 (IBS) are more likely to also suffer from psychological comorbidities like depression and anxiety.

A team, led by Andrea Shin, MD, Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, investigated the prevalence of IBS, the phenotypic, environmental, and psychosocial factors linked to the disease, and the associations of IBS with health-related quality of life and healthcare utilization in Veterans.

There are not many studies focusing on the prevalence of IBS in the Veteran population.

In the study, Veterans completed the Rome IV IBS questionnaire, Short Form-12, Post-Traumatic Stress Disorder (PTSD) checklist, Hospital Anxiety and Depression Scale, and questionnaires on general health, antibiotic-use, infective enteritis (IE), and healthcare utilization between June 2018 and April 2020.

A total of 858 Veteran responded, with 28.4% (n = 244) met the Rome IV IBS (47.5% IBS with diarrhea [IBS-D], 16.8% IBS with constipation [IBS-C], 33.6% mixed-IBS [IBS-M]).

An IBS was associated with greater anxiety and depression and a lower quality of life (all 

Patients with IBS more commonly had provisional post-traumatic stress disorder, IE, and bowel problems following antibiotic use (all 

 <0.001), as were multiple doctor visits (

After comparing results across patients with IBS subgroups and a control group, the investigators found overall associations of psychological comorbidities (

Patients with IBS-C also had the highest anxiety and depression scores, PTSD, multiple doctor visits, hospitalizations, and bowel problems after IE.

After conducting an adjusted analyses, the investigators found IBS was linked with anxiety (OR, 3.47), depression (OR, 2.88), lower quality of life, PTSD (OR, 3.09), IE (OR, 4.44), bowel problems after antibiotics (OR, 1.84), multiple doctor visits (OR, 2.08), and hospitalizations (OR, 1.78) (all 

“IBS is prevalent among Veterans and has a measurable impact on individuals and healthcare resources,” the authors wrote. “Veterans with IBS may experience significant psychological impairment.”

There is considerable disease burden for patients with 

irritable bowel syndrome with constipation

 (IBS-C) that was only exacerbated by the COVID-19 pandemic.

2021 Digestive Disease Week (DDW) Virtual Meeting

, a team of researchers led by Brian E. Lacy, MD, PhD, Gastroenterology, Neurogastroenterology, the Mayo Clinic, examined how the pandemic shaped disease presentation and health care utilization.

The researchers used a sampling of 130 IBS-C patients with 130 control patients between August and October 2020 and found more than a third of surveyed IBS-C patients indicated worsening symptoms during the duration of the pandemic and a quarter of patients cancelling health care visits during the study period.

The investigators also found 46% of IBS-C patients did not seek healthcare in the previous year because of their symptoms.

However, more IBS-C patients reported a higher proportion of moderate-to-severe anxiety and depression and a lower health-related quality of life.

The Prevalence, Humanistic Burden, and Healthcare Impact of Irritable Bowel Syndrome (IBS) Among United States Veterans

Articles

Patients with IBS more commonly had provisional post-traumatic stress disorder, IE, and bowel problems following antibiotic use.

IBS Prevalence High Among Veterans

New results from a real-world, clinical cohort study report positive long-term effectiveness and safety of adalimumab in patients with 

The findings additionally suggest that although relapse can occur, most patients achieved inactive disease or remission after cessation of adalimumab.

“This large retrospective clinical cohort study showed a favorable long-term effectiveness of adalimumab in uveitis patients, with an estimated recurrence free relapse time of the worst eye of more than 3 years and with an acceptable side effect profile,” wrote study author P. Martin van Hagen, MD, PhD, Erasmus University Medical Centre.

Recent studies with long-term follow-up have reported adalimumab as well-tolerated in patients with uveitis, but they did not address reasons for loss of effectiveness, how often antidrug antibodies were formed, and the relapse rate after adalimumab cessation.

Van Hagen and colleagues evaluated the long-term effectiveness of adalimumab and determined the reasoning behind the above factors. The retrospective study included all patients with uveitis treated with the agent for noninfectious uveitis who visited 2 tertiary care centers in Rotterdam, the Netherlands.

Patients started with subcutaneous adalimumab with a ≥40 mg biweekly dose, though some started with a 80 mg dose at baseline and 40 mg after 1 week in case of severe inflammation. Dosage can be adjusted by the treating physician based on response to therapy.

The study’s primary outcome consisted of the effectiveness of adalimumab, measured by the number of participants who achieved inactive disease or remission and by the relapse-free survival. Other outcomes were the percentage of patients with inactive disease at 6 months, 1 year, 3 years, 5 years, and 10 years as well as the number of patients experiencing side effects.

Data show uveitis was active in 244 of the 341 patients (72%) when starting adalimumab between May 2004 - September 2020. Inactive disease or remission was achieved in 298 of the 341 patients (87%).

Moreover, the majority of patients (72%) achieved inactive disease, while 51 patients (15%) achieved remission after discontinuing treatment. In total, 178 patients (86%) reached inactive disease and continued treatment with adalimumab at the end of follow-up, according to investigators.

Investigators noted the survival analysis revealed that the median time to the first relapse was 3,4 years (95% confidence interval [CI], 2.7 - 4.2). They additionally detected adalimumab antibodies in 40 of 115 patients (35%), measured 21 months after the start of adalimumab.

The antibodies were associated with lower adalimumab levels and observed more often in patients on adalimumab monotherapy (

The most common reason for discontinuation of adalimumab was disease inactivity (57 of 341, 15%), followed by nonresponse to the treatment (10 of 341, 2.9%), relapse of inflammation (27 of 341, 7.9%), and adverse events and complications (43 of 341, 13%).

“More prospective studies are necessary to elucidate the formation of antibodies, to observe whether co-medication can prevent antibodies, and to determine whether continued treatment with adalimumab at an increased dosage can be successful,” van Hagen added.

Long-Term Follow-up of Patients With Uveitis Treated With Adalimumab: Response Rates and Reasons for Discontinuation of Therapy

A total of 178 patients achieved inactive disease while continuing adalimumab, and 51 patients maintained remission after discontinuing adalimumab.

Long-Term Effectiveness of Adalimumab Reported in Patients with Noninfectious Uveitis

 who discontinued conventional systemic agent treatment had a reduced risk of depression, anxiety and adjustment disorder after receiving tumor necrosis factor (TNF) inhibitors or ustekinumab, a recent study found.

The retrospective cohort study included data from Quebec health administration databases on adults diagnosed with psoriasis between 1997 and 2015.

It included 1333 patients with psoriasis, including 183 treated with TNF inhibitors or ustekinumab, 625 current users of conventional systemic agents (CSA) and 525 previous CSA users.

Patients with moderate-to severe psoriasis who received TNF inhibitors or ustekinumab after failing CSA treatment had a 52% reduced risk of depression, anxiety and adjustment disorder than those who had discontinued CSA treatment (hazard ratio [HR], 0.48; 95% CI, 0.28 - 0.93), the study found. Among those who continued CSA treatment, a nonsignificant reduction in risk of mental health disorders was observed (HR, 0.48; 95% CI, 0.28 - 0.93).

Patients with psoriasis are at higher risk of depression, anxiety and adjustment disorder than the general population. Biologic agents have been more effective than conventional systemic agents, such as methotrexate, in improving psoriasis, trials have shown.

"Randomized controlled trials have found a decreased risk of mental health disorders with TNF inhibitors or ustekinumab compared to CSA and placebo in patients with moderate to severe psoriasis," first author Raymond Milan, MSc, of McGill University told 

However, the risk of mental health disorders was not previously compared among patients who received TNF inhibitors or ustekinumab after having failed CSA versus those who continued on CSA and those who discontinue CSA treatment for any reason."

“One would assume that patients receiving a TNF inhibitor or ustekinumab after failing CSA should be at higher risk of mental health outcomes than those who continue using CSA (presumably did not fail CSA) or using CSA (presumably no longer needed treatment),” he said. “However, my findings suggested otherwise, which is reassuring for those who use TNF inhibitors or ustekinumab, but disturbing for those who discontinue CSA treatment, as some seem to have discontinued because of CSA failure.”

The study was consistent with previous randomized controlled trials and observational studies. Further research is needed to determine the reason for discontinuation of CSA, including whether they may contribute to mental health improvement or deterioration.

“Those who discontinue because of CSA failure or mental health issues, should be offered TNF inhibitors or ustekinumab treatment if not contraindicated in them for health reasons,” Milan said. “In addition, on the health care system level, improving access to biologic agents for patients with moderate-to-severe psoriasis at high risk of CSA failure may save them the burden of going through a failed treatment experience and help improve their psoriasis outcomes, mental health outcomes and quality of life faster, especially since biologic agents are known for being more effective than CSA.”

Limitations of the study include a lack of data on psoriasis severity, health-related quality of life or physician advocacy for access to biologics. The study also didn’t assess biologic agents individually or consider switches in treatment.

“Future studies should include patients receiving newer generation of biologic agents such as interleukin 23 and 17 inhibitors,” Milan said. “Future studies should also be multi-province to increase the sample size, which will allow the study of the risk of mental health across different systemic agents.

Milan addtionally proposed a mediation analysis in order to determine any direct association between biologic agents and mental health outcomes—or if the link is indirectly related to quality-of-life and skin clearance outcomes.

"This type of study will determine the additional risk of having depression, anxiety and adjustment disorder in patients who have versus those who have not improved quality of life and/or skin clearance and will help understand if these clinical measures are full, partial or are not mediators in the association between biologic agents and mental health outcomes," he said.

Depression, anxiety and adjustment disorder among patients with psoriasis receiving systemic agents: A retrospective cohort study in Quebec, Canada

Biologic agents may reduce the risk of mental health disorders among patients with moderate-to-severe psoriasis who discontinued treatment with conventional systemic agents, researchers in Canada found.

Biologic Agents May Reduce Risk of Mental Health Disorders in Some Patients with Psoriasis

Mitapivat (Pyrukynd) has been undergoing investigation for the treatment of both α-thalassemia and β-thalassemia, which are part of a group of 

 that occur when the synthesis of one or more of an individual's hemoglobin chain is defective. 

According to the recently published study, patients with non-transfusion-dependent thalassemia (NTDT) can still result in a heavy burden of comorbidities. With no approved disease-modifying therapies for these patients, a team of investigators set out to evaluate the safety and efficacy of mitapivat, a pyruvate kinase activator.

Data from this phase 2 study revealed that the efficacy and safety results support the continued investigation of the therapy as a primary treatment for adults with either α-thalassemia or β-thalassemia who are not dependent on transfusions. 

Kevin H. M. Kuo, MD, Division of Haematology, University of Toronto, and investigators conducted an open-label, multicenter, phase 2 study in which they recruited patients from 4 academic clinical study sites in California, Massachussettes, Toronto, ON, and London, UK. 

Patients who were 18 years or older and diagnosed with non-transfusion-dependent thalassemia, including β-thalassemia with or without α-globin gene mutations, hemoglobin E β-thalassemia, or α-thalassemia, and a baseline hemoglobin concentration of 10.0 g/dL or lower.

Investigators assessed participating patients over a span of 24 weeks in which mitapivat 50 mg was administered orally twice daily for the first 6 weeks. The following 18 weeks consisted of an escalation period with a total of 100 mg administered twice daily. 

The primary endpoint focused on a hemoglobin response of greater than or equal to 1.0 g/dL in hemoglobin concentration when compared to baseline. This had to be maintained for one or more assessements between week 4 and week 12.

The timeline for study participation was December 2018-February 2020, in which 20 of 27 patients were enrolled. There were 15 (75%) with β-thalassemia and 5 (25%) with α-thalassemia, who then received mitapivat. The median age of patients was 44 years old with most (75%) being female. Of the participating patients 10 (50%) identified as Asian. 

Investigators stated that a hemoglobin response (

<0.0001) was observed in 16 (80%) patients. This included all 5 patients with α-thalassemia and 11 (73%) of 15 with β-thalassemia. The most frequently documented treatment-emergent adverse events were initial insomnia in 10 patients (50%), dizziness in 6 (30%), and headache in 5 (25%). No fatalities occurred during the study period.

Treatment-emergent events occurred in 17 (85%) patients, though only 13 of those were considered to be treatement related. There was a serious adverse event, where a patient presented with grade 3 renal impairment, but was considered unrelated to the therapy in question. This patient discontinued treatment. 

"These efficacy and safety results support the continued investigation of mitapivat for the treatment of both α-thalassaemia and β-thalassaemia," investigators concluded. 

Safety and efficacy of mitapivat, an oral pyruvate kinase activator, in adults with non-transfusion dependent α-thalassaemia or β-thalassaemia: an open-label, multicentre, phase 2 study

Data from this phase 2 study revealed that the efficacy and safety results support the continued investigation of mitapivat as treatment for adults with either α- or β-thalassemia who are not dependent on transfusions.

Phase 2 Data Support Continued Evaluation of Mitapivat for Alpha, Beta Thalassemia

New findings suggest a strict adherence to COVID-19-related guidelines for intravitreal anti-VEGF treatment for 

 was associated with better visual outcomes.

However, the study based in France reported a relatively low rate of adherence patients (40.7%) to the French Society of Ophthalmology intravitreal injection guidelines during the COVID-19 lockdown.

“Non-adherent patients were at greater risk of visual loss, confirming the need to maintain intravitreal injections in the event of a pandemic,” wrote study author Catherine Creuzot-Garcher, Service d’Ophtalmologie, CHU. “This study gives insight into patient profiles  at higher risk of non-adherence and could help identify the target population for preventive information.”

Due to few patients adhering to guidelines, Creuzot-Garcher and colleagues aimed to evaluate the impact of lockdown on visual outcomes in patients treated with intravitreal injections of anti-VEGF agents for macular diseases, particularly age-related macular degeneration (AMD).

Data from all patients scheduled for intravitreal injections of VEGF inhibitors during the lockdown from March - May 2020 were collected from 18 centers in France. Those who were not scheduled to be injected during this period were not included in the study.

Investigators collected data on the delay between initially planned and the real timing of the injection during the lockdown and visual acuity (VA) at 4-months post-lockdown. They defined three groups according to the guideline-adherence:

Non-strict adherence with delayed intravitreal injections (adherence group, NA+)

Non-adherence without any injection during lockdown (adherence, NA–)

The main objective was to measure the effect of lockdown and society guideline adherence on visual acuity change at 4 months, with secondary objectives assessing the influence of macular disease etiology on the visual outcome and identifying the risk factors for intravitreal injection, poor adherence and visual loss.

The study included a total of 3020 eyes of 3020 patients (59.8%) with a mean age of 77.8 years. Data show the mean visual acuity before the lockdown was 64.5 ± 18.4 ETDRS letters. A total of 2030 eyes (67.7%) were treated for neovascular AMD.

The findings suggest the rate of strict adherence to French guidelines (A) was 40.7% (n = 1230) of patients compared to non-adherence (NA+ and NA–) in 59.3% of patients (n = 1790).

For patients who attended a visit, the mean VA change at 4 months after the lockdown was –0.4 ± 6.8 ETDRS letters with a mean visual acuity at 4 months of 64.7 ± 18.9 ETDRS letters.

Investigators observed a significant difference in absolute visual acuity between groups at 1 and 4 months after lockdown. Data show 64.6 ± 18.9 ETDRS letters for group A versus. 60.4 ± 19.5 for the NA− group at 1 month. At 4 months, the data show 64.9 ±  19.0 vs. 61.4 ± 20.5 at 4 months in each group (

Moreover, the findings suggest the NA– group ​​(−1.5 ± 6.9 letters) had significantly lower mean visual acuity change 4 months after lockdown than the NA+ group (−0.3 ± 6.9 letters) and the A group (−0.2 ±  6.7  letters; 

Through multivariable analysis, factors associated with non-adherence included older age, hospital treatment, treat-and-extend protocol, high viral incidence areas, and longer intervals between injections, as well as those who lived in densely populated areas.

IMPACT study: Impact of adherence to anti-VEGF intravitreal injections for macular disease during COVID 19-related confinement in France

A smaller decrease in VA at 4 months was observed in the guideline adherent groups when compared with the non-adherent groups. 

Intravitreal Injection Adherence Associated with Better VA During COVID-19 Pandemic 

Dosage tapering for persons receiving long-term 

 may slightly increase risk of overdose or suicide compared to stable-dose regimens, according to new data.

In findings from a comparative effectiveness trial including a cohort of 200,000 individuals, a team of US investigators reported that both tapering and abruptly discontinuing prescribed opioid doses are associated with greater incidence of major use disorder-related adverse events. The data suggest policies requiring tapering of long-term opioid regimens or hard duration limits on regimens may not be as beneficial as suggested.

The team led by Marc R. Larochelle, MD, MPH, of the clinical addiction research and education unit of the Boston University School of Medicine, sought to interpret the link between opioid tapering or abrupt discontinuation with risk of overdose and suicides among patients without history of opioid misuse receive stable long-term prescription care. As they noted, the Centers for Disease Control and Prevention (CDC) released chronic pain opioid prescription guidelines in 2016 that recommended tapering dosages in instances when the addictive therapy’s benefits no longer outweighed its harms.

Since the recommendation, it’s become a common practice in various health systems and in US state legislation to enact “stringent dose limits that were applied with few exceptions regardless of individual patients’ risk of harms.” As such, opioid prescribing and dosage rates declined in the US.

However, observational studies and systematic reviews have identified potential risks associated with the practice—albeit with limitations in data and outcomes.

“We sought to overcome these limitations using data from a large claims database to compare the association of opioid tapering, abrupt discontinuation, or stable opioid therapy with opioid overdose or suicidal ideation or attempt among patients receiving stable long-term opioid dosages without signs of OUD or opioid misuse,” they wrote.

Larochelle and colleagues used a trial emulation strategy through a large national claims database to observe adult patients ≥18 years old receiving stable long-term opioid therapy without evidence of misuse from 2010 - 2018. They compared the 3 dosing strategies of stable dosing, abrupt discontinuation, or tapering—defined as a dosage reduction of ≥15%.

The team defined time to opioid overdose or suicide event per ICD-9 and ICD-10 in the medical claims data over 11 months of individual patient follow-up. Outcomes were adjusted for baseline confounders.

The final cohort included 199,386 individuals; mean age was 56.9 years old and a majority (57.6%) were aged 45-64 years old. Another 45.1% were men. Approximately one-quarter (415,123) had qualifying long-term opioid therapy episodes; 87.1% were considered stable, 11.1% were considered a taper, and 1.8% were considered an abrupt discontinuation.

Investigators observed a cumulative 0.96% incidence of opioid overdose or suicide events among stable-dose patients at 11 months (95% CI, 0.92 – 0.99), a 1.10% incidence among tapered-dose patients (95% CI, 0.99 – 1.22), and a 1.28% incidence among abrupt-discontinuation patients (95% CI, 0.93 – 1.38).

“We did not identify a difference in the risk of overdose or suicide events between abrupt discontinuation and stable dosage, although the smaller number of episodes categorized as abrupt discontinuation may have reduced precision,” they wrote. “The findings were robust to secondary and sensitivity analyses.”

While the data showed a more neutral association of opioid tapering with suicide or overdose incidence relative to previous trial, investigators stressed it was not a “protective association.” They concluded that evidence does not support tapering opioid dosages for the goal of reducing long-term stable opioid therapy harm risks.

“Policies establishing dosage thresholds or mandating tapers for all patients receiving long-term opioid therapy are not supported by existing data in terms of anticipated benefits even if, as we found, the rate of adverse outcomes is small,” Larochelle and colleagues wrote. “Health systems and clinicians must continue to develop and implement patient-centered approaches to pain management for patients with established long-term opioid therapy.”

Comparative Effectiveness of Opioid Tapering or Abrupt Discontinuation vs No Dosage Change for Opioid Overdose or Suicide for Patients Receiving Stable Long-term Opioid Therapy

New comparative effectiveness data go against CDC recommendations for tapering or abruptly ending long-term opioid prescription.

Long-Term Opioid Tapering Does Not Benefit Suicide, Overdose Risks

 in a rural population in China reported a 0.4% average annual incidence rate among subjects 40 years of age and older over a 5-year period.

Factors including older age, higher intraocular pressure (IOP), and vertical cup disc ratio (VCDR) ≥0.60 at baseline were linked to the highest risk of glaucoma development.

“When extrapolating the incidence rate to the national population of China, we estimated that, annually, approximately 2.97 million people aged 40 years or older will develop primary glaucoma,” wrote study author Ningli Wang, MD, PhD, Beijing Institute of Ophthalmology, Beijing Tongren Eye Center, Beijing Tongren Hospital.

Understanding the prevalence of eye disease may be useful in advocating for eye care resources and blindness prevention, Wang and colleagues noted. It may be more useful to determine both incidence and related risk factors to offer effective interventions to those at risk of the disease, they added.

The population-based cohort study reported important data for the 5-year incidence of primary glaucoma, including primary open-angle glaucoma (POAG) and primary angle closure glaucoma (PACG), and related risk factors obtained from follow-up of the Handan Eye Study (HES).

Participants aged 30 years or older without glaucoma at baseline attended standardized eye examinations at baseline and follow-up examination after a 5-year interval in the HES. Investigators noted the 5–year cumulative incidence of primary glaucoma was person-based and was defined as the development of primary glaucoma with definite and probable certainty in ≥1 during the 5-year follow-up.

The study performed univariate and multivariable logistic regression analyses to identify the baseline risk factors that could predict the incidence of glaucoma. The at-risk population in the study included 5184 participants (82.0%), with a median age of 52.0 years at baseline and 57.6 at follow-up.

In the 5-year follow-up, newly incident primary glaucoma developed in 82 subjects (crude incidence, 1.6%; 95% confidence interval [CI], 1.2% – 1.9%). Data show the age- and gender-standardized incidence of glaucoma among those aged ≥40 years was 2.1% and the annual age- and gender-standardized incidence was 0.4%.

In comparison to those who did not develop glaucoma, patients with developed cases were more likely to be older (

 <.001), have a higher systolic blood pressure (

 = 0.008). As well, patients had a lower education level (

According to the univariate and multivariate logistic regression analyses, baseline risk predictors associated with incidence glaucoma were older age (odds ratio [OR], 1.06; 95% CI, 1.04 - 1.09; 

 <.001), higher IOP (OR, 1.11; 95% CI, 1.02 - 1.20; 

 = .017) and a VCDR ≥0.60 (OR, 5.30; 95% CI, 3.22 - 8.73; 

Data suggest that for each year of older age, the risk of primary glaucoma increased by 1.2% per year. Then, for each mmHg higher IOP, the risk of primary glaucoma increased by 2.0% per year.

“However, it remains to be determined in future research whether aging itself is truly a risk factor for glaucoma development or if changes to the optic nerve head with age make the eye more vulnerable to high IOP, thereby producing an underlying risk factor for glaucoma,” Wang added.

Five-year incidence of primary glaucoma and related risk factors – The Handan eye study

New data on the incidence of glaucoma among rural subjects ≥40 years old in China report a 0.4% annual rate. 

Factors Linked to Primary Glaucoma Incidence Include Older Age, Higher IOP 

Carla Zema, PhD, and a team of investigators conducted retrospective research to further the understanding of flares in patients with 

 beyond single-center case studies which previously made up the extent of the topic's research.

The study revealed an unmet need among patients with this rare variation of psoriasis. Patients experience intermittent flares of generalized and localized noninfectious, neutrophil-containing pustules with associated erythema. The generalized flares are accompanied by systemic symptoms like fever, chills, malaise, anorexia, nausea, and severe pain. 

This can lead to patients requiring emergency care, as these flares can last for months at a time and cause life-threatening complications. While mortality estimates vary, a recent review across 5 studies reported a range of 5%-32%. A multitude of studies have shown these patients face increased healthcare costs and a higher comorbidity burden compared with patients with plaque psoriasis and the general population. 

Adult patients with generalized pustular psoriasis were included in this retrospective cohort sudy with the aim to assess GPP flares and treatment, as well as differences among patients with and without flares documented in the US electronic health records.

Investigators gathered data occurring in health records between July 2015-June 2020. Index GPP diagnosis was the initial occurence in electronic health records without a coded history of the disease for at least 6 months prior. They identified flare episodes by using an algorithm based on diagnosis coding, care setting, type of clinician, GPP disease terms, and flare terms and attributes. 

Main outcomes and measures included flare episodes that were characterized by frequency of presentation in each patient and subsequently the care setting, type of managing specialist, associated symptoms, and the type of treatment implemented before, during and after the episode. 

Investigators stratified patient data based on documented flares, and then analyzed comparisons between the groups, accounting for demographic charateristics, comorbidity burden, health care use, and treatments. 

According to the resutls, 1535 patients with generalized pustular psoriasis were identified, with 66.3% women, and a mean age of 53.4 years. Flares were documented in 271 of patients, with a collective total of 513 flares. Those with flares had a 34% higher mean Charlson Comorbidity Index score compared to those without, and were almost 3 times more likely to have inpatient visits.

Additionally, patients who experienced flares were more than twice as likely to visit the emergency department (ED) and had an increased use of almost all treatment classes. The absence of dermatological treatment for 30 days before, during, or after a flare episode was observed in almost a quarter of episodes (24%). 

Among flares identified in outpatient (53%), inpatient (36%), and emergency department (9%) settings, the most utilized treatments were topical corticosteroids (35%), opioids (21%), other oral treatments like methotrexate, cyclosporine, and tacrolimus (13%), and oral corticosteroids (11%). 

"This cohort study suggests that there is significant unmet need for the treatment of GPP and its flares, as evidenced by patients seeking treatment in inpatient and ED settings, as well as the lack of advanced treatments," investigators concluded. 

Understanding Flares in Patients With Generalized Pustular Psoriasis Documented in US Electronic Health Records

Among flares identified in outpatient (53%), inpatient (36%), and emergency department (9%) settings, the most utilized treatments were topical corticosteroids (35%), opioids (21%), and other oral treatments.

Investigators Highlight Unmet Needs of Patients with Generalized Pustular Psoriasis

Half of health care providers in Romania reported 

 during the COVID-19 pandemic, according to a recent survey that detailed inadequate management of the condition associated with prolonged use of medical face masks.

The study included an online-based cross-sectional survey of health care workers at medical centers throughout Romania between December 17, 2020, and February 17, 2021.

Among 134 survey respondents, 50% reported current acne lesions, with 56.7% requiring treatment. Most of those (65.8%) self-medicated, while only 34.2% sought medical advice and 9% reported using anti-acne medication but identified as not having acne.

“Our results from a national survey suggest inadequate treatment of acne in relation to medical face mask usage,” the study authors, led by Stefana Cretu, MD, of Carol Davila University of Medicine and Pharmacy in Bucharest, Romania, wrote. “Similar to how all workers receive training and education concerning other occupational hazards and proper (personal protective equipment [PPE]) usage, (health care providers) should receive clear training, adequate screening, and treatment for adverse reactions relating to PPE use.”

Salicylic acid was used by most participants (61.36%) who received treatment, followed by topical retinoids (40.91%), benzoyl peroxide (20.45%) and azelaic acid (18.8%). Four participants (9.09%) used topical antibiotics. 

Most common associations between treatments were retinoids and salicylic acid (18.18%), retinoids and benzoyl peroxide (13.64%), salicylic acid and benzoyl peroxide (13.64%) and azelaic acid with salicylic acid (9.09%). The study also found that only 14.2% of health care providers were open to accessing telemedicine as patients.

Respondents were mostly women (86.6%), doctors (79.9%) and millennials (74.62%). Those exhibiting acne reported black dots (59.7%), red papules (54.5%), rash (44.8%), erythema (41.8%), nodules (29.1%), itch (27.6%) and scales (26.9%).

“The participants from our cohort reported a high emotional impact of the lesions, and those who were more affected tended to seek help,” investigators wrote. “Few individuals reported acne treatment despite not self-identifying as having acne; one possible explanation could be disagreements regarding minimal criteria for acne diagnosis.”

Those who reported higher emotional impact of the acne lesions were more likely to seek treatment.

Multivariate analysis was used to adjust for other lifestyle factors that may influence acne.

Prolonged use of medical face masks contributes to acne because of friction, occlusion, moisture, increased temperature and changes to cutaneous microbiota. The resulting discomfort may lead to improper use of face masks, underscoring the need to properly address skin conditions, the study authors noted.

Along with treatment, other possible measures that could lessen the effects of prolonged medical mask use include shorter shifts, frequent breaks, rest in non-contaminated areas and telemedicine.

 and care during the pandemic, and a study in 2020 found that teledermatology was more 

“Reluctance regarding the use of telemedicine by the HCP from our cohort in their capacity as patients was surprising, considering that most of the cohort consisted of young individuals,” investigators wrote. “Although not evaluated in our study, this hesitancy may also be due to a preference for a physical consultation.”

Limitations of the study include its small size, lack of diversity in gender and age and the absence of a clinical evaluation of participants. The study also didn’t analyze the type of face masks used.

The study adds to ongoing research related to skin conditions during the pandemic. A recent 

 detailed mask-induced skin changes, including acne, pigmentation and seborrhea. That study found a significant association between skin changes among doctors using masks for more than 6 hours a day (69.7%) compared with those using masks for less than 6 hours a day (30.3%).

Acne care in health care providers during the COVID-19 pandemic: A national survey

The COVID-19 pandemic has drawn attention to acne associated with the prolonged use of medical face masks and raised awareness about the need for adequate screening, training and treatment of the condition.

Half of Health Care Providers Report Acne During COVID-19 Pandemic

neovascular age-related macular degeneration (nAMD)

 supported controlled studies that suggest it may not be necessary to achieve absence of subretinal fluid (SRF) for good visual outcomes with intravitreal anti-vascular endothelial growth factor (anti-VEGF) treatment.

Chang-Hao Yang, MD, PhD, Department of Opthamology, National Taiwan University, Taipei, Taiwan, and colleagues cited studies that have examined alternative treatment regimens, such as treat-and-extend (T&E) and pro re nata (PRN), to reduce the number of injections without compromising visual gains; but pointed out that few have addressed the impact of fluid tolerance on the treatment outcomes of nAMD in real world treatment settings..

"Our primary objective in the current study was to determine whether fluid tolerance in the implementation of intravitreal aflibercept treamtent affects anatomical or functional outcomes in nAMD patients presenting recurrent or persistent retinal fluid," they wrote.

The investigators retrospectively collected medical records of patients at a single treatment center, with a total of 90 treated eyes in 90 patients meeting criteria for inclusion in the study between January 2016 and July 2019. 

Patients had demonstrated persistent or recurrent retinal fluid from month 3 to month 18. Those with less than 18 months of follow-up were excluded from the study. Also excluded were patients with polypoidal choroidal vasculopathy, epiretinal membrane, diabetic retinopathy, or maculopathies other than nAMD. If both eyes of a patient met inclusion criteria, only the more affected eye was included in the study.

Patients were treated under the discretion of the attending physician, most with an extended PRN regimen. Inference of "tolerance" of retinal fluid, either intraretinal (RF) or SRF, was based on whether or not the patient received anti-VEGF injection when retinal fluid was detected at their examination.

Levels of tolerance were calculated from the duration between clinic visits before treatment was deemed necessary to maintain visual outcomes. A "fluid tolerance ratio" was determined from the summed duration of the fluid-tolerant periods divided by the total duration of fluid retention throughout the entire follow-up period. Fluid tolerance was categorized as strict (zero tolerance, requiring therapy to achieve dry retina with absence of both SRF and IRF); intermediate (tolerance ratio of less than 30%), and relaxed (tolerance ratio of 30% or greater).

The primary outcomes were best-corrected visual acuity (BCVA) and central retinal thickness (CRT), including retinal fluids, measured at baseline and at visits at 3, 6, 12 and 18 months.

Yang and colleagues reported that the relaxed group required fewer injections than the strict group (4.92 vs 7.50 injections) and presented a similar reduction in retinal thickness (-57.7 vs -71.65 μm), while having similar final visual acuity.

"A fluid-tolerant approach provides comparable gains in visual acuity," Yang and colleagues wrote. They noted that "reducing the number of injections may also improve adherence to therapy."

The investigators point out that retinal fluid is not always associated with neovascular activity, and cite several studies detecting the presence SRF or IRF without active vascular leakage. They also notethat there is some risk that additional injections could exacerbate the process of degeneration.

Yang and colleagues encouraged consideration of the different circumstances which may contribute to presence and tolerance of residual retinal fluid, and the possible feasibility of fewer anti-VEGF injections.

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