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Tune in to cardiovascular risk in psoriasis
Stay attentive to cardiovascular disease risk in patients with psoriasis because effective treatment of psoriasis could improve their vascular risk as well, said Jeffrey M. Sobell, MD, of Tufts University in Boston.
he said at the Caribbean Dermatology Symposium.
The metabolic syndrome and its associated cardiovascular risk of myocardial infarction and stroke is significantly more prevalent in psoriasis patients, compared with controls, Dr. Sobell said at the meeting, provided by Global Academy for Medical Education.
A possible reason for this link may be that the chronic inflammation associated with psoriasis leads to atherosclerosis, Dr. Sobell noted. The inflammation is evident on PET imaging with a radiolabeled glucose known as fluorodeoxyglucose positron emission tomography–computed tomography (FDG-PET/CT) The technology, first used in cancer and neuroimaging, can detect early subclinical inflammation and allows for exact measurements of inflammatory activity, and measuring inflammation of the aorta can serve as a surrogate marker for treatment, he said.
Treating skin disease appears to impact vascular disease, Dr. Sobell said. In a study published in JAMA Cardiology, researchers followed 115 patients for 1 year using FDG-PET/CT (JAMA Cardiol. 2017. doi: 10.1001/jamacardio.2017.1213)
Overall, when psoriasis improved, so did signs of vascular inflammation. “When the skin is more severe and treated more aggressively with anti-TNF therapy, the reduction in vascular disease is stronger,” Dr. Sobell said.
Data from another large study presented as a late-breaker at the American Academy of Dermatology in 2017 showed that treatment of psoriasis with tumor necrosis factor–alpha inhibitor therapy significantly reduced all-cause mortality in patients with psoriasis or psoriatic arthritis, he noted.
Psoriasis patients often are underscreened for cardiac risk factors, but identifying them can help guide treatment, Dr. Sobell said.
“Dermatologists should at minimum direct patients to primary care physicians for appropriate screening and assessment,” he emphasized.
Dr. Sobell disclosed relationships with Amgen, AbbVie, Celgene, Eli Lilly, Janssen, Merck, Novartis, Regeneron, and Sun Pharma.
Global Academy and this news organization are owned by the same parent company.
Stay attentive to cardiovascular disease risk in patients with psoriasis because effective treatment of psoriasis could improve their vascular risk as well, said Jeffrey M. Sobell, MD, of Tufts University in Boston.
he said at the Caribbean Dermatology Symposium.
The metabolic syndrome and its associated cardiovascular risk of myocardial infarction and stroke is significantly more prevalent in psoriasis patients, compared with controls, Dr. Sobell said at the meeting, provided by Global Academy for Medical Education.
A possible reason for this link may be that the chronic inflammation associated with psoriasis leads to atherosclerosis, Dr. Sobell noted. The inflammation is evident on PET imaging with a radiolabeled glucose known as fluorodeoxyglucose positron emission tomography–computed tomography (FDG-PET/CT) The technology, first used in cancer and neuroimaging, can detect early subclinical inflammation and allows for exact measurements of inflammatory activity, and measuring inflammation of the aorta can serve as a surrogate marker for treatment, he said.
Treating skin disease appears to impact vascular disease, Dr. Sobell said. In a study published in JAMA Cardiology, researchers followed 115 patients for 1 year using FDG-PET/CT (JAMA Cardiol. 2017. doi: 10.1001/jamacardio.2017.1213)
Overall, when psoriasis improved, so did signs of vascular inflammation. “When the skin is more severe and treated more aggressively with anti-TNF therapy, the reduction in vascular disease is stronger,” Dr. Sobell said.
Data from another large study presented as a late-breaker at the American Academy of Dermatology in 2017 showed that treatment of psoriasis with tumor necrosis factor–alpha inhibitor therapy significantly reduced all-cause mortality in patients with psoriasis or psoriatic arthritis, he noted.
Psoriasis patients often are underscreened for cardiac risk factors, but identifying them can help guide treatment, Dr. Sobell said.
“Dermatologists should at minimum direct patients to primary care physicians for appropriate screening and assessment,” he emphasized.
Dr. Sobell disclosed relationships with Amgen, AbbVie, Celgene, Eli Lilly, Janssen, Merck, Novartis, Regeneron, and Sun Pharma.
Global Academy and this news organization are owned by the same parent company.
Stay attentive to cardiovascular disease risk in patients with psoriasis because effective treatment of psoriasis could improve their vascular risk as well, said Jeffrey M. Sobell, MD, of Tufts University in Boston.
he said at the Caribbean Dermatology Symposium.
The metabolic syndrome and its associated cardiovascular risk of myocardial infarction and stroke is significantly more prevalent in psoriasis patients, compared with controls, Dr. Sobell said at the meeting, provided by Global Academy for Medical Education.
A possible reason for this link may be that the chronic inflammation associated with psoriasis leads to atherosclerosis, Dr. Sobell noted. The inflammation is evident on PET imaging with a radiolabeled glucose known as fluorodeoxyglucose positron emission tomography–computed tomography (FDG-PET/CT) The technology, first used in cancer and neuroimaging, can detect early subclinical inflammation and allows for exact measurements of inflammatory activity, and measuring inflammation of the aorta can serve as a surrogate marker for treatment, he said.
Treating skin disease appears to impact vascular disease, Dr. Sobell said. In a study published in JAMA Cardiology, researchers followed 115 patients for 1 year using FDG-PET/CT (JAMA Cardiol. 2017. doi: 10.1001/jamacardio.2017.1213)
Overall, when psoriasis improved, so did signs of vascular inflammation. “When the skin is more severe and treated more aggressively with anti-TNF therapy, the reduction in vascular disease is stronger,” Dr. Sobell said.
Data from another large study presented as a late-breaker at the American Academy of Dermatology in 2017 showed that treatment of psoriasis with tumor necrosis factor–alpha inhibitor therapy significantly reduced all-cause mortality in patients with psoriasis or psoriatic arthritis, he noted.
Psoriasis patients often are underscreened for cardiac risk factors, but identifying them can help guide treatment, Dr. Sobell said.
“Dermatologists should at minimum direct patients to primary care physicians for appropriate screening and assessment,” he emphasized.
Dr. Sobell disclosed relationships with Amgen, AbbVie, Celgene, Eli Lilly, Janssen, Merck, Novartis, Regeneron, and Sun Pharma.
Global Academy and this news organization are owned by the same parent company.
EXPERT ANALYSIS FROM THE CARIBBEAN DERMATOLOGY SYMPOSIUM
Macrophage activation syndrome’s impact in childhood SLE felt mostly early
Nearly 10% of children with systemic lupus erythematosus (SLE) developed macrophage activation syndrome (MAS) at some point during a mean follow-up time of more than 3 years at one center, and most were concomitantly diagnosed with the syndrome.
Although the investigators from the University of Toronto reported significantly higher mortality among patients with MAS, most cases were successfully treated with corticosteroids, and no relapses were observed during follow-up.
MAS was first identified in patients with juvenile idiopathic arthritis and is most well known as a complication of that broadly named disease, but data on outcomes and disease course in SLE patients are limited, first author Roberto Ezequiel Borgia, MD, and his colleagues wrote in their report in Arthritis & Rheumatology.
The researchers identified 403 children with SLE seen at the Hospital for Sick Children in Toronto during 2002-2012. Overall, 38 patients (9%) had MAS; of those patients, 68% received a MAS diagnosis within 7 days of the SLE diagnosis – termed “concomitant” diagnosis – while another 29% received a MAS diagnosis within 180 days of their SLE diagnosis.
The researchers explained that “since there are no validated nor universally accepted diagnostic criteria for MAS in SLE, the definition of MAS was based on the treating pediatric rheumatologist’s expert opinion at the time of the initial presentation.” The most common presenting feature of MAS was fever (100%), followed by generalized lymphadenopathy (24%), hepatomegaly (18%), CNS dysfunction secondary to MAS (18%), hemorrhage (13%), and splenomegaly (10%).
The average age of the children at diagnosis was nearly 14 years, and 79% were female. The average follow-up was 3.5 years. There were no significant differences in the demographic features of children with and without MAS nor were there any in variables used to assess lupus outcomes, which included immunosuppressive drug use, average daily corticosteroid dose (18.3 mg/day with MAS vs. 18.6 mg/day without MAS), and the number of pediatric ICU visits (incidence rate ratio for MAS vs. non-MAS, 1.60 [95% CI, 0.74-3.18]).
Mortality was significantly higher in children with MAS, compared with those without MAS (5.3% vs. 0.3%; P = .02), although the overall number of deaths in the cohort was small (n = 3). Apart from the “acute illness which was associated with 2 deaths secondary to MAS,” the investigators said that they “did not find any significant differences in the number of deaths or damage accrual between the cohorts, including overall SLICC [Systemic Lupus International Collaborating Clinics] damage score or any specific damage feature within the score.”
The study findings were limited by several factors including the lack of validated MAS criteria for children with SLE and a lack of follow-up data on the patients beyond 18 years of age, the researchers said.
The results suggest that MAS remains a life-threatening complication in children with SLE and should be considered an important cause of mortality for them, but “if the initial presentation does not result in death, the long-term outcome seem[s] to be comparable to those without MAS,” the investigators wrote.
The researchers had no financial conflicts to disclose.
SOURCE: Borgia R et al. Arthritis Rheumatol. 2018 Jan 17. doi: 10.1002/art.40417
As we learn more about the role of macrophage activation syndrome (MAS), a secondary form of hemophagocytic lymphohistiocytosis in rheumatic diseases, it has become clear that patients may develop this syndrome in a variety of settings. The most common presentation of MAS is in association with systemic onset juvenile idiopathic arthritis, but is has been described in other forms of childhood rheumatic diseases, including other types of juvenile idiopathic arthritis, lupus, mixed connective tissue disease, Kawasaki disease, and sarcoidosis. Study of secondary MAS has led to suggested diagnostic criteria; however, those criteria are very similar to the presentation of adult and childhood systemic lupus with cytopenias, hepatitis, and coagulopathy.
The work by Borgia et al. encourages us to look for evidence of MAS in our lupus patients as it allows us to identify patients at risk for poor outcomes and to provide interventions to reduce those risks.
Marisa S. Klein-Gitelman, MD , is a professor of pediatrics at Northwestern University, Chicago, and is a pediatric rheumatologist at the Ann & Robert H. Lurie Children’s Hospital of Chicago. She has no relevant disclosures.
As we learn more about the role of macrophage activation syndrome (MAS), a secondary form of hemophagocytic lymphohistiocytosis in rheumatic diseases, it has become clear that patients may develop this syndrome in a variety of settings. The most common presentation of MAS is in association with systemic onset juvenile idiopathic arthritis, but is has been described in other forms of childhood rheumatic diseases, including other types of juvenile idiopathic arthritis, lupus, mixed connective tissue disease, Kawasaki disease, and sarcoidosis. Study of secondary MAS has led to suggested diagnostic criteria; however, those criteria are very similar to the presentation of adult and childhood systemic lupus with cytopenias, hepatitis, and coagulopathy.
The work by Borgia et al. encourages us to look for evidence of MAS in our lupus patients as it allows us to identify patients at risk for poor outcomes and to provide interventions to reduce those risks.
Marisa S. Klein-Gitelman, MD , is a professor of pediatrics at Northwestern University, Chicago, and is a pediatric rheumatologist at the Ann & Robert H. Lurie Children’s Hospital of Chicago. She has no relevant disclosures.
As we learn more about the role of macrophage activation syndrome (MAS), a secondary form of hemophagocytic lymphohistiocytosis in rheumatic diseases, it has become clear that patients may develop this syndrome in a variety of settings. The most common presentation of MAS is in association with systemic onset juvenile idiopathic arthritis, but is has been described in other forms of childhood rheumatic diseases, including other types of juvenile idiopathic arthritis, lupus, mixed connective tissue disease, Kawasaki disease, and sarcoidosis. Study of secondary MAS has led to suggested diagnostic criteria; however, those criteria are very similar to the presentation of adult and childhood systemic lupus with cytopenias, hepatitis, and coagulopathy.
The work by Borgia et al. encourages us to look for evidence of MAS in our lupus patients as it allows us to identify patients at risk for poor outcomes and to provide interventions to reduce those risks.
Marisa S. Klein-Gitelman, MD , is a professor of pediatrics at Northwestern University, Chicago, and is a pediatric rheumatologist at the Ann & Robert H. Lurie Children’s Hospital of Chicago. She has no relevant disclosures.
Nearly 10% of children with systemic lupus erythematosus (SLE) developed macrophage activation syndrome (MAS) at some point during a mean follow-up time of more than 3 years at one center, and most were concomitantly diagnosed with the syndrome.
Although the investigators from the University of Toronto reported significantly higher mortality among patients with MAS, most cases were successfully treated with corticosteroids, and no relapses were observed during follow-up.
MAS was first identified in patients with juvenile idiopathic arthritis and is most well known as a complication of that broadly named disease, but data on outcomes and disease course in SLE patients are limited, first author Roberto Ezequiel Borgia, MD, and his colleagues wrote in their report in Arthritis & Rheumatology.
The researchers identified 403 children with SLE seen at the Hospital for Sick Children in Toronto during 2002-2012. Overall, 38 patients (9%) had MAS; of those patients, 68% received a MAS diagnosis within 7 days of the SLE diagnosis – termed “concomitant” diagnosis – while another 29% received a MAS diagnosis within 180 days of their SLE diagnosis.
The researchers explained that “since there are no validated nor universally accepted diagnostic criteria for MAS in SLE, the definition of MAS was based on the treating pediatric rheumatologist’s expert opinion at the time of the initial presentation.” The most common presenting feature of MAS was fever (100%), followed by generalized lymphadenopathy (24%), hepatomegaly (18%), CNS dysfunction secondary to MAS (18%), hemorrhage (13%), and splenomegaly (10%).
The average age of the children at diagnosis was nearly 14 years, and 79% were female. The average follow-up was 3.5 years. There were no significant differences in the demographic features of children with and without MAS nor were there any in variables used to assess lupus outcomes, which included immunosuppressive drug use, average daily corticosteroid dose (18.3 mg/day with MAS vs. 18.6 mg/day without MAS), and the number of pediatric ICU visits (incidence rate ratio for MAS vs. non-MAS, 1.60 [95% CI, 0.74-3.18]).
Mortality was significantly higher in children with MAS, compared with those without MAS (5.3% vs. 0.3%; P = .02), although the overall number of deaths in the cohort was small (n = 3). Apart from the “acute illness which was associated with 2 deaths secondary to MAS,” the investigators said that they “did not find any significant differences in the number of deaths or damage accrual between the cohorts, including overall SLICC [Systemic Lupus International Collaborating Clinics] damage score or any specific damage feature within the score.”
The study findings were limited by several factors including the lack of validated MAS criteria for children with SLE and a lack of follow-up data on the patients beyond 18 years of age, the researchers said.
The results suggest that MAS remains a life-threatening complication in children with SLE and should be considered an important cause of mortality for them, but “if the initial presentation does not result in death, the long-term outcome seem[s] to be comparable to those without MAS,” the investigators wrote.
The researchers had no financial conflicts to disclose.
SOURCE: Borgia R et al. Arthritis Rheumatol. 2018 Jan 17. doi: 10.1002/art.40417
Nearly 10% of children with systemic lupus erythematosus (SLE) developed macrophage activation syndrome (MAS) at some point during a mean follow-up time of more than 3 years at one center, and most were concomitantly diagnosed with the syndrome.
Although the investigators from the University of Toronto reported significantly higher mortality among patients with MAS, most cases were successfully treated with corticosteroids, and no relapses were observed during follow-up.
MAS was first identified in patients with juvenile idiopathic arthritis and is most well known as a complication of that broadly named disease, but data on outcomes and disease course in SLE patients are limited, first author Roberto Ezequiel Borgia, MD, and his colleagues wrote in their report in Arthritis & Rheumatology.
The researchers identified 403 children with SLE seen at the Hospital for Sick Children in Toronto during 2002-2012. Overall, 38 patients (9%) had MAS; of those patients, 68% received a MAS diagnosis within 7 days of the SLE diagnosis – termed “concomitant” diagnosis – while another 29% received a MAS diagnosis within 180 days of their SLE diagnosis.
The researchers explained that “since there are no validated nor universally accepted diagnostic criteria for MAS in SLE, the definition of MAS was based on the treating pediatric rheumatologist’s expert opinion at the time of the initial presentation.” The most common presenting feature of MAS was fever (100%), followed by generalized lymphadenopathy (24%), hepatomegaly (18%), CNS dysfunction secondary to MAS (18%), hemorrhage (13%), and splenomegaly (10%).
The average age of the children at diagnosis was nearly 14 years, and 79% were female. The average follow-up was 3.5 years. There were no significant differences in the demographic features of children with and without MAS nor were there any in variables used to assess lupus outcomes, which included immunosuppressive drug use, average daily corticosteroid dose (18.3 mg/day with MAS vs. 18.6 mg/day without MAS), and the number of pediatric ICU visits (incidence rate ratio for MAS vs. non-MAS, 1.60 [95% CI, 0.74-3.18]).
Mortality was significantly higher in children with MAS, compared with those without MAS (5.3% vs. 0.3%; P = .02), although the overall number of deaths in the cohort was small (n = 3). Apart from the “acute illness which was associated with 2 deaths secondary to MAS,” the investigators said that they “did not find any significant differences in the number of deaths or damage accrual between the cohorts, including overall SLICC [Systemic Lupus International Collaborating Clinics] damage score or any specific damage feature within the score.”
The study findings were limited by several factors including the lack of validated MAS criteria for children with SLE and a lack of follow-up data on the patients beyond 18 years of age, the researchers said.
The results suggest that MAS remains a life-threatening complication in children with SLE and should be considered an important cause of mortality for them, but “if the initial presentation does not result in death, the long-term outcome seem[s] to be comparable to those without MAS,” the investigators wrote.
The researchers had no financial conflicts to disclose.
SOURCE: Borgia R et al. Arthritis Rheumatol. 2018 Jan 17. doi: 10.1002/art.40417
FROM ARTHRITIS & RHEUMATOLOGY
Key clinical point: Nearly 10% of children with SLE developed MAS at some point during a mean follow-up time of more than 3 years, but many outcomes were the same in patients with and without MAS.
Major finding: Mortality was 5.3% in children with MAS, compared with 0.3% in those without MAS (P = .02), over a 3.5-year follow-up period.
Study details: The data come from 403 children with SLE seen at a single center during 2002-2012.
Disclosures: The researchers had no financial conflicts to disclose.
Source: Borgia R et al. Arthritis Rheumatol. 2018 Jan 17. doi: 10.1002/art.40417.
Children with sickle cell anemia fall short on antibiotic adherence
Despite the increased risk for invasive pneumococcal disease, prophylactic antibiotics are underused in children with sickle cell anemia, according to data from more than 2,000 children in six states.
Less than one-fifth (18%) of young children (aged 3 months to 5 years) with sickle cell anemia (SCA) receive at least 300 days of prophylactic antibiotics to reduce their risk of pneumococcal infections, the analysis found.
“Although the effectiveness of daily penicillin prophylaxis has been known for decades, limited evidence indicates low rates of compliance among children,” wrote Sarah L. Reeves, PhD, of the University of Michigan, Ann Arbor, and her colleagues. The report was published in Pediatrics.
The researchers reviewed Medicaid claims for 2,821 children with SCA from the period of 2005-2012 for a total of 5,014 person-years. The data were taken from six states: Florida, Illinois, Louisiana, Michigan, South Carolina, and Texas. Antibiotic prophylaxis was defined as four different treatment protocols: oral penicillin; oral penicillin or erythromycin; oral penicillin, erythromycin, or amoxicillin; or any antibiotic that could protect against Streptococcus pneumoniae.
Overall, the children in the study averaged 1.7 sickle cell disease–related inpatient hospitalizations annually, as well as 13.2 sickle cell disease–related outpatient visits and 3.8 emergency department visits per year.
The proportion of children who received 300 days or more of prophylactic antibiotics varied by state, by year, and by type of treatment. “In this multistate analysis, receipt of antibiotic prophylaxis among children with SCA was persistently low, irrespective of year or state,” the researchers noted.
The odds that a child received 300 days or more of prophylactic antibiotics increased with each outpatient visit, including well child visits and sickle cell disease–related visits (odds ratios 1.08 and 1.01, respectively).
A child in the third quartile of sickle cell disease–related outpatient visits (defined as 17 annual visits) was 15% more likely than was a child in the first quartile (defined as six annual visits) to receive at least 300 days of antibiotics.
The study findings were limited by several factors including potential overestimation of how many children received medication, the researchers said. However, the results suggest the need for practical and effective intervention that targets barriers to treatment adherence, they said.
“Provider-focused strategies to increase adherence could capitalize on the numerous annual outpatient encounters with the health care system that children with SCA are already experiencing,” they wrote.
The study was supported by a grant from the Agency for Healthcare Research and Quality and the Centers for Medicare and Medicaid Services. The researchers reported having no financial disclosures.
SOURCE: Reeves S et al. Pediatrics. 2018;141(3):e20172182. doi: 10.1542/peds.2017-2182.
Despite the increased risk for invasive pneumococcal disease, prophylactic antibiotics are underused in children with sickle cell anemia, according to data from more than 2,000 children in six states.
Less than one-fifth (18%) of young children (aged 3 months to 5 years) with sickle cell anemia (SCA) receive at least 300 days of prophylactic antibiotics to reduce their risk of pneumococcal infections, the analysis found.
“Although the effectiveness of daily penicillin prophylaxis has been known for decades, limited evidence indicates low rates of compliance among children,” wrote Sarah L. Reeves, PhD, of the University of Michigan, Ann Arbor, and her colleagues. The report was published in Pediatrics.
The researchers reviewed Medicaid claims for 2,821 children with SCA from the period of 2005-2012 for a total of 5,014 person-years. The data were taken from six states: Florida, Illinois, Louisiana, Michigan, South Carolina, and Texas. Antibiotic prophylaxis was defined as four different treatment protocols: oral penicillin; oral penicillin or erythromycin; oral penicillin, erythromycin, or amoxicillin; or any antibiotic that could protect against Streptococcus pneumoniae.
Overall, the children in the study averaged 1.7 sickle cell disease–related inpatient hospitalizations annually, as well as 13.2 sickle cell disease–related outpatient visits and 3.8 emergency department visits per year.
The proportion of children who received 300 days or more of prophylactic antibiotics varied by state, by year, and by type of treatment. “In this multistate analysis, receipt of antibiotic prophylaxis among children with SCA was persistently low, irrespective of year or state,” the researchers noted.
The odds that a child received 300 days or more of prophylactic antibiotics increased with each outpatient visit, including well child visits and sickle cell disease–related visits (odds ratios 1.08 and 1.01, respectively).
A child in the third quartile of sickle cell disease–related outpatient visits (defined as 17 annual visits) was 15% more likely than was a child in the first quartile (defined as six annual visits) to receive at least 300 days of antibiotics.
The study findings were limited by several factors including potential overestimation of how many children received medication, the researchers said. However, the results suggest the need for practical and effective intervention that targets barriers to treatment adherence, they said.
“Provider-focused strategies to increase adherence could capitalize on the numerous annual outpatient encounters with the health care system that children with SCA are already experiencing,” they wrote.
The study was supported by a grant from the Agency for Healthcare Research and Quality and the Centers for Medicare and Medicaid Services. The researchers reported having no financial disclosures.
SOURCE: Reeves S et al. Pediatrics. 2018;141(3):e20172182. doi: 10.1542/peds.2017-2182.
Despite the increased risk for invasive pneumococcal disease, prophylactic antibiotics are underused in children with sickle cell anemia, according to data from more than 2,000 children in six states.
Less than one-fifth (18%) of young children (aged 3 months to 5 years) with sickle cell anemia (SCA) receive at least 300 days of prophylactic antibiotics to reduce their risk of pneumococcal infections, the analysis found.
“Although the effectiveness of daily penicillin prophylaxis has been known for decades, limited evidence indicates low rates of compliance among children,” wrote Sarah L. Reeves, PhD, of the University of Michigan, Ann Arbor, and her colleagues. The report was published in Pediatrics.
The researchers reviewed Medicaid claims for 2,821 children with SCA from the period of 2005-2012 for a total of 5,014 person-years. The data were taken from six states: Florida, Illinois, Louisiana, Michigan, South Carolina, and Texas. Antibiotic prophylaxis was defined as four different treatment protocols: oral penicillin; oral penicillin or erythromycin; oral penicillin, erythromycin, or amoxicillin; or any antibiotic that could protect against Streptococcus pneumoniae.
Overall, the children in the study averaged 1.7 sickle cell disease–related inpatient hospitalizations annually, as well as 13.2 sickle cell disease–related outpatient visits and 3.8 emergency department visits per year.
The proportion of children who received 300 days or more of prophylactic antibiotics varied by state, by year, and by type of treatment. “In this multistate analysis, receipt of antibiotic prophylaxis among children with SCA was persistently low, irrespective of year or state,” the researchers noted.
The odds that a child received 300 days or more of prophylactic antibiotics increased with each outpatient visit, including well child visits and sickle cell disease–related visits (odds ratios 1.08 and 1.01, respectively).
A child in the third quartile of sickle cell disease–related outpatient visits (defined as 17 annual visits) was 15% more likely than was a child in the first quartile (defined as six annual visits) to receive at least 300 days of antibiotics.
The study findings were limited by several factors including potential overestimation of how many children received medication, the researchers said. However, the results suggest the need for practical and effective intervention that targets barriers to treatment adherence, they said.
“Provider-focused strategies to increase adherence could capitalize on the numerous annual outpatient encounters with the health care system that children with SCA are already experiencing,” they wrote.
The study was supported by a grant from the Agency for Healthcare Research and Quality and the Centers for Medicare and Medicaid Services. The researchers reported having no financial disclosures.
SOURCE: Reeves S et al. Pediatrics. 2018;141(3):e20172182. doi: 10.1542/peds.2017-2182.
FROM PEDIATRICS
Key clinical point:
Major finding: A total of 18% of children with sickle cell anemia in Florida, Illinois, Louisiana, Michigan, South Carolina, and Texas received 300 days or more of prophylactic antibiotics.
Study details: A review of 2,821 children aged 3 months to 5 years with sickle cell anemia.
Disclosures: The study was supported by a grant from the Agency for Healthcare Research and Quality and the Centers for Medicare and Medicaid Services. The researchers reported having no financial disclosures.
Source: Reeves S et al. Pediatrics. 2018;141(3):e20172182. doi: 10.1542/peds.2017-2182.
Postcolonoscopy cancer rates persist despite quality protocols
The number of colorectal cancers diagnosed after a colonoscopy remained consistent at approximately 8% over a 15-year period despite the introduction of quality improvement measures, according to data from a population-based cohort study of more than 1 million individuals in Canada.
“It is believed that the majority of PCCRCs [postcolonoscopy colorectal cancers] arise due to cancers or near cancers that were either missed or incompletely treated during colonoscopy,” wrote Sanjay K. Murthy, MD, of the University of Ottawa, and colleagues.
Established quality improvement measures included adenoma detection rate, cecal intubation rate, colonoscopy withdrawal time, and endoscopy training standards, but how well the measures have been implemented remains uncertain, the researchers said. In a study published in Gastrointestinal Endoscopy (2018 Jan 6. doi: 10.1016/j.gie.2017.12.027), the researchers assessed data from 1,093,658 eligible adults aged 50-74 years over a 15-year period. The time period was divided into three sections: July 1, 1996, to June 30, 2001; July 1, 2001, to June 30, 2006; and July 1, 2006, to Dec. 31, 2010.
Overall, the number of colonoscopy procedures increased during the study period, from 305 per 10,000 people in 1996-1997 to 870 per 10,000 people in 2010-2011, and the percentage of individuals who underwent complete colonoscopies increased from 67% in the 1996-2001 period to 88% in the 2006-2010 period. “There was a considerable increase in the proportion of colonoscopies performed in younger age groups and community clinics in successive study periods,” the researchers noted.
Comparing the 2006-2010 and 1996-2001 time periods yielded adjusted odds of PCCRC, distal PCCRC, and proximal PCCRC of 1.14, 1.11, and 1.14, respectively; the trends were not affected by endoscopist specialty or institutional setting.
“Our findings are concerning for lack of improvement in colonoscopy practice quality in Ontario, particularly in the wake of greater emphasis having been placed on colonoscopy quality metrics during the study period,” the researchers said. The findings contrast with the decline in PCCRC rates in the United Kingdom reported in a previous study of a similar time period, they noted.
The study findings were limited by several factors, including possible patient and outcome misclassification, an unvalidated definition for PCCRC, and unmeasured confounders such as changes in practice or changes in the definition of PCCRC. Although more research is needed in other jurisdictions to confirm, the results “call for increased population-based practice audit as well as endoscopy educational programs and certification requirements.”
The study was supported by a research grant to Dr. Murthy from the University of Ottawa. The researchers had no financial conflicts to disclose.
SOURCE: Murthy S et al. Gastrointest Endosc. 2018 Jan 6. doi: 10.1016/j.gie.2017.12.027
Postcolonoscopy colorectal cancers (PCCRCs) are those cancers that occur between 6 and 36 months after a complete colonoscopy. For cancers diagnosed less than 6 months from exam, it is presumed that the exam itself was diagnostic. Most of these cancers grow from cancers or near cancers missed or incompletely resected during the baseline colonoscopy. Clinical researchers have published extensively about reasons for missed lesions and we know that age, female sex, and proximal location of cancers increase rates of PCCRC. GI societies worldwide have developed training initiatives, performance metrics (adenoma detection rate or ADR, withdrawal time, and prep quality documentation), and postcolonoscopy guidelines, all intended to mitigate risk of PCCRCs. It would be nice to know whether such efforts have made a difference.
Murthy and colleagues studied PCCRC rates in Ottawa, Canada during three different time periods to determine whether quality and educational efforts impacted PCCRC rates. More than 99% of this population has health care covered under a single public payer system where all encounters are carefully tracked. Using population-level health data derived from over 1 million people (screen eligible people, 50-74 years of age with low to moderate CRC risk) they identified cancers diagnosed within 36 months of a colonoscopy and compared three 5-year periods (1996-2001, 2001-2006, and 2006-2010).
Their method of calculating PCCRC rates essentially says, “If I am destined to develop CRC in the next 3 years, what is my chance of a false-negative colonoscopy?” There are five published methods of calculating PCCRC rates (summarized in Gut 2015;64:1248-56) and each method uses different inclusion criteria and denominators. The question posed above yields “rates” that would terrify patients (4%-10%) without a detailed explanation (it took me about an hour of focused attention to finally understand this methodology). In essence, if we could, a priori, identify and examine only patients who have a prevalent cancer or near cancer, how close can we come to 100% accuracy with a colonoscopy? Turns out, that rate is somewhere between 90% and 96% and really hasn’t changed over time. Thus, these studies speak to the impact of our efforts around colonoscopy quality.
John I. Allen MD, MBA, AGAF, professor of medicine, department of gastroenterology and hepatology, University of Michigan, Ann Arbor, and Editor in Chief of GI & Hepatology News.
Postcolonoscopy colorectal cancers (PCCRCs) are those cancers that occur between 6 and 36 months after a complete colonoscopy. For cancers diagnosed less than 6 months from exam, it is presumed that the exam itself was diagnostic. Most of these cancers grow from cancers or near cancers missed or incompletely resected during the baseline colonoscopy. Clinical researchers have published extensively about reasons for missed lesions and we know that age, female sex, and proximal location of cancers increase rates of PCCRC. GI societies worldwide have developed training initiatives, performance metrics (adenoma detection rate or ADR, withdrawal time, and prep quality documentation), and postcolonoscopy guidelines, all intended to mitigate risk of PCCRCs. It would be nice to know whether such efforts have made a difference.
Murthy and colleagues studied PCCRC rates in Ottawa, Canada during three different time periods to determine whether quality and educational efforts impacted PCCRC rates. More than 99% of this population has health care covered under a single public payer system where all encounters are carefully tracked. Using population-level health data derived from over 1 million people (screen eligible people, 50-74 years of age with low to moderate CRC risk) they identified cancers diagnosed within 36 months of a colonoscopy and compared three 5-year periods (1996-2001, 2001-2006, and 2006-2010).
Their method of calculating PCCRC rates essentially says, “If I am destined to develop CRC in the next 3 years, what is my chance of a false-negative colonoscopy?” There are five published methods of calculating PCCRC rates (summarized in Gut 2015;64:1248-56) and each method uses different inclusion criteria and denominators. The question posed above yields “rates” that would terrify patients (4%-10%) without a detailed explanation (it took me about an hour of focused attention to finally understand this methodology). In essence, if we could, a priori, identify and examine only patients who have a prevalent cancer or near cancer, how close can we come to 100% accuracy with a colonoscopy? Turns out, that rate is somewhere between 90% and 96% and really hasn’t changed over time. Thus, these studies speak to the impact of our efforts around colonoscopy quality.
John I. Allen MD, MBA, AGAF, professor of medicine, department of gastroenterology and hepatology, University of Michigan, Ann Arbor, and Editor in Chief of GI & Hepatology News.
Postcolonoscopy colorectal cancers (PCCRCs) are those cancers that occur between 6 and 36 months after a complete colonoscopy. For cancers diagnosed less than 6 months from exam, it is presumed that the exam itself was diagnostic. Most of these cancers grow from cancers or near cancers missed or incompletely resected during the baseline colonoscopy. Clinical researchers have published extensively about reasons for missed lesions and we know that age, female sex, and proximal location of cancers increase rates of PCCRC. GI societies worldwide have developed training initiatives, performance metrics (adenoma detection rate or ADR, withdrawal time, and prep quality documentation), and postcolonoscopy guidelines, all intended to mitigate risk of PCCRCs. It would be nice to know whether such efforts have made a difference.
Murthy and colleagues studied PCCRC rates in Ottawa, Canada during three different time periods to determine whether quality and educational efforts impacted PCCRC rates. More than 99% of this population has health care covered under a single public payer system where all encounters are carefully tracked. Using population-level health data derived from over 1 million people (screen eligible people, 50-74 years of age with low to moderate CRC risk) they identified cancers diagnosed within 36 months of a colonoscopy and compared three 5-year periods (1996-2001, 2001-2006, and 2006-2010).
Their method of calculating PCCRC rates essentially says, “If I am destined to develop CRC in the next 3 years, what is my chance of a false-negative colonoscopy?” There are five published methods of calculating PCCRC rates (summarized in Gut 2015;64:1248-56) and each method uses different inclusion criteria and denominators. The question posed above yields “rates” that would terrify patients (4%-10%) without a detailed explanation (it took me about an hour of focused attention to finally understand this methodology). In essence, if we could, a priori, identify and examine only patients who have a prevalent cancer or near cancer, how close can we come to 100% accuracy with a colonoscopy? Turns out, that rate is somewhere between 90% and 96% and really hasn’t changed over time. Thus, these studies speak to the impact of our efforts around colonoscopy quality.
John I. Allen MD, MBA, AGAF, professor of medicine, department of gastroenterology and hepatology, University of Michigan, Ann Arbor, and Editor in Chief of GI & Hepatology News.
The number of colorectal cancers diagnosed after a colonoscopy remained consistent at approximately 8% over a 15-year period despite the introduction of quality improvement measures, according to data from a population-based cohort study of more than 1 million individuals in Canada.
“It is believed that the majority of PCCRCs [postcolonoscopy colorectal cancers] arise due to cancers or near cancers that were either missed or incompletely treated during colonoscopy,” wrote Sanjay K. Murthy, MD, of the University of Ottawa, and colleagues.
Established quality improvement measures included adenoma detection rate, cecal intubation rate, colonoscopy withdrawal time, and endoscopy training standards, but how well the measures have been implemented remains uncertain, the researchers said. In a study published in Gastrointestinal Endoscopy (2018 Jan 6. doi: 10.1016/j.gie.2017.12.027), the researchers assessed data from 1,093,658 eligible adults aged 50-74 years over a 15-year period. The time period was divided into three sections: July 1, 1996, to June 30, 2001; July 1, 2001, to June 30, 2006; and July 1, 2006, to Dec. 31, 2010.
Overall, the number of colonoscopy procedures increased during the study period, from 305 per 10,000 people in 1996-1997 to 870 per 10,000 people in 2010-2011, and the percentage of individuals who underwent complete colonoscopies increased from 67% in the 1996-2001 period to 88% in the 2006-2010 period. “There was a considerable increase in the proportion of colonoscopies performed in younger age groups and community clinics in successive study periods,” the researchers noted.
Comparing the 2006-2010 and 1996-2001 time periods yielded adjusted odds of PCCRC, distal PCCRC, and proximal PCCRC of 1.14, 1.11, and 1.14, respectively; the trends were not affected by endoscopist specialty or institutional setting.
“Our findings are concerning for lack of improvement in colonoscopy practice quality in Ontario, particularly in the wake of greater emphasis having been placed on colonoscopy quality metrics during the study period,” the researchers said. The findings contrast with the decline in PCCRC rates in the United Kingdom reported in a previous study of a similar time period, they noted.
The study findings were limited by several factors, including possible patient and outcome misclassification, an unvalidated definition for PCCRC, and unmeasured confounders such as changes in practice or changes in the definition of PCCRC. Although more research is needed in other jurisdictions to confirm, the results “call for increased population-based practice audit as well as endoscopy educational programs and certification requirements.”
The study was supported by a research grant to Dr. Murthy from the University of Ottawa. The researchers had no financial conflicts to disclose.
SOURCE: Murthy S et al. Gastrointest Endosc. 2018 Jan 6. doi: 10.1016/j.gie.2017.12.027
The number of colorectal cancers diagnosed after a colonoscopy remained consistent at approximately 8% over a 15-year period despite the introduction of quality improvement measures, according to data from a population-based cohort study of more than 1 million individuals in Canada.
“It is believed that the majority of PCCRCs [postcolonoscopy colorectal cancers] arise due to cancers or near cancers that were either missed or incompletely treated during colonoscopy,” wrote Sanjay K. Murthy, MD, of the University of Ottawa, and colleagues.
Established quality improvement measures included adenoma detection rate, cecal intubation rate, colonoscopy withdrawal time, and endoscopy training standards, but how well the measures have been implemented remains uncertain, the researchers said. In a study published in Gastrointestinal Endoscopy (2018 Jan 6. doi: 10.1016/j.gie.2017.12.027), the researchers assessed data from 1,093,658 eligible adults aged 50-74 years over a 15-year period. The time period was divided into three sections: July 1, 1996, to June 30, 2001; July 1, 2001, to June 30, 2006; and July 1, 2006, to Dec. 31, 2010.
Overall, the number of colonoscopy procedures increased during the study period, from 305 per 10,000 people in 1996-1997 to 870 per 10,000 people in 2010-2011, and the percentage of individuals who underwent complete colonoscopies increased from 67% in the 1996-2001 period to 88% in the 2006-2010 period. “There was a considerable increase in the proportion of colonoscopies performed in younger age groups and community clinics in successive study periods,” the researchers noted.
Comparing the 2006-2010 and 1996-2001 time periods yielded adjusted odds of PCCRC, distal PCCRC, and proximal PCCRC of 1.14, 1.11, and 1.14, respectively; the trends were not affected by endoscopist specialty or institutional setting.
“Our findings are concerning for lack of improvement in colonoscopy practice quality in Ontario, particularly in the wake of greater emphasis having been placed on colonoscopy quality metrics during the study period,” the researchers said. The findings contrast with the decline in PCCRC rates in the United Kingdom reported in a previous study of a similar time period, they noted.
The study findings were limited by several factors, including possible patient and outcome misclassification, an unvalidated definition for PCCRC, and unmeasured confounders such as changes in practice or changes in the definition of PCCRC. Although more research is needed in other jurisdictions to confirm, the results “call for increased population-based practice audit as well as endoscopy educational programs and certification requirements.”
The study was supported by a research grant to Dr. Murthy from the University of Ottawa. The researchers had no financial conflicts to disclose.
SOURCE: Murthy S et al. Gastrointest Endosc. 2018 Jan 6. doi: 10.1016/j.gie.2017.12.027
FROM GASTROINTESTINAL ENDOSCOPY
Key clinical point: Rates of postcolonoscopy colorectal cancer have not declined despite the introduction of quality improvement measures.
Major finding: The rate of colorectal cancers diagnosed after a colonoscopy has remained at approximately 8% over the past 15 years.
Study details: A population-based retrospective cohort study of Canadian adults aged 50-74 years without risk factors for CRC.
Disclosures: The researchers had no financial conflicts to disclose.
Source: Murthy S et al. Gastrointest Endosc. 2018 Jan 6. doi: 10.1016/j.gie.2017.12.027.
Multidisciplinary care improves surgical outcomes for elderly patients
and were able to leave the hospital after a shorter stay, according to findings from a case-control study of nearly 400 patients.
Data from previous studies suggest that preoperative assessment by geriatric experts can improve outcomes for the elderly, who are more likely than are younger patients to develop preventable postoperative complications, and “this evidence supports the formulation of a different approach to preoperative assessment and postoperative care for this population,” wrote Shelley R. McDonald, DO, of Duke University, Durham, N.C., and colleagues.
The intervention, known as the Perioperative Optimization of Senior Health (POSH), was described as “a quality improvement initiative with prospective data collection.” Patients in a geriatrics clinic within an academic center were selected for the study if they were at high risk for complications linked to elective abdominal surgery. High risk was defined as older than 85 years of age, or older than 65 years of age with conditions including cognitive impairment, recent weight loss, multiple comorbidities, and polypharmacy (JAMA Surg. 2018 Jan 3. doi: 10.1001/jamasurg.2017.5513).
The POSH intervention patients received preoperative evaluation from a team including a geriatrician, geriatric resource nurse, social worker, program administrator, and nurse practitioner from the preoperative anesthesia testing clinic. Patients and families were advised on risk management and care optimization involving cognition, comorbidities, medications, mobility, functional status, nutrition, hydration, pain, and advanced care planning.
Patients in the POSH group were on average older, had more comorbidities, and were more likely to be smokers. But despite these disadvantaging characteristics, they still had better outcomes in several important variables than did those in the control group.
The POSH group had significantly shorter hospital stays, compared with controls (4 days vs. 6 days), and significantly lower all-cause readmission rates at both 7 days (2.8% vs. 9.9%) and 30 days (7.8% vs. 18.3%). The significance persisted whether the surgeries were laparoscopic or open.
The overall complication rate was lower in the POSH group, compared with the controls, but fell short of statistical significance (44.8% vs. 58.7%, P = .01). However, rates of specific complications were significantly lower in the POSH group, compared with controls, including postoperative cardiogenic or hypovolemic shock (2.2% vs. 8.4%), bleeding, either during or after surgery (6.1% vs. 15.4%), and postoperative ileus (4.9% vs. 20.3%).
“Delirium was identified in POSH patients at higher rates than in the control group, which is not unexpected because higher postoperative delirium rates are known to be identified with increased screening,” the researchers noted. “Collaborative care allows for increasing the recognition of geriatric syndromes like delirium, more focus on symptom management, and proactively anticipating complications,” they said.
The study results were limited by several factors including a long enrollment period for the POSH patients, and potential changes in surgical protocols, the researchers said. However, the findings support the need for further research and more refined analysis to identify the most beneficial aspects of care, and to support better clinical decision making about the timing of interventions and the type of patient who could benefit, they noted.
The researchers had no financial conflicts to disclose. The John A. Hartford Foundation Center of Excellence National Program Award provided salary and database support.
SOURCE: McDonald S et al. JAMA Surg. 2018 Jan 3. doi: 10.1001/jamasurg.2017.5513.
and were able to leave the hospital after a shorter stay, according to findings from a case-control study of nearly 400 patients.
Data from previous studies suggest that preoperative assessment by geriatric experts can improve outcomes for the elderly, who are more likely than are younger patients to develop preventable postoperative complications, and “this evidence supports the formulation of a different approach to preoperative assessment and postoperative care for this population,” wrote Shelley R. McDonald, DO, of Duke University, Durham, N.C., and colleagues.
The intervention, known as the Perioperative Optimization of Senior Health (POSH), was described as “a quality improvement initiative with prospective data collection.” Patients in a geriatrics clinic within an academic center were selected for the study if they were at high risk for complications linked to elective abdominal surgery. High risk was defined as older than 85 years of age, or older than 65 years of age with conditions including cognitive impairment, recent weight loss, multiple comorbidities, and polypharmacy (JAMA Surg. 2018 Jan 3. doi: 10.1001/jamasurg.2017.5513).
The POSH intervention patients received preoperative evaluation from a team including a geriatrician, geriatric resource nurse, social worker, program administrator, and nurse practitioner from the preoperative anesthesia testing clinic. Patients and families were advised on risk management and care optimization involving cognition, comorbidities, medications, mobility, functional status, nutrition, hydration, pain, and advanced care planning.
Patients in the POSH group were on average older, had more comorbidities, and were more likely to be smokers. But despite these disadvantaging characteristics, they still had better outcomes in several important variables than did those in the control group.
The POSH group had significantly shorter hospital stays, compared with controls (4 days vs. 6 days), and significantly lower all-cause readmission rates at both 7 days (2.8% vs. 9.9%) and 30 days (7.8% vs. 18.3%). The significance persisted whether the surgeries were laparoscopic or open.
The overall complication rate was lower in the POSH group, compared with the controls, but fell short of statistical significance (44.8% vs. 58.7%, P = .01). However, rates of specific complications were significantly lower in the POSH group, compared with controls, including postoperative cardiogenic or hypovolemic shock (2.2% vs. 8.4%), bleeding, either during or after surgery (6.1% vs. 15.4%), and postoperative ileus (4.9% vs. 20.3%).
“Delirium was identified in POSH patients at higher rates than in the control group, which is not unexpected because higher postoperative delirium rates are known to be identified with increased screening,” the researchers noted. “Collaborative care allows for increasing the recognition of geriatric syndromes like delirium, more focus on symptom management, and proactively anticipating complications,” they said.
The study results were limited by several factors including a long enrollment period for the POSH patients, and potential changes in surgical protocols, the researchers said. However, the findings support the need for further research and more refined analysis to identify the most beneficial aspects of care, and to support better clinical decision making about the timing of interventions and the type of patient who could benefit, they noted.
The researchers had no financial conflicts to disclose. The John A. Hartford Foundation Center of Excellence National Program Award provided salary and database support.
SOURCE: McDonald S et al. JAMA Surg. 2018 Jan 3. doi: 10.1001/jamasurg.2017.5513.
and were able to leave the hospital after a shorter stay, according to findings from a case-control study of nearly 400 patients.
Data from previous studies suggest that preoperative assessment by geriatric experts can improve outcomes for the elderly, who are more likely than are younger patients to develop preventable postoperative complications, and “this evidence supports the formulation of a different approach to preoperative assessment and postoperative care for this population,” wrote Shelley R. McDonald, DO, of Duke University, Durham, N.C., and colleagues.
The intervention, known as the Perioperative Optimization of Senior Health (POSH), was described as “a quality improvement initiative with prospective data collection.” Patients in a geriatrics clinic within an academic center were selected for the study if they were at high risk for complications linked to elective abdominal surgery. High risk was defined as older than 85 years of age, or older than 65 years of age with conditions including cognitive impairment, recent weight loss, multiple comorbidities, and polypharmacy (JAMA Surg. 2018 Jan 3. doi: 10.1001/jamasurg.2017.5513).
The POSH intervention patients received preoperative evaluation from a team including a geriatrician, geriatric resource nurse, social worker, program administrator, and nurse practitioner from the preoperative anesthesia testing clinic. Patients and families were advised on risk management and care optimization involving cognition, comorbidities, medications, mobility, functional status, nutrition, hydration, pain, and advanced care planning.
Patients in the POSH group were on average older, had more comorbidities, and were more likely to be smokers. But despite these disadvantaging characteristics, they still had better outcomes in several important variables than did those in the control group.
The POSH group had significantly shorter hospital stays, compared with controls (4 days vs. 6 days), and significantly lower all-cause readmission rates at both 7 days (2.8% vs. 9.9%) and 30 days (7.8% vs. 18.3%). The significance persisted whether the surgeries were laparoscopic or open.
The overall complication rate was lower in the POSH group, compared with the controls, but fell short of statistical significance (44.8% vs. 58.7%, P = .01). However, rates of specific complications were significantly lower in the POSH group, compared with controls, including postoperative cardiogenic or hypovolemic shock (2.2% vs. 8.4%), bleeding, either during or after surgery (6.1% vs. 15.4%), and postoperative ileus (4.9% vs. 20.3%).
“Delirium was identified in POSH patients at higher rates than in the control group, which is not unexpected because higher postoperative delirium rates are known to be identified with increased screening,” the researchers noted. “Collaborative care allows for increasing the recognition of geriatric syndromes like delirium, more focus on symptom management, and proactively anticipating complications,” they said.
The study results were limited by several factors including a long enrollment period for the POSH patients, and potential changes in surgical protocols, the researchers said. However, the findings support the need for further research and more refined analysis to identify the most beneficial aspects of care, and to support better clinical decision making about the timing of interventions and the type of patient who could benefit, they noted.
The researchers had no financial conflicts to disclose. The John A. Hartford Foundation Center of Excellence National Program Award provided salary and database support.
SOURCE: McDonald S et al. JAMA Surg. 2018 Jan 3. doi: 10.1001/jamasurg.2017.5513.
FROM JAMA SURGERY
Key clinical point: A preoperative surgical intervention improved outcomes and shortened hospital stays for seniors.
Major finding: The POSH group had significantly shorter hospital stays compared with controls (4 days vs. 6 days).
Study details: The data come from a study of 183 surgery patients and 143 controls.
Disclosures: The researchers had no financial conflicts to disclose.
Source: McDonald S JAMA Surg. 2018 Jan 3. doi: 10.1001/jamasurg.2017.5513
Comparing arterial ratios may aid risk assessment in IPF
An arterial ratio can help identify idiopathic pulmonary fibrosis (IPF) patients with a poor prognosis, suggests the findings of registry data from 50 adults.
The ratio of the main pulmonary artery diameter (PA) to the ascending aorta diameter (A) as seen on a chest CT correlates with pulmonary artery pressure, M. Faisal Siddiqui, MD, a pulmonologist in New York, and his colleagues wrote in an abstract from the agenda of the CHEST annual meeting. To determine whether higher PA:A ratios were associated with more biomarker abnormalities, the researchers reviewed 122 CT scans from 50 adults with IPF.
Overall, 48% of the patients had a PA:A ratio of at least 1, according to Dr. Siddiqui and his coauthors. These patients had significantly higher fibrosis scores (P = .0006), GAP index scores (P = .0144), brain natriuretic peptide scores (P = .0046), and pulmonary arterial systolic pressure (P = .0063) compared with patients who had PA:A ratios of less than 1, according to the Kruskal-Wallis test. This test also showed no significant differences on measures of coronary artery calcium, aortic value calcifications, mitral valve calcifications, bronchial wall thickening, emphysema, and spirometry data between the two patient groups, based on PA:A ratios.
Use of the Pearson correlation revealed a positive relationship between PA:A ratios greater than 1 and coronary artery calcium scores, fibrosis scores, and pulmonary arterial systolic pressure, but a negative relationship between a high PA:A ratio and both diffusing capacity and forced vital capacity.
Although the findings were limited by a small study population, the results suggest that clinicians can use the finding of an increased PA:A ratio to help identify IPF patients at greater risk for poor outcomes. Such patients might benefit from pharmacotherapy or transplants, the researchers noted.
Dr. Siddiqui and his coauthors had no financial conflicts to disclose.
An arterial ratio can help identify idiopathic pulmonary fibrosis (IPF) patients with a poor prognosis, suggests the findings of registry data from 50 adults.
The ratio of the main pulmonary artery diameter (PA) to the ascending aorta diameter (A) as seen on a chest CT correlates with pulmonary artery pressure, M. Faisal Siddiqui, MD, a pulmonologist in New York, and his colleagues wrote in an abstract from the agenda of the CHEST annual meeting. To determine whether higher PA:A ratios were associated with more biomarker abnormalities, the researchers reviewed 122 CT scans from 50 adults with IPF.
Overall, 48% of the patients had a PA:A ratio of at least 1, according to Dr. Siddiqui and his coauthors. These patients had significantly higher fibrosis scores (P = .0006), GAP index scores (P = .0144), brain natriuretic peptide scores (P = .0046), and pulmonary arterial systolic pressure (P = .0063) compared with patients who had PA:A ratios of less than 1, according to the Kruskal-Wallis test. This test also showed no significant differences on measures of coronary artery calcium, aortic value calcifications, mitral valve calcifications, bronchial wall thickening, emphysema, and spirometry data between the two patient groups, based on PA:A ratios.
Use of the Pearson correlation revealed a positive relationship between PA:A ratios greater than 1 and coronary artery calcium scores, fibrosis scores, and pulmonary arterial systolic pressure, but a negative relationship between a high PA:A ratio and both diffusing capacity and forced vital capacity.
Although the findings were limited by a small study population, the results suggest that clinicians can use the finding of an increased PA:A ratio to help identify IPF patients at greater risk for poor outcomes. Such patients might benefit from pharmacotherapy or transplants, the researchers noted.
Dr. Siddiqui and his coauthors had no financial conflicts to disclose.
An arterial ratio can help identify idiopathic pulmonary fibrosis (IPF) patients with a poor prognosis, suggests the findings of registry data from 50 adults.
The ratio of the main pulmonary artery diameter (PA) to the ascending aorta diameter (A) as seen on a chest CT correlates with pulmonary artery pressure, M. Faisal Siddiqui, MD, a pulmonologist in New York, and his colleagues wrote in an abstract from the agenda of the CHEST annual meeting. To determine whether higher PA:A ratios were associated with more biomarker abnormalities, the researchers reviewed 122 CT scans from 50 adults with IPF.
Overall, 48% of the patients had a PA:A ratio of at least 1, according to Dr. Siddiqui and his coauthors. These patients had significantly higher fibrosis scores (P = .0006), GAP index scores (P = .0144), brain natriuretic peptide scores (P = .0046), and pulmonary arterial systolic pressure (P = .0063) compared with patients who had PA:A ratios of less than 1, according to the Kruskal-Wallis test. This test also showed no significant differences on measures of coronary artery calcium, aortic value calcifications, mitral valve calcifications, bronchial wall thickening, emphysema, and spirometry data between the two patient groups, based on PA:A ratios.
Use of the Pearson correlation revealed a positive relationship between PA:A ratios greater than 1 and coronary artery calcium scores, fibrosis scores, and pulmonary arterial systolic pressure, but a negative relationship between a high PA:A ratio and both diffusing capacity and forced vital capacity.
Although the findings were limited by a small study population, the results suggest that clinicians can use the finding of an increased PA:A ratio to help identify IPF patients at greater risk for poor outcomes. Such patients might benefit from pharmacotherapy or transplants, the researchers noted.
Dr. Siddiqui and his coauthors had no financial conflicts to disclose.
FROM CHEST 2017
Shorter walk test predicts IPF outcomes
, based on data from 179 adults. The findings were presented at the CHEST annual meeting.
The 6-minute test is often used to evaluate functional capacity in IPF patients, but is not always practical in a busy clinic setting, according to Flavia S. Nunes, MD, of Inova Fairfax Hospital in Falls Church, VA, and colleagues.
“Among the clinical and physiologic predictors associated with survival in IPF, the 6MWT has been increasingly used over the past 5 years as a secondary endpoint in the efficacy analyses of potential therapies for IPF. Validation of shorter time of walking might make the test more feasible to be applied in routine clinical care,” she said.
To determine the predictive value of the first minute of the 6-minute test, the researchers reviewed data from 142 men and 37 women at a tertiary referral center between May 2010 and February 2017. The average age of the patients was 68 years, the average body mass index was 28.3 kg/m2, and 27% used oxygen supplementation during the walk test.
Overall, the mean distance for the 6-minute test was 372 m, and the average distance for the 1-minute test was 65 m. Study participants who achieved a 6-minute walk distance greater than 372 m were defined as high walkers, and those with a 6-minute walk distance less than 372 m were defined as low walkers. A strong correlation appeared between the 6-minute distance and 1-minute distance in terms of predicting survival, and 1-year transplant-free survival was significantly better in high walkers than in low walkers (27 months vs. 22 months; P = .015).
Dr. Nunes said she was not surprised by the results, in part because previous research has shown a strong correlation among 2-minute, 6-minute, and 12-minute walking tests.
Although more research is needed to validate the findings, the results suggest that the 1-minute test might be a practical substitute for the 6-minute test by providing similar prognostic information more quickly and easily than the 6-minute test, the researchers said.
“It is important for clinicians to know that the time chosen to assess exercise tolerance by walking tests might not be critical,” said Dr. Nunes. “Shorter walks are not only less time consuming, and easier for both patients and clinicians, but are also reproducible and discriminatory of survival.
“We need to validate the test performance characteristics and prognostic value of distance walked in a 1MWT compared to the standard 6MWT in an independent cohort of patients with IPF,” Dr. Nunes noted. “Additionally, the evaluation of alternate instruction, for example changing the wording from ‘walk as far’ to ‘walk as fast’ might facilitate a better effort, and a greater distance with improved reproducibility. Other novel parameters and modifications to the 6MWT or 1MWT might further improve the utility of these tests in the management of IPF and other patients,” she added.
The researchers had no financial conflicts to disclose.
, based on data from 179 adults. The findings were presented at the CHEST annual meeting.
The 6-minute test is often used to evaluate functional capacity in IPF patients, but is not always practical in a busy clinic setting, according to Flavia S. Nunes, MD, of Inova Fairfax Hospital in Falls Church, VA, and colleagues.
“Among the clinical and physiologic predictors associated with survival in IPF, the 6MWT has been increasingly used over the past 5 years as a secondary endpoint in the efficacy analyses of potential therapies for IPF. Validation of shorter time of walking might make the test more feasible to be applied in routine clinical care,” she said.
To determine the predictive value of the first minute of the 6-minute test, the researchers reviewed data from 142 men and 37 women at a tertiary referral center between May 2010 and February 2017. The average age of the patients was 68 years, the average body mass index was 28.3 kg/m2, and 27% used oxygen supplementation during the walk test.
Overall, the mean distance for the 6-minute test was 372 m, and the average distance for the 1-minute test was 65 m. Study participants who achieved a 6-minute walk distance greater than 372 m were defined as high walkers, and those with a 6-minute walk distance less than 372 m were defined as low walkers. A strong correlation appeared between the 6-minute distance and 1-minute distance in terms of predicting survival, and 1-year transplant-free survival was significantly better in high walkers than in low walkers (27 months vs. 22 months; P = .015).
Dr. Nunes said she was not surprised by the results, in part because previous research has shown a strong correlation among 2-minute, 6-minute, and 12-minute walking tests.
Although more research is needed to validate the findings, the results suggest that the 1-minute test might be a practical substitute for the 6-minute test by providing similar prognostic information more quickly and easily than the 6-minute test, the researchers said.
“It is important for clinicians to know that the time chosen to assess exercise tolerance by walking tests might not be critical,” said Dr. Nunes. “Shorter walks are not only less time consuming, and easier for both patients and clinicians, but are also reproducible and discriminatory of survival.
“We need to validate the test performance characteristics and prognostic value of distance walked in a 1MWT compared to the standard 6MWT in an independent cohort of patients with IPF,” Dr. Nunes noted. “Additionally, the evaluation of alternate instruction, for example changing the wording from ‘walk as far’ to ‘walk as fast’ might facilitate a better effort, and a greater distance with improved reproducibility. Other novel parameters and modifications to the 6MWT or 1MWT might further improve the utility of these tests in the management of IPF and other patients,” she added.
The researchers had no financial conflicts to disclose.
, based on data from 179 adults. The findings were presented at the CHEST annual meeting.
The 6-minute test is often used to evaluate functional capacity in IPF patients, but is not always practical in a busy clinic setting, according to Flavia S. Nunes, MD, of Inova Fairfax Hospital in Falls Church, VA, and colleagues.
“Among the clinical and physiologic predictors associated with survival in IPF, the 6MWT has been increasingly used over the past 5 years as a secondary endpoint in the efficacy analyses of potential therapies for IPF. Validation of shorter time of walking might make the test more feasible to be applied in routine clinical care,” she said.
To determine the predictive value of the first minute of the 6-minute test, the researchers reviewed data from 142 men and 37 women at a tertiary referral center between May 2010 and February 2017. The average age of the patients was 68 years, the average body mass index was 28.3 kg/m2, and 27% used oxygen supplementation during the walk test.
Overall, the mean distance for the 6-minute test was 372 m, and the average distance for the 1-minute test was 65 m. Study participants who achieved a 6-minute walk distance greater than 372 m were defined as high walkers, and those with a 6-minute walk distance less than 372 m were defined as low walkers. A strong correlation appeared between the 6-minute distance and 1-minute distance in terms of predicting survival, and 1-year transplant-free survival was significantly better in high walkers than in low walkers (27 months vs. 22 months; P = .015).
Dr. Nunes said she was not surprised by the results, in part because previous research has shown a strong correlation among 2-minute, 6-minute, and 12-minute walking tests.
Although more research is needed to validate the findings, the results suggest that the 1-minute test might be a practical substitute for the 6-minute test by providing similar prognostic information more quickly and easily than the 6-minute test, the researchers said.
“It is important for clinicians to know that the time chosen to assess exercise tolerance by walking tests might not be critical,” said Dr. Nunes. “Shorter walks are not only less time consuming, and easier for both patients and clinicians, but are also reproducible and discriminatory of survival.
“We need to validate the test performance characteristics and prognostic value of distance walked in a 1MWT compared to the standard 6MWT in an independent cohort of patients with IPF,” Dr. Nunes noted. “Additionally, the evaluation of alternate instruction, for example changing the wording from ‘walk as far’ to ‘walk as fast’ might facilitate a better effort, and a greater distance with improved reproducibility. Other novel parameters and modifications to the 6MWT or 1MWT might further improve the utility of these tests in the management of IPF and other patients,” she added.
The researchers had no financial conflicts to disclose.
FROM CHEST 2017
Cesarean delivery reduces some risks, raises others
Cesarean deliveries may reduce a woman’s risk for urinary incontinence and pelvic organ prolapse but may raise her risk of complications with future pregnancies, based on data from a literature review including nearly 30,000,000 women.
Rates of cesarean delivery in 2016, often without medical indication, were approximately 25%, 32%, and 41% in Western Europe, North America, and South America, respectively, wrote Oonagh E. Keag, MD, of the Royal Infirmary of Edinburgh and colleagues in a study published in PLOS Medicine.
The researchers reviewed data from 79 observational studies and 1 randomized, controlled trial for a study population of 29,928,274 individuals.
Overall, women who had cesarean deliveries had a significantly lower risk of urinary incontinence (odds ratio, 0.56) and pelvic organ prolapse (OR, 0.29), compared with women who had vaginal deliveries.
No significant association appeared between type of delivery and risk of perinatal death, but women with a history of cesarean delivery were significantly more likely to experience miscarriage or stillbirth on a subsequent pregnancy, as well as placenta previa, placenta accreta, and placental abruption.
In addition, children born via cesarean delivery were significantly more likely than those born via vaginal delivery to have asthma at age 12 years (OR, 1.21) and to be obese up to age 5 years (OR, 1.59).
The findings were limited by the observational nature of most of the data, which does not imply causation, the researchers said. In addition, the study was not designed for subanalysis of elective vs. emergency cesarean delivery.
Although women will attach varying degrees of significance to the risks and benefits associated with cesarean delivery, “it is imperative that clinicians take care to ensure that women are made aware of any risk that they are likely to attach significance to,” the researchers said. “Women and clinicians thus should be aware of both the short- and long-term risks and benefits of cesarean delivery and discuss these when deciding on mode of delivery,” they noted.
The researchers had no financial conflicts to disclose.
SOURCE: Keag OE et al. PLoS Med. 2018 Jan 23. 15(1):e1002494.
As health care practitioners, ob.gyns. must continually evaluate potential consequences of a management strategy to our patients’ health and well-being. This is especially true when determining the best method of delivery – vaginal or cesarean section – because our approach can affect not only the mother but also the baby.
It is well known that vaginal deliveries can be associated with long-term complications for women, including pelvic floor disorders (that is, prolapse), pelvic injury, and incontinence. For women who have undergone a cesarean section, the uterine scars caused by the surgery can lead to increased risk for placenta previa or, more seriously, placenta accreta, as well as possible miscarriage or stillbirth.
Because the best possible care must also be informed care, every ob.gyn. should conduct periodic reviews of the scientific literature. Research continually advances our knowledge and our practice. For example, the recent work on the use of statins to prevent preeclampsia is an area of intense interest. Although we’ve known about hypertensive disorders of pregnancy for many years, management and prevention strategies are adequate at best. This new and exciting line of research has the potential to solve a conundrum we’ve grappled with for centuries.
The study by Keag et al. analyzes the findings from observational studies on the risks and benefits of cesarean versus vaginal delivery, within certain limitations. The study authors found that cesarean deliveries are associated with lower risk of urinary incontinence and pelvic prolapse, but higher risk of placenta previa, miscarriage, and stillbirth. Additionally, the authors reported that babies delivered by cesarean section had a higher risk of developing asthma and obesity.
Although the results of the study are not surprising, the findings reinforce the idea that ob.gyns must make decisions on a case-by-case basis and on obstetrical indications. We cannot use a set of possible complications as a reason to choose one delivery route over another. Every patient is unique. Every circumstance is unique. Every delivery requires us to make an informed decision to achieve the best possible outcome. Otherwise, we run the great risk of doing a disservice to our patients and their families.
E. Albert Reece, MD , PhD, MBA, specializes in maternal-fetal medicine and is vice president for medical affairs at the University of Maryland, Baltimore, as well as the John Z. and Akiko K. Bowers Distinguished Professor and dean of the school of medicine. He has no relevant financial disclosures.
As health care practitioners, ob.gyns. must continually evaluate potential consequences of a management strategy to our patients’ health and well-being. This is especially true when determining the best method of delivery – vaginal or cesarean section – because our approach can affect not only the mother but also the baby.
It is well known that vaginal deliveries can be associated with long-term complications for women, including pelvic floor disorders (that is, prolapse), pelvic injury, and incontinence. For women who have undergone a cesarean section, the uterine scars caused by the surgery can lead to increased risk for placenta previa or, more seriously, placenta accreta, as well as possible miscarriage or stillbirth.
Because the best possible care must also be informed care, every ob.gyn. should conduct periodic reviews of the scientific literature. Research continually advances our knowledge and our practice. For example, the recent work on the use of statins to prevent preeclampsia is an area of intense interest. Although we’ve known about hypertensive disorders of pregnancy for many years, management and prevention strategies are adequate at best. This new and exciting line of research has the potential to solve a conundrum we’ve grappled with for centuries.
The study by Keag et al. analyzes the findings from observational studies on the risks and benefits of cesarean versus vaginal delivery, within certain limitations. The study authors found that cesarean deliveries are associated with lower risk of urinary incontinence and pelvic prolapse, but higher risk of placenta previa, miscarriage, and stillbirth. Additionally, the authors reported that babies delivered by cesarean section had a higher risk of developing asthma and obesity.
Although the results of the study are not surprising, the findings reinforce the idea that ob.gyns must make decisions on a case-by-case basis and on obstetrical indications. We cannot use a set of possible complications as a reason to choose one delivery route over another. Every patient is unique. Every circumstance is unique. Every delivery requires us to make an informed decision to achieve the best possible outcome. Otherwise, we run the great risk of doing a disservice to our patients and their families.
E. Albert Reece, MD , PhD, MBA, specializes in maternal-fetal medicine and is vice president for medical affairs at the University of Maryland, Baltimore, as well as the John Z. and Akiko K. Bowers Distinguished Professor and dean of the school of medicine. He has no relevant financial disclosures.
As health care practitioners, ob.gyns. must continually evaluate potential consequences of a management strategy to our patients’ health and well-being. This is especially true when determining the best method of delivery – vaginal or cesarean section – because our approach can affect not only the mother but also the baby.
It is well known that vaginal deliveries can be associated with long-term complications for women, including pelvic floor disorders (that is, prolapse), pelvic injury, and incontinence. For women who have undergone a cesarean section, the uterine scars caused by the surgery can lead to increased risk for placenta previa or, more seriously, placenta accreta, as well as possible miscarriage or stillbirth.
Because the best possible care must also be informed care, every ob.gyn. should conduct periodic reviews of the scientific literature. Research continually advances our knowledge and our practice. For example, the recent work on the use of statins to prevent preeclampsia is an area of intense interest. Although we’ve known about hypertensive disorders of pregnancy for many years, management and prevention strategies are adequate at best. This new and exciting line of research has the potential to solve a conundrum we’ve grappled with for centuries.
The study by Keag et al. analyzes the findings from observational studies on the risks and benefits of cesarean versus vaginal delivery, within certain limitations. The study authors found that cesarean deliveries are associated with lower risk of urinary incontinence and pelvic prolapse, but higher risk of placenta previa, miscarriage, and stillbirth. Additionally, the authors reported that babies delivered by cesarean section had a higher risk of developing asthma and obesity.
Although the results of the study are not surprising, the findings reinforce the idea that ob.gyns must make decisions on a case-by-case basis and on obstetrical indications. We cannot use a set of possible complications as a reason to choose one delivery route over another. Every patient is unique. Every circumstance is unique. Every delivery requires us to make an informed decision to achieve the best possible outcome. Otherwise, we run the great risk of doing a disservice to our patients and their families.
E. Albert Reece, MD , PhD, MBA, specializes in maternal-fetal medicine and is vice president for medical affairs at the University of Maryland, Baltimore, as well as the John Z. and Akiko K. Bowers Distinguished Professor and dean of the school of medicine. He has no relevant financial disclosures.
Cesarean deliveries may reduce a woman’s risk for urinary incontinence and pelvic organ prolapse but may raise her risk of complications with future pregnancies, based on data from a literature review including nearly 30,000,000 women.
Rates of cesarean delivery in 2016, often without medical indication, were approximately 25%, 32%, and 41% in Western Europe, North America, and South America, respectively, wrote Oonagh E. Keag, MD, of the Royal Infirmary of Edinburgh and colleagues in a study published in PLOS Medicine.
The researchers reviewed data from 79 observational studies and 1 randomized, controlled trial for a study population of 29,928,274 individuals.
Overall, women who had cesarean deliveries had a significantly lower risk of urinary incontinence (odds ratio, 0.56) and pelvic organ prolapse (OR, 0.29), compared with women who had vaginal deliveries.
No significant association appeared between type of delivery and risk of perinatal death, but women with a history of cesarean delivery were significantly more likely to experience miscarriage or stillbirth on a subsequent pregnancy, as well as placenta previa, placenta accreta, and placental abruption.
In addition, children born via cesarean delivery were significantly more likely than those born via vaginal delivery to have asthma at age 12 years (OR, 1.21) and to be obese up to age 5 years (OR, 1.59).
The findings were limited by the observational nature of most of the data, which does not imply causation, the researchers said. In addition, the study was not designed for subanalysis of elective vs. emergency cesarean delivery.
Although women will attach varying degrees of significance to the risks and benefits associated with cesarean delivery, “it is imperative that clinicians take care to ensure that women are made aware of any risk that they are likely to attach significance to,” the researchers said. “Women and clinicians thus should be aware of both the short- and long-term risks and benefits of cesarean delivery and discuss these when deciding on mode of delivery,” they noted.
The researchers had no financial conflicts to disclose.
SOURCE: Keag OE et al. PLoS Med. 2018 Jan 23. 15(1):e1002494.
Cesarean deliveries may reduce a woman’s risk for urinary incontinence and pelvic organ prolapse but may raise her risk of complications with future pregnancies, based on data from a literature review including nearly 30,000,000 women.
Rates of cesarean delivery in 2016, often without medical indication, were approximately 25%, 32%, and 41% in Western Europe, North America, and South America, respectively, wrote Oonagh E. Keag, MD, of the Royal Infirmary of Edinburgh and colleagues in a study published in PLOS Medicine.
The researchers reviewed data from 79 observational studies and 1 randomized, controlled trial for a study population of 29,928,274 individuals.
Overall, women who had cesarean deliveries had a significantly lower risk of urinary incontinence (odds ratio, 0.56) and pelvic organ prolapse (OR, 0.29), compared with women who had vaginal deliveries.
No significant association appeared between type of delivery and risk of perinatal death, but women with a history of cesarean delivery were significantly more likely to experience miscarriage or stillbirth on a subsequent pregnancy, as well as placenta previa, placenta accreta, and placental abruption.
In addition, children born via cesarean delivery were significantly more likely than those born via vaginal delivery to have asthma at age 12 years (OR, 1.21) and to be obese up to age 5 years (OR, 1.59).
The findings were limited by the observational nature of most of the data, which does not imply causation, the researchers said. In addition, the study was not designed for subanalysis of elective vs. emergency cesarean delivery.
Although women will attach varying degrees of significance to the risks and benefits associated with cesarean delivery, “it is imperative that clinicians take care to ensure that women are made aware of any risk that they are likely to attach significance to,” the researchers said. “Women and clinicians thus should be aware of both the short- and long-term risks and benefits of cesarean delivery and discuss these when deciding on mode of delivery,” they noted.
The researchers had no financial conflicts to disclose.
SOURCE: Keag OE et al. PLoS Med. 2018 Jan 23. 15(1):e1002494.
FROM PLOS MEDICINE
Key clinical point: Cesarean delivery was associated with a reduced risk for incontinence and prolapse.
Major finding: Urinary incontinence and pelvic organ prolapse were less likely after cesarean vs. vaginal deliveries (OR, 0.56 and 0.29, respectively).
Study details: The data come from a review of 80 studies.
Disclosures: The researchers had no financial conflicts to disclose.
Source: Keag OE et al. PLoS Med. 2018 Jan 23. 15(1):e1002494.
Low-dose rituximab cuts infection risk
Treating rheumatoid arthritis patients with lower doses of rituximab for long-term maintenance reduced the risk of serious infections and saved money, based on data from approximately 1,200 patients in a French registry.
In a study published in Rheumatology, Julien Henry, MD, of Institut pour la Sante et la Recherche Medicale, Paris, and colleagues reviewed data from 1,278 patients; 1,093 (85.5%) received a standard dose of rituximab, and 185 (14.5%) received a reduced dose for maintenance therapy. A standard dose was 1,000 mg per infusion given in two infusions 2 weeks apart), and a reduced dose was 500 mg per infusion given in two infusions 2 weeks apart.
After 5 years, maintenance was 55.5% in the standard group and 53.8% in the reduced group; with no significant difference (hazard ratio, 1.03). However, the cumulative dose for retreatment was 39% less in the reduced group (1.4 g per year vs. 2.3 g per year), “which is greatly cost effective,” the researchers wrote.
In addition, the rate of serious infections was significantly lower in the reduced-dose group, compared with the standard-dose group (2.2 per 100 patient-years vs. 4.1 per 100 patient-years; adjusted hazard ratio = 0.50).
“Of note, factors associated with risk of serious infection, such as baseline low gamma globulin or IgG levels, chronic lung or cardiac disease, and extra-articular involvement, did not differ between groups,” the researchers said.
The study findings were limited by several factors including the observational design and lack of data on certain RA outcome measures such as radiographic progression and function, the researchers noted. However, the results support data from similar studies and suggest that a lower dose of rituximab for retreatment of RA “did not alter the maintenance of the treatment at 5 years and is associated with a significant lower rate of serious infections,” they said.
Dr. Henry had no financial conflicts to disclose. Several coauthors disclosed relationships with multiple drug companies, but the study received no specific funding from any of these companies.
SOURCE: Henry J et al. Rheumatology. 2017 Dec 15. doi: 10.1093/rheumatology/kex446.
Treating rheumatoid arthritis patients with lower doses of rituximab for long-term maintenance reduced the risk of serious infections and saved money, based on data from approximately 1,200 patients in a French registry.
In a study published in Rheumatology, Julien Henry, MD, of Institut pour la Sante et la Recherche Medicale, Paris, and colleagues reviewed data from 1,278 patients; 1,093 (85.5%) received a standard dose of rituximab, and 185 (14.5%) received a reduced dose for maintenance therapy. A standard dose was 1,000 mg per infusion given in two infusions 2 weeks apart), and a reduced dose was 500 mg per infusion given in two infusions 2 weeks apart.
After 5 years, maintenance was 55.5% in the standard group and 53.8% in the reduced group; with no significant difference (hazard ratio, 1.03). However, the cumulative dose for retreatment was 39% less in the reduced group (1.4 g per year vs. 2.3 g per year), “which is greatly cost effective,” the researchers wrote.
In addition, the rate of serious infections was significantly lower in the reduced-dose group, compared with the standard-dose group (2.2 per 100 patient-years vs. 4.1 per 100 patient-years; adjusted hazard ratio = 0.50).
“Of note, factors associated with risk of serious infection, such as baseline low gamma globulin or IgG levels, chronic lung or cardiac disease, and extra-articular involvement, did not differ between groups,” the researchers said.
The study findings were limited by several factors including the observational design and lack of data on certain RA outcome measures such as radiographic progression and function, the researchers noted. However, the results support data from similar studies and suggest that a lower dose of rituximab for retreatment of RA “did not alter the maintenance of the treatment at 5 years and is associated with a significant lower rate of serious infections,” they said.
Dr. Henry had no financial conflicts to disclose. Several coauthors disclosed relationships with multiple drug companies, but the study received no specific funding from any of these companies.
SOURCE: Henry J et al. Rheumatology. 2017 Dec 15. doi: 10.1093/rheumatology/kex446.
Treating rheumatoid arthritis patients with lower doses of rituximab for long-term maintenance reduced the risk of serious infections and saved money, based on data from approximately 1,200 patients in a French registry.
In a study published in Rheumatology, Julien Henry, MD, of Institut pour la Sante et la Recherche Medicale, Paris, and colleagues reviewed data from 1,278 patients; 1,093 (85.5%) received a standard dose of rituximab, and 185 (14.5%) received a reduced dose for maintenance therapy. A standard dose was 1,000 mg per infusion given in two infusions 2 weeks apart), and a reduced dose was 500 mg per infusion given in two infusions 2 weeks apart.
After 5 years, maintenance was 55.5% in the standard group and 53.8% in the reduced group; with no significant difference (hazard ratio, 1.03). However, the cumulative dose for retreatment was 39% less in the reduced group (1.4 g per year vs. 2.3 g per year), “which is greatly cost effective,” the researchers wrote.
In addition, the rate of serious infections was significantly lower in the reduced-dose group, compared with the standard-dose group (2.2 per 100 patient-years vs. 4.1 per 100 patient-years; adjusted hazard ratio = 0.50).
“Of note, factors associated with risk of serious infection, such as baseline low gamma globulin or IgG levels, chronic lung or cardiac disease, and extra-articular involvement, did not differ between groups,” the researchers said.
The study findings were limited by several factors including the observational design and lack of data on certain RA outcome measures such as radiographic progression and function, the researchers noted. However, the results support data from similar studies and suggest that a lower dose of rituximab for retreatment of RA “did not alter the maintenance of the treatment at 5 years and is associated with a significant lower rate of serious infections,” they said.
Dr. Henry had no financial conflicts to disclose. Several coauthors disclosed relationships with multiple drug companies, but the study received no specific funding from any of these companies.
SOURCE: Henry J et al. Rheumatology. 2017 Dec 15. doi: 10.1093/rheumatology/kex446.
FROM RHEUMATOLOGY
Key clinical point: A reduced dose of rituximab for RA maintenance resulted in fewer infections and lower cost.
Major finding: A long-term low dose of rituximab for RA patients led to a 39% total dose reduction.
Study details: An observational study of data from 1,278 adult patients in the Autoimmunity and Rituximab registry.
Disclosures: Dr. Henry had no financial conflicts to disclose. Several coauthors disclosed relationships with multiple drug companies, but the study received no specific funding from any of these companies.
Source: Henry J et al. Rheumatology. 2017 Dec 15. doi: 10.1093/rheumatology/kex446.
Gonadotropins succeed where clomifene fails
Switching to gonadotropins increased the odds of live births for women with normogonadotropic anovulation with little success for continuing with clomifene citrate, based on data from 666 women.
Women who have not become pregnant after six cycles of clomifene are often defined as having failed the treatment, but the effectiveness of continuing clomifene citrate or switching to gonadotropins had not been addressed in randomized trials, wrote Nienke S. Weiss, MD, of VU University Medical Center, Amsterdam, and her colleagues.
In a study published online in the Lancet, the researchers randomized 166 women to gonadotropins and intrauterine insemination, 165 to gonadotropins and intercourse, 163 to clomifene citrate and intrauterine insemination, and 172 to clomifene citrate and intercourse. The study population included women aged 18 years and older who had not become pregnant after six cycles of clomifene citrate. The clomifene citrate was given as oral doses of 50-150 mg daily, and gonadotropin was given subcutaneously at a starting dose of 50 IU or 75 IU daily.
Overall, live births were significantly more likely for women given gonadotropins, compared with those given clomifene citrate (52% of 327 women vs. 41% of 334 women, respectively; P = .0124). Rates of multiple pregnancies were similar and relatively low among the treatment groups.
Intrauterine insemination had no significant impact on live birth rates, compared with intercourse (49% vs. 43%, respectively; P = .1152).
A total of three adverse events were reported including one stillbirth and one case of congenital abnormality in the clomifene group and one delivery at 20 weeks’ gestational age caused by cervical insufficiency in the gonadotropin group. More miscarriages were reported in the gonadotropin group than in the clomifene group, but the study was not powered to address this difference, which should be addressed in future studies, the researchers said.
The findings were limited by each center’s use of its own ovulation induction protocols, the researchers noted. “Our results can be used by couples treated with first-line ovulatory drugs who weigh the pros and cons of switching to gonadotropins and addition of intrauterine insemination,” they said.
The study was supported by the Netherlands Organization for Health Research and Development.
SOURCE: Weiss N et al. Lancet. 2017 Dec 19. doi: 10.1016/S0140-6736(17)33308-1.
The study findings will be useful to clinicians in practice because infertile couples often balk at the idea of trying another several months of medication rather than trying in vitro fertilization (IVF) after 6 months of failed medical treatment, wrote Cynthia Farquhar, MD, in an accompanying editorial (Lancet. 2017 Dec 19. doi: 10.1016/S0140-6736[17]33310-X).
Data from previous studies have shown that ovarian induction and intrauterine insemination are as successful as IVF treatments, but many couples feel time pressured and want to move to IVF earlier, and data to support the success of medical treatments after 6 months have been lacking, she said.
Although intrauterine insemination had no additional effect on the live birth rates, the study results for both clomifene citrate and gonadotropins suggest that fertility clinics should offer ovulation induction for 12 months using either clomifene citrate or gonadotropins, according to cost and convenience, she said.
“If there is one thing to take away from this study, it is to offer up to 12 cycles of ovulation induction in women with normogonadotropic anovulation before offering assisted reproductive technology,” Dr. Farquhar noted.
Dr. Farquhar is affiliated with the department of obstetrics and gynaecology and the faculty of medical and health sciences at the University of Auckland, New Zealand. She had no financial conflicts to disclose.
The study findings will be useful to clinicians in practice because infertile couples often balk at the idea of trying another several months of medication rather than trying in vitro fertilization (IVF) after 6 months of failed medical treatment, wrote Cynthia Farquhar, MD, in an accompanying editorial (Lancet. 2017 Dec 19. doi: 10.1016/S0140-6736[17]33310-X).
Data from previous studies have shown that ovarian induction and intrauterine insemination are as successful as IVF treatments, but many couples feel time pressured and want to move to IVF earlier, and data to support the success of medical treatments after 6 months have been lacking, she said.
Although intrauterine insemination had no additional effect on the live birth rates, the study results for both clomifene citrate and gonadotropins suggest that fertility clinics should offer ovulation induction for 12 months using either clomifene citrate or gonadotropins, according to cost and convenience, she said.
“If there is one thing to take away from this study, it is to offer up to 12 cycles of ovulation induction in women with normogonadotropic anovulation before offering assisted reproductive technology,” Dr. Farquhar noted.
Dr. Farquhar is affiliated with the department of obstetrics and gynaecology and the faculty of medical and health sciences at the University of Auckland, New Zealand. She had no financial conflicts to disclose.
The study findings will be useful to clinicians in practice because infertile couples often balk at the idea of trying another several months of medication rather than trying in vitro fertilization (IVF) after 6 months of failed medical treatment, wrote Cynthia Farquhar, MD, in an accompanying editorial (Lancet. 2017 Dec 19. doi: 10.1016/S0140-6736[17]33310-X).
Data from previous studies have shown that ovarian induction and intrauterine insemination are as successful as IVF treatments, but many couples feel time pressured and want to move to IVF earlier, and data to support the success of medical treatments after 6 months have been lacking, she said.
Although intrauterine insemination had no additional effect on the live birth rates, the study results for both clomifene citrate and gonadotropins suggest that fertility clinics should offer ovulation induction for 12 months using either clomifene citrate or gonadotropins, according to cost and convenience, she said.
“If there is one thing to take away from this study, it is to offer up to 12 cycles of ovulation induction in women with normogonadotropic anovulation before offering assisted reproductive technology,” Dr. Farquhar noted.
Dr. Farquhar is affiliated with the department of obstetrics and gynaecology and the faculty of medical and health sciences at the University of Auckland, New Zealand. She had no financial conflicts to disclose.
Switching to gonadotropins increased the odds of live births for women with normogonadotropic anovulation with little success for continuing with clomifene citrate, based on data from 666 women.
Women who have not become pregnant after six cycles of clomifene are often defined as having failed the treatment, but the effectiveness of continuing clomifene citrate or switching to gonadotropins had not been addressed in randomized trials, wrote Nienke S. Weiss, MD, of VU University Medical Center, Amsterdam, and her colleagues.
In a study published online in the Lancet, the researchers randomized 166 women to gonadotropins and intrauterine insemination, 165 to gonadotropins and intercourse, 163 to clomifene citrate and intrauterine insemination, and 172 to clomifene citrate and intercourse. The study population included women aged 18 years and older who had not become pregnant after six cycles of clomifene citrate. The clomifene citrate was given as oral doses of 50-150 mg daily, and gonadotropin was given subcutaneously at a starting dose of 50 IU or 75 IU daily.
Overall, live births were significantly more likely for women given gonadotropins, compared with those given clomifene citrate (52% of 327 women vs. 41% of 334 women, respectively; P = .0124). Rates of multiple pregnancies were similar and relatively low among the treatment groups.
Intrauterine insemination had no significant impact on live birth rates, compared with intercourse (49% vs. 43%, respectively; P = .1152).
A total of three adverse events were reported including one stillbirth and one case of congenital abnormality in the clomifene group and one delivery at 20 weeks’ gestational age caused by cervical insufficiency in the gonadotropin group. More miscarriages were reported in the gonadotropin group than in the clomifene group, but the study was not powered to address this difference, which should be addressed in future studies, the researchers said.
The findings were limited by each center’s use of its own ovulation induction protocols, the researchers noted. “Our results can be used by couples treated with first-line ovulatory drugs who weigh the pros and cons of switching to gonadotropins and addition of intrauterine insemination,” they said.
The study was supported by the Netherlands Organization for Health Research and Development.
SOURCE: Weiss N et al. Lancet. 2017 Dec 19. doi: 10.1016/S0140-6736(17)33308-1.
Switching to gonadotropins increased the odds of live births for women with normogonadotropic anovulation with little success for continuing with clomifene citrate, based on data from 666 women.
Women who have not become pregnant after six cycles of clomifene are often defined as having failed the treatment, but the effectiveness of continuing clomifene citrate or switching to gonadotropins had not been addressed in randomized trials, wrote Nienke S. Weiss, MD, of VU University Medical Center, Amsterdam, and her colleagues.
In a study published online in the Lancet, the researchers randomized 166 women to gonadotropins and intrauterine insemination, 165 to gonadotropins and intercourse, 163 to clomifene citrate and intrauterine insemination, and 172 to clomifene citrate and intercourse. The study population included women aged 18 years and older who had not become pregnant after six cycles of clomifene citrate. The clomifene citrate was given as oral doses of 50-150 mg daily, and gonadotropin was given subcutaneously at a starting dose of 50 IU or 75 IU daily.
Overall, live births were significantly more likely for women given gonadotropins, compared with those given clomifene citrate (52% of 327 women vs. 41% of 334 women, respectively; P = .0124). Rates of multiple pregnancies were similar and relatively low among the treatment groups.
Intrauterine insemination had no significant impact on live birth rates, compared with intercourse (49% vs. 43%, respectively; P = .1152).
A total of three adverse events were reported including one stillbirth and one case of congenital abnormality in the clomifene group and one delivery at 20 weeks’ gestational age caused by cervical insufficiency in the gonadotropin group. More miscarriages were reported in the gonadotropin group than in the clomifene group, but the study was not powered to address this difference, which should be addressed in future studies, the researchers said.
The findings were limited by each center’s use of its own ovulation induction protocols, the researchers noted. “Our results can be used by couples treated with first-line ovulatory drugs who weigh the pros and cons of switching to gonadotropins and addition of intrauterine insemination,” they said.
The study was supported by the Netherlands Organization for Health Research and Development.
SOURCE: Weiss N et al. Lancet. 2017 Dec 19. doi: 10.1016/S0140-6736(17)33308-1.
FROM THE LANCET
Key clinical point: Gonadotropins surpassed clomifene citrate for women with normogonadotropic anovulation.
Major finding: Live births occurred in 52% of women assigned to gonadotropins vs. 41% of those given clomifene citrate.
Study details: A randomized trial of 666 women aged 18 years and older.
Disclosures: The study was supported by the Netherlands Organization for Health Research and Development.
Source: Weiss N et al. Lancet. 2017 Dec 19. doi: 10.1016/S0140-6736(17)33308-1.