by grants from the Centers for Disease Control and Prevention’s National Program of Cancer Registries and cancer registries supported by the National Cancer Institute’s Surveillance, Epidemiology, and End Results Program. No relevant conflicts of interest were disclosed by the authors.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article first appeared on Medscape.com.

TOPLINE:

Cancer survivors who had overweight or obesity at the time of their initial cancer diagnosis have a higher risk for a second primary cancer, particularly an obesity-related cancer, a new analysis found.

METHODOLOGY:

• Cancer survivors have an increased risk for another primary cancer. Studies suggest that lifestyle factors, such as excess body weight, may contribute to the risk for a second cancer; however, prospective long-term data on this association remain limited.
• Researchers evaluated 26,894 participants (mean age at first cancer diagnosis, 72.2 years; 97.6% White) from the Cancer Prevention Study II Nutrition cohort, who were diagnosed with a first nonmetastatic primary cancer between 1992 and 2015.
• Body mass index (BMI) was calculated from self-reported data at the time of the first primary cancer diagnosis; 10,713 participants had a normal BMI (18.5 to < 25.0), 11,497 had overweight (25.0 to < 30.0), and 4684 had obesity (≥ 30.0). Participants were followed through 2017.
• The study outcomes were the incidences of any second primary cancer and obesity-related second cancers.
• The most common first primary cancers were prostate (35.0%), breast (19.1%), and colorectal (9.5%) cancers; almost 40% of all first primary cancers were related to obesity.

TAKEAWAY:

• Overall, 13.9% participants (3749 of 26,894) were diagnosed with a second cancer over a median of 7.9 years; 33.2% of these cancers were related to obesity.
• Compared with participants with a normal BMI, those who had overweight had a 15% higher risk for any second cancer (adjusted hazard ratio [aHR], 1.15) and a 40% higher risk for an obesity-related second cancer (aHR, 1.40). Additionally, those with obesity had a 34% higher risk for any second cancer and a 78% higher risk for an obesity-related second cancer.
• For every 5-unit increase in BMI, the risk for an obesity-related cancer (aHR, 1.28) was considerably higher than the risk for any second cancer (aHR, 1.13).
• Among all survivors, every 5-unit increase in BMI was associated with a 42% increased risk for colorectal cancer as a second cancer (aHR, 1.42) and a 70% higher risk for kidney cancer as a second cancer (aHR, 1.70).

IN PRACTICE:

“In this cohort study of older survivors of nonmetastatic cancer, those who had overweight or obesity at the time of their first cancer diagnosis were at higher risk of developing a second cancer, especially obesity-related cancers,” the authors wrote. “These findings have important public health implications and may inform evidence-based survivorship guidelines to reduce the risk of second primary cancers among cancer survivors.”

SOURCE:

This study, led by Clara Bodelon, PhD, MS, American Cancer Society, Atlanta, was published online in JAMA Network Open.

LIMITATIONS:

The exclusion of multiple primary cancers in the same site could have underestimated the magnitude of the association of excess body weight with the risk for second primary cancers. BMI was used as a measure of excess body fat in this study, which does not differentiate between fat and lean mass. Unmeasured or residual confounding factors might be present.

DISCLOSURES:

The study was supported by grants from the Centers for Disease Control and Prevention’s National Program of Cancer Registries and cancer registries supported by the National Cancer Institute’s Surveillance, Epidemiology, and End Results Program. No relevant conflicts of interest were disclosed by the authors.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article first appeared on Medscape.com.

TOPLINE:

Cancer survivors who had overweight or obesity at the time of their initial cancer diagnosis have a higher risk for a second primary cancer, particularly an obesity-related cancer, a new analysis found.

METHODOLOGY:

• Cancer survivors have an increased risk for another primary cancer. Studies suggest that lifestyle factors, such as excess body weight, may contribute to the risk for a second cancer; however, prospective long-term data on this association remain limited.
• Researchers evaluated 26,894 participants (mean age at first cancer diagnosis, 72.2 years; 97.6% White) from the Cancer Prevention Study II Nutrition cohort, who were diagnosed with a first nonmetastatic primary cancer between 1992 and 2015.
• Body mass index (BMI) was calculated from self-reported data at the time of the first primary cancer diagnosis; 10,713 participants had a normal BMI (18.5 to < 25.0), 11,497 had overweight (25.0 to < 30.0), and 4684 had obesity (≥ 30.0). Participants were followed through 2017.
• The study outcomes were the incidences of any second primary cancer and obesity-related second cancers.
• The most common first primary cancers were prostate (35.0%), breast (19.1%), and colorectal (9.5%) cancers; almost 40% of all first primary cancers were related to obesity.

TAKEAWAY:

• Overall, 13.9% participants (3749 of 26,894) were diagnosed with a second cancer over a median of 7.9 years; 33.2% of these cancers were related to obesity.
• Compared with participants with a normal BMI, those who had overweight had a 15% higher risk for any second cancer (adjusted hazard ratio [aHR], 1.15) and a 40% higher risk for an obesity-related second cancer (aHR, 1.40). Additionally, those with obesity had a 34% higher risk for any second cancer and a 78% higher risk for an obesity-related second cancer.
• For every 5-unit increase in BMI, the risk for an obesity-related cancer (aHR, 1.28) was considerably higher than the risk for any second cancer (aHR, 1.13).
• Among all survivors, every 5-unit increase in BMI was associated with a 42% increased risk for colorectal cancer as a second cancer (aHR, 1.42) and a 70% higher risk for kidney cancer as a second cancer (aHR, 1.70).

IN PRACTICE:

“In this cohort study of older survivors of nonmetastatic cancer, those who had overweight or obesity at the time of their first cancer diagnosis were at higher risk of developing a second cancer, especially obesity-related cancers,” the authors wrote. “These findings have important public health implications and may inform evidence-based survivorship guidelines to reduce the risk of second primary cancers among cancer survivors.”

SOURCE:

This study, led by Clara Bodelon, PhD, MS, American Cancer Society, Atlanta, was published online in JAMA Network Open.

LIMITATIONS:

The exclusion of multiple primary cancers in the same site could have underestimated the magnitude of the association of excess body weight with the risk for second primary cancers. BMI was used as a measure of excess body fat in this study, which does not differentiate between fat and lean mass. Unmeasured or residual confounding factors might be present.

DISCLOSURES:

The study was supported by grants from the Centers for Disease Control and Prevention’s National Program of Cancer Registries and cancer registries supported by the National Cancer Institute’s Surveillance, Epidemiology, and End Results Program. No relevant conflicts of interest were disclosed by the authors.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article first appeared on Medscape.com.

A first stroke in older adults is associated with substantial immediate and accelerated long-term cognitive decline, suggested a new study that underscores the need for continuous cognitive monitoring in this patient population.

Results from the study, which included 14 international cohorts of older adults, showed that stroke was associated with a significant acute decline in global cognition and a small, but significant, acceleration in the rate of cognitive decline over time.

Cognitive assessments in primary care are “crucial, especially since cognitive impairment is frequently missed or undiagnosed in hospitals,” lead author Jessica Lo, MSc, biostatistician and research associate with the Center for Healthy Brain Aging, University of New South Wales, Sydney, Australia, told this news organization.

She suggested clinicians incorporate long-term cognitive assessments into care plans, using more sensitive neuropsychological tests in primary care to detect early signs of cognitive impairment. “Early detection would enable timely interventions to improve outcomes,” Lo said.

She also noted that poststroke care typically includes physical rehabilitation but not cognitive rehabilitation, which many rehabilitation centers aren’t equipped to provide.

The study was published online in JAMA Network Open.
 

Mapping Cognitive Decline Trajectory

Cognitive impairment after stroke is common, but the trajectory of cognitive decline following a first stroke, relative to prestroke cognitive function, remains unclear.

The investigators leveraged data from 14 population-based cohort studies of 20,860 adults (mean age, 73 years; 59% women) to map the trajectory of cognitive function before and after a first stroke.

The primary outcome was global cognition, defined as the standardized average of four cognitive domains (language, memory, processing speed, and executive function).

During a mean follow-up of 7.5 years, 1041 (5%) adults (mean age, 79 years) experienced a first stroke, a mean of 4.5 years after study entry.

In adjusted analyses, stroke was associated with a significant acute decline of 0.25 SD in global cognition and a “small but significant” acceleration in the rate of decline of −0.038 SD per year, the authors reported.

Stroke was also associated with acute decline in all individual cognitive domains except for memory, with effect sizes ranging from −0.17 to −0.22 SD. Poststroke declines in Mini-Mental State Examination scores (−0.36 SD) were also noted.

In terms of cognitive trajectory, the rate of decline before stroke in survivors was similar to that seen in peers who didn’t have a stroke (−0.048 and −0.049 SD per year in global cognition, respectively).

The researchers did not identify any vascular risk factors moderating cognitive decline following a stroke, consistent with prior research. However, cognitive decline was significantly more rapid in individuals without stroke, regardless of any future stroke, who had a history of diabetes, hypertension, high cholesterol, cardiovascular disease, depression, smoking, or were APOE4 carriers.

“Targeting modifiable vascular risk factors at an early stage may reduce the risk of stroke but also subsequent risk of stroke-related cognitive decline and cognitive impairment,” the researchers noted.
 

A ‘Major Step’ in the Right Direction

As previously reported by this news organization, in 2023 the American Heart Association (AHA) issued a statement noting that screening for cognitive impairment should be part of multidisciplinary care for stroke survivors.

Commenting for this news organization, Mitchell Elkind, MD, MS, AHA chief clinical science officer, said these new data are consistent with current AHA guidelines and statements that “support screening for cognitive and functional decline in patients both acutely and over the long term after stroke.”

Elkind noted that the 2022 guideline for intracerebral hemorrhage states that cognitive screening should occur “across the continuum of inpatient care and at intervals in the outpatient setting” and provides recommendations for cognitive therapy.

“Our 2021 scientific statement on the primary care of patients after stroke also recommends screening for both depression and cognitive impairment over both the short- and long-term,” said Elkind, professor of neurology and epidemiology at Columbia University Irving Medical Center in New York City.

“These documents recognize the fact that function and cognition can continue to decline years after stroke and that patients’ rehabilitation and support needs may therefore change over time after stroke,” Elkind added.

The authors of an accompanying commentary called it a “major step” in the right direction for the future of long-term stroke outcome assessment.

“As we develop new devices, indications, and time windows for stroke treatment, it may perhaps be wise to ensure trials steer away from simpler outcomes to more complex, granular ones,” wrote Yasmin Sadigh, MSc, and Victor Volovici, MD, PhD, with Erasmus University Medical Center, Rotterdam, the Netherlands.

The study had no commercial funding. The authors and commentary writers and Elkind have declared no conflicts of interest.

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

A first stroke in older adults is associated with substantial immediate and accelerated long-term cognitive decline, suggested a new study that underscores the need for continuous cognitive monitoring in this patient population.

Results from the study, which included 14 international cohorts of older adults, showed that stroke was associated with a significant acute decline in global cognition and a small, but significant, acceleration in the rate of cognitive decline over time.

Cognitive assessments in primary care are “crucial, especially since cognitive impairment is frequently missed or undiagnosed in hospitals,” lead author Jessica Lo, MSc, biostatistician and research associate with the Center for Healthy Brain Aging, University of New South Wales, Sydney, Australia, told this news organization.

She suggested clinicians incorporate long-term cognitive assessments into care plans, using more sensitive neuropsychological tests in primary care to detect early signs of cognitive impairment. “Early detection would enable timely interventions to improve outcomes,” Lo said.

She also noted that poststroke care typically includes physical rehabilitation but not cognitive rehabilitation, which many rehabilitation centers aren’t equipped to provide.

The study was published online in JAMA Network Open.
 

Mapping Cognitive Decline Trajectory

Cognitive impairment after stroke is common, but the trajectory of cognitive decline following a first stroke, relative to prestroke cognitive function, remains unclear.

The investigators leveraged data from 14 population-based cohort studies of 20,860 adults (mean age, 73 years; 59% women) to map the trajectory of cognitive function before and after a first stroke.

The primary outcome was global cognition, defined as the standardized average of four cognitive domains (language, memory, processing speed, and executive function).

During a mean follow-up of 7.5 years, 1041 (5%) adults (mean age, 79 years) experienced a first stroke, a mean of 4.5 years after study entry.

In adjusted analyses, stroke was associated with a significant acute decline of 0.25 SD in global cognition and a “small but significant” acceleration in the rate of decline of −0.038 SD per year, the authors reported.

Stroke was also associated with acute decline in all individual cognitive domains except for memory, with effect sizes ranging from −0.17 to −0.22 SD. Poststroke declines in Mini-Mental State Examination scores (−0.36 SD) were also noted.

In terms of cognitive trajectory, the rate of decline before stroke in survivors was similar to that seen in peers who didn’t have a stroke (−0.048 and −0.049 SD per year in global cognition, respectively).

The researchers did not identify any vascular risk factors moderating cognitive decline following a stroke, consistent with prior research. However, cognitive decline was significantly more rapid in individuals without stroke, regardless of any future stroke, who had a history of diabetes, hypertension, high cholesterol, cardiovascular disease, depression, smoking, or were APOE4 carriers.

“Targeting modifiable vascular risk factors at an early stage may reduce the risk of stroke but also subsequent risk of stroke-related cognitive decline and cognitive impairment,” the researchers noted.
 

A ‘Major Step’ in the Right Direction

As previously reported by this news organization, in 2023 the American Heart Association (AHA) issued a statement noting that screening for cognitive impairment should be part of multidisciplinary care for stroke survivors.

Commenting for this news organization, Mitchell Elkind, MD, MS, AHA chief clinical science officer, said these new data are consistent with current AHA guidelines and statements that “support screening for cognitive and functional decline in patients both acutely and over the long term after stroke.”

Elkind noted that the 2022 guideline for intracerebral hemorrhage states that cognitive screening should occur “across the continuum of inpatient care and at intervals in the outpatient setting” and provides recommendations for cognitive therapy.

“Our 2021 scientific statement on the primary care of patients after stroke also recommends screening for both depression and cognitive impairment over both the short- and long-term,” said Elkind, professor of neurology and epidemiology at Columbia University Irving Medical Center in New York City.

“These documents recognize the fact that function and cognition can continue to decline years after stroke and that patients’ rehabilitation and support needs may therefore change over time after stroke,” Elkind added.

The authors of an accompanying commentary called it a “major step” in the right direction for the future of long-term stroke outcome assessment.

“As we develop new devices, indications, and time windows for stroke treatment, it may perhaps be wise to ensure trials steer away from simpler outcomes to more complex, granular ones,” wrote Yasmin Sadigh, MSc, and Victor Volovici, MD, PhD, with Erasmus University Medical Center, Rotterdam, the Netherlands.

The study had no commercial funding. The authors and commentary writers and Elkind have declared no conflicts of interest.

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

A first stroke in older adults is associated with substantial immediate and accelerated long-term cognitive decline, suggested a new study that underscores the need for continuous cognitive monitoring in this patient population.

Results from the study, which included 14 international cohorts of older adults, showed that stroke was associated with a significant acute decline in global cognition and a small, but significant, acceleration in the rate of cognitive decline over time.

Cognitive assessments in primary care are “crucial, especially since cognitive impairment is frequently missed or undiagnosed in hospitals,” lead author Jessica Lo, MSc, biostatistician and research associate with the Center for Healthy Brain Aging, University of New South Wales, Sydney, Australia, told this news organization.

She suggested clinicians incorporate long-term cognitive assessments into care plans, using more sensitive neuropsychological tests in primary care to detect early signs of cognitive impairment. “Early detection would enable timely interventions to improve outcomes,” Lo said.

She also noted that poststroke care typically includes physical rehabilitation but not cognitive rehabilitation, which many rehabilitation centers aren’t equipped to provide.

The study was published online in JAMA Network Open.
 

Mapping Cognitive Decline Trajectory

Cognitive impairment after stroke is common, but the trajectory of cognitive decline following a first stroke, relative to prestroke cognitive function, remains unclear.

The investigators leveraged data from 14 population-based cohort studies of 20,860 adults (mean age, 73 years; 59% women) to map the trajectory of cognitive function before and after a first stroke.

The primary outcome was global cognition, defined as the standardized average of four cognitive domains (language, memory, processing speed, and executive function).

During a mean follow-up of 7.5 years, 1041 (5%) adults (mean age, 79 years) experienced a first stroke, a mean of 4.5 years after study entry.

In adjusted analyses, stroke was associated with a significant acute decline of 0.25 SD in global cognition and a “small but significant” acceleration in the rate of decline of −0.038 SD per year, the authors reported.

Stroke was also associated with acute decline in all individual cognitive domains except for memory, with effect sizes ranging from −0.17 to −0.22 SD. Poststroke declines in Mini-Mental State Examination scores (−0.36 SD) were also noted.

In terms of cognitive trajectory, the rate of decline before stroke in survivors was similar to that seen in peers who didn’t have a stroke (−0.048 and −0.049 SD per year in global cognition, respectively).

The researchers did not identify any vascular risk factors moderating cognitive decline following a stroke, consistent with prior research. However, cognitive decline was significantly more rapid in individuals without stroke, regardless of any future stroke, who had a history of diabetes, hypertension, high cholesterol, cardiovascular disease, depression, smoking, or were APOE4 carriers.

“Targeting modifiable vascular risk factors at an early stage may reduce the risk of stroke but also subsequent risk of stroke-related cognitive decline and cognitive impairment,” the researchers noted.
 

A ‘Major Step’ in the Right Direction

As previously reported by this news organization, in 2023 the American Heart Association (AHA) issued a statement noting that screening for cognitive impairment should be part of multidisciplinary care for stroke survivors.

Commenting for this news organization, Mitchell Elkind, MD, MS, AHA chief clinical science officer, said these new data are consistent with current AHA guidelines and statements that “support screening for cognitive and functional decline in patients both acutely and over the long term after stroke.”

Elkind noted that the 2022 guideline for intracerebral hemorrhage states that cognitive screening should occur “across the continuum of inpatient care and at intervals in the outpatient setting” and provides recommendations for cognitive therapy.

“Our 2021 scientific statement on the primary care of patients after stroke also recommends screening for both depression and cognitive impairment over both the short- and long-term,” said Elkind, professor of neurology and epidemiology at Columbia University Irving Medical Center in New York City.

“These documents recognize the fact that function and cognition can continue to decline years after stroke and that patients’ rehabilitation and support needs may therefore change over time after stroke,” Elkind added.

The authors of an accompanying commentary called it a “major step” in the right direction for the future of long-term stroke outcome assessment.

“As we develop new devices, indications, and time windows for stroke treatment, it may perhaps be wise to ensure trials steer away from simpler outcomes to more complex, granular ones,” wrote Yasmin Sadigh, MSc, and Victor Volovici, MD, PhD, with Erasmus University Medical Center, Rotterdam, the Netherlands.

The study had no commercial funding. The authors and commentary writers and Elkind have declared no conflicts of interest.

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

TOPLINE:

Maternal serum folate levels during early to midpregnancy show a U-shaped association with congenital heart disease (CHD) risk in offspring. Both low and high folate levels are linked to an increased risk, with vitamin B12 deficiency and elevated homocysteine levels further exacerbating this risk.

METHODOLOGY:

• Researchers conducted a case-control study with 129 participants with CHD and 516 matched control participants from Guangdong Provincial People’s Hospital in China between 2015 and 2018.
• Maternal serum levels of folate, vitamin B12, and homocysteine were measured at around 16 weeks of gestation using a chemiluminescence microparticle immunoassay.
• CHD was confirmed using echocardiography, and the participants were matched by maternal age at a ratio of 1:4.
• Covariates included periconceptional folic acid supplementation, maternal education, occupation, parity, abortion history, pregnancy complications, and genetic polymorphisms related to folate metabolism.
• Conditional logistic regression was used to assess the associations, with adjustments for various covariates and sensitivity analyses excluding participants with missing genetic data.

TAKEAWAY:

• A U-shaped association was found between maternal serum folate levels and CHD risk in offspring, with both low and high levels linked to increased risk (P < .001).
• Low maternal folate levels were associated with an adjusted odds ratio (aOR) of 3.09 (95% CI, 1.88-5.08) for CHD risk, whereas high levels had an aOR of 1.81 (95% CI, 1.07-3.06).
• Using World Health Organization criteria, folate deficiency (< 5.9 ng/mL) had an aOR of 18.97 (95% CI, 3.87-93.11) and elevated levels (> 20 ng/mL) had an aOR of 5.71 (95% CI, 2.72-11.98) for CHD risk.
• Vitamin B12 deficiency and elevated homocysteine levels further increased the risk associated with both low and high maternal folate levels.

IN PRACTICE:

“Insufficient folate and vitamin B12 can lead to increased homocysteine levels, which is harmful to the cardiovascular system. Thus, homocysteine might act as a central mediator in the relationships between deficiencies in folate and vitamin B12 and the risk of CHD. Additionally, the role of folate extends beyond homocysteine mediation, contributing independently to placental implantation and vascular remodeling, irrespective of vitamin B12 and homocysteine levels,” the authors wrote.

SOURCE:

The study was led by Yanji Qu, PhD, and Jie Li, PhD, Global Health Research Center, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Southern Medical University, Guangzhou, China. It was published online in JAMA Network Open.

LIMITATIONS:

The study’s limitations included the measurement of maternal serum folate levels at a single time point, which may not reflect preconception and early postconception periods. The study’s findings may not be generalizable to other populations as participants were recruited from a single cardiac referral center in Southern China. Additionally, the lack of dietary intake data limited the ability to account for related biases. The sample size, while relatively large for CHD research, may lack sufficient power for stratified analyses.

DISCLOSURES:

One coauthor reported receiving personal fees from Guangdong Cardiovascular Institute outside the submitted work. Additional disclosures are noted in the original article.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article first appeared on Medscape.com.

TOPLINE:

Maternal serum folate levels during early to midpregnancy show a U-shaped association with congenital heart disease (CHD) risk in offspring. Both low and high folate levels are linked to an increased risk, with vitamin B12 deficiency and elevated homocysteine levels further exacerbating this risk.

METHODOLOGY:

• Researchers conducted a case-control study with 129 participants with CHD and 516 matched control participants from Guangdong Provincial People’s Hospital in China between 2015 and 2018.
• Maternal serum levels of folate, vitamin B12, and homocysteine were measured at around 16 weeks of gestation using a chemiluminescence microparticle immunoassay.
• CHD was confirmed using echocardiography, and the participants were matched by maternal age at a ratio of 1:4.
• Covariates included periconceptional folic acid supplementation, maternal education, occupation, parity, abortion history, pregnancy complications, and genetic polymorphisms related to folate metabolism.
• Conditional logistic regression was used to assess the associations, with adjustments for various covariates and sensitivity analyses excluding participants with missing genetic data.

TAKEAWAY:

• A U-shaped association was found between maternal serum folate levels and CHD risk in offspring, with both low and high levels linked to increased risk (P < .001).
• Low maternal folate levels were associated with an adjusted odds ratio (aOR) of 3.09 (95% CI, 1.88-5.08) for CHD risk, whereas high levels had an aOR of 1.81 (95% CI, 1.07-3.06).
• Using World Health Organization criteria, folate deficiency (< 5.9 ng/mL) had an aOR of 18.97 (95% CI, 3.87-93.11) and elevated levels (> 20 ng/mL) had an aOR of 5.71 (95% CI, 2.72-11.98) for CHD risk.
• Vitamin B12 deficiency and elevated homocysteine levels further increased the risk associated with both low and high maternal folate levels.

IN PRACTICE:

“Insufficient folate and vitamin B12 can lead to increased homocysteine levels, which is harmful to the cardiovascular system. Thus, homocysteine might act as a central mediator in the relationships between deficiencies in folate and vitamin B12 and the risk of CHD. Additionally, the role of folate extends beyond homocysteine mediation, contributing independently to placental implantation and vascular remodeling, irrespective of vitamin B12 and homocysteine levels,” the authors wrote.

SOURCE:

The study was led by Yanji Qu, PhD, and Jie Li, PhD, Global Health Research Center, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Southern Medical University, Guangzhou, China. It was published online in JAMA Network Open.

LIMITATIONS:

The study’s limitations included the measurement of maternal serum folate levels at a single time point, which may not reflect preconception and early postconception periods. The study’s findings may not be generalizable to other populations as participants were recruited from a single cardiac referral center in Southern China. Additionally, the lack of dietary intake data limited the ability to account for related biases. The sample size, while relatively large for CHD research, may lack sufficient power for stratified analyses.

DISCLOSURES:

One coauthor reported receiving personal fees from Guangdong Cardiovascular Institute outside the submitted work. Additional disclosures are noted in the original article.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article first appeared on Medscape.com.

TOPLINE:

Maternal serum folate levels during early to midpregnancy show a U-shaped association with congenital heart disease (CHD) risk in offspring. Both low and high folate levels are linked to an increased risk, with vitamin B12 deficiency and elevated homocysteine levels further exacerbating this risk.

METHODOLOGY:

• Researchers conducted a case-control study with 129 participants with CHD and 516 matched control participants from Guangdong Provincial People’s Hospital in China between 2015 and 2018.
• Maternal serum levels of folate, vitamin B12, and homocysteine were measured at around 16 weeks of gestation using a chemiluminescence microparticle immunoassay.
• CHD was confirmed using echocardiography, and the participants were matched by maternal age at a ratio of 1:4.
• Covariates included periconceptional folic acid supplementation, maternal education, occupation, parity, abortion history, pregnancy complications, and genetic polymorphisms related to folate metabolism.
• Conditional logistic regression was used to assess the associations, with adjustments for various covariates and sensitivity analyses excluding participants with missing genetic data.

TAKEAWAY:

• A U-shaped association was found between maternal serum folate levels and CHD risk in offspring, with both low and high levels linked to increased risk (P < .001).
• Low maternal folate levels were associated with an adjusted odds ratio (aOR) of 3.09 (95% CI, 1.88-5.08) for CHD risk, whereas high levels had an aOR of 1.81 (95% CI, 1.07-3.06).
• Using World Health Organization criteria, folate deficiency (< 5.9 ng/mL) had an aOR of 18.97 (95% CI, 3.87-93.11) and elevated levels (> 20 ng/mL) had an aOR of 5.71 (95% CI, 2.72-11.98) for CHD risk.
• Vitamin B12 deficiency and elevated homocysteine levels further increased the risk associated with both low and high maternal folate levels.

IN PRACTICE:

“Insufficient folate and vitamin B12 can lead to increased homocysteine levels, which is harmful to the cardiovascular system. Thus, homocysteine might act as a central mediator in the relationships between deficiencies in folate and vitamin B12 and the risk of CHD. Additionally, the role of folate extends beyond homocysteine mediation, contributing independently to placental implantation and vascular remodeling, irrespective of vitamin B12 and homocysteine levels,” the authors wrote.

SOURCE:

The study was led by Yanji Qu, PhD, and Jie Li, PhD, Global Health Research Center, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Southern Medical University, Guangzhou, China. It was published online in JAMA Network Open.

LIMITATIONS:

The study’s limitations included the measurement of maternal serum folate levels at a single time point, which may not reflect preconception and early postconception periods. The study’s findings may not be generalizable to other populations as participants were recruited from a single cardiac referral center in Southern China. Additionally, the lack of dietary intake data limited the ability to account for related biases. The sample size, while relatively large for CHD research, may lack sufficient power for stratified analyses.

DISCLOSURES:

One coauthor reported receiving personal fees from Guangdong Cardiovascular Institute outside the submitted work. Additional disclosures are noted in the original article.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article first appeared on Medscape.com.

TOPLINE:

Fluconazole resistance in yeast isolates from women with recurrent vulvovaginal candidiasis in Leeds, England, increased from 3.5% to 9.6% over 3 years. Non–Candida albicans yeasts also rose from 6.0% to 12.6% during the same period.

METHODOLOGY:

• Researchers conducted a retrospective data search of vaginal cultures from adult women in Leeds, England, between April 2018 and March 2021.
• A total of 5461 vaginal samples from women with clinical information indicating complicated/recurrent vulvovaginal candidiasis were included.
• Samples were processed on the WASPLAB automated platform, and species identification and antifungal susceptibility testing were performed in the Mycology Reference Centre by Matrix-assisted laser desorption ionization–time-of-flight mass spectrometry.
• Susceptibility to fluconazole was determined using disc diffusion and the Sensititre YeastOne microbroth dilution assay.
•  

TAKEAWAY:

According to the authors, the prevalence of non–C albicans yeasts increased from 6.0% in 2018-2019 to 12.6% in 2020-2021 (P = .0003).

Fluconazole-sensitive (dose-dependent) and fluconazole-resistant isolates increased from 3.5% in 2018-2019 to 9.6% in 2020-2021 (P = .0001).

Most fluconazole resistance was observed in C albicans, with other species such as Nakaseomyces glabrata and Pichia kudriavzevii also showing resistance.

The authors state that the increase in fluconazole resistance and non–C albicans yeasts may be linked to a policy change encouraging empirical treatment of vulvovaginal candidiasis in primary care.

IN PRACTICE:

“This study shows that the rates of non–Candida albicans and fluconazole-resistant C albicans have increased year on year in the 3 years studied. The exact reasons for this increase remain unclear, but it follows the introduction of restricted access to fungal cultures for the diagnosis of vulvovaginal candidiasis by those working in primary care. A clinical diagnosis, followed by empirical treatment, has been recommended instead. Consequently, we believe this policy of encouraging empirical vaginitis treatment based on nonspecific symptoms and signs needs revisiting,” the authors wrote.

SOURCE:

The study was led by Jennifer C. Ratner, Leeds Teaching Hospitals NHS Trust, England. It was published online in Sexually Transmitted Infections.

LIMITATIONS:

The study’s limitations included a potential bias introduced by the reduced number of samples received from specialist sexual health clinics during the COVID-19 pandemic. Additionally, the study could not distinguish between cases of recurrent vulvovaginal candidiasis with complete resolution of symptoms and those with persistent symptoms despite treatment.

DISCLOSURES:

One coauthor disclosed receiving fees from Pfizer for contributing to webinar presentations in 2023. Additional disclosures are noted in the original article.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article first appeared on Medscape.com.

TOPLINE:

Fluconazole resistance in yeast isolates from women with recurrent vulvovaginal candidiasis in Leeds, England, increased from 3.5% to 9.6% over 3 years. Non–Candida albicans yeasts also rose from 6.0% to 12.6% during the same period.

METHODOLOGY:

• Researchers conducted a retrospective data search of vaginal cultures from adult women in Leeds, England, between April 2018 and March 2021.
• A total of 5461 vaginal samples from women with clinical information indicating complicated/recurrent vulvovaginal candidiasis were included.
• Samples were processed on the WASPLAB automated platform, and species identification and antifungal susceptibility testing were performed in the Mycology Reference Centre by Matrix-assisted laser desorption ionization–time-of-flight mass spectrometry.
• Susceptibility to fluconazole was determined using disc diffusion and the Sensititre YeastOne microbroth dilution assay.
•  

TAKEAWAY:

According to the authors, the prevalence of non–C albicans yeasts increased from 6.0% in 2018-2019 to 12.6% in 2020-2021 (P = .0003).

Fluconazole-sensitive (dose-dependent) and fluconazole-resistant isolates increased from 3.5% in 2018-2019 to 9.6% in 2020-2021 (P = .0001).

Most fluconazole resistance was observed in C albicans, with other species such as Nakaseomyces glabrata and Pichia kudriavzevii also showing resistance.

The authors state that the increase in fluconazole resistance and non–C albicans yeasts may be linked to a policy change encouraging empirical treatment of vulvovaginal candidiasis in primary care.

IN PRACTICE:

“This study shows that the rates of non–Candida albicans and fluconazole-resistant C albicans have increased year on year in the 3 years studied. The exact reasons for this increase remain unclear, but it follows the introduction of restricted access to fungal cultures for the diagnosis of vulvovaginal candidiasis by those working in primary care. A clinical diagnosis, followed by empirical treatment, has been recommended instead. Consequently, we believe this policy of encouraging empirical vaginitis treatment based on nonspecific symptoms and signs needs revisiting,” the authors wrote.

SOURCE:

The study was led by Jennifer C. Ratner, Leeds Teaching Hospitals NHS Trust, England. It was published online in Sexually Transmitted Infections.

LIMITATIONS:

The study’s limitations included a potential bias introduced by the reduced number of samples received from specialist sexual health clinics during the COVID-19 pandemic. Additionally, the study could not distinguish between cases of recurrent vulvovaginal candidiasis with complete resolution of symptoms and those with persistent symptoms despite treatment.

DISCLOSURES:

One coauthor disclosed receiving fees from Pfizer for contributing to webinar presentations in 2023. Additional disclosures are noted in the original article.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article first appeared on Medscape.com.

TOPLINE:

Fluconazole resistance in yeast isolates from women with recurrent vulvovaginal candidiasis in Leeds, England, increased from 3.5% to 9.6% over 3 years. Non–Candida albicans yeasts also rose from 6.0% to 12.6% during the same period.

METHODOLOGY:

• Researchers conducted a retrospective data search of vaginal cultures from adult women in Leeds, England, between April 2018 and March 2021.
• A total of 5461 vaginal samples from women with clinical information indicating complicated/recurrent vulvovaginal candidiasis were included.
• Samples were processed on the WASPLAB automated platform, and species identification and antifungal susceptibility testing were performed in the Mycology Reference Centre by Matrix-assisted laser desorption ionization–time-of-flight mass spectrometry.
• Susceptibility to fluconazole was determined using disc diffusion and the Sensititre YeastOne microbroth dilution assay.
•  

TAKEAWAY:

According to the authors, the prevalence of non–C albicans yeasts increased from 6.0% in 2018-2019 to 12.6% in 2020-2021 (P = .0003).

Fluconazole-sensitive (dose-dependent) and fluconazole-resistant isolates increased from 3.5% in 2018-2019 to 9.6% in 2020-2021 (P = .0001).

Most fluconazole resistance was observed in C albicans, with other species such as Nakaseomyces glabrata and Pichia kudriavzevii also showing resistance.

The authors state that the increase in fluconazole resistance and non–C albicans yeasts may be linked to a policy change encouraging empirical treatment of vulvovaginal candidiasis in primary care.

IN PRACTICE:

“This study shows that the rates of non–Candida albicans and fluconazole-resistant C albicans have increased year on year in the 3 years studied. The exact reasons for this increase remain unclear, but it follows the introduction of restricted access to fungal cultures for the diagnosis of vulvovaginal candidiasis by those working in primary care. A clinical diagnosis, followed by empirical treatment, has been recommended instead. Consequently, we believe this policy of encouraging empirical vaginitis treatment based on nonspecific symptoms and signs needs revisiting,” the authors wrote.

SOURCE:

The study was led by Jennifer C. Ratner, Leeds Teaching Hospitals NHS Trust, England. It was published online in Sexually Transmitted Infections.

LIMITATIONS:

The study’s limitations included a potential bias introduced by the reduced number of samples received from specialist sexual health clinics during the COVID-19 pandemic. Additionally, the study could not distinguish between cases of recurrent vulvovaginal candidiasis with complete resolution of symptoms and those with persistent symptoms despite treatment.

DISCLOSURES:

One coauthor disclosed receiving fees from Pfizer for contributing to webinar presentations in 2023. Additional disclosures are noted in the original article.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article first appeared on Medscape.com.

TOPLINE:

Mifepristone plus misoprostol reduces the need for subsequent uterine aspiration and emergency department visits in the management of early pregnancy loss. Despite its effectiveness, mifepristone remains underutilized, with 8.6% of patients receiving it in 2022.

METHODOLOGY:

• Researchers conducted a retrospective cohort study using national insurance claims data of US patients with commercial insurance.
• More than 31,000 pregnant women (mean age, 32.7 years) with a diagnosis of early pregnancy loss between 2015 and 2022 were included.
• The diagnosis of patients included having a missed abortion (72.3%), spontaneous abortion (26.9%), or both (0.8%).
• Researchers compared the outcomes of individuals who received a combination of mifepristone and misoprostol vs those who received misoprostol alone. The outcome measures included the need for subsequent procedural management (uterine aspiration), return visits to the emergency department or an outpatient clinic, hospitalizations, and complications within 6 weeks of initial diagnosis.

TAKEAWAY:

• The use of mifepristone was more common in outpatient clinics than in emergency departments (3.4% vs 0.9%; P < .001).
• The use of mifepristone plus misoprostol vs misoprostol alone was linked to a lower incidence of subsequent procedural management (10.5% vs 14.0%; P = .002) and fewer emergency department visits (3.5% vs 7.9%; P < .001).
• The multivariable analysis showed that the use of mifepristone was linked to decreased odds of subsequent procedural management (adjusted odds ratio, 0.71; 95% CI, 0.57-0.87).
• Despite its effectiveness, mifepristone was used in only 8.6% of those receiving medication management for early pregnancy loss in 2022.

IN PRACTICE:

“Continued efforts are needed to reduce barriers to mifepristone use for medication management of EPL,” the authors wrote.

“Any practitioner who cares for patients experiencing early pregnancy loss should consider mifepristone pretreatment to misoprostol to be the standard of care for medication management. Provision of the evidence-based standard of care with the use of mifepristone for early pregnancy loss is an opportunity to advocate for an essential strategy in improving sexual and reproductive health in the US,” wrote Sarita Sonalkar, MD, MPH, and Rachel McKean, MD, MPH, of the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, in an invited commentary.
 

SOURCE:

The study was led by Lyndsey S. Benson, MD, MS, of the University of Washington School of Medicine, Seattle, and was published online in JAMA Network Open.

LIMITATIONS:

The study was limited by the accuracy of the diagnosis of early pregnancy loss and procedure codes because claims data are intended for billing purposes and may be incomplete or inaccurate. The use of de-identified data meant that specific gestational durations, exact dosing, or routes of misoprostol administration could not be determined. The findings may not be generalizable to those with public insurance or no insurance.

DISCLOSURES:

The study was supported in part by a grant from a Women’s Reproductive Health Research grant from the National Institutes of Health Eunice Kennedy Shriver National Institute for Child Health and Human Development. One author reported serving as an adviser and investigator, while another reported receiving personal fees and serving as an expert witness, contributing editor, and course instructor outside the submitted work.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article first appeared on Medscape.com.

TOPLINE:

Mifepristone plus misoprostol reduces the need for subsequent uterine aspiration and emergency department visits in the management of early pregnancy loss. Despite its effectiveness, mifepristone remains underutilized, with 8.6% of patients receiving it in 2022.

METHODOLOGY:

• Researchers conducted a retrospective cohort study using national insurance claims data of US patients with commercial insurance.
• More than 31,000 pregnant women (mean age, 32.7 years) with a diagnosis of early pregnancy loss between 2015 and 2022 were included.
• The diagnosis of patients included having a missed abortion (72.3%), spontaneous abortion (26.9%), or both (0.8%).
• Researchers compared the outcomes of individuals who received a combination of mifepristone and misoprostol vs those who received misoprostol alone. The outcome measures included the need for subsequent procedural management (uterine aspiration), return visits to the emergency department or an outpatient clinic, hospitalizations, and complications within 6 weeks of initial diagnosis.

TAKEAWAY:

• The use of mifepristone was more common in outpatient clinics than in emergency departments (3.4% vs 0.9%; P < .001).
• The use of mifepristone plus misoprostol vs misoprostol alone was linked to a lower incidence of subsequent procedural management (10.5% vs 14.0%; P = .002) and fewer emergency department visits (3.5% vs 7.9%; P < .001).
• The multivariable analysis showed that the use of mifepristone was linked to decreased odds of subsequent procedural management (adjusted odds ratio, 0.71; 95% CI, 0.57-0.87).
• Despite its effectiveness, mifepristone was used in only 8.6% of those receiving medication management for early pregnancy loss in 2022.

IN PRACTICE:

“Continued efforts are needed to reduce barriers to mifepristone use for medication management of EPL,” the authors wrote.

“Any practitioner who cares for patients experiencing early pregnancy loss should consider mifepristone pretreatment to misoprostol to be the standard of care for medication management. Provision of the evidence-based standard of care with the use of mifepristone for early pregnancy loss is an opportunity to advocate for an essential strategy in improving sexual and reproductive health in the US,” wrote Sarita Sonalkar, MD, MPH, and Rachel McKean, MD, MPH, of the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, in an invited commentary.
 

SOURCE:

The study was led by Lyndsey S. Benson, MD, MS, of the University of Washington School of Medicine, Seattle, and was published online in JAMA Network Open.

LIMITATIONS:

The study was limited by the accuracy of the diagnosis of early pregnancy loss and procedure codes because claims data are intended for billing purposes and may be incomplete or inaccurate. The use of de-identified data meant that specific gestational durations, exact dosing, or routes of misoprostol administration could not be determined. The findings may not be generalizable to those with public insurance or no insurance.

DISCLOSURES:

The study was supported in part by a grant from a Women’s Reproductive Health Research grant from the National Institutes of Health Eunice Kennedy Shriver National Institute for Child Health and Human Development. One author reported serving as an adviser and investigator, while another reported receiving personal fees and serving as an expert witness, contributing editor, and course instructor outside the submitted work.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article first appeared on Medscape.com.

TOPLINE:

Mifepristone plus misoprostol reduces the need for subsequent uterine aspiration and emergency department visits in the management of early pregnancy loss. Despite its effectiveness, mifepristone remains underutilized, with 8.6% of patients receiving it in 2022.

METHODOLOGY:

• Researchers conducted a retrospective cohort study using national insurance claims data of US patients with commercial insurance.
• More than 31,000 pregnant women (mean age, 32.7 years) with a diagnosis of early pregnancy loss between 2015 and 2022 were included.
• The diagnosis of patients included having a missed abortion (72.3%), spontaneous abortion (26.9%), or both (0.8%).
• Researchers compared the outcomes of individuals who received a combination of mifepristone and misoprostol vs those who received misoprostol alone. The outcome measures included the need for subsequent procedural management (uterine aspiration), return visits to the emergency department or an outpatient clinic, hospitalizations, and complications within 6 weeks of initial diagnosis.

TAKEAWAY:

• The use of mifepristone was more common in outpatient clinics than in emergency departments (3.4% vs 0.9%; P < .001).
• The use of mifepristone plus misoprostol vs misoprostol alone was linked to a lower incidence of subsequent procedural management (10.5% vs 14.0%; P = .002) and fewer emergency department visits (3.5% vs 7.9%; P < .001).
• The multivariable analysis showed that the use of mifepristone was linked to decreased odds of subsequent procedural management (adjusted odds ratio, 0.71; 95% CI, 0.57-0.87).
• Despite its effectiveness, mifepristone was used in only 8.6% of those receiving medication management for early pregnancy loss in 2022.

IN PRACTICE:

“Continued efforts are needed to reduce barriers to mifepristone use for medication management of EPL,” the authors wrote.

“Any practitioner who cares for patients experiencing early pregnancy loss should consider mifepristone pretreatment to misoprostol to be the standard of care for medication management. Provision of the evidence-based standard of care with the use of mifepristone for early pregnancy loss is an opportunity to advocate for an essential strategy in improving sexual and reproductive health in the US,” wrote Sarita Sonalkar, MD, MPH, and Rachel McKean, MD, MPH, of the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, in an invited commentary.
 

SOURCE:

The study was led by Lyndsey S. Benson, MD, MS, of the University of Washington School of Medicine, Seattle, and was published online in JAMA Network Open.

LIMITATIONS:

The study was limited by the accuracy of the diagnosis of early pregnancy loss and procedure codes because claims data are intended for billing purposes and may be incomplete or inaccurate. The use of de-identified data meant that specific gestational durations, exact dosing, or routes of misoprostol administration could not be determined. The findings may not be generalizable to those with public insurance or no insurance.

DISCLOSURES:

The study was supported in part by a grant from a Women’s Reproductive Health Research grant from the National Institutes of Health Eunice Kennedy Shriver National Institute for Child Health and Human Development. One author reported serving as an adviser and investigator, while another reported receiving personal fees and serving as an expert witness, contributing editor, and course instructor outside the submitted work.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article first appeared on Medscape.com.

Many patients ask us to request a prostate-specific antigen (PSA) test. According to the Brazilian Ministry of Health, prostate cancer is the second most common type of cancer in the male population in all regions of our country. It is the second-leading cause of cancer death in the male population, reaffirming its epidemiologic importance in Brazil. On the other hand, a Ministry of Health technical paper recommends against population-based screening for prostate cancer. So, what should we do?

First, it is important to distinguish early diagnosis from screening. Early diagnosis is the identification of cancer in early stages in people with signs and symptoms. Screening is characterized by the systematic application of exams — digital rectal exam and PSA test — in asymptomatic people, with the aim of identifying cancer in an early stage.

Studies show that screening significantly increases the diagnosis of prostate cancer, without a significant reduction in specific mortality and with significant health damage to men. A recent European epidemiologic study reinforced this thesis and helps guide us.

The study included men aged 35-84 years from 26 European countries. Data on cancer incidence and mortality were collected between 1980 and 2017. The data suggested overdiagnosis of prostate cancer, which varied over time and among populations. The findings supported previous recommendations that any implementation of prostate cancer screening should be carefully designed, with an emphasis on minimizing the harms of overdiagnosis.

The clinical evolution of prostate cancer is still not well understood. Increasing age is associated with increased mortality. Many men with less aggressive disease tend to die with cancer rather than die of cancer. However, it is not always possible at the time of diagnosis to determine which tumors will be aggressive and which will grow slowly.

On the other hand, with screening, many of these indolent cancers are unnecessarily detected, generating excessive exams and treatments with negative repercussions (eg, pain, bleeding, infections, stress, and urinary and sexual dysfunction).

So, how should we as clinicians proceed regarding screening?

We should request the PSA test and emphasize the importance of digital rectal exam by a urologist for those at high risk for prostatic neoplasia (ie, those with family history) or those with urinary symptoms that may be associated with prostate cancer.

In general, we should draw attention to the possible risks and benefits of testing and adopt a shared decision-making approach with asymptomatic men or those at low risk who wish to have the screening exam. But achieving a shared decision is not a simple task.

I always have a thorough conversation with patients, but I confess that I request the exam in most cases.

Dr. Wajngarten is a professor of cardiology, Faculty of Medicine, at the University of São Paulo in Brazil. Dr. Wajngarten reported no conflicts of interest.

This story was translated from the Medscape Portuguese edition using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article appeared on Medscape.com.

Many patients ask us to request a prostate-specific antigen (PSA) test. According to the Brazilian Ministry of Health, prostate cancer is the second most common type of cancer in the male population in all regions of our country. It is the second-leading cause of cancer death in the male population, reaffirming its epidemiologic importance in Brazil. On the other hand, a Ministry of Health technical paper recommends against population-based screening for prostate cancer. So, what should we do?

First, it is important to distinguish early diagnosis from screening. Early diagnosis is the identification of cancer in early stages in people with signs and symptoms. Screening is characterized by the systematic application of exams — digital rectal exam and PSA test — in asymptomatic people, with the aim of identifying cancer in an early stage.

Studies show that screening significantly increases the diagnosis of prostate cancer, without a significant reduction in specific mortality and with significant health damage to men. A recent European epidemiologic study reinforced this thesis and helps guide us.

The study included men aged 35-84 years from 26 European countries. Data on cancer incidence and mortality were collected between 1980 and 2017. The data suggested overdiagnosis of prostate cancer, which varied over time and among populations. The findings supported previous recommendations that any implementation of prostate cancer screening should be carefully designed, with an emphasis on minimizing the harms of overdiagnosis.

The clinical evolution of prostate cancer is still not well understood. Increasing age is associated with increased mortality. Many men with less aggressive disease tend to die with cancer rather than die of cancer. However, it is not always possible at the time of diagnosis to determine which tumors will be aggressive and which will grow slowly.

On the other hand, with screening, many of these indolent cancers are unnecessarily detected, generating excessive exams and treatments with negative repercussions (eg, pain, bleeding, infections, stress, and urinary and sexual dysfunction).

So, how should we as clinicians proceed regarding screening?

We should request the PSA test and emphasize the importance of digital rectal exam by a urologist for those at high risk for prostatic neoplasia (ie, those with family history) or those with urinary symptoms that may be associated with prostate cancer.

In general, we should draw attention to the possible risks and benefits of testing and adopt a shared decision-making approach with asymptomatic men or those at low risk who wish to have the screening exam. But achieving a shared decision is not a simple task.

I always have a thorough conversation with patients, but I confess that I request the exam in most cases.

Dr. Wajngarten is a professor of cardiology, Faculty of Medicine, at the University of São Paulo in Brazil. Dr. Wajngarten reported no conflicts of interest.

This story was translated from the Medscape Portuguese edition using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article appeared on Medscape.com.

Many patients ask us to request a prostate-specific antigen (PSA) test. According to the Brazilian Ministry of Health, prostate cancer is the second most common type of cancer in the male population in all regions of our country. It is the second-leading cause of cancer death in the male population, reaffirming its epidemiologic importance in Brazil. On the other hand, a Ministry of Health technical paper recommends against population-based screening for prostate cancer. So, what should we do?

First, it is important to distinguish early diagnosis from screening. Early diagnosis is the identification of cancer in early stages in people with signs and symptoms. Screening is characterized by the systematic application of exams — digital rectal exam and PSA test — in asymptomatic people, with the aim of identifying cancer in an early stage.

Studies show that screening significantly increases the diagnosis of prostate cancer, without a significant reduction in specific mortality and with significant health damage to men. A recent European epidemiologic study reinforced this thesis and helps guide us.

The study included men aged 35-84 years from 26 European countries. Data on cancer incidence and mortality were collected between 1980 and 2017. The data suggested overdiagnosis of prostate cancer, which varied over time and among populations. The findings supported previous recommendations that any implementation of prostate cancer screening should be carefully designed, with an emphasis on minimizing the harms of overdiagnosis.

The clinical evolution of prostate cancer is still not well understood. Increasing age is associated with increased mortality. Many men with less aggressive disease tend to die with cancer rather than die of cancer. However, it is not always possible at the time of diagnosis to determine which tumors will be aggressive and which will grow slowly.

On the other hand, with screening, many of these indolent cancers are unnecessarily detected, generating excessive exams and treatments with negative repercussions (eg, pain, bleeding, infections, stress, and urinary and sexual dysfunction).

So, how should we as clinicians proceed regarding screening?

We should request the PSA test and emphasize the importance of digital rectal exam by a urologist for those at high risk for prostatic neoplasia (ie, those with family history) or those with urinary symptoms that may be associated with prostate cancer.

In general, we should draw attention to the possible risks and benefits of testing and adopt a shared decision-making approach with asymptomatic men or those at low risk who wish to have the screening exam. But achieving a shared decision is not a simple task.

I always have a thorough conversation with patients, but I confess that I request the exam in most cases.

Dr. Wajngarten is a professor of cardiology, Faculty of Medicine, at the University of São Paulo in Brazil. Dr. Wajngarten reported no conflicts of interest.

This story was translated from the Medscape Portuguese edition using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article appeared on Medscape.com.

TOPLINE:

Testing for mismatch repair (MMR) and microsatellite instability (MSI) among patients with colorectal cancer (CRC) increased from 22.7% in 2012 to 71.5% in 2021, but variations in access remain, with testing rates differing by cancer stage, individual hospital, patient sex, race, and insurance status.

METHODOLOGY:

• In 2017, the National Comprehensive Cancer Network (NCCN) recommended universal testing for MMR and MSI among patients with CRC, but studies suggest that testing may still be underused.
• To assess trends and factors associated with MMR/MSI testing in the United States, researchers evaluated 834,797 patients diagnosed with stage I-IV CRC between 2012 and 2021 across 1366 Commission on Cancer–accredited hospitals in the National Cancer Database.
• The variability in MMR/MSI testing was assessed in relation to both patient and hospital-level factors.
• Overall, 70.7% patients had colon cancer, 7.3% had rectosigmoid cancer, and 22.0% had rectal cancer. The median patient age was 66 years; just over half (53%) were men, 81.8% were White, and 11.9% were Black.

TAKEAWAY:

• Overall, 43.9% patients underwent MMR/MSI testing, but testing rates increased more than threefold between 2012 and 2021 — from 22.7% to 71.5%. Still, testing rates varied depending on a range of factors.
• About 22% variability in MMR/MSI testing was attributed to hospital-level variations, with the best vs worst performing hospitals reporting testing rates of 90% vs 2%. This hospital-level variation may be caused by testing protocol differences at individual institutions, the authors said.
• The likelihood of undergoing MMR/MSI testing was lower in patients with stage IV vs stage I disease (adjusted odds ratio [aOR], 0.78) but higher in those with stage II (aOR, 1.53) and III (aOR, 1.40) disease.
• The likelihood of undergoing MMR/MSI testing was slightly lower for men than for women (aOR, 0.98) and for Black patients than for White patients (aOR, 0.97). Having a lower household income, public or no insurance (vs private insurance), or living a longer distance (more than 5 miles) from the treatment facility was also associated with lower odds of testing.

IN PRACTICE:

“This cohort study indicated that MMR/MSI testing increased markedly, suggesting increased NCCN guideline adherence,” the authors said. However, variations still exist by cancer stage, hospital, and patient factors. Implementing “widespread institution-level reflexive testing for every initial diagnostic biopsy” can improve testing rates and reduce disparities, the authors suggested.

SOURCE:

This study, led by Totadri Dhimal, MD, University of Rochester Medical Center in New York, was published online in JAMA Oncology.

LIMITATIONS:

The study lacked clinical granularity, and potential coding inaccuracies and incomplete data could have affected the interpretation and generalizability of the findings.

DISCLOSURES:

No funding information was provided for the study. One author reported receiving author royalties from UpToDate outside the submitted work.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article first appeared on Medscape.com.

TOPLINE:

Testing for mismatch repair (MMR) and microsatellite instability (MSI) among patients with colorectal cancer (CRC) increased from 22.7% in 2012 to 71.5% in 2021, but variations in access remain, with testing rates differing by cancer stage, individual hospital, patient sex, race, and insurance status.

METHODOLOGY:

• In 2017, the National Comprehensive Cancer Network (NCCN) recommended universal testing for MMR and MSI among patients with CRC, but studies suggest that testing may still be underused.
• To assess trends and factors associated with MMR/MSI testing in the United States, researchers evaluated 834,797 patients diagnosed with stage I-IV CRC between 2012 and 2021 across 1366 Commission on Cancer–accredited hospitals in the National Cancer Database.
• The variability in MMR/MSI testing was assessed in relation to both patient and hospital-level factors.
• Overall, 70.7% patients had colon cancer, 7.3% had rectosigmoid cancer, and 22.0% had rectal cancer. The median patient age was 66 years; just over half (53%) were men, 81.8% were White, and 11.9% were Black.

TAKEAWAY:

• Overall, 43.9% patients underwent MMR/MSI testing, but testing rates increased more than threefold between 2012 and 2021 — from 22.7% to 71.5%. Still, testing rates varied depending on a range of factors.
• About 22% variability in MMR/MSI testing was attributed to hospital-level variations, with the best vs worst performing hospitals reporting testing rates of 90% vs 2%. This hospital-level variation may be caused by testing protocol differences at individual institutions, the authors said.
• The likelihood of undergoing MMR/MSI testing was lower in patients with stage IV vs stage I disease (adjusted odds ratio [aOR], 0.78) but higher in those with stage II (aOR, 1.53) and III (aOR, 1.40) disease.
• The likelihood of undergoing MMR/MSI testing was slightly lower for men than for women (aOR, 0.98) and for Black patients than for White patients (aOR, 0.97). Having a lower household income, public or no insurance (vs private insurance), or living a longer distance (more than 5 miles) from the treatment facility was also associated with lower odds of testing.

IN PRACTICE:

“This cohort study indicated that MMR/MSI testing increased markedly, suggesting increased NCCN guideline adherence,” the authors said. However, variations still exist by cancer stage, hospital, and patient factors. Implementing “widespread institution-level reflexive testing for every initial diagnostic biopsy” can improve testing rates and reduce disparities, the authors suggested.

SOURCE:

This study, led by Totadri Dhimal, MD, University of Rochester Medical Center in New York, was published online in JAMA Oncology.

LIMITATIONS:

The study lacked clinical granularity, and potential coding inaccuracies and incomplete data could have affected the interpretation and generalizability of the findings.

DISCLOSURES:

No funding information was provided for the study. One author reported receiving author royalties from UpToDate outside the submitted work.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article first appeared on Medscape.com.

TOPLINE:

Testing for mismatch repair (MMR) and microsatellite instability (MSI) among patients with colorectal cancer (CRC) increased from 22.7% in 2012 to 71.5% in 2021, but variations in access remain, with testing rates differing by cancer stage, individual hospital, patient sex, race, and insurance status.

METHODOLOGY:

• In 2017, the National Comprehensive Cancer Network (NCCN) recommended universal testing for MMR and MSI among patients with CRC, but studies suggest that testing may still be underused.
• To assess trends and factors associated with MMR/MSI testing in the United States, researchers evaluated 834,797 patients diagnosed with stage I-IV CRC between 2012 and 2021 across 1366 Commission on Cancer–accredited hospitals in the National Cancer Database.
• The variability in MMR/MSI testing was assessed in relation to both patient and hospital-level factors.
• Overall, 70.7% patients had colon cancer, 7.3% had rectosigmoid cancer, and 22.0% had rectal cancer. The median patient age was 66 years; just over half (53%) were men, 81.8% were White, and 11.9% were Black.

TAKEAWAY:

• Overall, 43.9% patients underwent MMR/MSI testing, but testing rates increased more than threefold between 2012 and 2021 — from 22.7% to 71.5%. Still, testing rates varied depending on a range of factors.
• About 22% variability in MMR/MSI testing was attributed to hospital-level variations, with the best vs worst performing hospitals reporting testing rates of 90% vs 2%. This hospital-level variation may be caused by testing protocol differences at individual institutions, the authors said.
• The likelihood of undergoing MMR/MSI testing was lower in patients with stage IV vs stage I disease (adjusted odds ratio [aOR], 0.78) but higher in those with stage II (aOR, 1.53) and III (aOR, 1.40) disease.
• The likelihood of undergoing MMR/MSI testing was slightly lower for men than for women (aOR, 0.98) and for Black patients than for White patients (aOR, 0.97). Having a lower household income, public or no insurance (vs private insurance), or living a longer distance (more than 5 miles) from the treatment facility was also associated with lower odds of testing.

IN PRACTICE:

“This cohort study indicated that MMR/MSI testing increased markedly, suggesting increased NCCN guideline adherence,” the authors said. However, variations still exist by cancer stage, hospital, and patient factors. Implementing “widespread institution-level reflexive testing for every initial diagnostic biopsy” can improve testing rates and reduce disparities, the authors suggested.

SOURCE:

This study, led by Totadri Dhimal, MD, University of Rochester Medical Center in New York, was published online in JAMA Oncology.

LIMITATIONS:

The study lacked clinical granularity, and potential coding inaccuracies and incomplete data could have affected the interpretation and generalizability of the findings.

DISCLOSURES:

No funding information was provided for the study. One author reported receiving author royalties from UpToDate outside the submitted work.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article first appeared on Medscape.com.

A psychosocial intervention designed to improve depressive symptoms and promote good parenting skills can be an effective way of treating male postpartum depression, according to new research.

In a study conducted in Pakistan, about 70% fathers with postpartum depression who received the intervention showed complete remission of their depressive symptoms and experienced enhanced relationships with their children and domestic partners.

Called Learning Through Play Plus Dads (LTP + Dads), the intervention, which can be delivered by community health workers, could improve paternal mental health and child development not only in Pakistan but also in other populations, the authors stated.

The results of the study were published on October 2, 2024, in JAMA Psychiatry.
 

Stigmatized and Understudied

“Pakistan is a patriarchal society with strict gender roles, and male mental health, particularly postpartum depression in new fathers, is stigmatized and understudied,” lead investigator Ishrat Husain, MD, a senior scientist at the Centre for Addiction and Mental Health and associate professor of psychiatry at the University of Toronto in Ontario, Canada, said in an interview.

“Historically, and rightly so, the focus has always been on the mother, but men also experience significant emotional challenges as they adapt to being a parent. Fathers are also in need of support,” said Husain.

Male postpartum depression is prevalent in all populations. Globally, about 10% fathers have postpartum depression. But in societies like Pakistan, rates of male postpartum depression have been reported to be as high as 23.5%.

The study included 357 fathers aged 18 years or older (mean age, 31.44 years) with a Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, diagnosis of major depressive episode and a child younger than 30 months.

They were randomly assigned either to receive treatment as usual (n = 186) or to participate in the LTP + Dads program (n = 171). LTP + Dads is a parenting and mental health initiative adapted from a similar program for Pakistani mothers. It combines parenting skills training, play therapy, and cognitive behavioral therapy. In this study, the initiative was delivered by community health workers in 12 group sessions over 4 months. Sessions took place weekly for the first 2 months and biweekly thereafter.

The researchers assessed changes in the 17-item Hamilton Depression Rating Scale (HDRS-17) score at 4 months and at 6 months. They also looked at anxiety symptoms; parenting stress; intimate partner violence; functioning; quality of life; and child social, emotional, and physical health outcomes.
 

Improved Child Development

There were significantly greater reductions in HDRS-17 scores in the LTP + Dads group than in the treatment as usual group at 4 months (group difference ratio [GDR], 0.66; P < .001) and at 6 months (GDR, 0.67; P < .001).

Similar results were seen for anxiety (GDR, 0.62; P < .001), parenting stress (GDR, −12.5; P < .001), intimate partner violence (GDR, 0.89; P = .05), disability (GDR, 0.77; P = .03), and health-related quality of life (GDR, 12.7; P < .001) at 4 months. The differences in depression and parenting stress were sustained at 6 months.

In addition, children of fathers who received the parenting intervention showed significantly greater improvements in social-emotional development scores (mean difference, −20.8; P < .001) at 6 months than children of those who received the treatment as usual.

“We believe that this program could also be successful in other countries, including Canada,” said Husain. “Canada is multicultural, and similar patterns of male postpartum depression probably exist here. We know that cultural and social pressures create barriers to seeking mental health support for men. Stigma and cultural beliefs often prevent new fathers from seeking the help they need. Programs like LTP + Dads can help men transition to their new role as fathers by giving them support to process their emotions,” he said.

Husain added that the program will be expanded throughout Pakistan to include about 4000 fathers and their partners.
 

‘Remarkable’ Success Rate

“Postpartum depression in men is still something that people are trying to understand,” John Ogrodniczuk, MD, professor of psychiatry and director of the psychotherapy program at The University of British Columbia, Vancouver, Canada, said in an interview. He did not participate in the study.

“Obviously, men aren’t going through the same endocrine changes that women are, but nonetheless, a lot of men do actually struggle with it,” said Ogrodniczuk, who is also the founder of HeadsUpGuys, a mental health resource for men.

“Understandably, most of the literature is around postpartum depression in women, not so much around men. The positive results seen here are interesting, especially in a country that is patriarchal and where there is not a lot of uptake of mental health interventions and services by men,” he said.

“The success rate of this psychosocial intervention is remarkable, so I am excited to see that the researchers have secured funding to expand the study and validate their results with a larger group of participants,” Simon B. Sherry, PhD, professor of psychology and neuroscience at Dalhousie University, Halifax, Nova Scotia, Canada, said in an interview.

“I am also encouraged by the inclusion of play-based activities in addition to cognitive behavioral therapy. Perhaps more than any other role we hold through life, the role of parent comes with copious societal and personal expectations, plus with all that pressure, transitioning into that role is hard for everyone, but especially for those with postpartum depression. Supporting parents and improving their mental well-being goes a long way toward raising mentally healthy kids,” said Sherry, who was not part of the study.

The study was funded by a grant from Grand Challenges Canada, an Academic Scholars Award from the Department of Psychiatry at the University of Toronto, and a Tier 2 Canada Research Chair from the Canadian Institutes of Health Research. Husain reported receiving grants from COMPASS Pathfinder, stock options from Mindset Pharma, and personal fees from Wake Network, outside the submitted work. He previously served as a trustee for the Pakistan Institute of Living and Learning. Ogrodniczuk and Sherry reported no relevant financial relationships.

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

A psychosocial intervention designed to improve depressive symptoms and promote good parenting skills can be an effective way of treating male postpartum depression, according to new research.

In a study conducted in Pakistan, about 70% fathers with postpartum depression who received the intervention showed complete remission of their depressive symptoms and experienced enhanced relationships with their children and domestic partners.

Called Learning Through Play Plus Dads (LTP + Dads), the intervention, which can be delivered by community health workers, could improve paternal mental health and child development not only in Pakistan but also in other populations, the authors stated.

The results of the study were published on October 2, 2024, in JAMA Psychiatry.
 

Stigmatized and Understudied

“Pakistan is a patriarchal society with strict gender roles, and male mental health, particularly postpartum depression in new fathers, is stigmatized and understudied,” lead investigator Ishrat Husain, MD, a senior scientist at the Centre for Addiction and Mental Health and associate professor of psychiatry at the University of Toronto in Ontario, Canada, said in an interview.

“Historically, and rightly so, the focus has always been on the mother, but men also experience significant emotional challenges as they adapt to being a parent. Fathers are also in need of support,” said Husain.

Male postpartum depression is prevalent in all populations. Globally, about 10% fathers have postpartum depression. But in societies like Pakistan, rates of male postpartum depression have been reported to be as high as 23.5%.

The study included 357 fathers aged 18 years or older (mean age, 31.44 years) with a Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, diagnosis of major depressive episode and a child younger than 30 months.

They were randomly assigned either to receive treatment as usual (n = 186) or to participate in the LTP + Dads program (n = 171). LTP + Dads is a parenting and mental health initiative adapted from a similar program for Pakistani mothers. It combines parenting skills training, play therapy, and cognitive behavioral therapy. In this study, the initiative was delivered by community health workers in 12 group sessions over 4 months. Sessions took place weekly for the first 2 months and biweekly thereafter.

The researchers assessed changes in the 17-item Hamilton Depression Rating Scale (HDRS-17) score at 4 months and at 6 months. They also looked at anxiety symptoms; parenting stress; intimate partner violence; functioning; quality of life; and child social, emotional, and physical health outcomes.
 

Improved Child Development

There were significantly greater reductions in HDRS-17 scores in the LTP + Dads group than in the treatment as usual group at 4 months (group difference ratio [GDR], 0.66; P < .001) and at 6 months (GDR, 0.67; P < .001).

Similar results were seen for anxiety (GDR, 0.62; P < .001), parenting stress (GDR, −12.5; P < .001), intimate partner violence (GDR, 0.89; P = .05), disability (GDR, 0.77; P = .03), and health-related quality of life (GDR, 12.7; P < .001) at 4 months. The differences in depression and parenting stress were sustained at 6 months.

In addition, children of fathers who received the parenting intervention showed significantly greater improvements in social-emotional development scores (mean difference, −20.8; P < .001) at 6 months than children of those who received the treatment as usual.

“We believe that this program could also be successful in other countries, including Canada,” said Husain. “Canada is multicultural, and similar patterns of male postpartum depression probably exist here. We know that cultural and social pressures create barriers to seeking mental health support for men. Stigma and cultural beliefs often prevent new fathers from seeking the help they need. Programs like LTP + Dads can help men transition to their new role as fathers by giving them support to process their emotions,” he said.

Husain added that the program will be expanded throughout Pakistan to include about 4000 fathers and their partners.
 

‘Remarkable’ Success Rate

“Postpartum depression in men is still something that people are trying to understand,” John Ogrodniczuk, MD, professor of psychiatry and director of the psychotherapy program at The University of British Columbia, Vancouver, Canada, said in an interview. He did not participate in the study.

“Obviously, men aren’t going through the same endocrine changes that women are, but nonetheless, a lot of men do actually struggle with it,” said Ogrodniczuk, who is also the founder of HeadsUpGuys, a mental health resource for men.

“Understandably, most of the literature is around postpartum depression in women, not so much around men. The positive results seen here are interesting, especially in a country that is patriarchal and where there is not a lot of uptake of mental health interventions and services by men,” he said.

“The success rate of this psychosocial intervention is remarkable, so I am excited to see that the researchers have secured funding to expand the study and validate their results with a larger group of participants,” Simon B. Sherry, PhD, professor of psychology and neuroscience at Dalhousie University, Halifax, Nova Scotia, Canada, said in an interview.

“I am also encouraged by the inclusion of play-based activities in addition to cognitive behavioral therapy. Perhaps more than any other role we hold through life, the role of parent comes with copious societal and personal expectations, plus with all that pressure, transitioning into that role is hard for everyone, but especially for those with postpartum depression. Supporting parents and improving their mental well-being goes a long way toward raising mentally healthy kids,” said Sherry, who was not part of the study.

The study was funded by a grant from Grand Challenges Canada, an Academic Scholars Award from the Department of Psychiatry at the University of Toronto, and a Tier 2 Canada Research Chair from the Canadian Institutes of Health Research. Husain reported receiving grants from COMPASS Pathfinder, stock options from Mindset Pharma, and personal fees from Wake Network, outside the submitted work. He previously served as a trustee for the Pakistan Institute of Living and Learning. Ogrodniczuk and Sherry reported no relevant financial relationships.

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

A psychosocial intervention designed to improve depressive symptoms and promote good parenting skills can be an effective way of treating male postpartum depression, according to new research.

In a study conducted in Pakistan, about 70% fathers with postpartum depression who received the intervention showed complete remission of their depressive symptoms and experienced enhanced relationships with their children and domestic partners.

Called Learning Through Play Plus Dads (LTP + Dads), the intervention, which can be delivered by community health workers, could improve paternal mental health and child development not only in Pakistan but also in other populations, the authors stated.

The results of the study were published on October 2, 2024, in JAMA Psychiatry.
 

Stigmatized and Understudied

“Pakistan is a patriarchal society with strict gender roles, and male mental health, particularly postpartum depression in new fathers, is stigmatized and understudied,” lead investigator Ishrat Husain, MD, a senior scientist at the Centre for Addiction and Mental Health and associate professor of psychiatry at the University of Toronto in Ontario, Canada, said in an interview.

“Historically, and rightly so, the focus has always been on the mother, but men also experience significant emotional challenges as they adapt to being a parent. Fathers are also in need of support,” said Husain.

Male postpartum depression is prevalent in all populations. Globally, about 10% fathers have postpartum depression. But in societies like Pakistan, rates of male postpartum depression have been reported to be as high as 23.5%.

The study included 357 fathers aged 18 years or older (mean age, 31.44 years) with a Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, diagnosis of major depressive episode and a child younger than 30 months.

They were randomly assigned either to receive treatment as usual (n = 186) or to participate in the LTP + Dads program (n = 171). LTP + Dads is a parenting and mental health initiative adapted from a similar program for Pakistani mothers. It combines parenting skills training, play therapy, and cognitive behavioral therapy. In this study, the initiative was delivered by community health workers in 12 group sessions over 4 months. Sessions took place weekly for the first 2 months and biweekly thereafter.

The researchers assessed changes in the 17-item Hamilton Depression Rating Scale (HDRS-17) score at 4 months and at 6 months. They also looked at anxiety symptoms; parenting stress; intimate partner violence; functioning; quality of life; and child social, emotional, and physical health outcomes.
 

Improved Child Development

There were significantly greater reductions in HDRS-17 scores in the LTP + Dads group than in the treatment as usual group at 4 months (group difference ratio [GDR], 0.66; P < .001) and at 6 months (GDR, 0.67; P < .001).

Similar results were seen for anxiety (GDR, 0.62; P < .001), parenting stress (GDR, −12.5; P < .001), intimate partner violence (GDR, 0.89; P = .05), disability (GDR, 0.77; P = .03), and health-related quality of life (GDR, 12.7; P < .001) at 4 months. The differences in depression and parenting stress were sustained at 6 months.

In addition, children of fathers who received the parenting intervention showed significantly greater improvements in social-emotional development scores (mean difference, −20.8; P < .001) at 6 months than children of those who received the treatment as usual.

“We believe that this program could also be successful in other countries, including Canada,” said Husain. “Canada is multicultural, and similar patterns of male postpartum depression probably exist here. We know that cultural and social pressures create barriers to seeking mental health support for men. Stigma and cultural beliefs often prevent new fathers from seeking the help they need. Programs like LTP + Dads can help men transition to their new role as fathers by giving them support to process their emotions,” he said.

Husain added that the program will be expanded throughout Pakistan to include about 4000 fathers and their partners.
 

‘Remarkable’ Success Rate

“Postpartum depression in men is still something that people are trying to understand,” John Ogrodniczuk, MD, professor of psychiatry and director of the psychotherapy program at The University of British Columbia, Vancouver, Canada, said in an interview. He did not participate in the study.

“Obviously, men aren’t going through the same endocrine changes that women are, but nonetheless, a lot of men do actually struggle with it,” said Ogrodniczuk, who is also the founder of HeadsUpGuys, a mental health resource for men.

“Understandably, most of the literature is around postpartum depression in women, not so much around men. The positive results seen here are interesting, especially in a country that is patriarchal and where there is not a lot of uptake of mental health interventions and services by men,” he said.

“The success rate of this psychosocial intervention is remarkable, so I am excited to see that the researchers have secured funding to expand the study and validate their results with a larger group of participants,” Simon B. Sherry, PhD, professor of psychology and neuroscience at Dalhousie University, Halifax, Nova Scotia, Canada, said in an interview.

“I am also encouraged by the inclusion of play-based activities in addition to cognitive behavioral therapy. Perhaps more than any other role we hold through life, the role of parent comes with copious societal and personal expectations, plus with all that pressure, transitioning into that role is hard for everyone, but especially for those with postpartum depression. Supporting parents and improving their mental well-being goes a long way toward raising mentally healthy kids,” said Sherry, who was not part of the study.

The study was funded by a grant from Grand Challenges Canada, an Academic Scholars Award from the Department of Psychiatry at the University of Toronto, and a Tier 2 Canada Research Chair from the Canadian Institutes of Health Research. Husain reported receiving grants from COMPASS Pathfinder, stock options from Mindset Pharma, and personal fees from Wake Network, outside the submitted work. He previously served as a trustee for the Pakistan Institute of Living and Learning. Ogrodniczuk and Sherry reported no relevant financial relationships.

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

Syphilis. It is often called the “great imitator.” It is speculated that this infection led to King George III of England going mad and likely contributing to his death. In the modern era, the discovery of penicillin in 1928 was instrumental in treating this once-deadly infection. Over the ensuing decades, rates of syphilis continued to decline. However, according to the Centers for Disease Control and Prevention, from 2018-2022 reported cases of syphilis in the United States have increased by 79% and continue to increase each year. Men who have sex with men (MSM) accounted for 41.4% of infections nationwide during this time period. This extraordinary rise highlights the need for better screening in our patients.

I currently live and practice in Texas, so I will use it as a case example. In 2013, Texas reported 1,471 cases of primary or secondary syphilis. By 2022, this number had risen to 4,655, a 216% increase. CDC data shows that Texas cases among men increased from 1,917 in 2019 to 3,324 in 2022, with MSM accounting for 1,341 (40%) of those infections. Adolescents and young adults aged 15-24 accounted for the second-highest number of new infections. Interestingly, rates of syphilis in men began to rise in Texas starting in 2013, the first full year that Truvada (emtricitabine and tenofovir disoproxil fumarate) was available for HIV pre-exposure prophylaxis (PrEP). While no definitive study has proven that the availability of PrEP caused an increase in condomless sexual intercourse, the number of high school students in Texas who did not use a condom at their last intercourse increased from 47.1% in 2013 to 50% in 2021.

UT Southwestern Medical Center

The data above highlights the need to increase screening, especially in primary care and emergency room settings. According to the 2021 Youth Risk Behavior Survey, 94.8% of high school students surveyed that they were not tested for STIs in the 12 months prior to the survey. This compares with 91.4% in the 2019 survey. When STI testing is done, many adolescents often choose to forgo blood testing for HIV and syphilis and decide only to do urine NAATs testing for Neisseria gonorrhoeae and Chlamydia trachomatis. Therefore, those physicians and other healthcare providers who take care of adolescents and young adults must work to improve screening for ALL STIs. According to the American Academy of Pediatrics Bright Futures Periodicity Guidelines, pediatricians should screen for HIV in all patients at least once starting at age 15 and then thereafter based on risk assessment. Adding syphilis screening at the same time as the above HIV screening is an easy way to improve testing and treatment for this potentially deadly condition. If access to phlebotomy is not available, there are rapid HIV and syphilis tests that can be done in physicians’ offices. To perform these risk assessments, pediatricians must spend time alone with their adolescent and young patients at nearly every visit to discuss behaviors. Pediatricians should also be aware to consider syphilis on their differential for patients with unexplained rashes, sores in the mouth, or flu-like symptoms if that young person is sexually active.

Compounding the issue of increasing cases of syphilis is a national shortage of intramuscular penicillin G benzathine, the preferred treatment, which began in April 2023 only recently began to improve as of August 2024. Oral doxycycline can be used as a backup for some patients. Still, IM penicillin G is the only recommended treatment available for pregnant patients or those with advanced disease. The increasing number of cases, as well as the medication shortages, remind all of us that we must continue to aggressively screen patients for sexually transmitted infections in all patients who are at risk to get patients on treatment and reduce the risk of further transmission in the community.

Dr. M. Brett Cooper, is an assistant professor of pediatrics at University of Texas Southwestern, Dallas, and an adolescent medicine specialist at Children’s Medical Center Dallas.

Syphilis. It is often called the “great imitator.” It is speculated that this infection led to King George III of England going mad and likely contributing to his death. In the modern era, the discovery of penicillin in 1928 was instrumental in treating this once-deadly infection. Over the ensuing decades, rates of syphilis continued to decline. However, according to the Centers for Disease Control and Prevention, from 2018-2022 reported cases of syphilis in the United States have increased by 79% and continue to increase each year. Men who have sex with men (MSM) accounted for 41.4% of infections nationwide during this time period. This extraordinary rise highlights the need for better screening in our patients.

I currently live and practice in Texas, so I will use it as a case example. In 2013, Texas reported 1,471 cases of primary or secondary syphilis. By 2022, this number had risen to 4,655, a 216% increase. CDC data shows that Texas cases among men increased from 1,917 in 2019 to 3,324 in 2022, with MSM accounting for 1,341 (40%) of those infections. Adolescents and young adults aged 15-24 accounted for the second-highest number of new infections. Interestingly, rates of syphilis in men began to rise in Texas starting in 2013, the first full year that Truvada (emtricitabine and tenofovir disoproxil fumarate) was available for HIV pre-exposure prophylaxis (PrEP). While no definitive study has proven that the availability of PrEP caused an increase in condomless sexual intercourse, the number of high school students in Texas who did not use a condom at their last intercourse increased from 47.1% in 2013 to 50% in 2021.

UT Southwestern Medical Center

The data above highlights the need to increase screening, especially in primary care and emergency room settings. According to the 2021 Youth Risk Behavior Survey, 94.8% of high school students surveyed that they were not tested for STIs in the 12 months prior to the survey. This compares with 91.4% in the 2019 survey. When STI testing is done, many adolescents often choose to forgo blood testing for HIV and syphilis and decide only to do urine NAATs testing for Neisseria gonorrhoeae and Chlamydia trachomatis. Therefore, those physicians and other healthcare providers who take care of adolescents and young adults must work to improve screening for ALL STIs. According to the American Academy of Pediatrics Bright Futures Periodicity Guidelines, pediatricians should screen for HIV in all patients at least once starting at age 15 and then thereafter based on risk assessment. Adding syphilis screening at the same time as the above HIV screening is an easy way to improve testing and treatment for this potentially deadly condition. If access to phlebotomy is not available, there are rapid HIV and syphilis tests that can be done in physicians’ offices. To perform these risk assessments, pediatricians must spend time alone with their adolescent and young patients at nearly every visit to discuss behaviors. Pediatricians should also be aware to consider syphilis on their differential for patients with unexplained rashes, sores in the mouth, or flu-like symptoms if that young person is sexually active.

Compounding the issue of increasing cases of syphilis is a national shortage of intramuscular penicillin G benzathine, the preferred treatment, which began in April 2023 only recently began to improve as of August 2024. Oral doxycycline can be used as a backup for some patients. Still, IM penicillin G is the only recommended treatment available for pregnant patients or those with advanced disease. The increasing number of cases, as well as the medication shortages, remind all of us that we must continue to aggressively screen patients for sexually transmitted infections in all patients who are at risk to get patients on treatment and reduce the risk of further transmission in the community.

Dr. M. Brett Cooper, is an assistant professor of pediatrics at University of Texas Southwestern, Dallas, and an adolescent medicine specialist at Children’s Medical Center Dallas.

Syphilis. It is often called the “great imitator.” It is speculated that this infection led to King George III of England going mad and likely contributing to his death. In the modern era, the discovery of penicillin in 1928 was instrumental in treating this once-deadly infection. Over the ensuing decades, rates of syphilis continued to decline. However, according to the Centers for Disease Control and Prevention, from 2018-2022 reported cases of syphilis in the United States have increased by 79% and continue to increase each year. Men who have sex with men (MSM) accounted for 41.4% of infections nationwide during this time period. This extraordinary rise highlights the need for better screening in our patients.

I currently live and practice in Texas, so I will use it as a case example. In 2013, Texas reported 1,471 cases of primary or secondary syphilis. By 2022, this number had risen to 4,655, a 216% increase. CDC data shows that Texas cases among men increased from 1,917 in 2019 to 3,324 in 2022, with MSM accounting for 1,341 (40%) of those infections. Adolescents and young adults aged 15-24 accounted for the second-highest number of new infections. Interestingly, rates of syphilis in men began to rise in Texas starting in 2013, the first full year that Truvada (emtricitabine and tenofovir disoproxil fumarate) was available for HIV pre-exposure prophylaxis (PrEP). While no definitive study has proven that the availability of PrEP caused an increase in condomless sexual intercourse, the number of high school students in Texas who did not use a condom at their last intercourse increased from 47.1% in 2013 to 50% in 2021.

UT Southwestern Medical Center

The data above highlights the need to increase screening, especially in primary care and emergency room settings. According to the 2021 Youth Risk Behavior Survey, 94.8% of high school students surveyed that they were not tested for STIs in the 12 months prior to the survey. This compares with 91.4% in the 2019 survey. When STI testing is done, many adolescents often choose to forgo blood testing for HIV and syphilis and decide only to do urine NAATs testing for Neisseria gonorrhoeae and Chlamydia trachomatis. Therefore, those physicians and other healthcare providers who take care of adolescents and young adults must work to improve screening for ALL STIs. According to the American Academy of Pediatrics Bright Futures Periodicity Guidelines, pediatricians should screen for HIV in all patients at least once starting at age 15 and then thereafter based on risk assessment. Adding syphilis screening at the same time as the above HIV screening is an easy way to improve testing and treatment for this potentially deadly condition. If access to phlebotomy is not available, there are rapid HIV and syphilis tests that can be done in physicians’ offices. To perform these risk assessments, pediatricians must spend time alone with their adolescent and young patients at nearly every visit to discuss behaviors. Pediatricians should also be aware to consider syphilis on their differential for patients with unexplained rashes, sores in the mouth, or flu-like symptoms if that young person is sexually active.

Compounding the issue of increasing cases of syphilis is a national shortage of intramuscular penicillin G benzathine, the preferred treatment, which began in April 2023 only recently began to improve as of August 2024. Oral doxycycline can be used as a backup for some patients. Still, IM penicillin G is the only recommended treatment available for pregnant patients or those with advanced disease. The increasing number of cases, as well as the medication shortages, remind all of us that we must continue to aggressively screen patients for sexually transmitted infections in all patients who are at risk to get patients on treatment and reduce the risk of further transmission in the community.

Dr. M. Brett Cooper, is an assistant professor of pediatrics at University of Texas Southwestern, Dallas, and an adolescent medicine specialist at Children’s Medical Center Dallas.