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VIDEO: ASCO Breast Cancer Symposium final wrap-up with Dr. Hope S. Rugo
SAN FRANCISCO – Can we figure out who doesn’t need excision of atypical ductal hyperplasia and intraepithelial neoplasia? Should we screen all women with low–estrogen receptor positivity (1%-9%) for BRCA mutations? Dr. Hope S. Rugo discusses these questions and others that came up during the final sessions at the breast cancer symposium sponsored by the American Society of Clinical Oncology.
The meeting closed out with discussions of evolving standards in the treatment of breast cancer, how to apply these standards to clinical practice, and talks on reversing hormone resistance, including new agents to improve response to hormone therapy.
Dr. Rugo, director of the Breast Oncology Clinical Trials Program at the University of California, San Francisco, also summarizes data presented in the final presentations, including results from a randomized phase II trial of a GP2 vaccine in the adjuvant setting for high-risk breast cancer patients, suggesting that it may reduce recurrence rates in some women with HER2-positive cancer. “It’s very encouraging because we’ve been sort of barking up the vaccine alley for a long, long time and not gotten anywhere. I think it’s quite encouraging data,” she says.
Dr. Rugo disclosed financial associations with Genomic Health, Plexxikon, Merck, and Novartis. She is on the scientific advisory board of Galena Biopharma, which is developing the breast cancer vaccines.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
On Twitter @sherryboschert
SAN FRANCISCO – Can we figure out who doesn’t need excision of atypical ductal hyperplasia and intraepithelial neoplasia? Should we screen all women with low–estrogen receptor positivity (1%-9%) for BRCA mutations? Dr. Hope S. Rugo discusses these questions and others that came up during the final sessions at the breast cancer symposium sponsored by the American Society of Clinical Oncology.
The meeting closed out with discussions of evolving standards in the treatment of breast cancer, how to apply these standards to clinical practice, and talks on reversing hormone resistance, including new agents to improve response to hormone therapy.
Dr. Rugo, director of the Breast Oncology Clinical Trials Program at the University of California, San Francisco, also summarizes data presented in the final presentations, including results from a randomized phase II trial of a GP2 vaccine in the adjuvant setting for high-risk breast cancer patients, suggesting that it may reduce recurrence rates in some women with HER2-positive cancer. “It’s very encouraging because we’ve been sort of barking up the vaccine alley for a long, long time and not gotten anywhere. I think it’s quite encouraging data,” she says.
Dr. Rugo disclosed financial associations with Genomic Health, Plexxikon, Merck, and Novartis. She is on the scientific advisory board of Galena Biopharma, which is developing the breast cancer vaccines.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
On Twitter @sherryboschert
SAN FRANCISCO – Can we figure out who doesn’t need excision of atypical ductal hyperplasia and intraepithelial neoplasia? Should we screen all women with low–estrogen receptor positivity (1%-9%) for BRCA mutations? Dr. Hope S. Rugo discusses these questions and others that came up during the final sessions at the breast cancer symposium sponsored by the American Society of Clinical Oncology.
The meeting closed out with discussions of evolving standards in the treatment of breast cancer, how to apply these standards to clinical practice, and talks on reversing hormone resistance, including new agents to improve response to hormone therapy.
Dr. Rugo, director of the Breast Oncology Clinical Trials Program at the University of California, San Francisco, also summarizes data presented in the final presentations, including results from a randomized phase II trial of a GP2 vaccine in the adjuvant setting for high-risk breast cancer patients, suggesting that it may reduce recurrence rates in some women with HER2-positive cancer. “It’s very encouraging because we’ve been sort of barking up the vaccine alley for a long, long time and not gotten anywhere. I think it’s quite encouraging data,” she says.
Dr. Rugo disclosed financial associations with Genomic Health, Plexxikon, Merck, and Novartis. She is on the scientific advisory board of Galena Biopharma, which is developing the breast cancer vaccines.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
On Twitter @sherryboschert
AT THE ASCO BREAST CANCER SYMPOSIUM
Fractures Increased With Two Diabetes Drugs
SAN FRANCISCO – Adults who started taking sulfonylurea drugs for diabetes were 9% more likely to develop fractures within 5 years, and patients starting thiazolidinediones were 9% more likely to have fractures, compared with patients on other medications in a retrospective study of 99,892 adults.
Those significantly increased risks emerged after adjusting for the effects of multiple factors including age, gender, region, medical conditions, and concomitant medications, Sandhya Mehta, Ph.D. and her associates reported at the annual scientific sessions of the American Diabetes Association. Patients had no prior history of fracture.
The longitudinal retrospective analysis of a large administrative claims database found a 10% incidence of fracture on sulfonylureas and 11% on thiazolidinediones, compared with 7% on biguanides (metformin), 8% on dipeptidyl peptidase-4 (DPP-4) inhibitors, 11% on meglitinide analogues, and 6% on incretin mimetic agents. After adjusting for the confounders, the hazard ratios for each of the other three types of drugs hovered around 1 and were not statistically significantly different but increased to 1.09 for sulfonylureas and 1.4 for thiazolidinediones, reported Dr. Mehta of Inovalon Inc. in Bowie, Md., a health care data analytics company.
In the cohort as a whole, 7% of patients developed fractures. Roughly 15% of patients started sulfonylureas, 3% took thiazolidinediones, 78% were on metformin, 3% took DPP-4 inhibitors, 1% were on incretin mimetics, and 1% took meglitinides.
Previous reports have shown an increased risk of fracture in patients on thiazolidinediones, compared with those on metformin, and the current results support the hypothesis that thiazolidinediones decrease bone mineral density, stimulate adipocyte and osteoclast differentiation, and inhibit osteoblast differentiation to make fracture more likely, Dr. Mehta said.
The association between sulfonylureas and increased fracture risk appears to be new, however, and deserves further study, she added.
The study did not look at the effects of combination drug therapy.
Data came from the Medical Outcomes Research for Effectiveness and Economics (MORE) Registry, which is owned by Inovalon, drawing from the years 2008-2012.
Dr. Mehta reported having no financial disclosures.
On Twitter @sherryboschert
Dr. Amanda Adler
This study confirms that we observe more fracture risks with thiazolidinediones. To my knowledge, this is the first time that this has been shown for sulfonylureas.
One concern about the study is so-called residual confounding. The confounders were not entirely clear in the presentation. One possible confounder is what might have preceded the fracture. If, in fact, patients on sulfonylureas were having more low blood glucose values and consequently fell, then that would be interesting to know. Unfortunately, the investigators couldn’t tell us that.
With thiazolidinediones, I’ve been told that a cell that hasn’t decided yet whether it’s going to be a bone cell or a fat cell might, in the presence of a thiazolidinedione, go on to be a fat cell instead of a bone cell. In which case, you would possibly have a problem with fewer bone cells. This study set out to look at bone metabolism but, to be fair, it could not show anything about that. That was rather ambitious.
I think there is no clinical message from this as yet. The investigators might want to look back at trials that randomized people to sulfonylureas or something else and meta-analyze that to see if there were differences in fractures.
The study suggests that the other second-line agents are okay, but again, we can’t really know what they’re doing to bones without knowing if there’s something else going on. If you took a drug that made you more likely to topple over, your bones could be equally strong as those who didn’t fall over, yet you end up with a fracture.
I’m not going to change my practice on the basis of this study.
Dr. Amanda Adler is consultant physician at Cambridge University’s Addenbrooke’s Hospital and chair of the technology appraisals committee for the National Institute for Health and Clinical Excellence in England. She gave these comments in an interview at the meeting.
This study confirms that we observe more fracture risks with thiazolidinediones. To my knowledge, this is the first time that this has been shown for sulfonylureas.
|
|
One concern about the study is so-called residual confounding. The confounders were not entirely clear in the presentation. One possible confounder is what might have preceded the fracture. If, in fact, patients on sulfonylureas were having more low blood glucose values and consequently fell, then that would be interesting to know. Unfortunately, the investigators couldn’t tell us that.
With thiazolidinediones, I’ve been told that a cell that hasn’t decided yet whether it’s going to be a bone cell or a fat cell might, in the presence of a thiazolidinedione, go on to be a fat cell instead of a bone cell. In which case, you would possibly have a problem with fewer bone cells. This study set out to look at bone metabolism but, to be fair, it could not show anything about that. That was rather ambitious.
I think there is no clinical message from this as yet. The investigators might want to look back at trials that randomized people to sulfonylureas or something else and meta-analyze that to see if there were differences in fractures.
The study suggests that the other second-line agents are okay, but again, we can’t really know what they’re doing to bones without knowing if there’s something else going on. If you took a drug that made you more likely to topple over, your bones could be equally strong as those who didn’t fall over, yet you end up with a fracture.
I’m not going to change my practice on the basis of this study.
Dr. Amanda Adler is consultant physician at Cambridge University’s Addenbrooke’s Hospital and chair of the technology appraisals committee for the National Institute for Health and Clinical Excellence in England. She gave these comments in an interview at the meeting.
This study confirms that we observe more fracture risks with thiazolidinediones. To my knowledge, this is the first time that this has been shown for sulfonylureas.
|
|
One concern about the study is so-called residual confounding. The confounders were not entirely clear in the presentation. One possible confounder is what might have preceded the fracture. If, in fact, patients on sulfonylureas were having more low blood glucose values and consequently fell, then that would be interesting to know. Unfortunately, the investigators couldn’t tell us that.
With thiazolidinediones, I’ve been told that a cell that hasn’t decided yet whether it’s going to be a bone cell or a fat cell might, in the presence of a thiazolidinedione, go on to be a fat cell instead of a bone cell. In which case, you would possibly have a problem with fewer bone cells. This study set out to look at bone metabolism but, to be fair, it could not show anything about that. That was rather ambitious.
I think there is no clinical message from this as yet. The investigators might want to look back at trials that randomized people to sulfonylureas or something else and meta-analyze that to see if there were differences in fractures.
The study suggests that the other second-line agents are okay, but again, we can’t really know what they’re doing to bones without knowing if there’s something else going on. If you took a drug that made you more likely to topple over, your bones could be equally strong as those who didn’t fall over, yet you end up with a fracture.
I’m not going to change my practice on the basis of this study.
Dr. Amanda Adler is consultant physician at Cambridge University’s Addenbrooke’s Hospital and chair of the technology appraisals committee for the National Institute for Health and Clinical Excellence in England. She gave these comments in an interview at the meeting.
This study confirms that we observe more fracture risks with thiazolidinediones. To my knowledge, this is the first time that this has been shown for sulfonylureas.
|
|
One concern about the study is so-called residual confounding. The confounders were not entirely clear in the presentation. One possible confounder is what might have preceded the fracture. If, in fact, patients on sulfonylureas were having more low blood glucose values and consequently fell, then that would be interesting to know. Unfortunately, the investigators couldn’t tell us that.
With thiazolidinediones, I’ve been told that a cell that hasn’t decided yet whether it’s going to be a bone cell or a fat cell might, in the presence of a thiazolidinedione, go on to be a fat cell instead of a bone cell. In which case, you would possibly have a problem with fewer bone cells. This study set out to look at bone metabolism but, to be fair, it could not show anything about that. That was rather ambitious.
I think there is no clinical message from this as yet. The investigators might want to look back at trials that randomized people to sulfonylureas or something else and meta-analyze that to see if there were differences in fractures.
The study suggests that the other second-line agents are okay, but again, we can’t really know what they’re doing to bones without knowing if there’s something else going on. If you took a drug that made you more likely to topple over, your bones could be equally strong as those who didn’t fall over, yet you end up with a fracture.
I’m not going to change my practice on the basis of this study.
Dr. Amanda Adler is consultant physician at Cambridge University’s Addenbrooke’s Hospital and chair of the technology appraisals committee for the National Institute for Health and Clinical Excellence in England. She gave these comments in an interview at the meeting.
SAN FRANCISCO – Adults who started taking sulfonylurea drugs for diabetes were 9% more likely to develop fractures within 5 years, and patients starting thiazolidinediones were 9% more likely to have fractures, compared with patients on other medications in a retrospective study of 99,892 adults.
Those significantly increased risks emerged after adjusting for the effects of multiple factors including age, gender, region, medical conditions, and concomitant medications, Sandhya Mehta, Ph.D. and her associates reported at the annual scientific sessions of the American Diabetes Association. Patients had no prior history of fracture.
The longitudinal retrospective analysis of a large administrative claims database found a 10% incidence of fracture on sulfonylureas and 11% on thiazolidinediones, compared with 7% on biguanides (metformin), 8% on dipeptidyl peptidase-4 (DPP-4) inhibitors, 11% on meglitinide analogues, and 6% on incretin mimetic agents. After adjusting for the confounders, the hazard ratios for each of the other three types of drugs hovered around 1 and were not statistically significantly different but increased to 1.09 for sulfonylureas and 1.4 for thiazolidinediones, reported Dr. Mehta of Inovalon Inc. in Bowie, Md., a health care data analytics company.
In the cohort as a whole, 7% of patients developed fractures. Roughly 15% of patients started sulfonylureas, 3% took thiazolidinediones, 78% were on metformin, 3% took DPP-4 inhibitors, 1% were on incretin mimetics, and 1% took meglitinides.
Previous reports have shown an increased risk of fracture in patients on thiazolidinediones, compared with those on metformin, and the current results support the hypothesis that thiazolidinediones decrease bone mineral density, stimulate adipocyte and osteoclast differentiation, and inhibit osteoblast differentiation to make fracture more likely, Dr. Mehta said.
The association between sulfonylureas and increased fracture risk appears to be new, however, and deserves further study, she added.
The study did not look at the effects of combination drug therapy.
Data came from the Medical Outcomes Research for Effectiveness and Economics (MORE) Registry, which is owned by Inovalon, drawing from the years 2008-2012.
Dr. Mehta reported having no financial disclosures.
On Twitter @sherryboschert
Dr. Amanda Adler
This study confirms that we observe more fracture risks with thiazolidinediones. To my knowledge, this is the first time that this has been shown for sulfonylureas.
One concern about the study is so-called residual confounding. The confounders were not entirely clear in the presentation. One possible confounder is what might have preceded the fracture. If, in fact, patients on sulfonylureas were having more low blood glucose values and consequently fell, then that would be interesting to know. Unfortunately, the investigators couldn’t tell us that.
With thiazolidinediones, I’ve been told that a cell that hasn’t decided yet whether it’s going to be a bone cell or a fat cell might, in the presence of a thiazolidinedione, go on to be a fat cell instead of a bone cell. In which case, you would possibly have a problem with fewer bone cells. This study set out to look at bone metabolism but, to be fair, it could not show anything about that. That was rather ambitious.
I think there is no clinical message from this as yet. The investigators might want to look back at trials that randomized people to sulfonylureas or something else and meta-analyze that to see if there were differences in fractures.
The study suggests that the other second-line agents are okay, but again, we can’t really know what they’re doing to bones without knowing if there’s something else going on. If you took a drug that made you more likely to topple over, your bones could be equally strong as those who didn’t fall over, yet you end up with a fracture.
I’m not going to change my practice on the basis of this study.
Dr. Amanda Adler is consultant physician at Cambridge University’s Addenbrooke’s Hospital and chair of the technology appraisals committee for the National Institute for Health and Clinical Excellence in England. She gave these comments in an interview at the meeting.
SAN FRANCISCO – Adults who started taking sulfonylurea drugs for diabetes were 9% more likely to develop fractures within 5 years, and patients starting thiazolidinediones were 9% more likely to have fractures, compared with patients on other medications in a retrospective study of 99,892 adults.
Those significantly increased risks emerged after adjusting for the effects of multiple factors including age, gender, region, medical conditions, and concomitant medications, Sandhya Mehta, Ph.D. and her associates reported at the annual scientific sessions of the American Diabetes Association. Patients had no prior history of fracture.
The longitudinal retrospective analysis of a large administrative claims database found a 10% incidence of fracture on sulfonylureas and 11% on thiazolidinediones, compared with 7% on biguanides (metformin), 8% on dipeptidyl peptidase-4 (DPP-4) inhibitors, 11% on meglitinide analogues, and 6% on incretin mimetic agents. After adjusting for the confounders, the hazard ratios for each of the other three types of drugs hovered around 1 and were not statistically significantly different but increased to 1.09 for sulfonylureas and 1.4 for thiazolidinediones, reported Dr. Mehta of Inovalon Inc. in Bowie, Md., a health care data analytics company.
In the cohort as a whole, 7% of patients developed fractures. Roughly 15% of patients started sulfonylureas, 3% took thiazolidinediones, 78% were on metformin, 3% took DPP-4 inhibitors, 1% were on incretin mimetics, and 1% took meglitinides.
Previous reports have shown an increased risk of fracture in patients on thiazolidinediones, compared with those on metformin, and the current results support the hypothesis that thiazolidinediones decrease bone mineral density, stimulate adipocyte and osteoclast differentiation, and inhibit osteoblast differentiation to make fracture more likely, Dr. Mehta said.
The association between sulfonylureas and increased fracture risk appears to be new, however, and deserves further study, she added.
The study did not look at the effects of combination drug therapy.
Data came from the Medical Outcomes Research for Effectiveness and Economics (MORE) Registry, which is owned by Inovalon, drawing from the years 2008-2012.
Dr. Mehta reported having no financial disclosures.
On Twitter @sherryboschert
Dr. Amanda Adler
This study confirms that we observe more fracture risks with thiazolidinediones. To my knowledge, this is the first time that this has been shown for sulfonylureas.
One concern about the study is so-called residual confounding. The confounders were not entirely clear in the presentation. One possible confounder is what might have preceded the fracture. If, in fact, patients on sulfonylureas were having more low blood glucose values and consequently fell, then that would be interesting to know. Unfortunately, the investigators couldn’t tell us that.
With thiazolidinediones, I’ve been told that a cell that hasn’t decided yet whether it’s going to be a bone cell or a fat cell might, in the presence of a thiazolidinedione, go on to be a fat cell instead of a bone cell. In which case, you would possibly have a problem with fewer bone cells. This study set out to look at bone metabolism but, to be fair, it could not show anything about that. That was rather ambitious.
I think there is no clinical message from this as yet. The investigators might want to look back at trials that randomized people to sulfonylureas or something else and meta-analyze that to see if there were differences in fractures.
The study suggests that the other second-line agents are okay, but again, we can’t really know what they’re doing to bones without knowing if there’s something else going on. If you took a drug that made you more likely to topple over, your bones could be equally strong as those who didn’t fall over, yet you end up with a fracture.
I’m not going to change my practice on the basis of this study.
Dr. Amanda Adler is consultant physician at Cambridge University’s Addenbrooke’s Hospital and chair of the technology appraisals committee for the National Institute for Health and Clinical Excellence in England. She gave these comments in an interview at the meeting.
AT THE ADA ANNUAL SCIENTIFIC SESSIONS
Hypoglycemia Common After Bariatric Surgery
SAN FRANCISCO – Hypoglycemic episodes were common and largely unnoticed after bariatric surgery, a controlled study of 45 patients found.
During a 3-day period of "normal living," symptomatic hypoglycemias occurred in 22% of 15 patients after gastric bypass surgery, 20% of 15 patients after biliopancreatic diversion with duodenal switch, and in none of 15 obese, nondiabetic control patients matched to the surgical patients by body mass index.
Continuous glucose monitoring showed that patients in both postsurgery groups spent significant amounts of time in hypoglycemia, Dr. Niclas Abrahamsson and his associates reported at the annual scientific session of the American Diabetes Association.
After gastric bypass, patients averaged 42 minutes per day with glucose levels lower than 3.3 mmol/L and 21 minutes per day with levels lower than 2.8 mmol/L. After duodenal switch surgery, patients averaged 85 minutes per day with glucose levels lower than 3.3 mmol/L and 39 minutes per day with levels lower than 2.8 mmol/L. No patients in the control group had glucose levels that low, reported Dr. Abrahamsson of the University of Uppsala, Sweden.
"We were very surprised that they had so many hypoglycemic episodes, especially since the controls had none," he said. Patients were unaware of approximately 80% of the hypoglycemic episodes, he added.
"The clinical significance should be that one should be alert to any hypoglycemia symptoms," Dr. Abrahamsson said.
Patients in the post–duodenal switch group had the lowest mean glucose level (4.6 mmol/L) and mean hemoglobin A1c level (29 mmol/mol), compared with the post–gastric bypass group (mean glucose 5.3 mmol/L and HbA1c 36 mmol/mol) and the control group (mean glucose 5.9 mmol/L and HbA1c 38 mmol/mol).
Glucose curves on continuous monitoring were more variable in the post–gastric bypass group, compared with controls, and less variable in the post–duodenal switch group, compared with controls. That difference between the two surgical groups probably relates to the different glucose absorption capabilities after surgery, he suggested.
Dr. Abrahamsson has been a speaker for Eli Lilly and Sanofi and has held stock in AstraZeneca.
On Twitter @sherryboschert
Dr. Thomas Barber
The finding that patients with recent duodenal switch surgery spent 85 minutes per day with hypoglycemia, compared with 42 minutes per 24 hours for patients in the gastric bypass group, is quite alarming. Although these hypoglycemias were largely unnoticed, we know that hypoglycemia can affect brain function, cognition, and motor function.
This study has safety and legal implications for things like driving and operating machinery and raises questions of how we can best manage patients in terms of mitigating the effects of hypoglycemia. I think it opens up a whole area of questions at which we need to look.The problem with continuous glucose monitoring is that it’s a research tool, but it’s not very practical to be doing in every single patient who’s had a gastric bypass surgery. The problem with doing blood glucose measurement is that it’s a snapshot and you can potentially miss hypoglycemia. So, this has a lot of clinical implications as to how we investigate such patients.
I think this study will change my practice. It has opened my eyes. I was quite shocked at the data. At my center, we don’t tend to do many duodenal switches. We do many more sleeve gastrectomies than the bypass procedures. But, certainly, following a bypass procedure, I will be much more cognizant of the potential for hypoglycemia and caution our patients regarding driving and about monitoring their sugars closely following the procedure.
Dr. Thomas Barber is an associate professor and honorary consultant endocrinologist at the University of Warwick, England. These comments are excerpted from an interview at the meeting. Dr. Barber reported having no financial disclosures.
The finding that patients with recent duodenal switch surgery spent 85 minutes per day with hypoglycemia, compared with 42 minutes per 24 hours for patients in the gastric bypass group, is quite alarming. Although these hypoglycemias were largely unnoticed, we know that hypoglycemia can affect brain function, cognition, and motor function.
 |
|
The problem with continuous glucose monitoring is that it’s a research tool, but it’s not very practical to be doing in every single patient who’s had a gastric bypass surgery. The problem with doing blood glucose measurement is that it’s a snapshot and you can potentially miss hypoglycemia. So, this has a lot of clinical implications as to how we investigate such patients.
This study has safety and legal implications for things like driving and operating machinery and raises questions of how we can best manage patients in terms of mitigating the effects of hypoglycemia. I think it opens up a whole area of questions at which we need to look.
I think this study will change my practice. It has opened my eyes. I was quite shocked at the data. At my center, we don’t tend to do many duodenal switches. We do many more sleeve gastrectomies than the bypass procedures. But, certainly, following a bypass procedure, I will be much more cognizant of the potential for hypoglycemia and caution our patients regarding driving and about monitoring their sugars closely following the procedure.
Dr. Thomas Barber is an associate professor and honorary consultant endocrinologist at the University of Warwick, England. These comments are excerpted from an interview at the meeting. Dr. Barber reported having no financial disclosures.
The finding that patients with recent duodenal switch surgery spent 85 minutes per day with hypoglycemia, compared with 42 minutes per 24 hours for patients in the gastric bypass group, is quite alarming. Although these hypoglycemias were largely unnoticed, we know that hypoglycemia can affect brain function, cognition, and motor function.
|
|
The problem with continuous glucose monitoring is that it’s a research tool, but it’s not very practical to be doing in every single patient who’s had a gastric bypass surgery. The problem with doing blood glucose measurement is that it’s a snapshot and you can potentially miss hypoglycemia. So, this has a lot of clinical implications as to how we investigate such patients.
This study has safety and legal implications for things like driving and operating machinery and raises questions of how we can best manage patients in terms of mitigating the effects of hypoglycemia. I think it opens up a whole area of questions at which we need to look.
I think this study will change my practice. It has opened my eyes. I was quite shocked at the data. At my center, we don’t tend to do many duodenal switches. We do many more sleeve gastrectomies than the bypass procedures. But, certainly, following a bypass procedure, I will be much more cognizant of the potential for hypoglycemia and caution our patients regarding driving and about monitoring their sugars closely following the procedure.
Dr. Thomas Barber is an associate professor and honorary consultant endocrinologist at the University of Warwick, England. These comments are excerpted from an interview at the meeting. Dr. Barber reported having no financial disclosures.
The finding that patients with recent duodenal switch surgery spent 85 minutes per day with hypoglycemia, compared with 42 minutes per 24 hours for patients in the gastric bypass group, is quite alarming. Although these hypoglycemias were largely unnoticed, we know that hypoglycemia can affect brain function, cognition, and motor function.
|
|
The problem with continuous glucose monitoring is that it’s a research tool, but it’s not very practical to be doing in every single patient who’s had a gastric bypass surgery. The problem with doing blood glucose measurement is that it’s a snapshot and you can potentially miss hypoglycemia. So, this has a lot of clinical implications as to how we investigate such patients.
This study has safety and legal implications for things like driving and operating machinery and raises questions of how we can best manage patients in terms of mitigating the effects of hypoglycemia. I think it opens up a whole area of questions at which we need to look.
I think this study will change my practice. It has opened my eyes. I was quite shocked at the data. At my center, we don’t tend to do many duodenal switches. We do many more sleeve gastrectomies than the bypass procedures. But, certainly, following a bypass procedure, I will be much more cognizant of the potential for hypoglycemia and caution our patients regarding driving and about monitoring their sugars closely following the procedure.
Dr. Thomas Barber is an associate professor and honorary consultant endocrinologist at the University of Warwick, England. These comments are excerpted from an interview at the meeting. Dr. Barber reported having no financial disclosures.
SAN FRANCISCO – Hypoglycemic episodes were common and largely unnoticed after bariatric surgery, a controlled study of 45 patients found.
During a 3-day period of "normal living," symptomatic hypoglycemias occurred in 22% of 15 patients after gastric bypass surgery, 20% of 15 patients after biliopancreatic diversion with duodenal switch, and in none of 15 obese, nondiabetic control patients matched to the surgical patients by body mass index.
Continuous glucose monitoring showed that patients in both postsurgery groups spent significant amounts of time in hypoglycemia, Dr. Niclas Abrahamsson and his associates reported at the annual scientific session of the American Diabetes Association.
After gastric bypass, patients averaged 42 minutes per day with glucose levels lower than 3.3 mmol/L and 21 minutes per day with levels lower than 2.8 mmol/L. After duodenal switch surgery, patients averaged 85 minutes per day with glucose levels lower than 3.3 mmol/L and 39 minutes per day with levels lower than 2.8 mmol/L. No patients in the control group had glucose levels that low, reported Dr. Abrahamsson of the University of Uppsala, Sweden.
"We were very surprised that they had so many hypoglycemic episodes, especially since the controls had none," he said. Patients were unaware of approximately 80% of the hypoglycemic episodes, he added.
"The clinical significance should be that one should be alert to any hypoglycemia symptoms," Dr. Abrahamsson said.
Patients in the post–duodenal switch group had the lowest mean glucose level (4.6 mmol/L) and mean hemoglobin A1c level (29 mmol/mol), compared with the post–gastric bypass group (mean glucose 5.3 mmol/L and HbA1c 36 mmol/mol) and the control group (mean glucose 5.9 mmol/L and HbA1c 38 mmol/mol).
Glucose curves on continuous monitoring were more variable in the post–gastric bypass group, compared with controls, and less variable in the post–duodenal switch group, compared with controls. That difference between the two surgical groups probably relates to the different glucose absorption capabilities after surgery, he suggested.
Dr. Abrahamsson has been a speaker for Eli Lilly and Sanofi and has held stock in AstraZeneca.
On Twitter @sherryboschert
Dr. Thomas Barber
The finding that patients with recent duodenal switch surgery spent 85 minutes per day with hypoglycemia, compared with 42 minutes per 24 hours for patients in the gastric bypass group, is quite alarming. Although these hypoglycemias were largely unnoticed, we know that hypoglycemia can affect brain function, cognition, and motor function.
This study has safety and legal implications for things like driving and operating machinery and raises questions of how we can best manage patients in terms of mitigating the effects of hypoglycemia. I think it opens up a whole area of questions at which we need to look.The problem with continuous glucose monitoring is that it’s a research tool, but it’s not very practical to be doing in every single patient who’s had a gastric bypass surgery. The problem with doing blood glucose measurement is that it’s a snapshot and you can potentially miss hypoglycemia. So, this has a lot of clinical implications as to how we investigate such patients.
I think this study will change my practice. It has opened my eyes. I was quite shocked at the data. At my center, we don’t tend to do many duodenal switches. We do many more sleeve gastrectomies than the bypass procedures. But, certainly, following a bypass procedure, I will be much more cognizant of the potential for hypoglycemia and caution our patients regarding driving and about monitoring their sugars closely following the procedure.
Dr. Thomas Barber is an associate professor and honorary consultant endocrinologist at the University of Warwick, England. These comments are excerpted from an interview at the meeting. Dr. Barber reported having no financial disclosures.
SAN FRANCISCO – Hypoglycemic episodes were common and largely unnoticed after bariatric surgery, a controlled study of 45 patients found.
During a 3-day period of "normal living," symptomatic hypoglycemias occurred in 22% of 15 patients after gastric bypass surgery, 20% of 15 patients after biliopancreatic diversion with duodenal switch, and in none of 15 obese, nondiabetic control patients matched to the surgical patients by body mass index.
Continuous glucose monitoring showed that patients in both postsurgery groups spent significant amounts of time in hypoglycemia, Dr. Niclas Abrahamsson and his associates reported at the annual scientific session of the American Diabetes Association.
After gastric bypass, patients averaged 42 minutes per day with glucose levels lower than 3.3 mmol/L and 21 minutes per day with levels lower than 2.8 mmol/L. After duodenal switch surgery, patients averaged 85 minutes per day with glucose levels lower than 3.3 mmol/L and 39 minutes per day with levels lower than 2.8 mmol/L. No patients in the control group had glucose levels that low, reported Dr. Abrahamsson of the University of Uppsala, Sweden.
"We were very surprised that they had so many hypoglycemic episodes, especially since the controls had none," he said. Patients were unaware of approximately 80% of the hypoglycemic episodes, he added.
"The clinical significance should be that one should be alert to any hypoglycemia symptoms," Dr. Abrahamsson said.
Patients in the post–duodenal switch group had the lowest mean glucose level (4.6 mmol/L) and mean hemoglobin A1c level (29 mmol/mol), compared with the post–gastric bypass group (mean glucose 5.3 mmol/L and HbA1c 36 mmol/mol) and the control group (mean glucose 5.9 mmol/L and HbA1c 38 mmol/mol).
Glucose curves on continuous monitoring were more variable in the post–gastric bypass group, compared with controls, and less variable in the post–duodenal switch group, compared with controls. That difference between the two surgical groups probably relates to the different glucose absorption capabilities after surgery, he suggested.
Dr. Abrahamsson has been a speaker for Eli Lilly and Sanofi and has held stock in AstraZeneca.
On Twitter @sherryboschert
Dr. Thomas Barber
The finding that patients with recent duodenal switch surgery spent 85 minutes per day with hypoglycemia, compared with 42 minutes per 24 hours for patients in the gastric bypass group, is quite alarming. Although these hypoglycemias were largely unnoticed, we know that hypoglycemia can affect brain function, cognition, and motor function.
This study has safety and legal implications for things like driving and operating machinery and raises questions of how we can best manage patients in terms of mitigating the effects of hypoglycemia. I think it opens up a whole area of questions at which we need to look.The problem with continuous glucose monitoring is that it’s a research tool, but it’s not very practical to be doing in every single patient who’s had a gastric bypass surgery. The problem with doing blood glucose measurement is that it’s a snapshot and you can potentially miss hypoglycemia. So, this has a lot of clinical implications as to how we investigate such patients.
I think this study will change my practice. It has opened my eyes. I was quite shocked at the data. At my center, we don’t tend to do many duodenal switches. We do many more sleeve gastrectomies than the bypass procedures. But, certainly, following a bypass procedure, I will be much more cognizant of the potential for hypoglycemia and caution our patients regarding driving and about monitoring their sugars closely following the procedure.
Dr. Thomas Barber is an associate professor and honorary consultant endocrinologist at the University of Warwick, England. These comments are excerpted from an interview at the meeting. Dr. Barber reported having no financial disclosures.
AT THE ADA ANNUAL SCIENTIFIC SESSION
VIDEO: Breast cancer symposium take-home messages, Day 1
SAN FRANCISCO – Dr. Eleftherios (Terry) Mamounas reviews the first day of the annual breast cancer symposium sponsored by the American Society of Clinical Oncology.
Key sessions covered the increasingly complex topic of genetic risk assessment and stirred up the debate about management of ductal carcinoma in situ (DCIS). Dr. Mamounas, professor of surgery at the University of Central Florida and medical director of the comprehensive breast program at the University of Florida Health Cancer Center, both in Orlando, discusses the significance of atypical hyperplasia, including new data suggesting that the fourfold increased risk of developing breast cancer in women with ductal carcinoma in situ (DCIS) is not further worsened by having a family history of DCIS.
Among the top oral presentations, one study suggested that a nomogram helped predict the risk of locoregional recurrence in patients treated for breast cancer using accelerated partial-breast irradiation. Another study examined the effect of hormone receptor status and local treatment on overall survival for patients with early-stage breast cancer.
Dr. Mamounas also discusses his own study, which he presented at the meeting, showing lower rates of locoregional recurrence in patients who have a pathologic complete response to neoadjuvant therapy. He puts the findings in context with tips on how to incorporate pathologic complete response data into clinical practice.
A separate study reported some of the first data on complication rates after unilateral or bilateral mastectomy and reconstruction. Dr. Mamounas wraps up the day’s review by discussing sessions on the effect of luteinizing hormone-releasing hormone agonists during chemotherapy in preserving ovarian function, and on breast cancer prevention, including the use of aromatase inhibitors.
For more of the meeting’s highlights, see our video interviews with Dr. Hope S. Rugo discussing the events of the second and third days of the Breast Cancer Symposium. Dr. Rugo is director of the Breast Oncology Clinical Trials Program at the University of California, San Francisco, Helen Diller Family Comprehensive Cancer Center.
Dr. Mamounas reported financial associations with Genomic Health, Genentech/Roche, Pfizer, GlaxoSmithKline, Eisai, Celgene, and GE Healthcare.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
On Twitter @sherryboschert
SAN FRANCISCO – Dr. Eleftherios (Terry) Mamounas reviews the first day of the annual breast cancer symposium sponsored by the American Society of Clinical Oncology.
Key sessions covered the increasingly complex topic of genetic risk assessment and stirred up the debate about management of ductal carcinoma in situ (DCIS). Dr. Mamounas, professor of surgery at the University of Central Florida and medical director of the comprehensive breast program at the University of Florida Health Cancer Center, both in Orlando, discusses the significance of atypical hyperplasia, including new data suggesting that the fourfold increased risk of developing breast cancer in women with ductal carcinoma in situ (DCIS) is not further worsened by having a family history of DCIS.
Among the top oral presentations, one study suggested that a nomogram helped predict the risk of locoregional recurrence in patients treated for breast cancer using accelerated partial-breast irradiation. Another study examined the effect of hormone receptor status and local treatment on overall survival for patients with early-stage breast cancer.
Dr. Mamounas also discusses his own study, which he presented at the meeting, showing lower rates of locoregional recurrence in patients who have a pathologic complete response to neoadjuvant therapy. He puts the findings in context with tips on how to incorporate pathologic complete response data into clinical practice.
A separate study reported some of the first data on complication rates after unilateral or bilateral mastectomy and reconstruction. Dr. Mamounas wraps up the day’s review by discussing sessions on the effect of luteinizing hormone-releasing hormone agonists during chemotherapy in preserving ovarian function, and on breast cancer prevention, including the use of aromatase inhibitors.
For more of the meeting’s highlights, see our video interviews with Dr. Hope S. Rugo discussing the events of the second and third days of the Breast Cancer Symposium. Dr. Rugo is director of the Breast Oncology Clinical Trials Program at the University of California, San Francisco, Helen Diller Family Comprehensive Cancer Center.
Dr. Mamounas reported financial associations with Genomic Health, Genentech/Roche, Pfizer, GlaxoSmithKline, Eisai, Celgene, and GE Healthcare.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
On Twitter @sherryboschert
SAN FRANCISCO – Dr. Eleftherios (Terry) Mamounas reviews the first day of the annual breast cancer symposium sponsored by the American Society of Clinical Oncology.
Key sessions covered the increasingly complex topic of genetic risk assessment and stirred up the debate about management of ductal carcinoma in situ (DCIS). Dr. Mamounas, professor of surgery at the University of Central Florida and medical director of the comprehensive breast program at the University of Florida Health Cancer Center, both in Orlando, discusses the significance of atypical hyperplasia, including new data suggesting that the fourfold increased risk of developing breast cancer in women with ductal carcinoma in situ (DCIS) is not further worsened by having a family history of DCIS.
Among the top oral presentations, one study suggested that a nomogram helped predict the risk of locoregional recurrence in patients treated for breast cancer using accelerated partial-breast irradiation. Another study examined the effect of hormone receptor status and local treatment on overall survival for patients with early-stage breast cancer.
Dr. Mamounas also discusses his own study, which he presented at the meeting, showing lower rates of locoregional recurrence in patients who have a pathologic complete response to neoadjuvant therapy. He puts the findings in context with tips on how to incorporate pathologic complete response data into clinical practice.
A separate study reported some of the first data on complication rates after unilateral or bilateral mastectomy and reconstruction. Dr. Mamounas wraps up the day’s review by discussing sessions on the effect of luteinizing hormone-releasing hormone agonists during chemotherapy in preserving ovarian function, and on breast cancer prevention, including the use of aromatase inhibitors.
For more of the meeting’s highlights, see our video interviews with Dr. Hope S. Rugo discussing the events of the second and third days of the Breast Cancer Symposium. Dr. Rugo is director of the Breast Oncology Clinical Trials Program at the University of California, San Francisco, Helen Diller Family Comprehensive Cancer Center.
Dr. Mamounas reported financial associations with Genomic Health, Genentech/Roche, Pfizer, GlaxoSmithKline, Eisai, Celgene, and GE Healthcare.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
On Twitter @sherryboschert
AT THE ASCO BREAST CANCER SYMPOSIUM
VIDEO: Dr. Hope S. Rugo on breast cancer symposium hot topics, Day 2
SAN FRANCISCO – Dr. Hope S. Rugo reviews the highlights of Day 2 at the breast cancer symposium sponsored by the American Society of Clinical Oncology, including presentations on new directions in neoadjuvant therapy. Data on pathologic complete response, immune modulation, and postneoadjuvant therapy are modifying oncology, with potential for significant changes in the near future. "I think that we’re seeing a whole new era of drugs in the postneoadjuvant setting," says Dr. Rugo, director of the Breast Oncology Clinical Trials Program at the University of California, San Francisco.
She describes a lively discussion in one session about when to apply data on neoadjuvant therapy to clinical practice.
A "great series of discussions" about managing survivors of breast cancer included a look at when advice on lifestyle modifications goes overboard, she says. For example, survivors do not need to avoid alcohol entirely. "It’s okay for a breast cancer survivor to have a couple of glasses of wine. It’s not the end of the world by any means," Dr. Rugo says.
Clinicians also can go overboard on surveillance after breast cancer treatment, according to Dr. Rugo, and she gives examples from a session debating intensive vs. nonintensive surveillance.
She finishes her recap of the day’s highlights with thoughts on breast reconstruction.
Dr. Rugo disclosed financial associations with Genomic Health, Plexxikon, Merck, and Novartis.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
On Twitter @sherryboschert
SAN FRANCISCO – Dr. Hope S. Rugo reviews the highlights of Day 2 at the breast cancer symposium sponsored by the American Society of Clinical Oncology, including presentations on new directions in neoadjuvant therapy. Data on pathologic complete response, immune modulation, and postneoadjuvant therapy are modifying oncology, with potential for significant changes in the near future. "I think that we’re seeing a whole new era of drugs in the postneoadjuvant setting," says Dr. Rugo, director of the Breast Oncology Clinical Trials Program at the University of California, San Francisco.
She describes a lively discussion in one session about when to apply data on neoadjuvant therapy to clinical practice.
A "great series of discussions" about managing survivors of breast cancer included a look at when advice on lifestyle modifications goes overboard, she says. For example, survivors do not need to avoid alcohol entirely. "It’s okay for a breast cancer survivor to have a couple of glasses of wine. It’s not the end of the world by any means," Dr. Rugo says.
Clinicians also can go overboard on surveillance after breast cancer treatment, according to Dr. Rugo, and she gives examples from a session debating intensive vs. nonintensive surveillance.
She finishes her recap of the day’s highlights with thoughts on breast reconstruction.
Dr. Rugo disclosed financial associations with Genomic Health, Plexxikon, Merck, and Novartis.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
On Twitter @sherryboschert
SAN FRANCISCO – Dr. Hope S. Rugo reviews the highlights of Day 2 at the breast cancer symposium sponsored by the American Society of Clinical Oncology, including presentations on new directions in neoadjuvant therapy. Data on pathologic complete response, immune modulation, and postneoadjuvant therapy are modifying oncology, with potential for significant changes in the near future. "I think that we’re seeing a whole new era of drugs in the postneoadjuvant setting," says Dr. Rugo, director of the Breast Oncology Clinical Trials Program at the University of California, San Francisco.
She describes a lively discussion in one session about when to apply data on neoadjuvant therapy to clinical practice.
A "great series of discussions" about managing survivors of breast cancer included a look at when advice on lifestyle modifications goes overboard, she says. For example, survivors do not need to avoid alcohol entirely. "It’s okay for a breast cancer survivor to have a couple of glasses of wine. It’s not the end of the world by any means," Dr. Rugo says.
Clinicians also can go overboard on surveillance after breast cancer treatment, according to Dr. Rugo, and she gives examples from a session debating intensive vs. nonintensive surveillance.
She finishes her recap of the day’s highlights with thoughts on breast reconstruction.
Dr. Rugo disclosed financial associations with Genomic Health, Plexxikon, Merck, and Novartis.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
On Twitter @sherryboschert
AT THE ASCO BREAST CANCER SYMPOSIUM
VIDEO: Complications increase with bilateral mastectomy and reconstruction
SAN FRANCISCO – Women undergoing mastectomy and breast reconstruction for the treatment of breast cancer are more likely to develop perioperative complications if they opt for prophylactic mastectomy of the other breast at the same time, a study of 18,229 cases found.
Compared with women who had a unilateral mastectomy and reconstruction, the 36% of patients who chose bilateral mastectomy and reconstruction were 55% more likely to lose a breast implant (if implants were used for reconstruction), twice as likely to need a transfusion regardless of whether the reconstruction used implants or autologous material, and twice as likely to remain hospitalized for at least 2 days regardless of reconstruction method, Dr. Amanda K. Silva and her associates reported in a poster presentation at a breast cancer symposium sponsored by the American Society of Clinical Oncology.
The reconstruction used implants in 89% of women undergoing bilateral mastectomy and 79% of those getting unilateral mastectomy, Dr. Silva and her colleagues reported.
The overall rate of complications was low, however, averaging 5%, said Dr. Silva, a surgeon at the University of Chicago, and her associates.
In this video interview, Dr. Silva discusses factors that physicians and patients should consider when choosing unilateral or bilateral mastectomy and reconstruction.
Previous studies have compared the risks of unilateral versus bilateral mastectomy without reconstruction, she said, and this study provides some of the first data of risks from either type of mastectomy with reconstruction.
Dr. Silva reported having no financial disclosures.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
On Twitter @sherryboschert
SAN FRANCISCO – Women undergoing mastectomy and breast reconstruction for the treatment of breast cancer are more likely to develop perioperative complications if they opt for prophylactic mastectomy of the other breast at the same time, a study of 18,229 cases found.
Compared with women who had a unilateral mastectomy and reconstruction, the 36% of patients who chose bilateral mastectomy and reconstruction were 55% more likely to lose a breast implant (if implants were used for reconstruction), twice as likely to need a transfusion regardless of whether the reconstruction used implants or autologous material, and twice as likely to remain hospitalized for at least 2 days regardless of reconstruction method, Dr. Amanda K. Silva and her associates reported in a poster presentation at a breast cancer symposium sponsored by the American Society of Clinical Oncology.
The reconstruction used implants in 89% of women undergoing bilateral mastectomy and 79% of those getting unilateral mastectomy, Dr. Silva and her colleagues reported.
The overall rate of complications was low, however, averaging 5%, said Dr. Silva, a surgeon at the University of Chicago, and her associates.
In this video interview, Dr. Silva discusses factors that physicians and patients should consider when choosing unilateral or bilateral mastectomy and reconstruction.
Previous studies have compared the risks of unilateral versus bilateral mastectomy without reconstruction, she said, and this study provides some of the first data of risks from either type of mastectomy with reconstruction.
Dr. Silva reported having no financial disclosures.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
On Twitter @sherryboschert
SAN FRANCISCO – Women undergoing mastectomy and breast reconstruction for the treatment of breast cancer are more likely to develop perioperative complications if they opt for prophylactic mastectomy of the other breast at the same time, a study of 18,229 cases found.
Compared with women who had a unilateral mastectomy and reconstruction, the 36% of patients who chose bilateral mastectomy and reconstruction were 55% more likely to lose a breast implant (if implants were used for reconstruction), twice as likely to need a transfusion regardless of whether the reconstruction used implants or autologous material, and twice as likely to remain hospitalized for at least 2 days regardless of reconstruction method, Dr. Amanda K. Silva and her associates reported in a poster presentation at a breast cancer symposium sponsored by the American Society of Clinical Oncology.
The reconstruction used implants in 89% of women undergoing bilateral mastectomy and 79% of those getting unilateral mastectomy, Dr. Silva and her colleagues reported.
The overall rate of complications was low, however, averaging 5%, said Dr. Silva, a surgeon at the University of Chicago, and her associates.
In this video interview, Dr. Silva discusses factors that physicians and patients should consider when choosing unilateral or bilateral mastectomy and reconstruction.
Previous studies have compared the risks of unilateral versus bilateral mastectomy without reconstruction, she said, and this study provides some of the first data of risks from either type of mastectomy with reconstruction.
Dr. Silva reported having no financial disclosures.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
On Twitter @sherryboschert
AT THE ASCO BREAST CANCER SYMPOSIUM
Guideline adds clarity on perioperative beta-blockers
A new clinical practice guideline on cardiovascular evaluation and management of patients undergoing noncardiac surgery adds some clarity around the controversial issue of beta-blocker therapy and updates other aspects of care.
If a patient on beta-blocker medication needs noncardiac surgery, continue the beta-blocker, because there is no evidence of harm from doing so; but you risk doing harm if the drug is stopped, according to the new guideline from the American College of Cardiology (ACC) and the American Heart Association (AHA).
Surgeons will be happy to hear that, said Dr. Lee A. Fleisher, the chair of the guideline-writing committee, because that conforms to one of the Surgical Care Improvement Project’s National Measures.
For patients at elevated risk of a cardiovascular event during noncardiac surgery who are not already on beta-blocker therapy, however, the new guideline steps back from the organization’s 2009 position that beta-blockers not be started, and says instead that it’s not unreasonable to start the drug, with a caveat. Be very cautious, and start the drug early enough before surgery that you can titrate it to avoid causing hypotension or a low heart rate.
"Make sure that you’re giving the right amount and monitoring their blood pressure and heart rate," Dr. Fleisher, chair of the guideline writing committee, said in an interview. "Really think once, twice, and thrice about starting a protocol," added Dr. Fleisher, the Robert D. Dripps Pprofessor ofAnesthesiology anesthesiology andCritical criticalCare care at the University of Pennsylvania, Philadelphia.
The ACC and AHA commissioned a committee to review the evidence for and against beta-blockers in patients undergoing noncardiac surgery. A separate writing committee then considered the evidence review committee’s report, reviewed the literature on other aspects of perioperative care for noncardiac surgery, and compiled a 102-page guideline with a 59-page executive summary.
The "2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery" will be published online on the ACC and AHA websites.
Dr. Fleisher described other highlights of the new guideline. For the first time, palliative care has been added as an option that may come out of the preoperative evaluation, he said. Patient categories of high risk and intermediate risk have been lumped together as having "elevated" risk for simplicity’s sake because recommendations for the two separate categories were so similar.
The guideline now endorses two tools to choose from for preoperative risk assessments: the Revised Cardiac Risk Index (RCRI) and the American College of Surgeons National Surgical Quality Improvement Project (NSQIP) risk calculator. "There have been a lot of comments that [the NSQIP] is a very useful tool to have shared decision-making conversations with patients," he said.
Another change applies to patients who receive second- or third-generation coronary stents. Instead of a wait of a year after stent implantation to perform noncardiac surgery, a 6-month wait may be reasonable if the risks of delaying noncardiac surgery outweigh the risks of interrupting dual-antiplatelet therapy for the noncardiac surgery.
In addition, the guideline incorporates findings from the recent POISE-2 study to say that aspirin can be stopped and clonidine is not useful in patients without stents undergoing noncardiac surgery (N. Engl. J. Med. 2014;370:1494-503).
A new statement in the guideline about troponin says to check troponin in high-risk patients with signs or symptoms of trouble but not to include troponin in routine screening.
The recommendations on beta-blockers, however, address the most controversial topic in the guideline, Dr. Fleisher said. "There is a lot of confusing evidence" on the use of beta-blockers, "so we’ve tried to clarify as much as we can."
The ACC and AHA funded the work. Dr. Fleisher reported having no financial disclosures.
sboschert@frontlinemedcom.com
On Twitter @sherryboschert
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Dr. Jun Chiong, FCCP, comments: The largest randomized controlled trial (RCT) ever undertaken in perioperative medicine, PeriOperative Ischemia Study Evaluation trial (POISE), showed that perioperative beta-blockade decreased cardiac risks but increased all-cause mortality and the risk of disabling stroke.
These findings called for a thorough review of previous guidelines and accepted practice.
Several editorials and comments followed the publication of POISE. As clinicians, we have to keep in mind that guidelines also advocate the careful assessment of patient- and surgery-specific risk factors in determining who should receive therapy that may benefit or, conversely, be exposed to harm by the introduction of beta-blockade before non-cardiac surgery.
Jun Chiong, M.D., FCCP, is an Associate Clinical Professor of Medicine, Pharmacy, and Outcomes Science at Loma Linda University, Loma Linda, CA.
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Dr. Jun Chiong, FCCP, comments: The largest randomized controlled trial (RCT) ever undertaken in perioperative medicine, PeriOperative Ischemia Study Evaluation trial (POISE), showed that perioperative beta-blockade decreased cardiac risks but increased all-cause mortality and the risk of disabling stroke.
These findings called for a thorough review of previous guidelines and accepted practice.
Several editorials and comments followed the publication of POISE. As clinicians, we have to keep in mind that guidelines also advocate the careful assessment of patient- and surgery-specific risk factors in determining who should receive therapy that may benefit or, conversely, be exposed to harm by the introduction of beta-blockade before non-cardiac surgery.
Jun Chiong, M.D., FCCP, is an Associate Clinical Professor of Medicine, Pharmacy, and Outcomes Science at Loma Linda University, Loma Linda, CA.
|
|
Dr. Jun Chiong, FCCP, comments: The largest randomized controlled trial (RCT) ever undertaken in perioperative medicine, PeriOperative Ischemia Study Evaluation trial (POISE), showed that perioperative beta-blockade decreased cardiac risks but increased all-cause mortality and the risk of disabling stroke.
These findings called for a thorough review of previous guidelines and accepted practice.
Several editorials and comments followed the publication of POISE. As clinicians, we have to keep in mind that guidelines also advocate the careful assessment of patient- and surgery-specific risk factors in determining who should receive therapy that may benefit or, conversely, be exposed to harm by the introduction of beta-blockade before non-cardiac surgery.
Jun Chiong, M.D., FCCP, is an Associate Clinical Professor of Medicine, Pharmacy, and Outcomes Science at Loma Linda University, Loma Linda, CA.
A new clinical practice guideline on cardiovascular evaluation and management of patients undergoing noncardiac surgery adds some clarity around the controversial issue of beta-blocker therapy and updates other aspects of care.
If a patient on beta-blocker medication needs noncardiac surgery, continue the beta-blocker, because there is no evidence of harm from doing so; but you risk doing harm if the drug is stopped, according to the new guideline from the American College of Cardiology (ACC) and the American Heart Association (AHA).
Surgeons will be happy to hear that, said Dr. Lee A. Fleisher, the chair of the guideline-writing committee, because that conforms to one of the Surgical Care Improvement Project’s National Measures.
For patients at elevated risk of a cardiovascular event during noncardiac surgery who are not already on beta-blocker therapy, however, the new guideline steps back from the organization’s 2009 position that beta-blockers not be started, and says instead that it’s not unreasonable to start the drug, with a caveat. Be very cautious, and start the drug early enough before surgery that you can titrate it to avoid causing hypotension or a low heart rate.
"Make sure that you’re giving the right amount and monitoring their blood pressure and heart rate," Dr. Fleisher, chair of the guideline writing committee, said in an interview. "Really think once, twice, and thrice about starting a protocol," added Dr. Fleisher, the Robert D. Dripps Pprofessor ofAnesthesiology anesthesiology andCritical criticalCare care at the University of Pennsylvania, Philadelphia.
The ACC and AHA commissioned a committee to review the evidence for and against beta-blockers in patients undergoing noncardiac surgery. A separate writing committee then considered the evidence review committee’s report, reviewed the literature on other aspects of perioperative care for noncardiac surgery, and compiled a 102-page guideline with a 59-page executive summary.
The "2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery" will be published online on the ACC and AHA websites.
Dr. Fleisher described other highlights of the new guideline. For the first time, palliative care has been added as an option that may come out of the preoperative evaluation, he said. Patient categories of high risk and intermediate risk have been lumped together as having "elevated" risk for simplicity’s sake because recommendations for the two separate categories were so similar.
The guideline now endorses two tools to choose from for preoperative risk assessments: the Revised Cardiac Risk Index (RCRI) and the American College of Surgeons National Surgical Quality Improvement Project (NSQIP) risk calculator. "There have been a lot of comments that [the NSQIP] is a very useful tool to have shared decision-making conversations with patients," he said.
Another change applies to patients who receive second- or third-generation coronary stents. Instead of a wait of a year after stent implantation to perform noncardiac surgery, a 6-month wait may be reasonable if the risks of delaying noncardiac surgery outweigh the risks of interrupting dual-antiplatelet therapy for the noncardiac surgery.
In addition, the guideline incorporates findings from the recent POISE-2 study to say that aspirin can be stopped and clonidine is not useful in patients without stents undergoing noncardiac surgery (N. Engl. J. Med. 2014;370:1494-503).
A new statement in the guideline about troponin says to check troponin in high-risk patients with signs or symptoms of trouble but not to include troponin in routine screening.
The recommendations on beta-blockers, however, address the most controversial topic in the guideline, Dr. Fleisher said. "There is a lot of confusing evidence" on the use of beta-blockers, "so we’ve tried to clarify as much as we can."
The ACC and AHA funded the work. Dr. Fleisher reported having no financial disclosures.
sboschert@frontlinemedcom.com
On Twitter @sherryboschert
A new clinical practice guideline on cardiovascular evaluation and management of patients undergoing noncardiac surgery adds some clarity around the controversial issue of beta-blocker therapy and updates other aspects of care.
If a patient on beta-blocker medication needs noncardiac surgery, continue the beta-blocker, because there is no evidence of harm from doing so; but you risk doing harm if the drug is stopped, according to the new guideline from the American College of Cardiology (ACC) and the American Heart Association (AHA).
Surgeons will be happy to hear that, said Dr. Lee A. Fleisher, the chair of the guideline-writing committee, because that conforms to one of the Surgical Care Improvement Project’s National Measures.
For patients at elevated risk of a cardiovascular event during noncardiac surgery who are not already on beta-blocker therapy, however, the new guideline steps back from the organization’s 2009 position that beta-blockers not be started, and says instead that it’s not unreasonable to start the drug, with a caveat. Be very cautious, and start the drug early enough before surgery that you can titrate it to avoid causing hypotension or a low heart rate.
"Make sure that you’re giving the right amount and monitoring their blood pressure and heart rate," Dr. Fleisher, chair of the guideline writing committee, said in an interview. "Really think once, twice, and thrice about starting a protocol," added Dr. Fleisher, the Robert D. Dripps Pprofessor ofAnesthesiology anesthesiology andCritical criticalCare care at the University of Pennsylvania, Philadelphia.
The ACC and AHA commissioned a committee to review the evidence for and against beta-blockers in patients undergoing noncardiac surgery. A separate writing committee then considered the evidence review committee’s report, reviewed the literature on other aspects of perioperative care for noncardiac surgery, and compiled a 102-page guideline with a 59-page executive summary.
The "2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery" will be published online on the ACC and AHA websites.
Dr. Fleisher described other highlights of the new guideline. For the first time, palliative care has been added as an option that may come out of the preoperative evaluation, he said. Patient categories of high risk and intermediate risk have been lumped together as having "elevated" risk for simplicity’s sake because recommendations for the two separate categories were so similar.
The guideline now endorses two tools to choose from for preoperative risk assessments: the Revised Cardiac Risk Index (RCRI) and the American College of Surgeons National Surgical Quality Improvement Project (NSQIP) risk calculator. "There have been a lot of comments that [the NSQIP] is a very useful tool to have shared decision-making conversations with patients," he said.
Another change applies to patients who receive second- or third-generation coronary stents. Instead of a wait of a year after stent implantation to perform noncardiac surgery, a 6-month wait may be reasonable if the risks of delaying noncardiac surgery outweigh the risks of interrupting dual-antiplatelet therapy for the noncardiac surgery.
In addition, the guideline incorporates findings from the recent POISE-2 study to say that aspirin can be stopped and clonidine is not useful in patients without stents undergoing noncardiac surgery (N. Engl. J. Med. 2014;370:1494-503).
A new statement in the guideline about troponin says to check troponin in high-risk patients with signs or symptoms of trouble but not to include troponin in routine screening.
The recommendations on beta-blockers, however, address the most controversial topic in the guideline, Dr. Fleisher said. "There is a lot of confusing evidence" on the use of beta-blockers, "so we’ve tried to clarify as much as we can."
The ACC and AHA funded the work. Dr. Fleisher reported having no financial disclosures.
sboschert@frontlinemedcom.com
On Twitter @sherryboschert
Rare Enterovirus Outbreaks Sending Children to Hospitals
A rare enterovirus caused outbreaks of severe pediatric respiratory illness in two US cities and may be active elsewhere, the Centers for Disease Control and Prevention reported.
The CDC found enterovirus D68 (EV-D68) in 19 of 22 (86%) samples it tested from patients in Kansas City, Mo., and in 11 of 14 (79%) samples from Chicago, and is testing samples from other states. Health officials from Alabama, Colorado, Georgia, Illinois, Iowa, Kansas, Kentucky, Missouri, Ohio, Oklahoma, and Utah have contacted the CDC about confirmed cases or suspected cases that are being tested, a CDC spokesman confirmed.
The outbreaks first were noticed in mid-August in Kansas City, Mo., where Children’s Mercy Hospital reported a 25%-30% increase beyond normal seasonal levels in the numbers of children visiting emergency departments and urgent care centers and being hospitalized for respiratory illness, the hospital said in a letter to community physicians. "To date, we have nearly 500 suspected cases including 61 children who were admitted to our intensive care unit presumptively with this viral infection," the letter said.
The University of Chicago Medicine Comer Children’s Hospital contacted the CDC a few days later about a similar outbreak there.
CDC testing shows "it’s not a new strain" of enterovirus, but the same EV-D68 reported in previous years in small numbers in the United States and other countries, Dr. Anne Schuchat said in a press briefing. Dr. Schuchat is director of the National Center for Immunization and Respiratory Diseases.
U.S. national surveillance systems received only 79 reports of EV-D68 during 2009-2013, and small clusters of respiratory illness were associated with EV-D68 infection in 2009-2010, the CDC reported (MMWR 2014;63:1-2). There is no vaccine or specific treatment for EV-D68 infection. Treatment consists of supportive care.
"Clinics across the country need to be on the alert and consider this in the differential diagnosis" of unexplained respiratory illnesses, Dr. Schuchat said. "We believe the unusual occurrences in Kansas City and Chicago may be occurring elsewhere in the weeks ahead." Clinicians should contact local and state health departments if they suspect an outbreak.
No patients in the recent outbreaks have died of the infection, and no cases have been confirmed in adults. The patients affected have been 6 weeks to 16 years of age, with a median age of 4-5 years, she said.
Enteroviruses can cause respiratory illness, febrile rash, and neurologic illness. EV-D68 is thought to cause primarily respiratory illness, but "we don’t know as much about it as we do of other respiratory viruses," Dr. Schuchat said. "The full spectrum of all the illnesses it can cause are not well defined."
More than half of the 30 patients in Kansas City and Chicago with confirmed EV-D68 had a history of asthma or wheezing. Only seven of the patients were febrile, the CDC reported.
Late summer and fall are common times for respiratory infections of many kinds. Patient specimens tested by the CDC that did not find EV-D68 detected rhinovirus or other common respiratory viruses, or were negative for infection.
Physicians should counsel parents to seek medical attention if a child develops difficulty breathing, but not be alarmed by every runny nose or sniffles, Dr. Schuchat said.
"Most of the runny noses out there are not going to turn into this," Dr. Schuchat said.
Keeping asthma under control and getting vaccinated for influenza are important, especially to avoid an overlay of problems if EV-D68 infection leads to illness, she added.
Dr. Schuchat reported having no financial disclosures.
On Twitter @sherryboschert
The Kansas City, Mo., outbreak of severe respiratory illness in children who require intensive care is "unprecedented in number and severity for this time of year," Dr. Mary Anne Jackson said in an interview.
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Her hospital tested specimens from 646 cases and found 498 (77%) positive for "rhinovirus/enterovirus," she said. "Not all were enterovirus D68, but 90% of those with the typical symptoms were confirmed in our initial CDC typing," which confirmed EV-D68 in 19 of 22 specimens. Testing results are preliminary and it’s "difficult to say with certainty what the scope of the outbreak is here, but we appear to be leveling off," with the number of hospitalized children decreasing.
As the number of patients surged, the hospital activated its network of infectious disease providers, pulmonologists, and others to cover pediatricians and handle some of the cases, and the hospital made extra beds available, she said.
"The scope and burden of infection in other communities reporting disease is not clear at this time," Dr. Jackson said, but she advised pediatricians to be alert for "unusually severe manifestations of what appears to be respiratory virus in children with and without asthma. Patients in our initial cohort who required pediatric ICU care appeared to routinely have hypoxemia and respiratory failure."
Health care facilities that see an unusually high burden of respiratory viral disease or unusually severe cases can test for EV-D68 with help from local and state health departments and the Centers for Disease Control and Prevention. Pediatricians can advise parents to treat common cold symptoms with fever control and fluids, she suggested, and to see a physician if the child develops difficulty breathing.
Parents of young children with asthma should have an active asthma management plan and a primary care provider they can call if they have questions. To limit spread of disease, recommend the standard practices of frequent hand washing, cleaning surfaces and toys, shielding coughs, and staying home if the child is ill.
Dr. Mary Anne Jackson is director of the division of infectious diseases at Children’s Mercy Hospital, Kansas City, Mo., and professor of pediatrics at the University of Missouri–Kansas City. She coauthored the Sept. 8, 2014, MMWR report on enterovirus D68. She reported having no financial disclosures.
The Kansas City, Mo., outbreak of severe respiratory illness in children who require intensive care is "unprecedented in number and severity for this time of year," Dr. Mary Anne Jackson said in an interview.
|
|
Her hospital tested specimens from 646 cases and found 498 (77%) positive for "rhinovirus/enterovirus," she said. "Not all were enterovirus D68, but 90% of those with the typical symptoms were confirmed in our initial CDC typing," which confirmed EV-D68 in 19 of 22 specimens. Testing results are preliminary and it’s "difficult to say with certainty what the scope of the outbreak is here, but we appear to be leveling off," with the number of hospitalized children decreasing.
As the number of patients surged, the hospital activated its network of infectious disease providers, pulmonologists, and others to cover pediatricians and handle some of the cases, and the hospital made extra beds available, she said.
"The scope and burden of infection in other communities reporting disease is not clear at this time," Dr. Jackson said, but she advised pediatricians to be alert for "unusually severe manifestations of what appears to be respiratory virus in children with and without asthma. Patients in our initial cohort who required pediatric ICU care appeared to routinely have hypoxemia and respiratory failure."
Health care facilities that see an unusually high burden of respiratory viral disease or unusually severe cases can test for EV-D68 with help from local and state health departments and the Centers for Disease Control and Prevention. Pediatricians can advise parents to treat common cold symptoms with fever control and fluids, she suggested, and to see a physician if the child develops difficulty breathing.
Parents of young children with asthma should have an active asthma management plan and a primary care provider they can call if they have questions. To limit spread of disease, recommend the standard practices of frequent hand washing, cleaning surfaces and toys, shielding coughs, and staying home if the child is ill.
Dr. Mary Anne Jackson is director of the division of infectious diseases at Children’s Mercy Hospital, Kansas City, Mo., and professor of pediatrics at the University of Missouri–Kansas City. She coauthored the Sept. 8, 2014, MMWR report on enterovirus D68. She reported having no financial disclosures.
The Kansas City, Mo., outbreak of severe respiratory illness in children who require intensive care is "unprecedented in number and severity for this time of year," Dr. Mary Anne Jackson said in an interview.
|
|
Her hospital tested specimens from 646 cases and found 498 (77%) positive for "rhinovirus/enterovirus," she said. "Not all were enterovirus D68, but 90% of those with the typical symptoms were confirmed in our initial CDC typing," which confirmed EV-D68 in 19 of 22 specimens. Testing results are preliminary and it’s "difficult to say with certainty what the scope of the outbreak is here, but we appear to be leveling off," with the number of hospitalized children decreasing.
As the number of patients surged, the hospital activated its network of infectious disease providers, pulmonologists, and others to cover pediatricians and handle some of the cases, and the hospital made extra beds available, she said.
"The scope and burden of infection in other communities reporting disease is not clear at this time," Dr. Jackson said, but she advised pediatricians to be alert for "unusually severe manifestations of what appears to be respiratory virus in children with and without asthma. Patients in our initial cohort who required pediatric ICU care appeared to routinely have hypoxemia and respiratory failure."
Health care facilities that see an unusually high burden of respiratory viral disease or unusually severe cases can test for EV-D68 with help from local and state health departments and the Centers for Disease Control and Prevention. Pediatricians can advise parents to treat common cold symptoms with fever control and fluids, she suggested, and to see a physician if the child develops difficulty breathing.
Parents of young children with asthma should have an active asthma management plan and a primary care provider they can call if they have questions. To limit spread of disease, recommend the standard practices of frequent hand washing, cleaning surfaces and toys, shielding coughs, and staying home if the child is ill.
Dr. Mary Anne Jackson is director of the division of infectious diseases at Children’s Mercy Hospital, Kansas City, Mo., and professor of pediatrics at the University of Missouri–Kansas City. She coauthored the Sept. 8, 2014, MMWR report on enterovirus D68. She reported having no financial disclosures.
A rare enterovirus caused outbreaks of severe pediatric respiratory illness in two US cities and may be active elsewhere, the Centers for Disease Control and Prevention reported.
The CDC found enterovirus D68 (EV-D68) in 19 of 22 (86%) samples it tested from patients in Kansas City, Mo., and in 11 of 14 (79%) samples from Chicago, and is testing samples from other states. Health officials from Alabama, Colorado, Georgia, Illinois, Iowa, Kansas, Kentucky, Missouri, Ohio, Oklahoma, and Utah have contacted the CDC about confirmed cases or suspected cases that are being tested, a CDC spokesman confirmed.
The outbreaks first were noticed in mid-August in Kansas City, Mo., where Children’s Mercy Hospital reported a 25%-30% increase beyond normal seasonal levels in the numbers of children visiting emergency departments and urgent care centers and being hospitalized for respiratory illness, the hospital said in a letter to community physicians. "To date, we have nearly 500 suspected cases including 61 children who were admitted to our intensive care unit presumptively with this viral infection," the letter said.
The University of Chicago Medicine Comer Children’s Hospital contacted the CDC a few days later about a similar outbreak there.
CDC testing shows "it’s not a new strain" of enterovirus, but the same EV-D68 reported in previous years in small numbers in the United States and other countries, Dr. Anne Schuchat said in a press briefing. Dr. Schuchat is director of the National Center for Immunization and Respiratory Diseases.
U.S. national surveillance systems received only 79 reports of EV-D68 during 2009-2013, and small clusters of respiratory illness were associated with EV-D68 infection in 2009-2010, the CDC reported (MMWR 2014;63:1-2). There is no vaccine or specific treatment for EV-D68 infection. Treatment consists of supportive care.
"Clinics across the country need to be on the alert and consider this in the differential diagnosis" of unexplained respiratory illnesses, Dr. Schuchat said. "We believe the unusual occurrences in Kansas City and Chicago may be occurring elsewhere in the weeks ahead." Clinicians should contact local and state health departments if they suspect an outbreak.
No patients in the recent outbreaks have died of the infection, and no cases have been confirmed in adults. The patients affected have been 6 weeks to 16 years of age, with a median age of 4-5 years, she said.
Enteroviruses can cause respiratory illness, febrile rash, and neurologic illness. EV-D68 is thought to cause primarily respiratory illness, but "we don’t know as much about it as we do of other respiratory viruses," Dr. Schuchat said. "The full spectrum of all the illnesses it can cause are not well defined."
More than half of the 30 patients in Kansas City and Chicago with confirmed EV-D68 had a history of asthma or wheezing. Only seven of the patients were febrile, the CDC reported.
Late summer and fall are common times for respiratory infections of many kinds. Patient specimens tested by the CDC that did not find EV-D68 detected rhinovirus or other common respiratory viruses, or were negative for infection.
Physicians should counsel parents to seek medical attention if a child develops difficulty breathing, but not be alarmed by every runny nose or sniffles, Dr. Schuchat said.
"Most of the runny noses out there are not going to turn into this," Dr. Schuchat said.
Keeping asthma under control and getting vaccinated for influenza are important, especially to avoid an overlay of problems if EV-D68 infection leads to illness, she added.
Dr. Schuchat reported having no financial disclosures.
On Twitter @sherryboschert
A rare enterovirus caused outbreaks of severe pediatric respiratory illness in two US cities and may be active elsewhere, the Centers for Disease Control and Prevention reported.
The CDC found enterovirus D68 (EV-D68) in 19 of 22 (86%) samples it tested from patients in Kansas City, Mo., and in 11 of 14 (79%) samples from Chicago, and is testing samples from other states. Health officials from Alabama, Colorado, Georgia, Illinois, Iowa, Kansas, Kentucky, Missouri, Ohio, Oklahoma, and Utah have contacted the CDC about confirmed cases or suspected cases that are being tested, a CDC spokesman confirmed.
The outbreaks first were noticed in mid-August in Kansas City, Mo., where Children’s Mercy Hospital reported a 25%-30% increase beyond normal seasonal levels in the numbers of children visiting emergency departments and urgent care centers and being hospitalized for respiratory illness, the hospital said in a letter to community physicians. "To date, we have nearly 500 suspected cases including 61 children who were admitted to our intensive care unit presumptively with this viral infection," the letter said.
The University of Chicago Medicine Comer Children’s Hospital contacted the CDC a few days later about a similar outbreak there.
CDC testing shows "it’s not a new strain" of enterovirus, but the same EV-D68 reported in previous years in small numbers in the United States and other countries, Dr. Anne Schuchat said in a press briefing. Dr. Schuchat is director of the National Center for Immunization and Respiratory Diseases.
U.S. national surveillance systems received only 79 reports of EV-D68 during 2009-2013, and small clusters of respiratory illness were associated with EV-D68 infection in 2009-2010, the CDC reported (MMWR 2014;63:1-2). There is no vaccine or specific treatment for EV-D68 infection. Treatment consists of supportive care.
"Clinics across the country need to be on the alert and consider this in the differential diagnosis" of unexplained respiratory illnesses, Dr. Schuchat said. "We believe the unusual occurrences in Kansas City and Chicago may be occurring elsewhere in the weeks ahead." Clinicians should contact local and state health departments if they suspect an outbreak.
No patients in the recent outbreaks have died of the infection, and no cases have been confirmed in adults. The patients affected have been 6 weeks to 16 years of age, with a median age of 4-5 years, she said.
Enteroviruses can cause respiratory illness, febrile rash, and neurologic illness. EV-D68 is thought to cause primarily respiratory illness, but "we don’t know as much about it as we do of other respiratory viruses," Dr. Schuchat said. "The full spectrum of all the illnesses it can cause are not well defined."
More than half of the 30 patients in Kansas City and Chicago with confirmed EV-D68 had a history of asthma or wheezing. Only seven of the patients were febrile, the CDC reported.
Late summer and fall are common times for respiratory infections of many kinds. Patient specimens tested by the CDC that did not find EV-D68 detected rhinovirus or other common respiratory viruses, or were negative for infection.
Physicians should counsel parents to seek medical attention if a child develops difficulty breathing, but not be alarmed by every runny nose or sniffles, Dr. Schuchat said.
"Most of the runny noses out there are not going to turn into this," Dr. Schuchat said.
Keeping asthma under control and getting vaccinated for influenza are important, especially to avoid an overlay of problems if EV-D68 infection leads to illness, she added.
Dr. Schuchat reported having no financial disclosures.
On Twitter @sherryboschert
FROM THE MMWR
Cessation by text? Interactive app helps smokers quit
Text-messaging programs on phones seem to help smokers quit. The jury’s still out on smartphone apps for smoking cessation when used by patients, but they may help nurses improve screening, several separate studies suggest.
The interactive text-messaging program Text2Quit helped U.S. smokers quit and stay off cigarettes in a 6-month randomized, controlled trial in 503 adults who smoked at least five cigarettes a day, owned a cell phone with an unlimited service plan for short text messaging, and had expressed an interest in quitting cigarettes. Participants already were avid texters, sending or receiving an average of 29 text messages per day before they enrolled in the study.
At the 6-month follow-up, 20% of 241 people in the Text2Quit group said they had not smoked in the prior 7 days, versus 10% of 262 people in the control group, reported Lorien C. Abroms, Sc.D., and her associates.
Laboratory analyses of saliva from 54 members of the intervention group and 32 in the control group showed that nearly a quarter of participants had lied about quitting. Text2Quit still was effective, however, with biochemically confirmed abstinence from smoking in 11% of the intervention group and 5% of the control group (Am. J. Prev. Med. 2014 June 5 [doi: 10.1016/j.amepre.2014.04.010]). Those biochemical quit rates are similar to rates reported in studies of other text-messaging programs for smoking cessation or of telephone quit-line counseling, she said.
The results support a meta-analysis of five studies that found mobile phone–based interventions (predominantly text messaging) for smoking cessation increased 6-month quit rates (Cochrane Database Syst. Rev. 2012;11:CD006611 [doi: 10.1002/14651858]). Most U.S. studies, however, have been small, uncontrolled pilot trials with no biochemical verification of quit rates, said Dr. Abroms, who designed Text2Quit and receives royalties from sales..
What’s involved?
Text2Quit costs $30 for a 4-month subscription unless you have a code from a sponsoring organization. When U.S. smokers call the national quit-line number (1-800-QUIT-NOW), residents of some states get offered Text2Quit. More than 50,000 smokers have enrolled since the program became available in 2011, reported Dr. Abroms of George Washington University, Washington. Other text-messaging programs are available, such as the free SmokefreeTXT program from the National Cancer Institute’s smokefree.gov site.
People randomized to the control group in Dr. Abroms’ trial initially were given a link to smokefree.gov, but after the launch of SmokefreeTXT in 2011, new control group members instead were given a link to the National Cancer Institute’s "Clearing the Air" guidebook on quitting smoking.
Text2Quit consists of automated, bidirectional text messages, with extra support from e-mails and a web portal. The texts prompt users to track their smoking and report on their cravings and smoking status, with the messages to participants tailored by the reasons for quitting, money saved, and use of medications for smoking cessation. The frequency of texts peaked around the smoker’s chosen quit date, with five texts on that date, approximately two per day in the following week, three per week in the next 2 months, and less than one per week after that.
Considering that an estimated 75% of adults around the world have access to cell phones, text-messaging interventions potentially could puff up the number of quitters, she said.
Apps reach far, but may say little
Smartphones aren’t yet as ubiquitous but, still, an estimated 11 million U.S. smokers own a smartphone, Dr. Abroms wrote in a separate study of apps for smoking cessation. We don’t yet know if any of the 400 smoking cessation apps that were available in 2012 work, but her analysis of 98 of the most popular smoking cessation apps found that they seldom include information and strategies that have been proven to help smokers quit.
She and her associates rated 47 apps for iPhones and 51 for Android phones on a 42-point scale, with a top score indicating adherence to the U.S. Public Health Service’s Clinical Practice Guidelines for Treating Tobacco Use and Dependence. The average score was 13. No apps recommended calling a quit line, for example. Only 4% recommended using medications approved for smoking cessation. Only 19% offered practical counseling or advice on how to quit (Am. J. Prev. Med. 2013;45:732-6).
On the other hand, it’s possible that national guidelines that were developed for clinical settings don’t apply to mobile apps. If the apps somehow are effective, their reach could magnify any impact, Dr. Abroms suggested.
"Text messaging programs for smoking cessation have a reasonably good evidence base," according to Dr. Abroms. "The evidence for smartphone apps is still in its early stages. I would not recommend them as a stand-alone intervention, though many with tracking elements may be useful as part of a comprehensive program. Apps that include games could be good as a distraction from smoking."
sboschert@frontlinemedcom.com
On Twitter @sherryboschert
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Dr. Vera DePalo, FCCP, comments: Instant messaging and texting have become prominent communication and reminder tools with a high degree of integration in daily life. One can see the potential of their use in medicine, particularly in messaging wellness.
As apps and messaging use continues to grow and as the segments of society that are most comfortable with this technology age and become consumers of health services, these may be important tools for improving population health.
Vera DePalo, MD, FCCP, is an internist in Pawtucket, Rhode Island and is affiliated with the Pulmonary Division of the Memorial Hospital of Rhode Island.
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Dr. Vera DePalo, FCCP, comments: Instant messaging and texting have become prominent communication and reminder tools with a high degree of integration in daily life. One can see the potential of their use in medicine, particularly in messaging wellness.
As apps and messaging use continues to grow and as the segments of society that are most comfortable with this technology age and become consumers of health services, these may be important tools for improving population health.
Vera DePalo, MD, FCCP, is an internist in Pawtucket, Rhode Island and is affiliated with the Pulmonary Division of the Memorial Hospital of Rhode Island.
|
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Dr. Vera DePalo, FCCP, comments: Instant messaging and texting have become prominent communication and reminder tools with a high degree of integration in daily life. One can see the potential of their use in medicine, particularly in messaging wellness.
As apps and messaging use continues to grow and as the segments of society that are most comfortable with this technology age and become consumers of health services, these may be important tools for improving population health.
Vera DePalo, MD, FCCP, is an internist in Pawtucket, Rhode Island and is affiliated with the Pulmonary Division of the Memorial Hospital of Rhode Island.
Text-messaging programs on phones seem to help smokers quit. The jury’s still out on smartphone apps for smoking cessation when used by patients, but they may help nurses improve screening, several separate studies suggest.
The interactive text-messaging program Text2Quit helped U.S. smokers quit and stay off cigarettes in a 6-month randomized, controlled trial in 503 adults who smoked at least five cigarettes a day, owned a cell phone with an unlimited service plan for short text messaging, and had expressed an interest in quitting cigarettes. Participants already were avid texters, sending or receiving an average of 29 text messages per day before they enrolled in the study.
At the 6-month follow-up, 20% of 241 people in the Text2Quit group said they had not smoked in the prior 7 days, versus 10% of 262 people in the control group, reported Lorien C. Abroms, Sc.D., and her associates.
Laboratory analyses of saliva from 54 members of the intervention group and 32 in the control group showed that nearly a quarter of participants had lied about quitting. Text2Quit still was effective, however, with biochemically confirmed abstinence from smoking in 11% of the intervention group and 5% of the control group (Am. J. Prev. Med. 2014 June 5 [doi: 10.1016/j.amepre.2014.04.010]). Those biochemical quit rates are similar to rates reported in studies of other text-messaging programs for smoking cessation or of telephone quit-line counseling, she said.
The results support a meta-analysis of five studies that found mobile phone–based interventions (predominantly text messaging) for smoking cessation increased 6-month quit rates (Cochrane Database Syst. Rev. 2012;11:CD006611 [doi: 10.1002/14651858]). Most U.S. studies, however, have been small, uncontrolled pilot trials with no biochemical verification of quit rates, said Dr. Abroms, who designed Text2Quit and receives royalties from sales..
What’s involved?
Text2Quit costs $30 for a 4-month subscription unless you have a code from a sponsoring organization. When U.S. smokers call the national quit-line number (1-800-QUIT-NOW), residents of some states get offered Text2Quit. More than 50,000 smokers have enrolled since the program became available in 2011, reported Dr. Abroms of George Washington University, Washington. Other text-messaging programs are available, such as the free SmokefreeTXT program from the National Cancer Institute’s smokefree.gov site.
People randomized to the control group in Dr. Abroms’ trial initially were given a link to smokefree.gov, but after the launch of SmokefreeTXT in 2011, new control group members instead were given a link to the National Cancer Institute’s "Clearing the Air" guidebook on quitting smoking.
Text2Quit consists of automated, bidirectional text messages, with extra support from e-mails and a web portal. The texts prompt users to track their smoking and report on their cravings and smoking status, with the messages to participants tailored by the reasons for quitting, money saved, and use of medications for smoking cessation. The frequency of texts peaked around the smoker’s chosen quit date, with five texts on that date, approximately two per day in the following week, three per week in the next 2 months, and less than one per week after that.
Considering that an estimated 75% of adults around the world have access to cell phones, text-messaging interventions potentially could puff up the number of quitters, she said.
Apps reach far, but may say little
Smartphones aren’t yet as ubiquitous but, still, an estimated 11 million U.S. smokers own a smartphone, Dr. Abroms wrote in a separate study of apps for smoking cessation. We don’t yet know if any of the 400 smoking cessation apps that were available in 2012 work, but her analysis of 98 of the most popular smoking cessation apps found that they seldom include information and strategies that have been proven to help smokers quit.
She and her associates rated 47 apps for iPhones and 51 for Android phones on a 42-point scale, with a top score indicating adherence to the U.S. Public Health Service’s Clinical Practice Guidelines for Treating Tobacco Use and Dependence. The average score was 13. No apps recommended calling a quit line, for example. Only 4% recommended using medications approved for smoking cessation. Only 19% offered practical counseling or advice on how to quit (Am. J. Prev. Med. 2013;45:732-6).
On the other hand, it’s possible that national guidelines that were developed for clinical settings don’t apply to mobile apps. If the apps somehow are effective, their reach could magnify any impact, Dr. Abroms suggested.
"Text messaging programs for smoking cessation have a reasonably good evidence base," according to Dr. Abroms. "The evidence for smartphone apps is still in its early stages. I would not recommend them as a stand-alone intervention, though many with tracking elements may be useful as part of a comprehensive program. Apps that include games could be good as a distraction from smoking."
sboschert@frontlinemedcom.com
On Twitter @sherryboschert
Text-messaging programs on phones seem to help smokers quit. The jury’s still out on smartphone apps for smoking cessation when used by patients, but they may help nurses improve screening, several separate studies suggest.
The interactive text-messaging program Text2Quit helped U.S. smokers quit and stay off cigarettes in a 6-month randomized, controlled trial in 503 adults who smoked at least five cigarettes a day, owned a cell phone with an unlimited service plan for short text messaging, and had expressed an interest in quitting cigarettes. Participants already were avid texters, sending or receiving an average of 29 text messages per day before they enrolled in the study.
At the 6-month follow-up, 20% of 241 people in the Text2Quit group said they had not smoked in the prior 7 days, versus 10% of 262 people in the control group, reported Lorien C. Abroms, Sc.D., and her associates.
Laboratory analyses of saliva from 54 members of the intervention group and 32 in the control group showed that nearly a quarter of participants had lied about quitting. Text2Quit still was effective, however, with biochemically confirmed abstinence from smoking in 11% of the intervention group and 5% of the control group (Am. J. Prev. Med. 2014 June 5 [doi: 10.1016/j.amepre.2014.04.010]). Those biochemical quit rates are similar to rates reported in studies of other text-messaging programs for smoking cessation or of telephone quit-line counseling, she said.
The results support a meta-analysis of five studies that found mobile phone–based interventions (predominantly text messaging) for smoking cessation increased 6-month quit rates (Cochrane Database Syst. Rev. 2012;11:CD006611 [doi: 10.1002/14651858]). Most U.S. studies, however, have been small, uncontrolled pilot trials with no biochemical verification of quit rates, said Dr. Abroms, who designed Text2Quit and receives royalties from sales..
What’s involved?
Text2Quit costs $30 for a 4-month subscription unless you have a code from a sponsoring organization. When U.S. smokers call the national quit-line number (1-800-QUIT-NOW), residents of some states get offered Text2Quit. More than 50,000 smokers have enrolled since the program became available in 2011, reported Dr. Abroms of George Washington University, Washington. Other text-messaging programs are available, such as the free SmokefreeTXT program from the National Cancer Institute’s smokefree.gov site.
People randomized to the control group in Dr. Abroms’ trial initially were given a link to smokefree.gov, but after the launch of SmokefreeTXT in 2011, new control group members instead were given a link to the National Cancer Institute’s "Clearing the Air" guidebook on quitting smoking.
Text2Quit consists of automated, bidirectional text messages, with extra support from e-mails and a web portal. The texts prompt users to track their smoking and report on their cravings and smoking status, with the messages to participants tailored by the reasons for quitting, money saved, and use of medications for smoking cessation. The frequency of texts peaked around the smoker’s chosen quit date, with five texts on that date, approximately two per day in the following week, three per week in the next 2 months, and less than one per week after that.
Considering that an estimated 75% of adults around the world have access to cell phones, text-messaging interventions potentially could puff up the number of quitters, she said.
Apps reach far, but may say little
Smartphones aren’t yet as ubiquitous but, still, an estimated 11 million U.S. smokers own a smartphone, Dr. Abroms wrote in a separate study of apps for smoking cessation. We don’t yet know if any of the 400 smoking cessation apps that were available in 2012 work, but her analysis of 98 of the most popular smoking cessation apps found that they seldom include information and strategies that have been proven to help smokers quit.
She and her associates rated 47 apps for iPhones and 51 for Android phones on a 42-point scale, with a top score indicating adherence to the U.S. Public Health Service’s Clinical Practice Guidelines for Treating Tobacco Use and Dependence. The average score was 13. No apps recommended calling a quit line, for example. Only 4% recommended using medications approved for smoking cessation. Only 19% offered practical counseling or advice on how to quit (Am. J. Prev. Med. 2013;45:732-6).
On the other hand, it’s possible that national guidelines that were developed for clinical settings don’t apply to mobile apps. If the apps somehow are effective, their reach could magnify any impact, Dr. Abroms suggested.
"Text messaging programs for smoking cessation have a reasonably good evidence base," according to Dr. Abroms. "The evidence for smartphone apps is still in its early stages. I would not recommend them as a stand-alone intervention, though many with tracking elements may be useful as part of a comprehensive program. Apps that include games could be good as a distraction from smoking."
sboschert@frontlinemedcom.com
On Twitter @sherryboschert
Rare enterovirus outbreaks sending children to hospitals
A rare enterovirus caused outbreaks of severe pediatric respiratory illness in two U.S. cities and may be active elsewhere, the Centers for Disease Control and Prevention reported.
The CDC found enterovirus D68 (EV-D68) in 19 of 22 (86%) samples it tested from patients in Kansas City, Mo., and in 11 of 14 (79%) samples from Chicago, and is testing samples from other states. Health officials from Alabama, Colorado, Georgia, Illinois, Iowa, Kansas, Kentucky, Missouri, Ohio, Oklahoma, and Utah have contacted the CDC about confirmed cases or suspected cases that are being tested, a CDC spokesman confirmed.
The outbreaks first were noticed in mid-August in Kansas City, Mo., where Children’s Mercy Hospital reported a 25%-30% increase beyond normal seasonal levels in the numbers of children visiting emergency departments and urgent care centers and being hospitalized for respiratory illness, the hospital said in a letter to community physicians. "To date, we have nearly 500 suspected cases including 61 children who were admitted to our intensive care unit presumptively with this viral infection," the letter said.
The University of Chicago Medicine Comer Children’s Hospital contacted the CDC a few days later about a similar outbreak there.
CDC testing shows "it’s not a new strain" of enterovirus, but the same EV-D68 reported in previous years in small numbers in the United States and other countries, Dr. Anne Schuchat said in a press briefing. Dr. Schuchat is director of the National Center for Immunization and Respiratory Diseases.
U.S. national surveillance systems received only 79 reports of EV-D68 during 2009-2013, and small clusters of respiratory illness were associated with EV-D68 infection in 2009-2010, the CDC reported (MMWR 2014;63:1-2). There is no vaccine or specific treatment for EV-D68 infection. Treatment consists of supportive care.
"Clinics across the country need to be on the alert and consider this in the differential diagnosis" of unexplained respiratory illnesses, Dr. Schuchat said. "We believe the unusual occurrences in Kansas City and Chicago may be occurring elsewhere in the weeks ahead." Clinicians should contact local and state health departments if they suspect an outbreak.
No patients in the recent outbreaks have died of the infection, and no cases have been confirmed in adults. The patients affected have been 6 weeks to 16 years of age, with a median age of 4-5 years, she said.
Enteroviruses can cause respiratory illness, febrile rash, and neurologic illness. EV-D68 is thought to cause primarily respiratory illness, but "we don’t know as much about it as we do of other respiratory viruses," Dr. Schuchat said. "The full spectrum of all the illnesses it can cause are not well defined."
More than half of the 30 patients in Kansas City and Chicago with confirmed EV-D68 had a history of asthma or wheezing. Only seven of the patients were febrile, the CDC reported.
Late summer and fall are common times for respiratory infections of many kinds. Patient specimens tested by the CDC that did not find EV-D68 detected rhinovirus or other common respiratory viruses, or were negative for infection.
Physicians should counsel parents to seek medical attention if a child develops difficulty breathing, but not be alarmed by every runny nose or sniffles, Dr. Schuchat said.
"Most of the runny noses out there are not going to turn into this," Dr. Schuchat said.
Keeping asthma under control and getting vaccinated for influenza are important, especially to avoid an overlay of problems if EV-D68 infection leads to illness, she added.
Dr. Schuchat reported having no financial disclosures.
On Twitter @sherryboschert
The Kansas City, Mo., outbreak of severe respiratory illness in children who require intensive care is "unprecedented in number and severity for this time of year," Dr. Mary Anne Jackson said in an interview.
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Her hospital tested specimens from 646 cases and found 498 (77%) positive for "rhinovirus/enterovirus," she said. "Not all were enterovirus D68, but 90% of those with the typical symptoms were confirmed in our initial CDC typing," which confirmed EV-D68 in 19 of 22 specimens. Testing results are preliminary and it’s "difficult to say with certainty what the scope of the outbreak is here, but we appear to be leveling off," with the number of hospitalized children decreasing.
As the number of patients surged, the hospital activated its network of infectious disease providers, pulmonologists, and others to cover pediatricians and handle some of the cases, and the hospital made extra beds available, she said.
"The scope and burden of infection in other communities reporting disease is not clear at this time," Dr. Jackson said, but she advised pediatricians to be alert for "unusually severe manifestations of what appears to be respiratory virus in children with and without asthma. Patients in our initial cohort who required pediatric ICU care appeared to routinely have hypoxemia and respiratory failure."
Health care facilities that see an unusually high burden of respiratory viral disease or unusually severe cases can test for EV-D68 with help from local and state health departments and the Centers for Disease Control and Prevention. Pediatricians can advise parents to treat common cold symptoms with fever control and fluids, she suggested, and to see a physician if the child develops difficulty breathing.
Parents of young children with asthma should have an active asthma management plan and a primary care provider they can call if they have questions. To limit spread of disease, recommend the standard practices of frequent hand washing, cleaning surfaces and toys, shielding coughs, and staying home if the child is ill.
Dr. Mary Anne Jackson is director of the division of infectious diseases at Children’s Mercy Hospital, Kansas City, Mo., and professor of pediatrics at the University of Missouri–Kansas City. She coauthored the Sept. 8, 2014, MMWR report on enterovirus D68. She reported having no financial disclosures.
The Kansas City, Mo., outbreak of severe respiratory illness in children who require intensive care is "unprecedented in number and severity for this time of year," Dr. Mary Anne Jackson said in an interview.
|
|
Her hospital tested specimens from 646 cases and found 498 (77%) positive for "rhinovirus/enterovirus," she said. "Not all were enterovirus D68, but 90% of those with the typical symptoms were confirmed in our initial CDC typing," which confirmed EV-D68 in 19 of 22 specimens. Testing results are preliminary and it’s "difficult to say with certainty what the scope of the outbreak is here, but we appear to be leveling off," with the number of hospitalized children decreasing.
As the number of patients surged, the hospital activated its network of infectious disease providers, pulmonologists, and others to cover pediatricians and handle some of the cases, and the hospital made extra beds available, she said.
"The scope and burden of infection in other communities reporting disease is not clear at this time," Dr. Jackson said, but she advised pediatricians to be alert for "unusually severe manifestations of what appears to be respiratory virus in children with and without asthma. Patients in our initial cohort who required pediatric ICU care appeared to routinely have hypoxemia and respiratory failure."
Health care facilities that see an unusually high burden of respiratory viral disease or unusually severe cases can test for EV-D68 with help from local and state health departments and the Centers for Disease Control and Prevention. Pediatricians can advise parents to treat common cold symptoms with fever control and fluids, she suggested, and to see a physician if the child develops difficulty breathing.
Parents of young children with asthma should have an active asthma management plan and a primary care provider they can call if they have questions. To limit spread of disease, recommend the standard practices of frequent hand washing, cleaning surfaces and toys, shielding coughs, and staying home if the child is ill.
Dr. Mary Anne Jackson is director of the division of infectious diseases at Children’s Mercy Hospital, Kansas City, Mo., and professor of pediatrics at the University of Missouri–Kansas City. She coauthored the Sept. 8, 2014, MMWR report on enterovirus D68. She reported having no financial disclosures.
The Kansas City, Mo., outbreak of severe respiratory illness in children who require intensive care is "unprecedented in number and severity for this time of year," Dr. Mary Anne Jackson said in an interview.
|
|
Her hospital tested specimens from 646 cases and found 498 (77%) positive for "rhinovirus/enterovirus," she said. "Not all were enterovirus D68, but 90% of those with the typical symptoms were confirmed in our initial CDC typing," which confirmed EV-D68 in 19 of 22 specimens. Testing results are preliminary and it’s "difficult to say with certainty what the scope of the outbreak is here, but we appear to be leveling off," with the number of hospitalized children decreasing.
As the number of patients surged, the hospital activated its network of infectious disease providers, pulmonologists, and others to cover pediatricians and handle some of the cases, and the hospital made extra beds available, she said.
"The scope and burden of infection in other communities reporting disease is not clear at this time," Dr. Jackson said, but she advised pediatricians to be alert for "unusually severe manifestations of what appears to be respiratory virus in children with and without asthma. Patients in our initial cohort who required pediatric ICU care appeared to routinely have hypoxemia and respiratory failure."
Health care facilities that see an unusually high burden of respiratory viral disease or unusually severe cases can test for EV-D68 with help from local and state health departments and the Centers for Disease Control and Prevention. Pediatricians can advise parents to treat common cold symptoms with fever control and fluids, she suggested, and to see a physician if the child develops difficulty breathing.
Parents of young children with asthma should have an active asthma management plan and a primary care provider they can call if they have questions. To limit spread of disease, recommend the standard practices of frequent hand washing, cleaning surfaces and toys, shielding coughs, and staying home if the child is ill.
Dr. Mary Anne Jackson is director of the division of infectious diseases at Children’s Mercy Hospital, Kansas City, Mo., and professor of pediatrics at the University of Missouri–Kansas City. She coauthored the Sept. 8, 2014, MMWR report on enterovirus D68. She reported having no financial disclosures.
A rare enterovirus caused outbreaks of severe pediatric respiratory illness in two U.S. cities and may be active elsewhere, the Centers for Disease Control and Prevention reported.
The CDC found enterovirus D68 (EV-D68) in 19 of 22 (86%) samples it tested from patients in Kansas City, Mo., and in 11 of 14 (79%) samples from Chicago, and is testing samples from other states. Health officials from Alabama, Colorado, Georgia, Illinois, Iowa, Kansas, Kentucky, Missouri, Ohio, Oklahoma, and Utah have contacted the CDC about confirmed cases or suspected cases that are being tested, a CDC spokesman confirmed.
The outbreaks first were noticed in mid-August in Kansas City, Mo., where Children’s Mercy Hospital reported a 25%-30% increase beyond normal seasonal levels in the numbers of children visiting emergency departments and urgent care centers and being hospitalized for respiratory illness, the hospital said in a letter to community physicians. "To date, we have nearly 500 suspected cases including 61 children who were admitted to our intensive care unit presumptively with this viral infection," the letter said.
The University of Chicago Medicine Comer Children’s Hospital contacted the CDC a few days later about a similar outbreak there.
CDC testing shows "it’s not a new strain" of enterovirus, but the same EV-D68 reported in previous years in small numbers in the United States and other countries, Dr. Anne Schuchat said in a press briefing. Dr. Schuchat is director of the National Center for Immunization and Respiratory Diseases.
U.S. national surveillance systems received only 79 reports of EV-D68 during 2009-2013, and small clusters of respiratory illness were associated with EV-D68 infection in 2009-2010, the CDC reported (MMWR 2014;63:1-2). There is no vaccine or specific treatment for EV-D68 infection. Treatment consists of supportive care.
"Clinics across the country need to be on the alert and consider this in the differential diagnosis" of unexplained respiratory illnesses, Dr. Schuchat said. "We believe the unusual occurrences in Kansas City and Chicago may be occurring elsewhere in the weeks ahead." Clinicians should contact local and state health departments if they suspect an outbreak.
No patients in the recent outbreaks have died of the infection, and no cases have been confirmed in adults. The patients affected have been 6 weeks to 16 years of age, with a median age of 4-5 years, she said.
Enteroviruses can cause respiratory illness, febrile rash, and neurologic illness. EV-D68 is thought to cause primarily respiratory illness, but "we don’t know as much about it as we do of other respiratory viruses," Dr. Schuchat said. "The full spectrum of all the illnesses it can cause are not well defined."
More than half of the 30 patients in Kansas City and Chicago with confirmed EV-D68 had a history of asthma or wheezing. Only seven of the patients were febrile, the CDC reported.
Late summer and fall are common times for respiratory infections of many kinds. Patient specimens tested by the CDC that did not find EV-D68 detected rhinovirus or other common respiratory viruses, or were negative for infection.
Physicians should counsel parents to seek medical attention if a child develops difficulty breathing, but not be alarmed by every runny nose or sniffles, Dr. Schuchat said.
"Most of the runny noses out there are not going to turn into this," Dr. Schuchat said.
Keeping asthma under control and getting vaccinated for influenza are important, especially to avoid an overlay of problems if EV-D68 infection leads to illness, she added.
Dr. Schuchat reported having no financial disclosures.
On Twitter @sherryboschert
A rare enterovirus caused outbreaks of severe pediatric respiratory illness in two U.S. cities and may be active elsewhere, the Centers for Disease Control and Prevention reported.
The CDC found enterovirus D68 (EV-D68) in 19 of 22 (86%) samples it tested from patients in Kansas City, Mo., and in 11 of 14 (79%) samples from Chicago, and is testing samples from other states. Health officials from Alabama, Colorado, Georgia, Illinois, Iowa, Kansas, Kentucky, Missouri, Ohio, Oklahoma, and Utah have contacted the CDC about confirmed cases or suspected cases that are being tested, a CDC spokesman confirmed.
The outbreaks first were noticed in mid-August in Kansas City, Mo., where Children’s Mercy Hospital reported a 25%-30% increase beyond normal seasonal levels in the numbers of children visiting emergency departments and urgent care centers and being hospitalized for respiratory illness, the hospital said in a letter to community physicians. "To date, we have nearly 500 suspected cases including 61 children who were admitted to our intensive care unit presumptively with this viral infection," the letter said.
The University of Chicago Medicine Comer Children’s Hospital contacted the CDC a few days later about a similar outbreak there.
CDC testing shows "it’s not a new strain" of enterovirus, but the same EV-D68 reported in previous years in small numbers in the United States and other countries, Dr. Anne Schuchat said in a press briefing. Dr. Schuchat is director of the National Center for Immunization and Respiratory Diseases.
U.S. national surveillance systems received only 79 reports of EV-D68 during 2009-2013, and small clusters of respiratory illness were associated with EV-D68 infection in 2009-2010, the CDC reported (MMWR 2014;63:1-2). There is no vaccine or specific treatment for EV-D68 infection. Treatment consists of supportive care.
"Clinics across the country need to be on the alert and consider this in the differential diagnosis" of unexplained respiratory illnesses, Dr. Schuchat said. "We believe the unusual occurrences in Kansas City and Chicago may be occurring elsewhere in the weeks ahead." Clinicians should contact local and state health departments if they suspect an outbreak.
No patients in the recent outbreaks have died of the infection, and no cases have been confirmed in adults. The patients affected have been 6 weeks to 16 years of age, with a median age of 4-5 years, she said.
Enteroviruses can cause respiratory illness, febrile rash, and neurologic illness. EV-D68 is thought to cause primarily respiratory illness, but "we don’t know as much about it as we do of other respiratory viruses," Dr. Schuchat said. "The full spectrum of all the illnesses it can cause are not well defined."
More than half of the 30 patients in Kansas City and Chicago with confirmed EV-D68 had a history of asthma or wheezing. Only seven of the patients were febrile, the CDC reported.
Late summer and fall are common times for respiratory infections of many kinds. Patient specimens tested by the CDC that did not find EV-D68 detected rhinovirus or other common respiratory viruses, or were negative for infection.
Physicians should counsel parents to seek medical attention if a child develops difficulty breathing, but not be alarmed by every runny nose or sniffles, Dr. Schuchat said.
"Most of the runny noses out there are not going to turn into this," Dr. Schuchat said.
Keeping asthma under control and getting vaccinated for influenza are important, especially to avoid an overlay of problems if EV-D68 infection leads to illness, she added.
Dr. Schuchat reported having no financial disclosures.
On Twitter @sherryboschert
FROM THE MMWR
Key clinical point: Consider enterovirus D68 in the differential diagnosis of unexplained severe respiratory illness.
Major finding: Enterovirus D68 caused severe respiratory illness in 30 of 36 (83%) cases at two U.S. hospitals.
Data source: CDC testing and confirmation of samples from Kansas and Illinois.
Disclosures: Dr. Schuchat reported having no financial disclosures.
