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

Articles

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.

The impact of retinal fluid tolerance on the outcomes of neovascular age-related macular degeneration treated using aflibercept: A real-world study

Higher tolerance of retinal fluid in neovascular AMD corresponded to needing fewer anti-VEGF treatment injections for same visual outcomes.

Tolerance of Some Retinal Fluid Requires Less Anti-VEGF Therapy

And the rates and severity of postpartum depression and postpartum anxiety has only increased during the COVID-19 pandemic.

Anita Clayton, MD, chair of psychiatry and neurobehavioral sciences at the University of Virginia School of Medicine, explained in an interview with 

 why many women are facing these postpartum concerns.

“So I’d say that women who do have postpartum depression often attribute it to other things,” Clayton said. “The baby is up in the night and they need to breastfeed it. That they aren’t getting much sleep. That they need to lose weight.”

2022 Annual Psychiatric Times™ World CME Conference

Clayton also discussed how critical it is for OBGYN doctors to collaborate with psychiatrists when an issue is identified.

“I think the area that OBGYN’s are most concerned about is postpartum depression from their mothers or just from neglect because the mother is depressed,” she said.

Clayton went on to say there is a recommended screening tool commonly used in the US for postpartum depression and there is also an intravenous treatment that has shown promise in this patient population.

Videos

Postpartum depression rates have increased since the COVID-19 pandemic.

Anita Clayton, MD: Women's Issues in Psychiatry

Identifying and forecasting when a patient might become 

 in San Diego on August 12, Michael Thase, MD, professor of psychiatry, Perelman School of Medicine, University of Pennsylvania, spoke about the need for more medications for treatment-resistant depression.

, Thase explained how there is a segment of the population that the existing medications just will not work for them.

“For many people depression is a short lasting somewhat limiting condition,” Thase said. “Sometimes people can’t get out of it.”

Thase said one of the risk factors for this type of depression is substance use, such as drugs and alcohol. And the COVID-19 only exacerbated some of those issues.

“Rates of depression have gone up during the pandemic,” Thase said. “And since one risk factor for becoming chronically depressed is not getting help and since the pandemic has challenged the treatment capability of society, more people are not only depressed but fewer people are getting help. I am fairly confident we are going to have trouble ahead.”

Alcohol, stress, drug use, and not seeking help are all risk factors for chronic depression.

Michael Thase, MD: Risk Factors for Chronically Depressed Patients

 is something that has become much more complex in recent decades.

Whether or not the drug has positive psychiatric effects can be largely based on the individual percentages of the 2 main compounds of marijuana--tetrahydrocannabinol (THC) and cannabidiol (CBD).

, John J. Miller, MD, Medical Director, Brain Health Website, Seacoast Mental Health Center and co-chair of the 

 in San Diego, explained how complicated the guidance for promoting cannabis is for patients with conditions like depression and anxiety.

“One of the biggest issues currently is that cannabis is a very vague and general term,” Miller said. “Back in the early 60s when it was being used recreationally it was from the original plant. Those strains of cannabis had about 2% THC and 2% CBD.”

Miller said the CBD molecule is the part that has shown efficacy in treating conditions like psychosis and anxiety, while also having inflammatory properties.

He also said 1 of the issues with current studies is they will use the term “cannabis” without breaking down the percentages of THC and CBD.

“A lot of the literature because it doesn’t differentiate the components of the cannabis it is hard to draw evidence based conclusions that we can apply clinically,” Miller said.

CBD has shown promise in treating anxiety and psychosis. 

John J. Miller, MD: Guidance on Cannabis Use in Psychiatry

There remains significant gaps in treatment for patients with 

, particularly when the disease is identified early.

 in San Diego on August 12, Christopher Schneck

University of Colorado HIV Clinic, talked about how we can improve treatment strategies when bipolar disorder is identified early.

“Really this is thinking about what groups who have not fully developed bipolar disorder can we stage an intervention,” Schneck said. “And thinking about both psychopharmaceutic interventions and psychotherapeutic interventions. There really isn’t much out there in the literature.”

In combat these gaps in care, Schneck said there have been a number of recent studies involving both adult patients with bipolar disorder and pediatric patients as well.

He also said studies have looked at siblings of patients with bipolar disorder.

“The way families interact with each other has a great influence on a child’s developmental process and ultimately the development or not of the mood disorder.”

Schneck said there is a 12 session model for treatment in which he will educate both the patient and families about the illness and how to effectively communicate with each other.

There remains a need for better treatments for bipolar disorder when it is identified early. 

Christopher Schneck, MD: Early Interventions for Bipolar Disorder

news page, resources on the topics of disease- and specialty-specific medical news and expert insight can be found. Content includes articles, interviews, videos, podcasts, and breaking news on health care research, treatment, and drug development.

All News

Latest News