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Parents say teens' time alone with pediatricians is important

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June 18, 2018 / 10:13 PM / Updated an hour ago

Parents say teens' time alone with pediatricians is important

(Reuters Health) – Most parents believe their adolescents should spend time alone with the pediatrician during routine visits to talk about any concerns or questions, according to a new study.

“Kids don’t always disclose their health information to doctors and parents, which means they try to negotiate serious health issues without a trusted adult,” said Dr. Melissa McKee of Albert Einstein College of Medicine in Bronx, New York.

McKee, who wasn’t involved with this study, has researched the challenges of providing confidential care to adolescents. Teens are more likely to seek health care and openly talk to doctors when they’re assured of privacy, particularly for issues related to sexual behaviors, substance use and mental health.

“Kids need a trusted adult as they transition from a setting where health decisions are typically made for them to adulthood when they’re completely in charge of their own health,” she told Reuters Health by phone.

Researchers at the Children’s Hospital of Philadelphia surveyed 91 parents and teens ages 14 to 17 who attended a routine wellness visit with a pediatrician. During a follow-up phone call two weeks after the visit, parents reported whether their child met with the pediatrician alone, rated the importance of alone time and talked about the barriers of adolescent-pediatrician communication.

Ultimately, 86 percent of adolescents had time alone for part of the wellness visit, ranging from five to 30 minutes. Fifty-three parents, or 58 percent, said this private time had “a lot” of importance, and another 25 parents (27 percent) ranked it a bit lower but still said it had “quite a bit” of importance. Parents of males were almost twice as likely to agree that alone time with the doctor was important. Parents also said communication barriers included rapport and familiarity with the pediatrician, privacy concerns, emotional comfort, trust and support.

“We need to start creating opportunities for kids to have autonomy with regard to health issues,” McKee said. “It’s not all or nothing at a certain age. They don’t suddenly become fully in charge of themselves.”

Future studies should focus on the gender difference, McKee added. She and colleagues found that moms with daughters, in particular, were nervous about losing the leadership role in health decisions and didn’t want their daughters to be exposed to certain topics related to sexuality.

“Some mothers believed certain conversations might even be a green light for (their daughters) to be sexually active,” she said. “The gender difference is a consistent pattern we see.”

To battle the barriers to communication with teens, some pediatricians implement mandatory alone time early and build it into annual visits as patients approach their teen years.

At age 10, for instance, doctors can begin talking to children about privacy and confidentiality in health care settings. Then at ages 11 and 12, kids can consider whether they’d like alone time with the doctor. By the teen years, pediatricians can build mandatory time into the visit, even a few minutes with the parent out of the room, said Dr. Joe Hagan of the University of Vermont College of Medicine in Burlington, Vermont.

Hagan, who wasn’t involved with this study, co-authored Bright Futures, a national health promotion and prevention initiative of the American Academy of Pediatrics, includes a section about the ways doctors can discuss privacy and confidentiality with children, as well as begin to build alone time into their appointments.

“If doctors in the same office are willing to set up mandatory alone time, it’s easy to move forward,” Hagan told Reuters Health by phone. “When everybody does it together, parents know to expect it and aren’t caught off guard.”

SOURCE: bit.ly/2yjsq2t Journal of Adolescent Health, online June 7, 2018.




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Marriage tied to lower risk of fatal heart attacks and strokes

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June 18, 2018 / 10:48 PM / Updated 24 minutes ago

Marriage tied to lower risk of fatal heart attacks and strokes

(Reuters Health) – People who are married may be less likely to develop cardiovascular disease or die from a heart attack or stroke than individuals who aren’t, a research review suggests.

Researchers examined data from 34 previous studies involving more than two million people. Overall, they found that compared to married people, adults who were divorced, widowed or never married were 42 percent more likely to develop cardiovascular disease and 16 percent more likely to develop coronary artery disease.

Unmarried people were also 43 percent more likely to die from heart disease and 55 percent more likely to die from strokes, researchers report in the journal Heart.

While the study wasn’t a controlled experiment designed to prove whether or how marriage might help improve heart health, there are many reasons marriage might have a protective effect including potentially more financial stability and social support, said senior study author Dr. Mamas Mamas of the University of Keele in the U.K.

“For example, it is well known that patients are more likely to take important medications after an event such as a heart attack or a stroke if they are married, perhaps because of spousal pressure,” Mamas said by email. “Similarly, they are more likely to take part in rehabilitation which improves outcomes after strokes or heart attacks.”

Having a spouse around may also help patients recognize early symptoms from heart disease or the start of a heart attack, Mamas added.

Marriage isn’t the biggest predictor of heart disease, however. Well-known risk factors like age, sex, high blood pressure, elevated cholesterol, smoking and diabetes account for about 80 percent of the risk, researchers note.

All of the studies in the current analysis were published between 1963 and 2015 and included people ranging in age from 42 to 77 from Europe, Scandinavia, North America, the Middle East, and Asia.

Divorce was associated with 33 percent higher odds of death from coronary heart disease and a more than doubled risk of death from strokes, the study found. Men and women who divorced were also 35 percent more likely to develop heart disease than married people.

Widows, meanwhile, were 16 percent more likely to have a stroke than married couples, but they didn’t appear to have an increased risk of heart attacks.

Even though previous research has linked marriage to better outcomes for patients with heart problems, the current study offers fresh evidence of the risk for people unmarried for different reasons, said Brian Chin, a psychology researcher at Carnegie Mellon University in Pittsburgh, Pennsylvania who wasn’t involved in the study.

“Given that previous work has suggested that the health benefits of marriage are significantly stronger for men than women, it was especially surprising that this study found no differences between men and women in how marital status affected cardiovascular disease risk,” Chin said by email.

Gender relations may still play a role in the different outcomes for married and unmarried patients, Dr. Stefania Basili of Sapienza University of Rome and colleagues write in an accompanying editorial.

“A wide range of behavioral factors, psychosocial processes, and personal and cultural factors can create, suppress or amplify underlying biological differences in cardiovascular disease,” Basili and colleagues write.

Limitations of the study include the lack of data on same-sex couples or the quality of marital relationships, researchers note.

It’s possible that single people might not take care of their heart health as much as married individuals, Mamas said.

Regardless of marital status, people can reduce their risk by leading a healthy lifestyle, not smoking, and getting regular physicals, Mamas added. Exercise is important, too.

“I often advise couples to exercise together because they are more likely to stick with it,” Mamas said. “Go to the gym together, run together or cycle together – doing activities together strengthens the relationship and improves both partners’ cardiovascular health.”

SOURCE: bit.ly/2ysMBey Heart, released June 18, 2018.




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Sjogren's Oral Drug Fails in Small Trial

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Medpage Today

Sjogren’s Oral Drug Fails in Small Trial

More than half of patients developed rashes

MedpageToday

  • by Senior Staff Writer, MedPage Today

AMSTERDAM — Leniolisib, an oral inhibitor of the lipid kinase PI3Kδ, failed to provide symptomatic improvements among patients with Sjogren’s syndrome in a small placebo-controlled trial reported here.

In a study that included 30 patients, the response curves for disease activity in patients randomized to leniolisib, 70 mg twice daily, and those receiving placebo did not differentiate at week 12 and the confidence intervals were overlapping, reported Thomas Dörner, MD, of Charité University Hospital in Berlin, at the annual European Congress of Rheumatology here, which is sponsored by the European League Against Rheumatism (EULAR).

Moreover, more than half of patients receiving the active treatment developed skin rashes, and in one, the rash was sufficiently severe to require hospitalization.

Current thinking about the pathogenesis of Sjogren’s syndrome suggests a substantial role for the intracellular kinase PI3Kδ for the formulation and maintenance of germinal centers in the inflamed glandular tissues. This kinase also is important in B-cell activation and antigen presentation as well as in the production of autoantibodies, T-cell activation, and toll-like receptor signaling. It also has critical downstream effects such as inhibiting the phosphorylation of AkT, which is required for the survival of immune cells, Dörner explained.

In an earlier study of healthy volunteers, leniolisib showed good pharmacokinetic properties and demonstrated effects on phosphorylated AkT in ex vivo-stimulated B cells.

The patients included in the current study were mostly women; mean age was 48. They had clinically active disease, with EULAR Sjogren’s Syndrome Disease Activity Index (ESSDAI) scores at baseline of at least 6 and EULAR Sjogren’s Syndrome Patient Reported Index (ESSPRI) scores of at least 5. The mean ESSDAI scores at baseline ranged from 9.1 to 10.3, and all participants had some residual salivary flow.

They were randomized in a 2:1 ratio to receive the active treatment or placebo for 3 months, at which time the response curves for both ESSDAI and ESSPRI did not clearly differentiate. There were slight improvements, albeit not statistically significant, in dryness, pain, and fatigue, on the mental and physical components of the Short Form-36 Health Assessment Questionnaire, and in lachrimal function.

However, analysis of the biologic effects of the compound confirmed target engagement, with decreases in phosphorylation of AkT in B cells only in the active treatment group. There also was a significant decrease in serum levels of the chemokine CXCL13, which plays a key role in germinal center maintenance, and in circulating levels of follicular T-helper cells.

“These results seem a little disappointing,” said the session moderator David Isenberg, MD, of University College London, who was not involved in the study.

“A lot of patients with Sjogren’s present several years after they had had dryness of their eyes and mouth, saying they thought it was old age,” Isenberg said. “Do you think part of the problem with Sjogren’s trials is that by the time they present, many patients had damage so it’s impossible to change anything?” he asked.

Dörner said that can’t be ruled out, but there could also be functional abnormalities involved that have not been shown to be amenable to therapeutics. “And in terms of glandular function, we have not seen improvements even with high doses of corticosteroids, which I consider a reference intervention,” he said.

“In addition, we probably are not patient enough, and need longer treatment,” he concluded.

Dorner reported no conflicts of interest.

1969-12-31T19:00:00-0500

last updated

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Accessibility Statement

At MedPage Today, we are committed to ensuring that individuals with disabilities can access all of the content offered by MedPage Today through our website and other properties. If you are having trouble accessing www.medpagetoday.com, MedPageToday's mobile apps, please email legal@ziffdavis.com for assistance. Please put "ADA Inquiry" in the subject line of your email.

Medpage Today

Sjogren's Oral Drug Fails in Small Trial

More than half of patients developed rashes

MedpageToday

  • by Senior Staff Writer, MedPage Today

AMSTERDAM -- Leniolisib, an oral inhibitor of the lipid kinase PI3Kδ, failed to provide symptomatic improvements among patients with Sjogren's syndrome in a small placebo-controlled trial reported here.

In a study that included 30 patients, the response curves for disease activity in patients randomized to leniolisib, 70 mg twice daily, and those receiving placebo did not differentiate at week 12 and the confidence intervals were overlapping, reported Thomas Dörner, MD, of Charité University Hospital in Berlin, at the annual European Congress of Rheumatology here, which is sponsored by the European League Against Rheumatism (EULAR).

Moreover, more than half of patients receiving the active treatment developed skin rashes, and in one, the rash was sufficiently severe to require hospitalization.

Current thinking about the pathogenesis of Sjogren's syndrome suggests a substantial role for the intracellular kinase PI3Kδ for the formulation and maintenance of germinal centers in the inflamed glandular tissues. This kinase also is important in B-cell activation and antigen presentation as well as in the production of autoantibodies, T-cell activation, and toll-like receptor signaling. It also has critical downstream effects such as inhibiting the phosphorylation of AkT, which is required for the survival of immune cells, Dörner explained.

In an earlier study of healthy volunteers, leniolisib showed good pharmacokinetic properties and demonstrated effects on phosphorylated AkT in ex vivo-stimulated B cells.

The patients included in the current study were mostly women; mean age was 48. They had clinically active disease, with EULAR Sjogren's Syndrome Disease Activity Index (ESSDAI) scores at baseline of at least 6 and EULAR Sjogren's Syndrome Patient Reported Index (ESSPRI) scores of at least 5. The mean ESSDAI scores at baseline ranged from 9.1 to 10.3, and all participants had some residual salivary flow.

They were randomized in a 2:1 ratio to receive the active treatment or placebo for 3 months, at which time the response curves for both ESSDAI and ESSPRI did not clearly differentiate. There were slight improvements, albeit not statistically significant, in dryness, pain, and fatigue, on the mental and physical components of the Short Form-36 Health Assessment Questionnaire, and in lachrimal function.

However, analysis of the biologic effects of the compound confirmed target engagement, with decreases in phosphorylation of AkT in B cells only in the active treatment group. There also was a significant decrease in serum levels of the chemokine CXCL13, which plays a key role in germinal center maintenance, and in circulating levels of follicular T-helper cells.

"These results seem a little disappointing," said the session moderator David Isenberg, MD, of University College London, who was not involved in the study.

"A lot of patients with Sjogren's present several years after they had had dryness of their eyes and mouth, saying they thought it was old age," Isenberg said. "Do you think part of the problem with Sjogren's trials is that by the time they present, many patients had damage so it's impossible to change anything?" he asked.

Dörner said that can't be ruled out, but there could also be functional abnormalities involved that have not been shown to be amenable to therapeutics. "And in terms of glandular function, we have not seen improvements even with high doses of corticosteroids, which I consider a reference intervention," he said.

"In addition, we probably are not patient enough, and need longer treatment," he concluded.

Dorner reported no conflicts of interest.

1969-12-31T19:00:00-0500

last updated

Comments

Accessibility Statement

At MedPage Today, we are committed to ensuring that individuals with disabilities can access all of the content offered by MedPage Today through our website and other properties. If you are having trouble accessing www.medpagetoday.com, MedPageToday's mobile apps, please email legal@ziffdavis.com for assistance. Please put "ADA Inquiry" in the subject line of your email.



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Diabetes Dx Predicted Accurately with Single Blood Sample (CME/CE)

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Medpage Today

Diabetes Dx Predicted Accurately with Single Blood Sample

One measurement of HbA1c and fasting glucose may be enough for diagnosis

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  • by Staff Writer, MedPage Today
  • This article is a collaboration between MedPage Today® and:

    Medpage Today

Action Points

  • Note that this longitudinal study found that a single determination of HbA1c was strongly associated with subsequent diabetes diagnosis.
  • A single-test approach may streamline the approach to identifying at-risk individuals, leading to earlier diagnoses.

A single blood sample may be enough for confirmatory testing to diagnose diabetes, researchers suggested.

In a large prospective cohort study, use of a single blood sample to measure fasting glucose and HbA1c levels resulted in a high specificity and positive predictive value for risk of developing diabetes in the future, according to Elizabeth Selvin, PhD, of Johns Hopkins Bloomberg School of Public Health in Baltimore, and colleagues.

According to the results reported online in Annals of Internal Medicine, the confirmatory definition of a single blood sample — defined as a fasting glucose level of ≥126 mg/dL (≥7.0 mmol/L) and an HbA1c of ≥6.5% — showed high specificity (98.1%) but moderate sensitivity (54.9%) in identifying diagnosed diabetes occurring within the first 5 years of follow-up. In a 15-year follow-up period, specificity increased to 99.6%.

During the 15-year follow-up period, the single blood sample confirmatory definition had a predictive value of 88.7%, compared with 71.1% when combining both confirmed and unconfirmed cases of diabetes. Unconfirmed cases of undiagnosed diabetes were defined as having only one elevated measure of either fasting glucose or HbA1c.

“It is common for physicians to measure two laboratory tests, such as fasting glucose and HbA1c, in a single blood sample,” Selvin explained to MedPage Today. “Our results suggest that a single-sample definition of diabetes is a streamlined process for diagnosis of diabetes. This definition had a high positive predictive value for future diabetes and was also associated with diabetes complications like kidney disease and heart disease.

“Patients with single elevations in HbA1c or fasting glucose — unconfirmed cases — should have their tests repeated at a second time point, consistent with current clinical practice guidelines.”

Current clinical guidelines for diagnosing diabetes require repeated blood work — two blood draws occurring on two separate occasions, she continued. “The goal of the repeat testing is to reduce the possibility of a false-positive diagnosis. The guidelines, however, are not clear about whether a doctor could use a combination of elevated fasting glucose and elevated hemoglobin A1c from a single blood sample to make the diagnosis of diabetes.”

The researchers analyzed data on 12,268 participants from the Atherosclerosis Risk in Communities study without a diagnosis of diabetes — 978 of whom had elevated baseline levels of fasting glucose or HbA1c. Among this subset, 39% had confirmed undiagnosed diabetes, marked by elevated fasting glucose and HbA1c measures, and 61% had unconfirmed undiagnosed diabetes, defined as having only one elevated measure.

Among those with only one elevated measure, having an isolated elevation of fasting glucose was more common than having only an elevated A1c (4% versus 1% of population).

In another model, the researchers reported that confirmed undiagnosed diabetes in this population was significantly tied to high risk for receiving a clinical diagnosis of diabetes during a 25-year follow-up period (HR 25, 95% CI 22.10-28.28). Confirmed undiagnosed diabetes was also significantly associated with a higher risk for other comorbidities including peripheral artery disease (HR 3.50, 95% CI 2.44-5.01) and cardiovascular disease (HR 1.99, 95% CI 1.68-2.36).

However, in an accompanying editorial, K.M. Venkat Narayan, MD, and Ram Jagannathan, PhD, of Emory University in Atlanta, expressed concern that this proposed method for diagnosing diabetes could potentially miss quite a few cases of diabetes: “The concordance between elevated HbA1c and fasting glucose levels from the single-sample determination was approximately 40% in this study, but approximately 70% for repeated measurements of fasting glucose based on conventional criteria.”

Narayan and Jagannathan added, however, that despite some possible limitations to this proposed method, Selvin’s group should be praised for their innovation, and underscored the positive clinical implications of simplifying diagnostic methods, particularly for “resource-challenged settings.”

Still, the editorial stated, the single-sample approach does “need replication in other populations before becoming accepted clinical practice.”

The study was funded by the National Institute of Diabetes and Digestive and Kidney Diseases and the National Heart, Lung, and Blood Institute.

Selvin reported having no conflicts of interest; one co-author reported relationships with Fukuda Denshi and Kyowa Hakko Kirin outside of the study.

The editorialists reported supported from the National Institutes of Health.

  • Reviewed by F. Perry Wilson, MD, MSCE Assistant Professor, Section of Nephrology, Yale School of Medicine and Dorothy Caputo, MA, BSN, RN, Nurse Planner
2018-06-18T17:00:00-0400
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At MedPage Today, we are committed to ensuring that individuals with disabilities can access all of the content offered by MedPage Today through our website and other properties. If you are having trouble accessing www.medpagetoday.com, MedPageToday's mobile apps, please email legal@ziffdavis.com for assistance. Please put "ADA Inquiry" in the subject line of your email.

Medpage Today

Diabetes Dx Predicted Accurately with Single Blood Sample

One measurement of HbA1c and fasting glucose may be enough for diagnosis

MedpageToday

  • register today

    Earn Free CME Credits by reading the latest medical news in your specialty.

    sign up

  • by Staff Writer, MedPage Today
  • This article is a collaboration between MedPage Today® and:

    Medpage Today

Action Points

  • Note that this longitudinal study found that a single determination of HbA1c was strongly associated with subsequent diabetes diagnosis.
  • A single-test approach may streamline the approach to identifying at-risk individuals, leading to earlier diagnoses.

A single blood sample may be enough for confirmatory testing to diagnose diabetes, researchers suggested.

In a large prospective cohort study, use of a single blood sample to measure fasting glucose and HbA1c levels resulted in a high specificity and positive predictive value for risk of developing diabetes in the future, according to Elizabeth Selvin, PhD, of Johns Hopkins Bloomberg School of Public Health in Baltimore, and colleagues.

According to the results reported online in Annals of Internal Medicine, the confirmatory definition of a single blood sample -- defined as a fasting glucose level of ≥126 mg/dL (≥7.0 mmol/L) and an HbA1c of ≥6.5% -- showed high specificity (98.1%) but moderate sensitivity (54.9%) in identifying diagnosed diabetes occurring within the first 5 years of follow-up. In a 15-year follow-up period, specificity increased to 99.6%.

During the 15-year follow-up period, the single blood sample confirmatory definition had a predictive value of 88.7%, compared with 71.1% when combining both confirmed and unconfirmed cases of diabetes. Unconfirmed cases of undiagnosed diabetes were defined as having only one elevated measure of either fasting glucose or HbA1c.

"It is common for physicians to measure two laboratory tests, such as fasting glucose and HbA1c, in a single blood sample," Selvin explained to MedPage Today. "Our results suggest that a single-sample definition of diabetes is a streamlined process for diagnosis of diabetes. This definition had a high positive predictive value for future diabetes and was also associated with diabetes complications like kidney disease and heart disease.

"Patients with single elevations in HbA1c or fasting glucose -- unconfirmed cases -- should have their tests repeated at a second time point, consistent with current clinical practice guidelines."

Current clinical guidelines for diagnosing diabetes require repeated blood work -- two blood draws occurring on two separate occasions, she continued. "The goal of the repeat testing is to reduce the possibility of a false-positive diagnosis. The guidelines, however, are not clear about whether a doctor could use a combination of elevated fasting glucose and elevated hemoglobin A1c from a single blood sample to make the diagnosis of diabetes."

The researchers analyzed data on 12,268 participants from the Atherosclerosis Risk in Communities study without a diagnosis of diabetes -- 978 of whom had elevated baseline levels of fasting glucose or HbA1c. Among this subset, 39% had confirmed undiagnosed diabetes, marked by elevated fasting glucose and HbA1c measures, and 61% had unconfirmed undiagnosed diabetes, defined as having only one elevated measure.

Among those with only one elevated measure, having an isolated elevation of fasting glucose was more common than having only an elevated A1c (4% versus 1% of population).

In another model, the researchers reported that confirmed undiagnosed diabetes in this population was significantly tied to high risk for receiving a clinical diagnosis of diabetes during a 25-year follow-up period (HR 25, 95% CI 22.10-28.28). Confirmed undiagnosed diabetes was also significantly associated with a higher risk for other comorbidities including peripheral artery disease (HR 3.50, 95% CI 2.44-5.01) and cardiovascular disease (HR 1.99, 95% CI 1.68-2.36).

However, in an accompanying editorial, K.M. Venkat Narayan, MD, and Ram Jagannathan, PhD, of Emory University in Atlanta, expressed concern that this proposed method for diagnosing diabetes could potentially miss quite a few cases of diabetes: "The concordance between elevated HbA1c and fasting glucose levels from the single-sample determination was approximately 40% in this study, but approximately 70% for repeated measurements of fasting glucose based on conventional criteria."

Narayan and Jagannathan added, however, that despite some possible limitations to this proposed method, Selvin's group should be praised for their innovation, and underscored the positive clinical implications of simplifying diagnostic methods, particularly for "resource-challenged settings."

Still, the editorial stated, the single-sample approach does "need replication in other populations before becoming accepted clinical practice."

The study was funded by the National Institute of Diabetes and Digestive and Kidney Diseases and the National Heart, Lung, and Blood Institute.

Selvin reported having no conflicts of interest; one co-author reported relationships with Fukuda Denshi and Kyowa Hakko Kirin outside of the study.

The editorialists reported supported from the National Institutes of Health.

  • Reviewed by F. Perry Wilson, MD, MSCE Assistant Professor, Section of Nephrology, Yale School of Medicine and Dorothy Caputo, MA, BSN, RN, Nurse Planner
2018-06-18T17:00:00-0400
Take Posttest Comments

Accessibility Statement

At MedPage Today, we are committed to ensuring that individuals with disabilities can access all of the content offered by MedPage Today through our website and other properties. If you are having trouble accessing www.medpagetoday.com, MedPageToday's mobile apps, please email legal@ziffdavis.com for assistance. Please put "ADA Inquiry" in the subject line of your email.



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MAT Tied to Fewer Deaths a Year after Opioid Overdose (CME/CE)

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Medpage Today

MAT Tied to Fewer Deaths a Year after Opioid Overdose

But only three in 10 overdose survivors receive treatment

MedpageToday

  • register today

    Earn Free CME Credits by reading the latest medical news in your specialty.

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  • by Contributing Writer, MedPage Today

Action Points

  • Note that this observational study found that, after opioid overdose, those who received medication-assisted treatment (MAT) had a dramatically reduced risk of death at 1 year.
  • Be aware that few patients received MAT, which may represent significant opportunity to improve care.

Treating opioid overdose survivors with buprenorphine or methadone was linked to a 40% to 60% drop in mortality 1 year later, but the treatments were significantly underused, an observational study found.

While both buprenorphine and methadone were tied to fewer all-cause and opioid-related deaths, only three in 10 overdose survivors received medication for opioid use disorder (OUD) in the year after overdose, reported Marc Larochelle, MD, MPH, of Boston Medical Center, and colleagues in the Annals of Internal Medicine.

“People who survive an overdose are young; most are under age 45, yet mortality rate is very high at around 5% in one year,” Larochelle told MedPage Today. “I think this is a call to action for us in the healthcare system to improve access to these medications.”

The situation is akin to giving aspirin to patients who come into the hospital with a heart attack, Larochelle added, “We have long recognized the benefit of giving these people aspirin and we make sure everyone gets it; 98% get aspirin upon leaving the hospital.”

In 2016, 42,249 Americans fatally overdosed on an opioid. While opioid prescribing has declined, increasing numbers of people are initiating opioid use with heroin and nearly half of fatal opioid overdoses in 2016 involved fentanyl and synthetic analogues, wrote Nora Volkow, MD, and Eric Wargo, PhD, of the National Institute on Drug Abuse (NIDA) in Bethesda, Maryland, in an accompanying editorial. (Volkow is NIDA’s director and Wargo is a staff writer in the agency’s Science Policy Branch.)

Three FDA-approved drugs — the opioid agonist methadone, the partial agonist buprenorphine, and the extended-release formulation of the antagonist naltrexone — have been shown to reduce opioid use, but data tying treatment to mortality after an overdose are limited.

For this analysis, researchers used seven individually linked data sets from Massachusetts government agencies to study adults who survived one or more opioid overdoses between 2012 and 2014, excluding people who died within 30 days after overdosing or who had cancer.

Of 17,568 persons included in the analysis, 62% were male and 69% were age <45. In the 12 months before their first (index) overdose, 26% received one or more types of OUD medications, 41% received prescriptions for opioid analgesics, and 28% received prescriptions for benzodiazepines. About a fifth (22%) had opioid detoxification treatment.

In the 12 months after a nonfatal overdose, 11% of survivors enrolled in methadone maintenance treatment for a median of 5 months, 17% received buprenorphine for a median of 4 months, and 6% received naltrexone for a median of 1 month. Baseline characteristics and treatment history differed for persons who received medications after their index overdose; they were more likely to be <45, have a diagnosis of anxiety or depression, and received detoxification treatment in the past 12 months.

All-cause mortality was 4.7 deaths per 100 person-years and opioid-related mortality was 2.1 deaths per 100 person-years across the entire cohort.

Methadone treatment was associated with decreased all-cause mortality (adjusted HR 0.47, 95% CI 0.32-0.71) and opioid-related mortality (adjusted HR 0.41, 95% CI 0.24-0.70) compared with no OUD treatment.

Buprenorphine also was linked to decreased all-cause mortality (adjusted HR 0.63, 95% CI 0.46-0.87) and opioid-related mortality (adjusted HR 0.62, 95% CI 0.41-0.92). There were no associations between naltrexone and all-cause mortality (adjusted HR 1.44, 95% CI 0.84-2.46) or opioid-related mortality (adjusted HR 1.42, 95% CI 0.73-2.79), most likely due to the small number of persons treated with naltrexone for brief durations.

These findings identify treatment deficiencies, notably medication-assisted treatment (MAT) underuse and a fracture in the healthcare system about how to manage OUD, Volkow and Wargo observed.

“Stigma is a root reason for both,” they wrote. “Despite increased integration of the opioid treatment system with the rest of health care (thanks to health care reform), policy and infrastructural factors continue to impede MAT uptake.” Treatment centers may lack waivered personnel who can prescribe buprenorphine, for example, and insurance often does not pay for all forms of MAT or reduces treatment effectiveness by limiting coverage.

The findings also are “alarming because, although participants met criteria for OUD and had had an overdose, many were subsequently given prescriptions for opioids (34%) or benzodiazepines (26%) in the 12 months after the overdose,” Volkow and Wargo added. “This indicates that guidelines cautioning against prescription opioids and their co-use with benzodiazepines are not being followed.”

The study had limitations, such as the potential for residual confounding, although the authors attempted to control for differences between patients who did and did not receive treatment. Also, variables may have been misclassified. Finally, the findings might not apply to other populations, as Massachusetts has higher opioid-related mortality, and a higher prevalence of insurance coverage, than the U.S. average, which may have led to higher treatment rates.

The study was supported by the National Center for Advancing Translational Sciences, NIDA, Boston University School of Medicine Department of Medicine Career Investment Award, and GE Foundation.

Larochelle and co-authors, as well as Volkow and Wargo, disclosed no relevant relationships with industry.

  • Reviewed by F. Perry Wilson, MD, MSCE Assistant Professor, Section of Nephrology, Yale School of Medicine and Dorothy Caputo, MA, BSN, RN, Nurse Planner
1969-12-31T19:00:00-0500

last updated

Take Posttest Comments

Accessibility Statement

At MedPage Today, we are committed to ensuring that individuals with disabilities can access all of the content offered by MedPage Today through our website and other properties. If you are having trouble accessing www.medpagetoday.com, MedPageToday's mobile apps, please email legal@ziffdavis.com for assistance. Please put "ADA Inquiry" in the subject line of your email.

Medpage Today

MAT Tied to Fewer Deaths a Year after Opioid Overdose

But only three in 10 overdose survivors receive treatment

MedpageToday

  • register today

    Earn Free CME Credits by reading the latest medical news in your specialty.

    sign up

  • by Contributing Writer, MedPage Today

Action Points

  • Note that this observational study found that, after opioid overdose, those who received medication-assisted treatment (MAT) had a dramatically reduced risk of death at 1 year.
  • Be aware that few patients received MAT, which may represent significant opportunity to improve care.

Treating opioid overdose survivors with buprenorphine or methadone was linked to a 40% to 60% drop in mortality 1 year later, but the treatments were significantly underused, an observational study found.

While both buprenorphine and methadone were tied to fewer all-cause and opioid-related deaths, only three in 10 overdose survivors received medication for opioid use disorder (OUD) in the year after overdose, reported Marc Larochelle, MD, MPH, of Boston Medical Center, and colleagues in the Annals of Internal Medicine.

"People who survive an overdose are young; most are under age 45, yet mortality rate is very high at around 5% in one year," Larochelle told MedPage Today. "I think this is a call to action for us in the healthcare system to improve access to these medications."

The situation is akin to giving aspirin to patients who come into the hospital with a heart attack, Larochelle added, "We have long recognized the benefit of giving these people aspirin and we make sure everyone gets it; 98% get aspirin upon leaving the hospital."

In 2016, 42,249 Americans fatally overdosed on an opioid. While opioid prescribing has declined, increasing numbers of people are initiating opioid use with heroin and nearly half of fatal opioid overdoses in 2016 involved fentanyl and synthetic analogues, wrote Nora Volkow, MD, and Eric Wargo, PhD, of the National Institute on Drug Abuse (NIDA) in Bethesda, Maryland, in an accompanying editorial. (Volkow is NIDA's director and Wargo is a staff writer in the agency's Science Policy Branch.)

Three FDA-approved drugs -- the opioid agonist methadone, the partial agonist buprenorphine, and the extended-release formulation of the antagonist naltrexone -- have been shown to reduce opioid use, but data tying treatment to mortality after an overdose are limited.

For this analysis, researchers used seven individually linked data sets from Massachusetts government agencies to study adults who survived one or more opioid overdoses between 2012 and 2014, excluding people who died within 30 days after overdosing or who had cancer.

Of 17,568 persons included in the analysis, 62% were male and 69% were age <45. In the 12 months before their first (index) overdose, 26% received one or more types of OUD medications, 41% received prescriptions for opioid analgesics, and 28% received prescriptions for benzodiazepines. About a fifth (22%) had opioid detoxification treatment.

In the 12 months after a nonfatal overdose, 11% of survivors enrolled in methadone maintenance treatment for a median of 5 months, 17% received buprenorphine for a median of 4 months, and 6% received naltrexone for a median of 1 month. Baseline characteristics and treatment history differed for persons who received medications after their index overdose; they were more likely to be <45, have a diagnosis of anxiety or depression, and received detoxification treatment in the past 12 months.

All-cause mortality was 4.7 deaths per 100 person-years and opioid-related mortality was 2.1 deaths per 100 person-years across the entire cohort.

Methadone treatment was associated with decreased all-cause mortality (adjusted HR 0.47, 95% CI 0.32-0.71) and opioid-related mortality (adjusted HR 0.41, 95% CI 0.24-0.70) compared with no OUD treatment.

Buprenorphine also was linked to decreased all-cause mortality (adjusted HR 0.63, 95% CI 0.46-0.87) and opioid-related mortality (adjusted HR 0.62, 95% CI 0.41-0.92). There were no associations between naltrexone and all-cause mortality (adjusted HR 1.44, 95% CI 0.84-2.46) or opioid-related mortality (adjusted HR 1.42, 95% CI 0.73-2.79), most likely due to the small number of persons treated with naltrexone for brief durations.

These findings identify treatment deficiencies, notably medication-assisted treatment (MAT) underuse and a fracture in the healthcare system about how to manage OUD, Volkow and Wargo observed.

"Stigma is a root reason for both," they wrote. "Despite increased integration of the opioid treatment system with the rest of health care (thanks to health care reform), policy and infrastructural factors continue to impede MAT uptake." Treatment centers may lack waivered personnel who can prescribe buprenorphine, for example, and insurance often does not pay for all forms of MAT or reduces treatment effectiveness by limiting coverage.

The findings also are "alarming because, although participants met criteria for OUD and had had an overdose, many were subsequently given prescriptions for opioids (34%) or benzodiazepines (26%) in the 12 months after the overdose," Volkow and Wargo added. "This indicates that guidelines cautioning against prescription opioids and their co-use with benzodiazepines are not being followed."

The study had limitations, such as the potential for residual confounding, although the authors attempted to control for differences between patients who did and did not receive treatment. Also, variables may have been misclassified. Finally, the findings might not apply to other populations, as Massachusetts has higher opioid-related mortality, and a higher prevalence of insurance coverage, than the U.S. average, which may have led to higher treatment rates.

The study was supported by the National Center for Advancing Translational Sciences, NIDA, Boston University School of Medicine Department of Medicine Career Investment Award, and GE Foundation.

Larochelle and co-authors, as well as Volkow and Wargo, disclosed no relevant relationships with industry.

  • Reviewed by F. Perry Wilson, MD, MSCE Assistant Professor, Section of Nephrology, Yale School of Medicine and Dorothy Caputo, MA, BSN, RN, Nurse Planner
1969-12-31T19:00:00-0500

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Lymphoma Risk with JAK Inhibitors for MPNs

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Medpage Today

Lymphoma Risk with JAK Inhibitors for MPNs

Preexisting aberrant B-cell clone implicated

MedpageToday

  • by Senior Associate Editor, MedPage Today

A small but significant proportion of patients with the rare bone marrow malignancy myelofibrosis (MFB) developed aggressive lymphomas during treatment with a Janus kinase (JAK) inhibitor, two large retrospective cohort studies showed.

In a study of 626 patients, 5.8% of those treated with JAK1/2 inhibitors developed aggressive B-cell lymphomas. By comparison, 0.36% of patients treated with other drugs developed developed B-cell lymphomas, reported Ulrich Jaeger, MD, of the Medical University of Vienna (MUV) in Austria, and colleagues. in Blood.

A separate group of 929 patients with myeloproliferative neoplasms (MPNs), including MFB, had a similar disparity of B-cell lymphoma cases, 9.7% of patients with primary MFB treated with JAK inhibitors versus 0.54% of patients who received other therapies.

Most of the patients who developed lymphoma had a pre-existing B-cell clone that underwent transformation during treatment with JAK inhibitors. Using a mouse model, investigators replicated the associations between MFB, abnormal B-cell clones, JAK1/2 inhibitor treatment, and development of aggressive lymphomas.

“We determined that patients with this preexisting B-cell clone in their bone marrow are most at risk for developing aggressive lymphoma,” Jaeger said in a statement. “We also know that up to 16% of people with myelofibrosis have immunoglobulin gene rearrangements like this B-cell clone. Therefore, our findings suggest that all patients with myelofibrosis should be tested for such gene rearrangements before prescribing JAK inhibitors to treat their disease.”

The findings were reported simultaneously at the European Hematology Association meeting in Barcelona.

The observation of lymphoma in patients with MFB treated with JAK inhibitors is not new, but the degree to which the association was documented, particularly the study in the mouse model, is a new reinforces previously reported data, said David Steensma, MD, of Dana-Farber Cancer Institute in Boston.

“This is something that we need to be counseling patients about when they start treatment with these drugs,” said Steensma, a clinical expert for the American Society of Hematology. “It’s a rare complication. That being said, we know about second malignancies with other types of treatments, and I think this is just another example. I think almost certainly that it’s real.”

Whether JAK inhibitors pose a similar risk when used to treat patients with other conditions, notably arthritis and psoriasis, remains unclear. Steensma, who was not involved in the research, said he is unaware of any reports of secondary lymphoma in those populations.

“There may be two reasons for that,” he said. “Patients with those conditions have almost an inherent incidence of B-cell lymphomas, regardless of treatment. In the era of JAK inhibitors, I doubt anyone would make very much of a few more cases of lymphoma. The other difference is that the drugs most commonly used in those other settings are different — tofacitinib (Xeljanz), for example, is a JAK3 inhibitor — and JAK1 is what seems to be important in the lymphomas that develop in patients with myeloproliferative neoplasms.”

MPNs arise from abnormalities in bone marrow stem-cell formation and development. The disease classification of MPN includes essential thrombocytopenia (ET) and polycythemia vera (PV), in addition to MFB. Both ET and PV can transform into MFB. Though the precise mechanisms underlying the evolution of MPNs remain unknown, the discovery of an association with the JAK2 V617F mutation led to development of JAK1/2 inhibitors, which have become a mainstay of treatment for MPNs.

Clinical experience with JAK1/2 inhibitors led to observations of sporadic B-cell non-Hodgkin lymphomas in patients with MPNs treated with JAK1/2 inhibitors, Jaeger’s group noted. The frequency and potential causes of the lymphomas remained unclear.

To investigate the association between JAK1/2 inhibitor-treated MPNs and development of lymphomas, the authors reviewed medical records of 626 patients with MPNs treated at MUV from 1997 to 2016. The cohort included 69 patients treated with JAK1/2 inhibitors. Investigators also analyzed bone marrow samples from 54 of the 69 patients, all treated with ruxolitinib (Jakafi).

The results showed that four of the 69 patients treated with a JAK1/2 inhibitor developed aggressive lymphomas, as compared with two of the remaining 557 patients, all of whom received conventional therapies. The difference represented a 16-fold increase in lymphoma risk among patients who received a JAK1/2 inhibitor (P=0.0017). A separate analysis of 216 patients with primary MFB showed that three of 31 (9.7%) patients treated with a JAK inhibitor developed lymphoma versus one of 185 (0.54%) conventionally treated patients, a 19-fold increase in the odds ratio (P=0.01). The median time from start of JAK inhibitor treatment to lymphoma diagnosis was 25 months.

For comparison, the authors examined data for a French cohort of 929 patients with MPNs. The data showed a 0.23% incidence of lymphoma in 872 patients treated with conventional therapies versus 3.51% among 57 patients treated with JAK1/2 inhibitors, a 15-fold increase in the OR (P=0.0205).

Examination of the 54 bone marrow samples from the Vienna cohort showed that all three who subsequently developed aggressive lymphomas during treatment with a JAK inhibitor had a preexisting immunoglobulin rearrangement (IgR) before exposure to the JAK inhibitor. Comparison with the lymphoma samples confirmed the association between the abnormality and lymphoma transformation.

Overall, nine of the 54 patients (16.7%) tested positive for IgR. Additionally, seven of 44 (15.9%) age- and sex-matched control patients who received conventional therapy or none (15.9%) tested positive for IgR.

“This indicates the presence of clonal B cells in the bone marrow of approximately 15% of primary myelofibrosis patients, regardless of treatment,” the authors noted.

As a final means of confirming the results, the authors studied JAK1/2 inhibition in Stat1 altered mice and found that 16 of 24 animals developed a spontaneous myeloid hyperplasia associated with the presence of aberrant B cells.

The study was supported by Austrian Science Fund, the Anniversary Fund of the Austrian National Bank, and the WWTF Precision Medicine Program.

Jaeger and co-authors disclosed relevant relationships with Roche, Novartis, Boehringer-Ingelheim, Bristol-Myers Squibb, Meda, Celgene, Teva, and Jazz.

2018-06-18T17:30:00-0400
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Medpage Today

Lymphoma Risk with JAK Inhibitors for MPNs

Preexisting aberrant B-cell clone implicated

MedpageToday

  • by Senior Associate Editor, MedPage Today

A small but significant proportion of patients with the rare bone marrow malignancy myelofibrosis (MFB) developed aggressive lymphomas during treatment with a Janus kinase (JAK) inhibitor, two large retrospective cohort studies showed.

In a study of 626 patients, 5.8% of those treated with JAK1/2 inhibitors developed aggressive B-cell lymphomas. By comparison, 0.36% of patients treated with other drugs developed developed B-cell lymphomas, reported Ulrich Jaeger, MD, of the Medical University of Vienna (MUV) in Austria, and colleagues. in Blood.

A separate group of 929 patients with myeloproliferative neoplasms (MPNs), including MFB, had a similar disparity of B-cell lymphoma cases, 9.7% of patients with primary MFB treated with JAK inhibitors versus 0.54% of patients who received other therapies.

Most of the patients who developed lymphoma had a pre-existing B-cell clone that underwent transformation during treatment with JAK inhibitors. Using a mouse model, investigators replicated the associations between MFB, abnormal B-cell clones, JAK1/2 inhibitor treatment, and development of aggressive lymphomas.

"We determined that patients with this preexisting B-cell clone in their bone marrow are most at risk for developing aggressive lymphoma," Jaeger said in a statement. "We also know that up to 16% of people with myelofibrosis have immunoglobulin gene rearrangements like this B-cell clone. Therefore, our findings suggest that all patients with myelofibrosis should be tested for such gene rearrangements before prescribing JAK inhibitors to treat their disease."

The findings were reported simultaneously at the European Hematology Association meeting in Barcelona.

The observation of lymphoma in patients with MFB treated with JAK inhibitors is not new, but the degree to which the association was documented, particularly the study in the mouse model, is a new reinforces previously reported data, said David Steensma, MD, of Dana-Farber Cancer Institute in Boston.

"This is something that we need to be counseling patients about when they start treatment with these drugs," said Steensma, a clinical expert for the American Society of Hematology. "It's a rare complication. That being said, we know about second malignancies with other types of treatments, and I think this is just another example. I think almost certainly that it's real."

Whether JAK inhibitors pose a similar risk when used to treat patients with other conditions, notably arthritis and psoriasis, remains unclear. Steensma, who was not involved in the research, said he is unaware of any reports of secondary lymphoma in those populations.

"There may be two reasons for that," he said. "Patients with those conditions have almost an inherent incidence of B-cell lymphomas, regardless of treatment. In the era of JAK inhibitors, I doubt anyone would make very much of a few more cases of lymphoma. The other difference is that the drugs most commonly used in those other settings are different -- tofacitinib (Xeljanz), for example, is a JAK3 inhibitor -- and JAK1 is what seems to be important in the lymphomas that develop in patients with myeloproliferative neoplasms."

MPNs arise from abnormalities in bone marrow stem-cell formation and development. The disease classification of MPN includes essential thrombocytopenia (ET) and polycythemia vera (PV), in addition to MFB. Both ET and PV can transform into MFB. Though the precise mechanisms underlying the evolution of MPNs remain unknown, the discovery of an association with the JAK2 V617F mutation led to development of JAK1/2 inhibitors, which have become a mainstay of treatment for MPNs.

Clinical experience with JAK1/2 inhibitors led to observations of sporadic B-cell non-Hodgkin lymphomas in patients with MPNs treated with JAK1/2 inhibitors, Jaeger's group noted. The frequency and potential causes of the lymphomas remained unclear.

To investigate the association between JAK1/2 inhibitor-treated MPNs and development of lymphomas, the authors reviewed medical records of 626 patients with MPNs treated at MUV from 1997 to 2016. The cohort included 69 patients treated with JAK1/2 inhibitors. Investigators also analyzed bone marrow samples from 54 of the 69 patients, all treated with ruxolitinib (Jakafi).

The results showed that four of the 69 patients treated with a JAK1/2 inhibitor developed aggressive lymphomas, as compared with two of the remaining 557 patients, all of whom received conventional therapies. The difference represented a 16-fold increase in lymphoma risk among patients who received a JAK1/2 inhibitor (P=0.0017). A separate analysis of 216 patients with primary MFB showed that three of 31 (9.7%) patients treated with a JAK inhibitor developed lymphoma versus one of 185 (0.54%) conventionally treated patients, a 19-fold increase in the odds ratio (P=0.01). The median time from start of JAK inhibitor treatment to lymphoma diagnosis was 25 months.

For comparison, the authors examined data for a French cohort of 929 patients with MPNs. The data showed a 0.23% incidence of lymphoma in 872 patients treated with conventional therapies versus 3.51% among 57 patients treated with JAK1/2 inhibitors, a 15-fold increase in the OR (P=0.0205).

Examination of the 54 bone marrow samples from the Vienna cohort showed that all three who subsequently developed aggressive lymphomas during treatment with a JAK inhibitor had a preexisting immunoglobulin rearrangement (IgR) before exposure to the JAK inhibitor. Comparison with the lymphoma samples confirmed the association between the abnormality and lymphoma transformation.

Overall, nine of the 54 patients (16.7%) tested positive for IgR. Additionally, seven of 44 (15.9%) age- and sex-matched control patients who received conventional therapy or none (15.9%) tested positive for IgR.

"This indicates the presence of clonal B cells in the bone marrow of approximately 15% of primary myelofibrosis patients, regardless of treatment," the authors noted.

As a final means of confirming the results, the authors studied JAK1/2 inhibition in Stat1 altered mice and found that 16 of 24 animals developed a spontaneous myeloid hyperplasia associated with the presence of aberrant B cells.

The study was supported by Austrian Science Fund, the Anniversary Fund of the Austrian National Bank, and the WWTF Precision Medicine Program.

Jaeger and co-authors disclosed relevant relationships with Roche, Novartis, Boehringer-Ingelheim, Bristol-Myers Squibb, Meda, Celgene, Teva, and Jazz.

2018-06-18T17:30:00-0400
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Preventing Nurse Suicide: HealthLeaders Media

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Medpage Today

Preventing Nurse Suicide: HealthLeaders Media

Also, keeping patients’ names straight

MedpageToday

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Medpage Today

Preventing Nurse Suicide: HealthLeaders Media

Also, keeping patients' names straight

MedpageToday

  • by

Here are several strategies to help recognize and prevent nurse suicide.

Researchers provide six tips for avoiding patient misidentification.

A recent analysis found that enhancing the role nurse practitioners play in the primary care arena will help practices handle increasing patient demand.

Another take on that study finding that patients tend to prefer when doctors wear formal attire and a white coat.

This report is brought to you by HealthLeaders Media.

1969-12-31T19:00:00-0500

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More weight loss tied to less knee pain for obese people

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June 18, 2018 / 9:28 PM / Updated 5 minutes ago

More weight loss tied to less knee pain for obese people