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Medscape
4 days ago
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- Medscape
Are Europe's Open Waters Safe for Swimming?
Laura Reineke is an avid open water swimmer. Her passion has taken her from crossing the English Channel to circumnavigating Manhattan Island. But the hobby has also made her feel poorly on several occasions. 'They're always severe. They always take you by surprise. Joint pain, full body aches, diarrhea, vomiting,' recalled Reineke, who has founded Henley Mermaids, a grassroots campaign against sewage pollution, and Friends of the Thames, a charity organization that aims to protect the English river. Laura Reineke As temperatures warm across Europe, many more open water swimming enthusiasts are venturing into rivers, lakes, reservoirs, and seas. While offering significant physical and mental health benefits, the burgeoning pastime increasingly exposed people to waterborne contaminants. But the risks are difficult to quantify. Therese Westrell, PhD, principal expert for Food and Waterborne Diseases at the European Centre for Disease Prevention and Control (ECDC), told Medscape Medical News , 'We don't really know how big of a problem there is across Europe. There are risks that we know of when there is high contamination.' The Microbial Menace Europe's bathing waters are routinely monitored for Escherichia coli and intestinal enterococci, which serve as bacterial indicators of fecal contamination, as mandated under the European Union (EU) Bathing Water Directive. The latest figures for the 2023 season show that 85.4% of bathing waters in the EU were classified as 'excellent,' indicating high overall quality. However, a persistent 1.5% of sites, amounting to 321 locations, were still classified as 'poor.' A significant disparity in water quality exists between inland and coastal areas. Inland bathing waters, including rivers and lakes, generally exhibit poorer quality, with 2.4% of inland sites categorized as 'poor' in 2023 compared with 1% of coastal sites. The European Environment Agency wrote to Medscape Medical News in an email that these inland waters 'are more susceptible than coastal areas to short-term pollution caused by heavy rains or droughts.' The primary sources of microbial contamination are human activities and animal waste. Inadequate urban wastewater treatment, agricultural runoff carrying livestock waste, and even direct contamination from waterfowl like mallards can elevate bacterial levels in water. In some big, older cities, such as London and Paris, combined sewer overflows are used as safety release valves to prevent urban flooding during heavy rainfall. However, their frequent activation leads to the direct discharge of enormous volumes of untreated sewage into waterways. In England alone, more than 400,000 such discharges occurred in 2020. Common illnesses associated with microbial contamination include gastrointestinal infections caused by pathogens like Norovirus, E. coli , Giardia , and Cryptosporidium , which give symptoms such as diarrhea, vomiting, and abdominal pain. Other manifestations include respiratory, dermatologic, ear, nose, and throat infections. A more severe, albeit rarer, bacterial infection is leptospirosis (Weil's disease), which can cause significant liver and kidney deterioration. Quantifying the exact extent of these problems across Europe remains challenging due to the complexities of attributing specific transmission modes to surveillance data. 'The information we have on which cases come from swimming and which are from food is not really there,' Westrell said. Therese Westrell, PhD However, specific microbes are closely monitored. Vibrio species, for instance, are naturally occurring bacteria in coastal waters that thrive in elevated temperatures and brackish water. Ingestion can cause mild gastrointestinal symptoms, but wound infections are more concerning. 'If you get it through a wound, you can get a very severe infection. You can also get the blood infection, which could be fatal,' Westrell explained. The Baltic Sea has been a hot spot for these bacteria, with a significant increase in reported cases from several countries during the 2018 heatwave, Westrell said. With global temperatures rising, Vibrio species are expanding beyond the Baltic area, and the ECDC is actively increasing its surveillance on the microbe. European Member States report on the occurrence and management of local infectious disease outbreaks linked to water swimming, but comprehensive pan-European data is fragmented and not routinely collected in all waters. Chemical Contaminants European waters also contain a 'cocktail of chemicals,' said Helena Rapp Wright, PhD, a research associate at Imperial College London, London, England. These compounds originate from many sources, including pharmaceuticals and personal care products, industrial discharges, agricultural pesticides, and vehicle emissions. Most wastewater treatment plants remove pathogens but are not designed to remove these chemicals. Consequently, many of these substances pass through treatment processes and are discharged directly into rivers and other water bodies. While their concentration is generally low in large bodies of water, the continuous input means they are persistently present. Rapp Wright and her colleagues have found 'loads of chemicals' in English and Irish waters. While many pose no risk at current concentrations, some compounds are 'quite toxic,' she said. Particularly concerning are pesticides detected at high-risk levels, such as imidacloprid, which was banned in 2018 but is still used for pet flea treatments, and antibiotics due to their potential contribution to antimicrobial resistance, she explained. But for swimmers like Reineke, who trains at least 1 hour in the Thames 6 days a week, the primary health concern related to chemical contaminants is often long-term exposure and the potential of developing chronic conditions, rather than immediate acute effects, which are more commonly associated with microbial pathogens. What General Practitioners (GPs) Should Be Aware of and Do To reap the health benefits of open water swimming while minimizing the possible hazards associated with exposure to pathogens and pollutants, GPs can help their patients practice this sport in the safest way: Understand risk profiles: While many coastal bathing areas are designated and monitored, rivers and inland lakes often lack this official status, implying a higher inherent health risk for swimmers in these less-regulated environments. While many coastal bathing areas are designated and monitored, rivers and inland lakes often lack this official status, implying a higher inherent health risk for swimmers in these less-regulated environments. Advise on avoidance: It is important to advise patients to avoid open water swimming during and immediately after periods of heavy rainfall, especially if these follow dry spells. Such conditions significantly increase the likelihood of combined sewer overflows discharging untreated sewage directly into waterways. It is important to advise patients to avoid open water swimming during and immediately after periods of heavy rainfall, especially if these follow dry spells. Such conditions significantly increase the likelihood of combined sewer overflows discharging untreated sewage directly into waterways. Encourage informed decisions: Encourage patients to utilize readily available public resources before swimming. These include official online bathing water profiles provided by environmental agencies, such as the Environment Agency's Swimfo in the United Kingdom, and local real-time pollution maps, such as Wild Swim Map, which visually indicate safe (green) vs recently polluted (red) areas. Encourage patients to utilize readily available public resources before swimming. These include official online bathing water profiles provided by environmental agencies, such as the Environment Agency's Swimfo in the United Kingdom, and local real-time pollution maps, such as Wild Swim Map, which visually indicate safe (green) vs recently polluted (red) areas. Clinical suspicion: When patients present with unexplained gastrointestinal issues, skin rashes, respiratory symptoms, or ear, nose, and throat infections, GPs should always inquire about recent open water swimming exposure in their history taking. For severe wound infections, particularly after swimming in warmer brackish waters, consider Vibrio as a potential pathogen. Ultimately, Rapp Wright said that the goal is not to deter enthusiasts from the therapeutic joys of open water bathing and swimming. 'We don't want people to stop [swimming], we want to make sure that they do it safely.' As for Reineke, the potential of falling ill has not stopped her from dipping into the water. 'I want to do Oceans Seven and become the first British female to do that.' Medscape Medical News reached out to the European Commission spokesperson responsible for health, but they declined an interview. Reineke, Westrell, and Rapp Wright disclosed no relevant financial relationships.
Medscape
5 days ago
- Health
- Medscape
Vitamin D Especially Important for Women's Brain Health
LOS ANGELES — Vitamin D is important for brain health, but this might be particularly true for women but doesn't appear to have this beneficial effect in men, early research suggested. The large study showed an association between greater plasma vitamin D levels in females and better memory and larger subcortical brain structures. 'We found that vitamin D for women was correlated with better cognitive outcomes, but we need to do more research to find out what role vitamin D actually plays at a mechanistic level,' study investigator Meghan Reddy, MD, Psychiatry Resident, UCLA Semel Institute for Neuroscience and Human Behavior, Los Angeles, told Medscape Medical News . The findings were presented here at the American Psychiatric Association (APA) 2025 Annual Meeting. Protective Effects This latest study added to the growing body of literature of research on vitamin D and brain health. Previous studies have shown that vitamin D may influence cognition and brain function in older adults, potentially through its anti-inflammatory, antioxidant, and neuroprotective effects. Research also suggested it may promote brain health by increasing neurotrophic factors and aiding in the clearance of amyloid from the brain. Recent findings published in the American Journal of Clinical Nutrition suggested that vitamin D may also affect biological aging by preserving telomeres — the protective caps at the ends of chromosomes that shorten with age. Other research has also shown telomere length may help protect against brain diseases, including a study previously reported by Medscape Medical News , which linked longer leukocyte telomere length to a lower risk for stroke, dementia, and late-life depression. Meghan Reddy, MD In the current study, Reddy and colleagues used data from the multisite Human Connectome Project to track individuals over time to understand age-related changes in brain structure, function, and connectivity. They are investigating various biomarkers that might correlate with aging, including hemoglobin, creatine, glycated hemoglobin (for blood glucose levels), high-density lipoprotein, and low-density lipoprotein, in addition to vitamin D. The idea, said Reddy, is to track cognitive health using biomarkers in addition to brain imaging and cognitive testing. The study included 1132 individuals, 57% of whom were women and 66% of whom were White. The average age was approximately 62 years, with participants ranging from 36 to 102 years old. Participants underwent neuropsychological testing to assess short-term memory and fluid intelligence — the capacity to reason and solve problems, which is closely linked to comprehension and learning. They also provided blood samples and underwent MRI scans. Researchers divided participants into two age groups: those younger than 65 years and those 65 years or older. The investigators found a significant association between vitamin D levels and memory in women ( P = .04). Sex Differences 'What's interesting is that when we looked specifically at memory, higher vitamin D levels were linked to better memory performance — but only in women, not men,' said Reddy, adding that she found this somewhat surprising. In women, investigators found a significant association between vitamin D levels and the volume of the putamen ( P = .05) and pallidum ( P = .08), with a near-significant trend for the thalamus. In contrast, studies show that in men, higher vitamin D levels were associated with smaller volumes of the thalamus, putamen, and pallidum. There were no differences in the impact of vitamin D by age group. Sex differences in the relationship between vitamin D, cognition, and brain volume warrant further investigation, Reddy said. She also noted that the study is correlational, examining memory, brain volume, and vitamin D levels at a single timepoint, and therefore it can only offer a hypothesis. Future studies will include multiple time points to explore these relationships over time. The results did not determine an ideal vitamin D plasma level to promote brain health in women. Commenting on the research for Medscape Medical News , Badr Ratnakaran, MD, a geriatric psychiatrist in Roanoke, Virginia, and chair of the APA's Council on Geriatric Psychiatry, said the finding that women may get more brain benefits from vitamin D than men is 'key' because dementia is more prevalent among women since they tend to live longer. Other research has shown vitamin D may help manage depression in older women, which makes some sense as dementia and depression 'go hand in hand,' he said. Ratnakaran recommended that women take a vitamin supplement only if they're deficient, as too much vitamin D can lead to kidney stones and other adverse side effects.
Medscape
5 days ago
- Health
- Medscape
Growing Evidence for the Healing Power of ‘Forest Therapy'
LOS ANGELES — Spending time in a forest — an experience known as Shinrin-Yoku, or 'forest bathing,' in Japan where the practice originated — can lift mood, reduce stress, and promote physical health, a new literature review suggested. Most of the studies included in the review reported moderate to strong effect sizes, using validated measures such as the Profile of Mood States (POMS) and physiological indicators like blood pressure. Taking a walk in the forest appears to be beneficial and may have therapeutic potential, said study investigator Donovan Dennis, a third-year medical student at Michigan State University, East Lansing, Michigan. It's something physicians could consider prescribing to their patients, he told Medscape Medical News . Donovan Dennis The findings were presented on May 18 at the American Psychiatry Association (APA) 2025 Annual Meeting. Designated Forests More than half of the world's population lives in urban environments, where managing stress and maintaining a positive mindset during crises can be difficult. Over time, chronic stress can contribute to anxiety and fatigue. In response, experts are increasingly exploring alternative and holistic approaches to mental well-being, spurring research into the psychological benefits of immersing oneself in nature, particularly forest settings. Japan has been a leader in this movement. As of 2019, the country had designated approximately 60 official forestry therapy trails. The review included 15 studies conducted in Japan, the United States, Poland, and several other countries. Study designs varied: One was a meta-analysis, three were systematic reviews, and the remaining 11 were observational studies or randomized experimental models. Most participants were considered 'healthy,' although some studies included individuals 'with depressive tendencies,' said Dennis. The study populations also varied by setting — for example, one study focused on healthcare workers, while another involved patients from a psychiatric hospital. Although all of the studies examined forest bathing, typically defined as walking in a forest, the practice itself lacks a standardized definition, Dennis noted. Positive Therapeutic Effects Most of the studies involved walking in a forest for about 2 hours, twice a week. However, durations varied — some had participants walk for as little as 10 minutes, while others extended sessions to 3 hours, said Dennis. In some cases, the intervention was defined by distance rather than time; for example, one study involved a 2.5-km walk, and another covered 4 km. The overall length of the studies also varied, ranging from a few weeks to several months. Researchers examined both psychological and physiological effects of forest bathing. While most studies used POMS to assess mood, several also measured physiological markers such as serotonin levels, blood pressure, and heart rate, Dennis noted. The analyses generally showed positive effects of forest therapy on mental health, with some studies also reporting benefits for the cardiovascular and immune systems, as well as improvements in inflammation and antioxidant activity. 'Forest therapy might be therapeutic for folks living with depression or anxiety, but also preventatively to support general wellness, and connectedness with nature,' said Dennis. However, the review did not clarify the role of factors such as frequency, duration, or seasonality in shaping the benefits of forest therapy, Dennis noted. While the findings are promising, they do not support forest therapy as a replacement for pharmacological treatment. Larger, well-controlled studies with standardized protocols are needed to confirm its benefits, he said. Growing Acceptance Commenting on the research for Medscape Medical News , Environmental Psychologist Sabine Huemer, PhD, assistant professor, School of Psychological Science, Oregon State University, Corvallis, Oregon, said she was surprised but pleased that forest therapy was discussed at a psychiatry conference. Huemer said she initially believed that psychiatry remained rooted in traditional therapy and medical treatments but now recognizes that the field is expanding to include alternative approaches such as psychedelic-assisted therapy, transcranial magnetic stimulation, and ecotherapy or nature therapy. Huemer pointed to resources like Park Rx America, which encourage physicians to prescribe time in nature as part of routine healthcare. In Japan, doctors often prescribe forest therapy to stressed businesspeople as a way to 'recharge and recover,' she noted. An eco-therapist herself, Huemer has developed a 'mindfulness in nature' program aimed at reducing stress and promoting mental well-being, that draws on the principles of Shinrin-Yoku. Although the review did not include original data and was based on a limited number of studies, it highlights the rejuvenating effects of nature, Huemer said. She noted that these benefits apply not only to adults but also to children, many of whom are spending less time outdoors. Huemer and her colleagues have been studying eco-anxiety among US college students. Eco-anxiety — defined as worry about the future of the planet — primarily affects members of Generation Z and younger cohorts, those born in the mid-to-late 1990s, she said. It can interfere with daily functioning and sleep, and often leads to intrusive, recurring thoughts. Their research, presented in a poster at the APA 2025 Annual Meeting, showed that higher levels of eco-anxiety were associated with personal experiences of climate change and a prior diagnosis of generalized anxiety disorder. Interestingly, and in contrast to findings from other studies, they did not find that collective activism — such as participation in environmental clubs — served as a buffer against eco-anxiety. Also commenting on the forest bathing review, Umadevi Naidoo, MD, an instructor in the Department of Psychiatry, Division of Nutrition at Harvard Medical School and Director of Nutritional and Lifestyle Psychiatry at Massachusetts General Hospital in Boston, said she was 'happy to see a poster on forest bathing,' noting that it aligns with the focus on lifestyle interventions at the APA 2025 annual meeting. She noted that forest medicine is gaining acceptance as an additional lifestyle option for patients. Naidoo, who is often referred to as 'America's Nutritional Psychiatrist,' is a professional chef, nutritional biologist, and author of several books on the impact of food on brain health.
Medscape
21-05-2025
- Health
- Medscape
Beyond the Glasgow Coma Scale: New TBI Framework Proposed
After more than half a century, assessment of acute traumatic brain injury (TBI) is getting a makeover. A newly proposed framework expands assessment of acute TBI beyond the Glasgow Coma Scale (GCS) to include biomarkers, CT and MRI scans, and 'modifiers' such as other medical conditions and how the injury occurred. 'Multiple factors prompted this initiative. First was a growing consensus among clinicians, researchers, and patients alike around the need for an improved system for the characterization of TBI,' co-senior author Michael McCrea, PhD, co-director of the Center for Neurotrauma Research at the Medical College of Wisconsin in Milwaukee, told Medscape Medical News . 'Second, was the recognition that a multidimensional framework could better guide individualized treatments that give TBI patients the best chance of survival, recovery, and return to life function.' 'Finally, this movement is now enabled by decades of progress in translational research that informed the components of a multidimensional framework for classification of TBI,' he added. The proposed framework was published online on May 20 in The Lancet Neurology . Beyond Level of Consciousness Since 1974, the clinical TBI severity has been classified according to the GCS sum score as mild, moderate, or severe, based largely on a patient's level of consciousness. Given its limitations, in 2022, the US National Institute of Neurological Disorders and Stroke (NINDS) launched an international initiative to develop a multidimensional classification system for acute TBI. The so-called 'CBI-M framework' is made up of four pillars — clinical, biomarker, imaging, and modifiers — and was developed by TBI experts, implementation scientists, people with lived experience, and partners from 14 countries. The clinical pillar retains the full GCS total score as a central element of assessment, measuring consciousness along with pupil reactivity as an indication of brain function. The framework recommends including the scale's responses to eye, verbal, and motor commands or stimuli, as well as the presence of amnesia and symptoms such as headache, dizziness, and sensitivity to noise. The clinical pillar 'should be assessed as first priority in all patients. Research has shown that the elements of this pillar are highly predictive of injury severity and patient outcome,' co-senior author Andrew Maas, MD, PhD, emeritus professor of neurosurgery, University of Antwerp, Antwerp, Belgium, said in a news release. Other Critical Clues to Recovery The second pillar uses blood-based biomarkers to provide objective indicators of tissue damage. Measurement of one or more of the following three biomarkers is recommended in the first 24 hours after injury: Glial fibrillary acidic protein, ubiquitin C-terminal hydrolase L1, or S100 calcium-binding protein B. The working group noted that this recommendation was based on the diagnostic and prognostic utility of these biomarkers demonstrated in acute care settings. Low levels of each of the three biomarkers accurately indicate a very low risk for traumatic intracranial injury on head CT scans and can be used to rule out the need for CT imaging. The third pillar of the CBI-M framework is neuroimaging, which offers a 'great source' of information about the type and extent of brain injury, the authors reported. This pillar focuses on CT, the most widely used imaging modality within the first 24 h of injury, but recognizes that MRI is more sensitive than CT and can provide additional information while acknowledging certain practicalities around its use in the acute phase. The final pillar in the CBI-M framework is 'modifiers,' which includes assessment of injury-related factors (how the injury happened) and patient- and society-related factors (such as medications, healthcare access, prior TBI, substance abuse, and living circumstances). 'This pillar summarizes the factors that research tells us need to be considered when we interpret a patient's clinical, blood biomarker, and neuroimaging exams,' co-first author Kristen Dams-O'Connor, PhD, professor in the Department of Rehabilitation and Human Performance and Department of Neurology, and director of the Brain Injury Research Center at the Icahn School of Medicine at Mount Sinai in New York City, said in the release. 'One example is a patient with underlying cognitive impairment who may require acute monitoring for risk of clinical deterioration, regardless of findings on the initial clinical exam,' she said. Testing and Validation The proposed framework is being phased in at trauma centers on a trial basis. It will be refined and validated before it is fully implemented. The authors of a linked Comment in The Lancet Neurology , led by Junfeng Feng, MD, Shanghai Institute of Head Trauma in Shanghai, China , offer several cautionary notes on the proposed CBI-M framework for acute TBI assessment. The new assessment model is a 'substantial advancement' in integrating the characterization of acute TBI but is 'not yet ideal,' they wrote. In their view, the biomarker pillar is limited in that testing for biomarkers requires time, their specificity for the diagnosis of TBI is not high, and the use of biomarkers is minimal in low-income and middle-income countries. 'Similar to the biomarker pillar, the modifier pillar — an individual's biopsychosocial characteristics — can be valuable for predicting outcomes in patients with TBI but has minimal effect on decision-making, particularly during the acute phase of TBI,' Feng and co-authors said. 'Another deficiency of the CBI-M framework is that it cannot quantitatively or semiquantitatively assess the condition of patients with TBI yet,' they pointed out. 'To gain recognition and application in countries around the world, the CBI-M framework requires improvement and practical testing through global multicenter, large-scale, prospective cohort studies,' Feng and colleagues cautioned. Another concern the Comment authors have is that the CBI-M framework does not consider intracranial pressure monitoring, which 'should be conducted in specific patients, if possible, and be eventually incorporated into the CBI-M framework for characterization of acute TBI,' they wrote. Asked why intracranial pressure monitoring was not included in the framework, McCrea said that 'while intracranial pressure monitoring is an important element of care for patients in the intensive care unit after TBI, the aim of this movement was to develop a multidimensional framework for characterization of acute TBI across the full spectrum of injury severity and all care settings.'
Medscape
21-05-2025
- Health
- Medscape
Rheumatology Guideline Updates Take New Life Course Approach
MANCHESTER, England — The latest guidelines on systemic sclerosis (SSc), axial spondyloarthritis (axSpA), and systemic lupus erythematosus (SLE) from the British Society for Rheumatology (BSR) have been updated and, where appropriate, now consider the full life course of these rheumatologic diseases, experts said at BSR 2025 Annual Meeting. BSR Clinical Guidelines Program Manager Lindsay Turner told Medscape Medical News that the approach was 'really valuable because often it's hard to get evidence in a pediatric population. The updates now mean that recommendations relevant to that population are included.' BSR guidelines are generally updated every 5 years, unless evidence becomes available that warrants a 'mini update,' Turner said. But that time schedule can get stretched out over longer periods, as occurred with the SSc guideline update, as Christopher Denton, MBChB, PhD, professor of experimental rheumatology at UCL Medical School in London, England, told Medscape Medical News . 'Obviously, COVID got in the way for 2 years,' he said. 'And of course, the process itself takes at least 2 years. So I think inevitably that even if you start to do the update, it's going to be about 7-8 years.' SSc Guideline Highlights Denton, who is also head of the Centre for Rheumatology at the Royal Free Hospital, London, England, presented highlights only of the updated SSc guideline at the conference because these have already been published. Christopher Denton, MBChB, PhD One of the key recommendations he highlighted is to use nailfold capillaroscopy during the diagnosis of SSc, as this is as important as antinuclear antibody testing, taking the history, and a physical examination. Moreover, all patients diagnosed with SSc should have a baseline assessment done regardless of what treatment plan is being considered and that should include bloodwork, ECGs, echocardiograms, pulmonary function tests, and a high-resolution CT (HRCT). Discussing the HRCT recommendation, Denton said: 'I think it does reflect the importance of knowing as early as possible whether there is interstitial lung disease present and also to help you follow patients noninvasively over time.' Another 'cornerstone' of the updated guidance is being vigilant and looking out for potential complications, such as malignancy. As for treatment, 'the general recommendation, or preference, was that mycophenolate mofetil is the drug that seems to be the most effective for diffuse cutaneous disease and for interstitial lung disease and limited skin involvement,' Denton said. The guideline also tries to make it clear when autologous hematopoietic stem cell transplantation (AHSCT) may or may not be suitable based on current evidence and states that this approach must be delivered within an experienced specialized center. As such, the recommendation is that AHSCT may be considered an option for diffuse cutaneous SSc, where the benefit is felt to outweigh any risks. However, if there is severe internal organ disease, then this approach may not be appropriate and careful evaluation is required. Also, while AHSCT may be considered an option for children and young people who have severe or refractory disease, regardless of whether they have diffuse cutaneous or limited disease, it is not for adults who have later-stage diffuse cutaneous or limited disease because there is not enough evidence currently to support its use, Denton said. AxSpA Guideline Highlights As for the updated axSpA guideline on management using biologic and targeted synthetic disease-modifying antirheumatic drugs, Sizheng Steven Zhao, MBChB, PhD, clinical senior lecturer and honorary consultant in rheumatology at The University of Manchester, Manchester, England, said there were three key points. Sizheng Steven Zhao, MBChB, PhD First, be open to re-evaluating the diagnosis, Zhao said: 'Getting the diagnosis right can be challenging. Be humble. Be open with your patients about the uncertainty around diagnosis and be willing to revisit that. Re-look at the [MRI] images if treatment response doesn't make sense.' Second, 'start recording the ASDAS [Ankylosing Spondylitis Disease Activity Score],' Zhao said, in addition to recording disease activity using the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI). Recording the BASDAI is a requirement of the National Institute for Health and Care Excellence, but using ASDAS is 'where the future is. That's where we're moving toward,' Zhao said. He indicated that this should not be too difficult to incorporate into routine practice given that rheumatologists are already using scores such as the DAS in 28 joints for rheumatoid arthritis. Third, do not rule out using certain drug classes. 'Although we're blessed with three classes of drug, we only still have three classes of drug for a condition that needs many decades of treatment. Don't reflexively rule out a mechanism of action,' Zhao said. Specifically, he mentioned not ruling out the use of interleukin 17 inhibitors in a patient who had uveitis or inflammatory bowel disease (IBD). Work with ophthalmologists and gastroenterologists on a case-by-case basis to see if that drug class could still be suitable, Zhao said. Three overarching principles have been added to the guidance, which consider the goals for treatment, shared care decision-making, and the need for a multidisciplinary approach. Zhao urged his audience to read these and the full guideline, which was published in April. There were 'a lot of nuances,' put into the writing of overarching principles and the 15 recommendations, he said. The recommendations have been grouped into three broad areas: General, which covers starting, monitoring, and switching treatments; extra-musculoskeletal manifestations (EMMs), which includes uveitis, psoriasis, and IBD; and treatment strategy, which encompasses the treat-to-target approach, tapering, and treatment withdrawal. The BSR guideline is unique in its discussion of EMMs, Zhao said. This is not done in the American or European guidelines to the same extent: 'We spent that much time thinking about this because, quite frankly, all the therapies have similar efficacy across musculoskeletal features. It is the EMMs that influence which one we choose.' Zhao emphasized that physical therapy was not to be ignored and that pharmacologic treatments were there to 'enable our patients to continue physical activity, not instead of physical therapy.' SLE Guideline Highlights The updated BSR guideline for the management and treatment of SLE is just a few weeks away from publication, said Md Yuzaiful Md Yusof, MBChB, PhD, consultant rheumatologist and senior research fellow at the University of Leeds and Leeds Teaching Hospitals NHS Trust, both in Leeds, England. Md Yuzaiful Md Yusof, MBChB, PhD The updated guideline covers a much broader scope than its previous iteration, as it now includes recommendations for the management of children and adolescents, as well as adults. Literature searches were done from inception rather than from where the last guideline left off, 'particularly for the pediatric field,' Md Yusof said. Detailed guidance on the management of lupus nephritis has been included, and other new features of the guideline were the inclusion of cutaneous lupus, nonpharmacologic care, and the delivery of care, Md Yusof said. Of course, he added, 'we can't do it all,' and areas not covered were neonatal lupus, contraception and reproductive health, treatment during pregnancy and breastfeeding, complications and comorbidities, and detailed management of thrombosis and antiphospholipid syndrome. However, other national guidelines should already cover these topics. The guideline included 102 recommendations. 'I know it sounds a bit alarming, but they're quite logical and self-explanatory,' Md Yusof said. Overall, 96 of these are shown in a single infographic which is intended to act as a 'cheat code,' he added. The recommendations concern diagnosis, assessment and monitoring, management, and the delivery of care. In terms of diagnosis, timing is key, Md Yusof said. When primary care physicians have a strong suspicion of SLE, they should be looking to refer to secondary or tertiary care within 3 weeks, he said. Treat-to-target is one of the key recommendations regarding assessment and monitoring. The primary treatment goal is to meet the 2021 Definition of Remission in SLE criteria, Md Yusof said. And if that is not possible, the target should be to reach the Lupus Low Disease Activity State. As for management, there is guidance on what rheumatologists could prescribe for cutaneous disease without consulting a dermatologist, such as non-facial topical glucocorticoids and non-facial topical calcineurin inhibitors. The of use of the British Isles Lupus Assessment Group (BILAG)-2004 index and SLE Disease Activity Index 2000 to guide management choices was recommended, with the addition of Easy-BILAG, Md Yusof said. 'We recommend all people with mild lupus to be on hydroxychloroquine at a dose of 5 mg/kg of actual body weight per day,' he said. Glucocorticoids could be used as bridging therapy to settle disease flare but not for routine long-term maintenance. For moderate to severe disease activity, methotrexate or immunosuppression with mycophenolate mofetil, azathioprine, cyclosporin, or tacrolimus is recommended to be started early if there is no organ- or life-threatening disease. Biologics and trials are then advocated for more moderate to severe disease, where there is no renal involvement or if glucocorticoids could not be withdrawn. Trials, belimumab, rituximab, or anifrolumab are recommended for more severe disease activity. Regarding lupus nephritis, all patients should be managed jointly between rheumatology and renal services. 'Timely biopsy is really key, and also identifying poor prognostic markers from the outset,' Md Yusof said. A key message regarding glucocorticoid use is to put an end date on the prescription and 'to make sure you have a tapering plan.' Detailed advice is provided in the guideline on how to taper appropriately. The recommendation on induction treatment for lupus nephritis is the most up-to-date available, with combination therapy recommended over single-agent mycophenolate mofetil. 'Whichever combination that you use for remission induction, you carry on for the maintenance,' Md Yusof added. He concluded that the British guidelines were 'definitely more directive and also more up-to-date' than other available guidelines. Turner reported having no relevant financial relationships. Denton reported receiving research and grant funding and consultancy and speaker fees from or acting as a clinical trial investigator and serving on a steering committee for more than 20 companies. Zhao reported receiving consultancy or speaker fees from AbbVie, Alfasigma, Novartis, and UCB. He also acknowledged receiving financial support for attending conferences from Alfasigma, Eli Lilly & Company, Novartis, and UCB. Md Yusof reported acting as an advisory board member, consultant, or speaker for Alumis, Aurinia, GlaxoSmithKline, Novartis, Roche, UCB, and Vifor.
