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Aspirin or rivaroxaban plus P2Y12 inhibitor equals 5% bleeding risk
Clinically significant bleeding in acute coronary patients was approximately 5% when their P2Y12 inhibitor treatment was combined with either rivaroxaban or with aspirin, based on data from a randomized, multicenter study of 3,037 adults.
The findings support the use of low-dose rivaroxaban as a safe strategy and an alternative to aspirin for postacute care of coronary syndromes, wrote E. Magnus Ohman, MD, of Duke University in Durham, N.C., and his colleagues.
The study was presented at the annual meeting of the American College of Cardiology and published simultaneously in the Lancet (2017. Mar 18. doi: org/10.1016/S0140-6736[17]30751-1).
The GEMINI ACS 1 trial included patients older than 18 years, who were randomized to P2Y12 with rivaroxaban or P2Y12 with aspirin within 10 days of admission for acute coronary syndrome events, from 371 clinical centers in 21 countries. The patients received 2.5 mg of low-dose rivaroxaban twice daily plus a P2Y12 inhibitor (clopidogrel or ticagrelor, based on national availability) or 100 mg of aspirin daily plus a P2Y12 inhibitor. Patients were assessed at 30, 90, 180, and 270 days.
Overall, 154 patients (5%) met the primary endpoint of thrombolysis in myocardial infarction (TIMI) of clinically significant bleeding – 80 patients (5%) in the rivaroxaban group and 74 (5%) in the aspirin group. Baseline demographics were not significantly different between the groups, and clinically significant bleeding was not significantly different among subgroups.
TIMI bleeding that required medical attention was the most common, occurring in 4% of each group. Both groups had a low frequency of severe or major bleeding based on the TIMI bleeding definitions, the researchers noted.
The composite ischemic endpoint of cardiovascular death, myocardial infarction, stroke, or definite stent thrombosis was 5% in both groups, and both groups had a similar frequency of all-cause mortality and of each of the composite ischemic elements. Rivaroxaban was associated with a higher occurrence of the ischemic composite endpoint in the first 30 days (hazard ratio, 1.48), but this difference was not statistically significant.
“Additionally, no significant interaction was noted for the risk of clinically significant bleeding by P2Y12 inhibitor strata (ticagrelor vs. clopidogrel), but these stratified bleeding analyses were exploratory and hypothesis generating,” the researchers wrote.
The findings were limited by several factors, including a delay in randomization from the patients’ index events, a homogeneous population, and exclusion of patients treated with prasugrel, the researchers noted. However, “based upon these findings and the unmet need for improved treatments in the postacute coronary syndromes setting, further testing of the efficacy and safety of this novel dual pathway antithrombotic regimen in an adequately powered trial should be considered,” they said.
The study was funded by Janssen Research & Development and Bayer. Lead author Dr. Ohman has received research grants from Janssen and other companies. Several coauthors disclosed relationships with multiple companies, including Janssen.
“The antithrombotic effect of aspirin is largely explained by inhibition of COX [cyclo-oxygenase] 1, a central enzyme mediating platelet activation,” wrote Paul A. Gurbel, MD, and Udaya S. Tantry, PhD, in an accompanying comment. “This and pleiotropic cardioprotective properties should be considered before forsaking or replacing aspirin, particularly early in the highly prothrombotic state of a new acute coronary syndrome (panel),” they said.
The major downside of aspirin is gastrointestinal bleeding, the commenters wrote. “But, almost all bleeding metrics were nonsignificantly lower with aspirin, and a 50% increased bleed rate with rivaroxaban cannot be excluded,” they said. Also, although the frequency of major bleeding was similar between the groups, “numerically, the lowest composite ischaemic endpoint rate was noted with aspirin plus ticagrelor therapy (ticagrelor plus aspirin = 3.9%; ticagrelor plus rivaroxaban = 4.7%; clopidogrel plus rivaroxaban = 5.4%; and clopidogrel plus aspirin = 5.9%),” they said. “Thus, it might be premature to believe that a low-dose Xa inhibitor on top of a P2Y12 inhibitor can be [an] effective and safe therapy for most stabilized patients with acute coronary syndromes” (Lancet. 2017 Mar 18. doi: org/10.1016/S0140-6736[17]30760-2).
Dr. Gurbel and Dr. Tantry are affiliated with the Inova Heart and Vascular Institute, Falls Church, VA. Dr. Gurbel disclosed relationships with multiple companies including study sponsor Janssen.
“The antithrombotic effect of aspirin is largely explained by inhibition of COX [cyclo-oxygenase] 1, a central enzyme mediating platelet activation,” wrote Paul A. Gurbel, MD, and Udaya S. Tantry, PhD, in an accompanying comment. “This and pleiotropic cardioprotective properties should be considered before forsaking or replacing aspirin, particularly early in the highly prothrombotic state of a new acute coronary syndrome (panel),” they said.
The major downside of aspirin is gastrointestinal bleeding, the commenters wrote. “But, almost all bleeding metrics were nonsignificantly lower with aspirin, and a 50% increased bleed rate with rivaroxaban cannot be excluded,” they said. Also, although the frequency of major bleeding was similar between the groups, “numerically, the lowest composite ischaemic endpoint rate was noted with aspirin plus ticagrelor therapy (ticagrelor plus aspirin = 3.9%; ticagrelor plus rivaroxaban = 4.7%; clopidogrel plus rivaroxaban = 5.4%; and clopidogrel plus aspirin = 5.9%),” they said. “Thus, it might be premature to believe that a low-dose Xa inhibitor on top of a P2Y12 inhibitor can be [an] effective and safe therapy for most stabilized patients with acute coronary syndromes” (Lancet. 2017 Mar 18. doi: org/10.1016/S0140-6736[17]30760-2).
Dr. Gurbel and Dr. Tantry are affiliated with the Inova Heart and Vascular Institute, Falls Church, VA. Dr. Gurbel disclosed relationships with multiple companies including study sponsor Janssen.
“The antithrombotic effect of aspirin is largely explained by inhibition of COX [cyclo-oxygenase] 1, a central enzyme mediating platelet activation,” wrote Paul A. Gurbel, MD, and Udaya S. Tantry, PhD, in an accompanying comment. “This and pleiotropic cardioprotective properties should be considered before forsaking or replacing aspirin, particularly early in the highly prothrombotic state of a new acute coronary syndrome (panel),” they said.
The major downside of aspirin is gastrointestinal bleeding, the commenters wrote. “But, almost all bleeding metrics were nonsignificantly lower with aspirin, and a 50% increased bleed rate with rivaroxaban cannot be excluded,” they said. Also, although the frequency of major bleeding was similar between the groups, “numerically, the lowest composite ischaemic endpoint rate was noted with aspirin plus ticagrelor therapy (ticagrelor plus aspirin = 3.9%; ticagrelor plus rivaroxaban = 4.7%; clopidogrel plus rivaroxaban = 5.4%; and clopidogrel plus aspirin = 5.9%),” they said. “Thus, it might be premature to believe that a low-dose Xa inhibitor on top of a P2Y12 inhibitor can be [an] effective and safe therapy for most stabilized patients with acute coronary syndromes” (Lancet. 2017 Mar 18. doi: org/10.1016/S0140-6736[17]30760-2).
Dr. Gurbel and Dr. Tantry are affiliated with the Inova Heart and Vascular Institute, Falls Church, VA. Dr. Gurbel disclosed relationships with multiple companies including study sponsor Janssen.
Clinically significant bleeding in acute coronary patients was approximately 5% when their P2Y12 inhibitor treatment was combined with either rivaroxaban or with aspirin, based on data from a randomized, multicenter study of 3,037 adults.
The findings support the use of low-dose rivaroxaban as a safe strategy and an alternative to aspirin for postacute care of coronary syndromes, wrote E. Magnus Ohman, MD, of Duke University in Durham, N.C., and his colleagues.
The study was presented at the annual meeting of the American College of Cardiology and published simultaneously in the Lancet (2017. Mar 18. doi: org/10.1016/S0140-6736[17]30751-1).
The GEMINI ACS 1 trial included patients older than 18 years, who were randomized to P2Y12 with rivaroxaban or P2Y12 with aspirin within 10 days of admission for acute coronary syndrome events, from 371 clinical centers in 21 countries. The patients received 2.5 mg of low-dose rivaroxaban twice daily plus a P2Y12 inhibitor (clopidogrel or ticagrelor, based on national availability) or 100 mg of aspirin daily plus a P2Y12 inhibitor. Patients were assessed at 30, 90, 180, and 270 days.
Overall, 154 patients (5%) met the primary endpoint of thrombolysis in myocardial infarction (TIMI) of clinically significant bleeding – 80 patients (5%) in the rivaroxaban group and 74 (5%) in the aspirin group. Baseline demographics were not significantly different between the groups, and clinically significant bleeding was not significantly different among subgroups.
TIMI bleeding that required medical attention was the most common, occurring in 4% of each group. Both groups had a low frequency of severe or major bleeding based on the TIMI bleeding definitions, the researchers noted.
The composite ischemic endpoint of cardiovascular death, myocardial infarction, stroke, or definite stent thrombosis was 5% in both groups, and both groups had a similar frequency of all-cause mortality and of each of the composite ischemic elements. Rivaroxaban was associated with a higher occurrence of the ischemic composite endpoint in the first 30 days (hazard ratio, 1.48), but this difference was not statistically significant.
“Additionally, no significant interaction was noted for the risk of clinically significant bleeding by P2Y12 inhibitor strata (ticagrelor vs. clopidogrel), but these stratified bleeding analyses were exploratory and hypothesis generating,” the researchers wrote.
The findings were limited by several factors, including a delay in randomization from the patients’ index events, a homogeneous population, and exclusion of patients treated with prasugrel, the researchers noted. However, “based upon these findings and the unmet need for improved treatments in the postacute coronary syndromes setting, further testing of the efficacy and safety of this novel dual pathway antithrombotic regimen in an adequately powered trial should be considered,” they said.
The study was funded by Janssen Research & Development and Bayer. Lead author Dr. Ohman has received research grants from Janssen and other companies. Several coauthors disclosed relationships with multiple companies, including Janssen.
Clinically significant bleeding in acute coronary patients was approximately 5% when their P2Y12 inhibitor treatment was combined with either rivaroxaban or with aspirin, based on data from a randomized, multicenter study of 3,037 adults.
The findings support the use of low-dose rivaroxaban as a safe strategy and an alternative to aspirin for postacute care of coronary syndromes, wrote E. Magnus Ohman, MD, of Duke University in Durham, N.C., and his colleagues.
The study was presented at the annual meeting of the American College of Cardiology and published simultaneously in the Lancet (2017. Mar 18. doi: org/10.1016/S0140-6736[17]30751-1).
The GEMINI ACS 1 trial included patients older than 18 years, who were randomized to P2Y12 with rivaroxaban or P2Y12 with aspirin within 10 days of admission for acute coronary syndrome events, from 371 clinical centers in 21 countries. The patients received 2.5 mg of low-dose rivaroxaban twice daily plus a P2Y12 inhibitor (clopidogrel or ticagrelor, based on national availability) or 100 mg of aspirin daily plus a P2Y12 inhibitor. Patients were assessed at 30, 90, 180, and 270 days.
Overall, 154 patients (5%) met the primary endpoint of thrombolysis in myocardial infarction (TIMI) of clinically significant bleeding – 80 patients (5%) in the rivaroxaban group and 74 (5%) in the aspirin group. Baseline demographics were not significantly different between the groups, and clinically significant bleeding was not significantly different among subgroups.
TIMI bleeding that required medical attention was the most common, occurring in 4% of each group. Both groups had a low frequency of severe or major bleeding based on the TIMI bleeding definitions, the researchers noted.
The composite ischemic endpoint of cardiovascular death, myocardial infarction, stroke, or definite stent thrombosis was 5% in both groups, and both groups had a similar frequency of all-cause mortality and of each of the composite ischemic elements. Rivaroxaban was associated with a higher occurrence of the ischemic composite endpoint in the first 30 days (hazard ratio, 1.48), but this difference was not statistically significant.
“Additionally, no significant interaction was noted for the risk of clinically significant bleeding by P2Y12 inhibitor strata (ticagrelor vs. clopidogrel), but these stratified bleeding analyses were exploratory and hypothesis generating,” the researchers wrote.
The findings were limited by several factors, including a delay in randomization from the patients’ index events, a homogeneous population, and exclusion of patients treated with prasugrel, the researchers noted. However, “based upon these findings and the unmet need for improved treatments in the postacute coronary syndromes setting, further testing of the efficacy and safety of this novel dual pathway antithrombotic regimen in an adequately powered trial should be considered,” they said.
The study was funded by Janssen Research & Development and Bayer. Lead author Dr. Ohman has received research grants from Janssen and other companies. Several coauthors disclosed relationships with multiple companies, including Janssen.
FROM ACC 17
Key clinical point: The risk of major bleeding was similar between acute coronary syndrome patients treated with a combination of low-dose rivaroxaban and P2Y12 inhibitor and those treated with aspirin and P2Y12 inhibitor.
Major finding: Clinically significant bleeding occurred in 5% of patients in each treatment group (HR, 1.09).
Data source: A double-blind, multicenter, randomized trial (GEMINI ACS 1) including 3,037 adults.
Disclosures: The study was funded by Janssen Research & Development and Bayer. Lead author Dr. Ohman has received research grants from Janssen and other companies. Several coauthors disclosed relationships with multiple companies, including Janssen.
Infant hepatitis B vaccine protection lingers into adolescence
Adolescents who received hepatitis B virus (HBV) vaccinations as infants still showed protection despite little evidence of residual antibodies, a study showed.
This finding was based on data from a prospective study of 137 children, aged 10-11 years, and 213 children, aged 15-16 years, with no history of HBV infection who were vaccinated at 2, 4, and 6 months of age. Michelle Pinto, MD, of the Vaccine Evaluation Center in Vancouver and her colleagues measured residual immunity to determine whether HBV boosters might be needed in adolescents vaccinated as infants to prolong immunity and reduce disease transmission in adulthood.
Overall, 97% of the younger age group and 91% of the older age group showed reactions to an HBV vaccine challenge. An additional 3 (2%) younger children and 12 (6%) older children responded to a second vaccine challenge after failing to respond to the first.
Limitations of the study included a “limited ability of the challenge vaccine procedure to accurately identify immune memory and anamnestic responses” and the differences between the findings and those from long-term outcome data in similar studies in other countries, Dr. Pinto and her associates wrote.
However, “the fact that substantial differences exist in measures of residual protection among teenagers after infant or adolescent HBV vaccinations warrants close ongoing scrutiny of whether important differences will emerge in long-term protection, with or without booster vaccination,” they said (Pediatr Infect Dis J. 2017. doi: 10.1097/INF.0000000000001543).
Adolescents who received hepatitis B virus (HBV) vaccinations as infants still showed protection despite little evidence of residual antibodies, a study showed.
This finding was based on data from a prospective study of 137 children, aged 10-11 years, and 213 children, aged 15-16 years, with no history of HBV infection who were vaccinated at 2, 4, and 6 months of age. Michelle Pinto, MD, of the Vaccine Evaluation Center in Vancouver and her colleagues measured residual immunity to determine whether HBV boosters might be needed in adolescents vaccinated as infants to prolong immunity and reduce disease transmission in adulthood.
Overall, 97% of the younger age group and 91% of the older age group showed reactions to an HBV vaccine challenge. An additional 3 (2%) younger children and 12 (6%) older children responded to a second vaccine challenge after failing to respond to the first.
Limitations of the study included a “limited ability of the challenge vaccine procedure to accurately identify immune memory and anamnestic responses” and the differences between the findings and those from long-term outcome data in similar studies in other countries, Dr. Pinto and her associates wrote.
However, “the fact that substantial differences exist in measures of residual protection among teenagers after infant or adolescent HBV vaccinations warrants close ongoing scrutiny of whether important differences will emerge in long-term protection, with or without booster vaccination,” they said (Pediatr Infect Dis J. 2017. doi: 10.1097/INF.0000000000001543).
Adolescents who received hepatitis B virus (HBV) vaccinations as infants still showed protection despite little evidence of residual antibodies, a study showed.
This finding was based on data from a prospective study of 137 children, aged 10-11 years, and 213 children, aged 15-16 years, with no history of HBV infection who were vaccinated at 2, 4, and 6 months of age. Michelle Pinto, MD, of the Vaccine Evaluation Center in Vancouver and her colleagues measured residual immunity to determine whether HBV boosters might be needed in adolescents vaccinated as infants to prolong immunity and reduce disease transmission in adulthood.
Overall, 97% of the younger age group and 91% of the older age group showed reactions to an HBV vaccine challenge. An additional 3 (2%) younger children and 12 (6%) older children responded to a second vaccine challenge after failing to respond to the first.
Limitations of the study included a “limited ability of the challenge vaccine procedure to accurately identify immune memory and anamnestic responses” and the differences between the findings and those from long-term outcome data in similar studies in other countries, Dr. Pinto and her associates wrote.
However, “the fact that substantial differences exist in measures of residual protection among teenagers after infant or adolescent HBV vaccinations warrants close ongoing scrutiny of whether important differences will emerge in long-term protection, with or without booster vaccination,” they said (Pediatr Infect Dis J. 2017. doi: 10.1097/INF.0000000000001543).
FROM THE PEDIATRIC INFECTIOUS DISEASE JOURNAL
More time in aftercare improves abstinence
Patients treated for addiction for longer than 30 days showed a significantly higher abstinence success rate of 84%, compared with 55% for patients whose treatment stopped at 30 days, a study of 72 adults shows.
The findings were not significantly different among different kinds of addictions, such as alcohol and amphetamine addiction or opioid and benzodiazepine dependency (Open J Psychiatr. Jan 2017;7:51-60).
“Recovery is an ongoing process once a client leaves treatment,” wrote Akikur R. Mohammad, MD, CEO/founder of the Inspire Malibu drug and alcohol treatment center in Southern California, and his colleagues. “Clients who adhere to their discharge plan and immerse themselves in recovery-related activities and lifestyle are likely to achieve sobriety for longer periods of time, if not indefinitely.”
To assess the efficacy of treatment and the predictors of relapse, the researchers enrolled 32 men and 40 women who were undergoing clinical treatment for various types of addiction. The average age was 30 years for the men and 30.7 years for the women.
In addition, the researchers developed models of treatment outcomes. They found a relative risk of substance abuse relapse of 18.1 for patients who failed to answer the phone at least three times during a 12-month follow-up period, compared with patients who only failed to answer the phone either zero, one, or two times.
Although the results were limited by the use of self reports, the findings support the role of aftercare follow-up in identifying addiction patients at risk for relapse, noted Dr. Mohammad of the University of California, Los Angeles, and his colleagues.
The researchers had no financial conflicts to disclose.
Patients treated for addiction for longer than 30 days showed a significantly higher abstinence success rate of 84%, compared with 55% for patients whose treatment stopped at 30 days, a study of 72 adults shows.
The findings were not significantly different among different kinds of addictions, such as alcohol and amphetamine addiction or opioid and benzodiazepine dependency (Open J Psychiatr. Jan 2017;7:51-60).
“Recovery is an ongoing process once a client leaves treatment,” wrote Akikur R. Mohammad, MD, CEO/founder of the Inspire Malibu drug and alcohol treatment center in Southern California, and his colleagues. “Clients who adhere to their discharge plan and immerse themselves in recovery-related activities and lifestyle are likely to achieve sobriety for longer periods of time, if not indefinitely.”
To assess the efficacy of treatment and the predictors of relapse, the researchers enrolled 32 men and 40 women who were undergoing clinical treatment for various types of addiction. The average age was 30 years for the men and 30.7 years for the women.
In addition, the researchers developed models of treatment outcomes. They found a relative risk of substance abuse relapse of 18.1 for patients who failed to answer the phone at least three times during a 12-month follow-up period, compared with patients who only failed to answer the phone either zero, one, or two times.
Although the results were limited by the use of self reports, the findings support the role of aftercare follow-up in identifying addiction patients at risk for relapse, noted Dr. Mohammad of the University of California, Los Angeles, and his colleagues.
The researchers had no financial conflicts to disclose.
Patients treated for addiction for longer than 30 days showed a significantly higher abstinence success rate of 84%, compared with 55% for patients whose treatment stopped at 30 days, a study of 72 adults shows.
The findings were not significantly different among different kinds of addictions, such as alcohol and amphetamine addiction or opioid and benzodiazepine dependency (Open J Psychiatr. Jan 2017;7:51-60).
“Recovery is an ongoing process once a client leaves treatment,” wrote Akikur R. Mohammad, MD, CEO/founder of the Inspire Malibu drug and alcohol treatment center in Southern California, and his colleagues. “Clients who adhere to their discharge plan and immerse themselves in recovery-related activities and lifestyle are likely to achieve sobriety for longer periods of time, if not indefinitely.”
To assess the efficacy of treatment and the predictors of relapse, the researchers enrolled 32 men and 40 women who were undergoing clinical treatment for various types of addiction. The average age was 30 years for the men and 30.7 years for the women.
In addition, the researchers developed models of treatment outcomes. They found a relative risk of substance abuse relapse of 18.1 for patients who failed to answer the phone at least three times during a 12-month follow-up period, compared with patients who only failed to answer the phone either zero, one, or two times.
Although the results were limited by the use of self reports, the findings support the role of aftercare follow-up in identifying addiction patients at risk for relapse, noted Dr. Mohammad of the University of California, Los Angeles, and his colleagues.
The researchers had no financial conflicts to disclose.
FROM THE OPEN JOURNAL OF PSYCHIATRY
Pneumococcal conjugate vaccine beats Streptococcus pneumoniae bacteremia
Routine use of the 13-valent pneumococcal conjugate vaccine (PCV13) reduced the incidence of Streptococcus pneumoniae bacteremia by 95% from a time period before to a time period after the vaccine was implemented, based on a review of more than 57,000 blood cultures from children aged 3-36 months.
Kaiser Permanente implemented universal immunization with PCV13 in June 2010. “Initial trends through 2012 demonstrated continued decline in pneumococcal infections, with the biggest impact in children less than 5 years old,” wrote Tara Greenhow, MD, of Kaiser Permanente Northern California, San Francisco, and her colleagues.
Overall, the incidence of S. pneumoniae bacteremia declined from 74.5 per 100,000 children during the period before PCV7 (1998-1999) to 3.5 per 100,000 children during a period after routine use of PCV13 (2013-2014). The annual number of bacteremia cases from any cause dropped by 78% between these two time periods.
As bacteremia caused by pneumococci decreased, 77% of cases in the post-PCV13 time period were caused by Escherichia coli, Salmonella spp., and Staphylococcus aureus. “A total of 76% of bacteremia occurred with a source, including 34% urinary tract infections, 17% gastroenteritis, 8% pneumonias, 8% osteomyelitis, 6% skin and soft tissue infections, and 3% other,” Dr. Greenhow and her associates reported.
The large population of the Kaiser Permanente system supports the accuracy of the now rare incidence of bacteremia in young children, the researchers noted. However, “because bacteremia in the post-PCV13 era is more likely to occur with a source, a focused examination should be performed and appropriate studies should be obtained at the time of a blood culture collection,” they said.
Routine use of the 13-valent pneumococcal conjugate vaccine (PCV13) reduced the incidence of Streptococcus pneumoniae bacteremia by 95% from a time period before to a time period after the vaccine was implemented, based on a review of more than 57,000 blood cultures from children aged 3-36 months.
Kaiser Permanente implemented universal immunization with PCV13 in June 2010. “Initial trends through 2012 demonstrated continued decline in pneumococcal infections, with the biggest impact in children less than 5 years old,” wrote Tara Greenhow, MD, of Kaiser Permanente Northern California, San Francisco, and her colleagues.
Overall, the incidence of S. pneumoniae bacteremia declined from 74.5 per 100,000 children during the period before PCV7 (1998-1999) to 3.5 per 100,000 children during a period after routine use of PCV13 (2013-2014). The annual number of bacteremia cases from any cause dropped by 78% between these two time periods.
As bacteremia caused by pneumococci decreased, 77% of cases in the post-PCV13 time period were caused by Escherichia coli, Salmonella spp., and Staphylococcus aureus. “A total of 76% of bacteremia occurred with a source, including 34% urinary tract infections, 17% gastroenteritis, 8% pneumonias, 8% osteomyelitis, 6% skin and soft tissue infections, and 3% other,” Dr. Greenhow and her associates reported.
The large population of the Kaiser Permanente system supports the accuracy of the now rare incidence of bacteremia in young children, the researchers noted. However, “because bacteremia in the post-PCV13 era is more likely to occur with a source, a focused examination should be performed and appropriate studies should be obtained at the time of a blood culture collection,” they said.
Routine use of the 13-valent pneumococcal conjugate vaccine (PCV13) reduced the incidence of Streptococcus pneumoniae bacteremia by 95% from a time period before to a time period after the vaccine was implemented, based on a review of more than 57,000 blood cultures from children aged 3-36 months.
Kaiser Permanente implemented universal immunization with PCV13 in June 2010. “Initial trends through 2012 demonstrated continued decline in pneumococcal infections, with the biggest impact in children less than 5 years old,” wrote Tara Greenhow, MD, of Kaiser Permanente Northern California, San Francisco, and her colleagues.
Overall, the incidence of S. pneumoniae bacteremia declined from 74.5 per 100,000 children during the period before PCV7 (1998-1999) to 3.5 per 100,000 children during a period after routine use of PCV13 (2013-2014). The annual number of bacteremia cases from any cause dropped by 78% between these two time periods.
As bacteremia caused by pneumococci decreased, 77% of cases in the post-PCV13 time period were caused by Escherichia coli, Salmonella spp., and Staphylococcus aureus. “A total of 76% of bacteremia occurred with a source, including 34% urinary tract infections, 17% gastroenteritis, 8% pneumonias, 8% osteomyelitis, 6% skin and soft tissue infections, and 3% other,” Dr. Greenhow and her associates reported.
The large population of the Kaiser Permanente system supports the accuracy of the now rare incidence of bacteremia in young children, the researchers noted. However, “because bacteremia in the post-PCV13 era is more likely to occur with a source, a focused examination should be performed and appropriate studies should be obtained at the time of a blood culture collection,” they said.
FROM PEDIATRICS
Esophageal variceal bleeding, portal hypertension tied to recurrent pediatric GI bleeds
Readmission to the hospital after acute GI bleeding in children is most often associated with an initial diagnosis of portal hypertension or esophageal variceal hemorrhage, based on data from a retrospective study of 9,902 patients.
Rebleeding in adults may be predicted by endoscopic characteristics of the bleeding source in some cases, but “there is still a considerable subgroup of children admitted with acute gastrointestinal bleeding and not endoscoped but in whom we do not have any measure to predict rebleeding including after discharge,” Thomas M. Attard, MD, Children’s Mercy Hospital, Kansas City, Mo., and his colleagues said.
The study included children aged 1-21 years with upper or indeterminate GI bleeding who were discharged from 49 pediatric hospitals between January 1, 2007 and September 30, 2015. Overall, 1,460 children (16%) were readmitted at least once within 30 days, with 72 readmitted twice and an average of 10 days’ time to readmission.
Readmission for recurrent bleeding was most frequently associated with an initial diagnosis of portal hypertension (20%) or esophageal variceal hemorrhage (20%). Children who had undergone endoscopy (odds ratio, 0.77) or Meckel’s scan (OR, 0.51) on initial admission were least likely to require readmission.
Children with one or two complex chronic conditions were almost twice as likely to be readmitted than were those with no complex chronic conditions, and a longer initial hospital stay and early treatment with proton pump inhibitors were associated with increased likelihood of readmission. “These may be indicative of more medically frail patients and greater severity of initial illness, respectively,” the researchers said. They found no association between increased risk of readmission and demographic factors including age, sex, race, and urban vs. rural residence (J Pediatr. 2017 Feb. doi: 10.1016/j.jpeds.2017.01.044).
Readmission to the hospital after acute GI bleeding in children is most often associated with an initial diagnosis of portal hypertension or esophageal variceal hemorrhage, based on data from a retrospective study of 9,902 patients.
Rebleeding in adults may be predicted by endoscopic characteristics of the bleeding source in some cases, but “there is still a considerable subgroup of children admitted with acute gastrointestinal bleeding and not endoscoped but in whom we do not have any measure to predict rebleeding including after discharge,” Thomas M. Attard, MD, Children’s Mercy Hospital, Kansas City, Mo., and his colleagues said.
The study included children aged 1-21 years with upper or indeterminate GI bleeding who were discharged from 49 pediatric hospitals between January 1, 2007 and September 30, 2015. Overall, 1,460 children (16%) were readmitted at least once within 30 days, with 72 readmitted twice and an average of 10 days’ time to readmission.
Readmission for recurrent bleeding was most frequently associated with an initial diagnosis of portal hypertension (20%) or esophageal variceal hemorrhage (20%). Children who had undergone endoscopy (odds ratio, 0.77) or Meckel’s scan (OR, 0.51) on initial admission were least likely to require readmission.
Children with one or two complex chronic conditions were almost twice as likely to be readmitted than were those with no complex chronic conditions, and a longer initial hospital stay and early treatment with proton pump inhibitors were associated with increased likelihood of readmission. “These may be indicative of more medically frail patients and greater severity of initial illness, respectively,” the researchers said. They found no association between increased risk of readmission and demographic factors including age, sex, race, and urban vs. rural residence (J Pediatr. 2017 Feb. doi: 10.1016/j.jpeds.2017.01.044).
Readmission to the hospital after acute GI bleeding in children is most often associated with an initial diagnosis of portal hypertension or esophageal variceal hemorrhage, based on data from a retrospective study of 9,902 patients.
Rebleeding in adults may be predicted by endoscopic characteristics of the bleeding source in some cases, but “there is still a considerable subgroup of children admitted with acute gastrointestinal bleeding and not endoscoped but in whom we do not have any measure to predict rebleeding including after discharge,” Thomas M. Attard, MD, Children’s Mercy Hospital, Kansas City, Mo., and his colleagues said.
The study included children aged 1-21 years with upper or indeterminate GI bleeding who were discharged from 49 pediatric hospitals between January 1, 2007 and September 30, 2015. Overall, 1,460 children (16%) were readmitted at least once within 30 days, with 72 readmitted twice and an average of 10 days’ time to readmission.
Readmission for recurrent bleeding was most frequently associated with an initial diagnosis of portal hypertension (20%) or esophageal variceal hemorrhage (20%). Children who had undergone endoscopy (odds ratio, 0.77) or Meckel’s scan (OR, 0.51) on initial admission were least likely to require readmission.
Children with one or two complex chronic conditions were almost twice as likely to be readmitted than were those with no complex chronic conditions, and a longer initial hospital stay and early treatment with proton pump inhibitors were associated with increased likelihood of readmission. “These may be indicative of more medically frail patients and greater severity of initial illness, respectively,” the researchers said. They found no association between increased risk of readmission and demographic factors including age, sex, race, and urban vs. rural residence (J Pediatr. 2017 Feb. doi: 10.1016/j.jpeds.2017.01.044).
FROM THE JOURNAL OF PEDIATRICS
USPSTF affirms optional pelvic screening
Current evidence fails to support or reject routine screening pelvic exams for asymptomatic, low-risk, nonpregnant adult women, the U.S. Preventive Services Task Force concluded after reviewing the evidence on the accuracy, benefits, and potential harms.
The USPSTF issued an inconclusive “I” statement that was published online March 7 (JAMA. 2017;317[9]:947-53).
Researchers found no data comparing the impact of no screening versus screening pelvic examinations on patient health outcomes including reducing all-cause mortality, reducing cancer-specific and disease-specific morbidity and mortality, and improving quality of life.
“No direct evidence was identified for overall benefits and harms of the pelvic examination as a one-time or periodic screening test,” Janelle M. Guirguis-Blake, MD, of the University of Washington, Tacoma, and colleagues wrote in the accompanying evidence report (JAMA. 2017;317[9]:954-66). The review comprised nine studies: one addressing the harms of screening and eight addressing both harms and accuracy.
Although screening pelvic exams may identify serious conditions as well as benign ones, the potential remains for false-positive and false-negative results that might lead to invasive surgery and unnecessary testing and procedures, the researchers noted. However, the recommendations do not apply to certain conditions for which screening is already recommended, including cervical cancer (via Pap smear), gonorrhea, and chlamydia.
The recommendations are primarily a call for more research rather than a clear guide for clinicians, according to the USPSTF. The research gaps include studies on the physical and psychological harms of pelvic screening for asymptomatic women in primary care; the ability of screening to detect conditions beyond ovarian cancer, genital herpes, bacterial vaginosis, and trichomoniasis; and the impact of screening on a variety of health outcomes, including quality of life.
Given the inadequate evidence to recommend for or against screening, the USPSTF cited the recommendations of other organizations. Both the American College of Physicians and the American Academy of Family Physicians recommend against performing screening pelvic exams in asymptomatic, nonpregnant adult women. The American College of Obstetricians and Gynecologists recommends annual pelvic exams for women 21 years and older but acknowledges a lack of evidence and has said it should be a shared decision between the patient and clinician.
The USPSTF members reported having no relevant financial conflicts.
The USPSTF task force finding of insufficient evidence to support or refute screening pelvic exams conflicts with the views of other organizations, George F. Sawaya, MD, wrote in an editorial (JAMA 2017 Mar 7. doi: 10.1001/jamainternmed.2017.0271).
The American College of Physicians currently recommends against routine screening in asymptomatic, nonpregnant women, while the American College of Obstetricians and Gynecologists recommends in favor of an annual pelvic exam “based on expert opinion” despite the lack of evidence, he said.
“The USPSTF believes that in the setting of an ‘I’ statement, clinicians should be forthright with patients about the uncertainty concerning the balance of benefits and harms,” Dr. Sawaya wrote.
“But perhaps the conversation should focus on the uncertainty among the three professional groups,” he added. “Women should know the facts: that all three groups agree there is no scientific evidence that these examinations are beneficial; that there is evidence of harms including ‘false alarms,’ further testing, and even unnecessary surgery; and that one group strongly recommends against screening examinations, believing them to be more harmful than beneficial,” he said.
The USPSTF recommendation is not a surprise, Colleen McNicholas, DO, MSCI, and Jeffrey F. Peipert, MD, PhD, noted in a second editorial (JAMA 2017;317[9]:910-11). “Despite lack of rigorous research, many would argue that the periodic examination provides opportunity for counseling and trust building between the patient and physician and thus should be universally implemented,” they wrote. However, many women express fear and anxiety before the exam and discomfort, pain, or embarrassment during the exam. “To ignore this aspect when comparing individual parts of the examination seems insensitive and inappropriate,” they added.
“Women, as patients, should be involved in the decision regarding whether to perform a pelvic examination, and clinicians should not require that the patient undergo this procedure to obtain screening, counseling, and age-appropriate health services,” they concluded.
Dr. Sawaya is affiliated with the University of California, San Francisco. He reported having no financial conflicts. Dr. Peipert is affiliated with Indiana University School of Medicine, Indianapolis, and disclosed receiving grants from Teva Pharmaceuticals, Bayer Healthcare Pharmaceuticals, and Merck, as well as serving on the advisory boards of Perrigo and Teva. Dr. McNicholas is affiliated with Washington University, St. Louis, and reported having no financial conflicts.
The USPSTF task force finding of insufficient evidence to support or refute screening pelvic exams conflicts with the views of other organizations, George F. Sawaya, MD, wrote in an editorial (JAMA 2017 Mar 7. doi: 10.1001/jamainternmed.2017.0271).
The American College of Physicians currently recommends against routine screening in asymptomatic, nonpregnant women, while the American College of Obstetricians and Gynecologists recommends in favor of an annual pelvic exam “based on expert opinion” despite the lack of evidence, he said.
“The USPSTF believes that in the setting of an ‘I’ statement, clinicians should be forthright with patients about the uncertainty concerning the balance of benefits and harms,” Dr. Sawaya wrote.
“But perhaps the conversation should focus on the uncertainty among the three professional groups,” he added. “Women should know the facts: that all three groups agree there is no scientific evidence that these examinations are beneficial; that there is evidence of harms including ‘false alarms,’ further testing, and even unnecessary surgery; and that one group strongly recommends against screening examinations, believing them to be more harmful than beneficial,” he said.
The USPSTF recommendation is not a surprise, Colleen McNicholas, DO, MSCI, and Jeffrey F. Peipert, MD, PhD, noted in a second editorial (JAMA 2017;317[9]:910-11). “Despite lack of rigorous research, many would argue that the periodic examination provides opportunity for counseling and trust building between the patient and physician and thus should be universally implemented,” they wrote. However, many women express fear and anxiety before the exam and discomfort, pain, or embarrassment during the exam. “To ignore this aspect when comparing individual parts of the examination seems insensitive and inappropriate,” they added.
“Women, as patients, should be involved in the decision regarding whether to perform a pelvic examination, and clinicians should not require that the patient undergo this procedure to obtain screening, counseling, and age-appropriate health services,” they concluded.
Dr. Sawaya is affiliated with the University of California, San Francisco. He reported having no financial conflicts. Dr. Peipert is affiliated with Indiana University School of Medicine, Indianapolis, and disclosed receiving grants from Teva Pharmaceuticals, Bayer Healthcare Pharmaceuticals, and Merck, as well as serving on the advisory boards of Perrigo and Teva. Dr. McNicholas is affiliated with Washington University, St. Louis, and reported having no financial conflicts.
The USPSTF task force finding of insufficient evidence to support or refute screening pelvic exams conflicts with the views of other organizations, George F. Sawaya, MD, wrote in an editorial (JAMA 2017 Mar 7. doi: 10.1001/jamainternmed.2017.0271).
The American College of Physicians currently recommends against routine screening in asymptomatic, nonpregnant women, while the American College of Obstetricians and Gynecologists recommends in favor of an annual pelvic exam “based on expert opinion” despite the lack of evidence, he said.
“The USPSTF believes that in the setting of an ‘I’ statement, clinicians should be forthright with patients about the uncertainty concerning the balance of benefits and harms,” Dr. Sawaya wrote.
“But perhaps the conversation should focus on the uncertainty among the three professional groups,” he added. “Women should know the facts: that all three groups agree there is no scientific evidence that these examinations are beneficial; that there is evidence of harms including ‘false alarms,’ further testing, and even unnecessary surgery; and that one group strongly recommends against screening examinations, believing them to be more harmful than beneficial,” he said.
The USPSTF recommendation is not a surprise, Colleen McNicholas, DO, MSCI, and Jeffrey F. Peipert, MD, PhD, noted in a second editorial (JAMA 2017;317[9]:910-11). “Despite lack of rigorous research, many would argue that the periodic examination provides opportunity for counseling and trust building between the patient and physician and thus should be universally implemented,” they wrote. However, many women express fear and anxiety before the exam and discomfort, pain, or embarrassment during the exam. “To ignore this aspect when comparing individual parts of the examination seems insensitive and inappropriate,” they added.
“Women, as patients, should be involved in the decision regarding whether to perform a pelvic examination, and clinicians should not require that the patient undergo this procedure to obtain screening, counseling, and age-appropriate health services,” they concluded.
Dr. Sawaya is affiliated with the University of California, San Francisco. He reported having no financial conflicts. Dr. Peipert is affiliated with Indiana University School of Medicine, Indianapolis, and disclosed receiving grants from Teva Pharmaceuticals, Bayer Healthcare Pharmaceuticals, and Merck, as well as serving on the advisory boards of Perrigo and Teva. Dr. McNicholas is affiliated with Washington University, St. Louis, and reported having no financial conflicts.
Current evidence fails to support or reject routine screening pelvic exams for asymptomatic, low-risk, nonpregnant adult women, the U.S. Preventive Services Task Force concluded after reviewing the evidence on the accuracy, benefits, and potential harms.
The USPSTF issued an inconclusive “I” statement that was published online March 7 (JAMA. 2017;317[9]:947-53).
Researchers found no data comparing the impact of no screening versus screening pelvic examinations on patient health outcomes including reducing all-cause mortality, reducing cancer-specific and disease-specific morbidity and mortality, and improving quality of life.
“No direct evidence was identified for overall benefits and harms of the pelvic examination as a one-time or periodic screening test,” Janelle M. Guirguis-Blake, MD, of the University of Washington, Tacoma, and colleagues wrote in the accompanying evidence report (JAMA. 2017;317[9]:954-66). The review comprised nine studies: one addressing the harms of screening and eight addressing both harms and accuracy.
Although screening pelvic exams may identify serious conditions as well as benign ones, the potential remains for false-positive and false-negative results that might lead to invasive surgery and unnecessary testing and procedures, the researchers noted. However, the recommendations do not apply to certain conditions for which screening is already recommended, including cervical cancer (via Pap smear), gonorrhea, and chlamydia.
The recommendations are primarily a call for more research rather than a clear guide for clinicians, according to the USPSTF. The research gaps include studies on the physical and psychological harms of pelvic screening for asymptomatic women in primary care; the ability of screening to detect conditions beyond ovarian cancer, genital herpes, bacterial vaginosis, and trichomoniasis; and the impact of screening on a variety of health outcomes, including quality of life.
Given the inadequate evidence to recommend for or against screening, the USPSTF cited the recommendations of other organizations. Both the American College of Physicians and the American Academy of Family Physicians recommend against performing screening pelvic exams in asymptomatic, nonpregnant adult women. The American College of Obstetricians and Gynecologists recommends annual pelvic exams for women 21 years and older but acknowledges a lack of evidence and has said it should be a shared decision between the patient and clinician.
The USPSTF members reported having no relevant financial conflicts.
Current evidence fails to support or reject routine screening pelvic exams for asymptomatic, low-risk, nonpregnant adult women, the U.S. Preventive Services Task Force concluded after reviewing the evidence on the accuracy, benefits, and potential harms.
The USPSTF issued an inconclusive “I” statement that was published online March 7 (JAMA. 2017;317[9]:947-53).
Researchers found no data comparing the impact of no screening versus screening pelvic examinations on patient health outcomes including reducing all-cause mortality, reducing cancer-specific and disease-specific morbidity and mortality, and improving quality of life.
“No direct evidence was identified for overall benefits and harms of the pelvic examination as a one-time or periodic screening test,” Janelle M. Guirguis-Blake, MD, of the University of Washington, Tacoma, and colleagues wrote in the accompanying evidence report (JAMA. 2017;317[9]:954-66). The review comprised nine studies: one addressing the harms of screening and eight addressing both harms and accuracy.
Although screening pelvic exams may identify serious conditions as well as benign ones, the potential remains for false-positive and false-negative results that might lead to invasive surgery and unnecessary testing and procedures, the researchers noted. However, the recommendations do not apply to certain conditions for which screening is already recommended, including cervical cancer (via Pap smear), gonorrhea, and chlamydia.
The recommendations are primarily a call for more research rather than a clear guide for clinicians, according to the USPSTF. The research gaps include studies on the physical and psychological harms of pelvic screening for asymptomatic women in primary care; the ability of screening to detect conditions beyond ovarian cancer, genital herpes, bacterial vaginosis, and trichomoniasis; and the impact of screening on a variety of health outcomes, including quality of life.
Given the inadequate evidence to recommend for or against screening, the USPSTF cited the recommendations of other organizations. Both the American College of Physicians and the American Academy of Family Physicians recommend against performing screening pelvic exams in asymptomatic, nonpregnant adult women. The American College of Obstetricians and Gynecologists recommends annual pelvic exams for women 21 years and older but acknowledges a lack of evidence and has said it should be a shared decision between the patient and clinician.
The USPSTF members reported having no relevant financial conflicts.
FROM JAMA
Teen indoor tanning drops, but schools fall short on sun safety
Indoor tanning among adolescents in the United States has dropped significantly, but fewer than half of schools in the United States reported sun safety practices to help minimize students’ UV exposure in the school setting, based on data from two studies presented at the annual meeting of the American Academy of Dermatology and published simultaneously in JAMA Dermatology.
“Data suggest that intermittent, recreational exposure (vs. chronic exposure, as with outdoor workers) more often leads to sunburn,” wrote Sherry Everett Jones, PhD, MPH, and Gery P. Guy Jr, PhD, MPH, of the Centers for Disease Control and Prevention. “Although a small proportion of school districts and schools have adopted policies to address sun safety, most have not, even though it is common for students to be outside during the midday hours or after school when the sun is still at peak intensity.”
To characterize sun safety practices at schools, the researchers reviewed data from the 2014 School Health Policies and Practices Study Healthy and Safe School Environment questionnaire including 577 elementary, middle, and high schools (JAMA Dermatol. 2017. doi: 10.1001/jamadermatol.2016.6274).
Overall, 48% of schools reported that teachers allowed students time to apply sunscreen at school (the most frequent sun safety practice). However, only 13% made sunscreen available, 16% asked parents to ensure sunscreen application before school, and 15% made an effort to avoid scheduling outdoor activities during times of peak sun intensity. High schools were less likely than elementary or middle schools to follow sun safety practices.
“None of the sun safety policies or practices were statistically significantly associated with metropolitan status,” the researchers noted. However, the findings were limited by the cross-sectional nature of the study and lack of data about natural shade and man made shade structures in outdoor areas of the schools.
“Interventions driven by the public health and medical community educating school leadership and policy makers about the importance of sun safety are needed regardless of level, location, size, and poverty concentration of the school. These efforts could be instrumental in increasing the adoption of sun safety practices among schools,” Dr. Jones and Dr. Guy emphasized.
However, data from another study showed a significant reduction in the prevalence of indoor tanning among adolescents.
In particular, indoor tanning among non-Hispanic white females (the group at highest risk for skin cancer) dropped from 37% in 2009 to 15% in 2015. CDC researchers led by Dr. Guy pooled data from the 2009, 2011, 2013, and 2015 national Youth Risk Behavior Surveillance System Surveys (JAMA Dermatol. 2017. doi:10.1001/jamadermatol.2016.6273). Overall, the prevalence of indoor tanning among U.S. high school students decreased from 16% in 2009 to 7% in 2015.
“Despite declines in indoor tanning, continued efforts are needed,” the researchers wrote. “Public health efforts could help address the misconception that indoor tanning protects against sunburn. The medical community also can play a key role in counseling adolescents and young adults in accordance with the U.S. Preventive Services Task Force guidelines.”
The findings were limited by several factors including the use of self-reports and the inability to control for skin type, the researchers wrote. However, “Reducing the proportion of youth who engage in indoor tanning and experience sunburns presents an important cancer prevention opportunity.”
None of the researchers on either study had relevant financial conflicts to disclose.
Explore best practices for public education campaigns “For more than 10 years, much effort has been made to educate the public on sun-safety practices, including warnings about the harmful effects of indoor tanning on those at higher risk, such as young adults and children. In this issue of JAMA Dermatology, 2 important articles describe the progress made toward sun safety,” wrote Henry W. Lim, MD, and Samantha L. Schneider, MD, in the accompanying editorial.
Data from a study of indoor tanning showed a significant decrease in prevalence of indoor tanning among adolescents, from 16% in 2009 to 7% in 2015. Although these results are encouraging, public education is needed for further improvement, they said. “One myth is that UV radiation prevents vitamin D deficiency; however, oral vitamin D supplementation is known to be a safer alternative. Another myth is that obtaining a baseline tan before the summer or a vacation reduces the risk of sunburn. However, as Guy and colleagues observed, those who tanned indoors were more likely to develop sunburn than students who did not engage in indoor tanning.”
“Clearly, both the dermatology and medical communities need to continue public awareness campaigns regarding photoprotection, including sun-safety practices such as seeking shade when outdoors and wearing photoprotective clothing, wide-brimmed hats, and sunglasses,” they emphasized.
In addition, “A highly effective means of public education may be to identify a campaign, such as Portugal’s sugar packet initiative, that makes sun-safety awareness and practice a part of everyone’s daily routine,” they said (JAMA Dermatol. 2017. doi: 10.1001/jamadermatol.2016.6272).
Dr. Lim and Dr. Schneider are affiliated with the department of dermatology at Henry Ford Hospital in Detroit. Dr Lim disclosed serving as an investigator or coinvestigator on clinical research projects for Ferndale Pharma, Estée Lauder, and Allergan. Dr. Schneider had no relevant conflicts to disclose.
Explore best practices for public education campaigns “For more than 10 years, much effort has been made to educate the public on sun-safety practices, including warnings about the harmful effects of indoor tanning on those at higher risk, such as young adults and children. In this issue of JAMA Dermatology, 2 important articles describe the progress made toward sun safety,” wrote Henry W. Lim, MD, and Samantha L. Schneider, MD, in the accompanying editorial.
Data from a study of indoor tanning showed a significant decrease in prevalence of indoor tanning among adolescents, from 16% in 2009 to 7% in 2015. Although these results are encouraging, public education is needed for further improvement, they said. “One myth is that UV radiation prevents vitamin D deficiency; however, oral vitamin D supplementation is known to be a safer alternative. Another myth is that obtaining a baseline tan before the summer or a vacation reduces the risk of sunburn. However, as Guy and colleagues observed, those who tanned indoors were more likely to develop sunburn than students who did not engage in indoor tanning.”
“Clearly, both the dermatology and medical communities need to continue public awareness campaigns regarding photoprotection, including sun-safety practices such as seeking shade when outdoors and wearing photoprotective clothing, wide-brimmed hats, and sunglasses,” they emphasized.
In addition, “A highly effective means of public education may be to identify a campaign, such as Portugal’s sugar packet initiative, that makes sun-safety awareness and practice a part of everyone’s daily routine,” they said (JAMA Dermatol. 2017. doi: 10.1001/jamadermatol.2016.6272).
Dr. Lim and Dr. Schneider are affiliated with the department of dermatology at Henry Ford Hospital in Detroit. Dr Lim disclosed serving as an investigator or coinvestigator on clinical research projects for Ferndale Pharma, Estée Lauder, and Allergan. Dr. Schneider had no relevant conflicts to disclose.
Explore best practices for public education campaigns “For more than 10 years, much effort has been made to educate the public on sun-safety practices, including warnings about the harmful effects of indoor tanning on those at higher risk, such as young adults and children. In this issue of JAMA Dermatology, 2 important articles describe the progress made toward sun safety,” wrote Henry W. Lim, MD, and Samantha L. Schneider, MD, in the accompanying editorial.
Data from a study of indoor tanning showed a significant decrease in prevalence of indoor tanning among adolescents, from 16% in 2009 to 7% in 2015. Although these results are encouraging, public education is needed for further improvement, they said. “One myth is that UV radiation prevents vitamin D deficiency; however, oral vitamin D supplementation is known to be a safer alternative. Another myth is that obtaining a baseline tan before the summer or a vacation reduces the risk of sunburn. However, as Guy and colleagues observed, those who tanned indoors were more likely to develop sunburn than students who did not engage in indoor tanning.”
“Clearly, both the dermatology and medical communities need to continue public awareness campaigns regarding photoprotection, including sun-safety practices such as seeking shade when outdoors and wearing photoprotective clothing, wide-brimmed hats, and sunglasses,” they emphasized.
In addition, “A highly effective means of public education may be to identify a campaign, such as Portugal’s sugar packet initiative, that makes sun-safety awareness and practice a part of everyone’s daily routine,” they said (JAMA Dermatol. 2017. doi: 10.1001/jamadermatol.2016.6272).
Dr. Lim and Dr. Schneider are affiliated with the department of dermatology at Henry Ford Hospital in Detroit. Dr Lim disclosed serving as an investigator or coinvestigator on clinical research projects for Ferndale Pharma, Estée Lauder, and Allergan. Dr. Schneider had no relevant conflicts to disclose.
Indoor tanning among adolescents in the United States has dropped significantly, but fewer than half of schools in the United States reported sun safety practices to help minimize students’ UV exposure in the school setting, based on data from two studies presented at the annual meeting of the American Academy of Dermatology and published simultaneously in JAMA Dermatology.
“Data suggest that intermittent, recreational exposure (vs. chronic exposure, as with outdoor workers) more often leads to sunburn,” wrote Sherry Everett Jones, PhD, MPH, and Gery P. Guy Jr, PhD, MPH, of the Centers for Disease Control and Prevention. “Although a small proportion of school districts and schools have adopted policies to address sun safety, most have not, even though it is common for students to be outside during the midday hours or after school when the sun is still at peak intensity.”
To characterize sun safety practices at schools, the researchers reviewed data from the 2014 School Health Policies and Practices Study Healthy and Safe School Environment questionnaire including 577 elementary, middle, and high schools (JAMA Dermatol. 2017. doi: 10.1001/jamadermatol.2016.6274).
Overall, 48% of schools reported that teachers allowed students time to apply sunscreen at school (the most frequent sun safety practice). However, only 13% made sunscreen available, 16% asked parents to ensure sunscreen application before school, and 15% made an effort to avoid scheduling outdoor activities during times of peak sun intensity. High schools were less likely than elementary or middle schools to follow sun safety practices.
“None of the sun safety policies or practices were statistically significantly associated with metropolitan status,” the researchers noted. However, the findings were limited by the cross-sectional nature of the study and lack of data about natural shade and man made shade structures in outdoor areas of the schools.
“Interventions driven by the public health and medical community educating school leadership and policy makers about the importance of sun safety are needed regardless of level, location, size, and poverty concentration of the school. These efforts could be instrumental in increasing the adoption of sun safety practices among schools,” Dr. Jones and Dr. Guy emphasized.
However, data from another study showed a significant reduction in the prevalence of indoor tanning among adolescents.
In particular, indoor tanning among non-Hispanic white females (the group at highest risk for skin cancer) dropped from 37% in 2009 to 15% in 2015. CDC researchers led by Dr. Guy pooled data from the 2009, 2011, 2013, and 2015 national Youth Risk Behavior Surveillance System Surveys (JAMA Dermatol. 2017. doi:10.1001/jamadermatol.2016.6273). Overall, the prevalence of indoor tanning among U.S. high school students decreased from 16% in 2009 to 7% in 2015.
“Despite declines in indoor tanning, continued efforts are needed,” the researchers wrote. “Public health efforts could help address the misconception that indoor tanning protects against sunburn. The medical community also can play a key role in counseling adolescents and young adults in accordance with the U.S. Preventive Services Task Force guidelines.”
The findings were limited by several factors including the use of self-reports and the inability to control for skin type, the researchers wrote. However, “Reducing the proportion of youth who engage in indoor tanning and experience sunburns presents an important cancer prevention opportunity.”
None of the researchers on either study had relevant financial conflicts to disclose.
Indoor tanning among adolescents in the United States has dropped significantly, but fewer than half of schools in the United States reported sun safety practices to help minimize students’ UV exposure in the school setting, based on data from two studies presented at the annual meeting of the American Academy of Dermatology and published simultaneously in JAMA Dermatology.
“Data suggest that intermittent, recreational exposure (vs. chronic exposure, as with outdoor workers) more often leads to sunburn,” wrote Sherry Everett Jones, PhD, MPH, and Gery P. Guy Jr, PhD, MPH, of the Centers for Disease Control and Prevention. “Although a small proportion of school districts and schools have adopted policies to address sun safety, most have not, even though it is common for students to be outside during the midday hours or after school when the sun is still at peak intensity.”
To characterize sun safety practices at schools, the researchers reviewed data from the 2014 School Health Policies and Practices Study Healthy and Safe School Environment questionnaire including 577 elementary, middle, and high schools (JAMA Dermatol. 2017. doi: 10.1001/jamadermatol.2016.6274).
Overall, 48% of schools reported that teachers allowed students time to apply sunscreen at school (the most frequent sun safety practice). However, only 13% made sunscreen available, 16% asked parents to ensure sunscreen application before school, and 15% made an effort to avoid scheduling outdoor activities during times of peak sun intensity. High schools were less likely than elementary or middle schools to follow sun safety practices.
“None of the sun safety policies or practices were statistically significantly associated with metropolitan status,” the researchers noted. However, the findings were limited by the cross-sectional nature of the study and lack of data about natural shade and man made shade structures in outdoor areas of the schools.
“Interventions driven by the public health and medical community educating school leadership and policy makers about the importance of sun safety are needed regardless of level, location, size, and poverty concentration of the school. These efforts could be instrumental in increasing the adoption of sun safety practices among schools,” Dr. Jones and Dr. Guy emphasized.
However, data from another study showed a significant reduction in the prevalence of indoor tanning among adolescents.
In particular, indoor tanning among non-Hispanic white females (the group at highest risk for skin cancer) dropped from 37% in 2009 to 15% in 2015. CDC researchers led by Dr. Guy pooled data from the 2009, 2011, 2013, and 2015 national Youth Risk Behavior Surveillance System Surveys (JAMA Dermatol. 2017. doi:10.1001/jamadermatol.2016.6273). Overall, the prevalence of indoor tanning among U.S. high school students decreased from 16% in 2009 to 7% in 2015.
“Despite declines in indoor tanning, continued efforts are needed,” the researchers wrote. “Public health efforts could help address the misconception that indoor tanning protects against sunburn. The medical community also can play a key role in counseling adolescents and young adults in accordance with the U.S. Preventive Services Task Force guidelines.”
The findings were limited by several factors including the use of self-reports and the inability to control for skin type, the researchers wrote. However, “Reducing the proportion of youth who engage in indoor tanning and experience sunburns presents an important cancer prevention opportunity.”
None of the researchers on either study had relevant financial conflicts to disclose.
FROM AAD 2017
Key clinical point:
Major finding: Fewer than half (48%) of schools in the United States allowed time for sunscreen application, and fewer than 15% provided sunscreen. However, overall prevalence of indoor tanning among U.S. adolescents dropped from 16% in 2009 to 7% in 2015.
Data source: Data were taken from the 2014 School Health Policies and Practices Study in the first study and from the 2009, 2011, 2013, and 2015 national Youth Risk Behavior Surveys in the second.
Disclosures: The researchers had no financial conflicts to disclose.
Chikungunya implicated in long-term joint disease
A majority of Chikungunya infections can cause arthritis and arthralgia months or years after the initial infection, based on data from a prospective study of 307 patients.
“The most common symptoms of Chikungunya virus infection are fever associated with rheumatic manifestations,” wrote rheumatologist Eric Bouquillard, MD, of Saint-Pierre, Reunion, France, and his colleagues.
Overall, 83% of the patients showed persistent joint pain after an average of 32 months. In addition, synovitis occurred in 64% of the patients who experienced chronic joint pain, mainly in the wrists, fingers, and ankles.
At baseline, the average number of painful joints was 6.5. At follow-up, the average number of painful joints was 3.3, and 43% of patients reported persistence of one or more swollen joints.
However, the patients reported little functional impairment; the average Health Assessment Questionnaire score was 0.44.
“RT-PCR [reverse transcription–polymerase chain reaction] was used in an attempt to detect the viral genome in synovial fluid samples from 10 patients, including 2 patients in the viremic phase, but the results were always negative,” the researchers noted.
Dr. Bouquillard and his colleagues enrolled the patients during April 2005-December 2006. Rheumatologic exams were conducted at baseline, and follow-up data were collected by phone surveys at 1 and 2 years after the onset of Chikungunya infection. Phone surveys were conducted by the Reunion Island Clinical Investigation Centre for Clinical Epidemiology, and interviewers also assessed patients for signs of anxiety, depression, and weakness.
The study was not designed to address treatment, but data from previous studies suggest that combination disease-modifying antirheumatic drug therapy may be more effective than hydroxychloroquine monotherapy for chronic joint pain post Chikungunya, the researchers noted.
The researchers had no financial conflicts to disclose. The study was supported in part by the Union Régionale des Médecins Libéraux de La Réunion.
A majority of Chikungunya infections can cause arthritis and arthralgia months or years after the initial infection, based on data from a prospective study of 307 patients.
“The most common symptoms of Chikungunya virus infection are fever associated with rheumatic manifestations,” wrote rheumatologist Eric Bouquillard, MD, of Saint-Pierre, Reunion, France, and his colleagues.
Overall, 83% of the patients showed persistent joint pain after an average of 32 months. In addition, synovitis occurred in 64% of the patients who experienced chronic joint pain, mainly in the wrists, fingers, and ankles.
At baseline, the average number of painful joints was 6.5. At follow-up, the average number of painful joints was 3.3, and 43% of patients reported persistence of one or more swollen joints.
However, the patients reported little functional impairment; the average Health Assessment Questionnaire score was 0.44.
“RT-PCR [reverse transcription–polymerase chain reaction] was used in an attempt to detect the viral genome in synovial fluid samples from 10 patients, including 2 patients in the viremic phase, but the results were always negative,” the researchers noted.
Dr. Bouquillard and his colleagues enrolled the patients during April 2005-December 2006. Rheumatologic exams were conducted at baseline, and follow-up data were collected by phone surveys at 1 and 2 years after the onset of Chikungunya infection. Phone surveys were conducted by the Reunion Island Clinical Investigation Centre for Clinical Epidemiology, and interviewers also assessed patients for signs of anxiety, depression, and weakness.
The study was not designed to address treatment, but data from previous studies suggest that combination disease-modifying antirheumatic drug therapy may be more effective than hydroxychloroquine monotherapy for chronic joint pain post Chikungunya, the researchers noted.
The researchers had no financial conflicts to disclose. The study was supported in part by the Union Régionale des Médecins Libéraux de La Réunion.
A majority of Chikungunya infections can cause arthritis and arthralgia months or years after the initial infection, based on data from a prospective study of 307 patients.
“The most common symptoms of Chikungunya virus infection are fever associated with rheumatic manifestations,” wrote rheumatologist Eric Bouquillard, MD, of Saint-Pierre, Reunion, France, and his colleagues.
Overall, 83% of the patients showed persistent joint pain after an average of 32 months. In addition, synovitis occurred in 64% of the patients who experienced chronic joint pain, mainly in the wrists, fingers, and ankles.
At baseline, the average number of painful joints was 6.5. At follow-up, the average number of painful joints was 3.3, and 43% of patients reported persistence of one or more swollen joints.
However, the patients reported little functional impairment; the average Health Assessment Questionnaire score was 0.44.
“RT-PCR [reverse transcription–polymerase chain reaction] was used in an attempt to detect the viral genome in synovial fluid samples from 10 patients, including 2 patients in the viremic phase, but the results were always negative,” the researchers noted.
Dr. Bouquillard and his colleagues enrolled the patients during April 2005-December 2006. Rheumatologic exams were conducted at baseline, and follow-up data were collected by phone surveys at 1 and 2 years after the onset of Chikungunya infection. Phone surveys were conducted by the Reunion Island Clinical Investigation Centre for Clinical Epidemiology, and interviewers also assessed patients for signs of anxiety, depression, and weakness.
The study was not designed to address treatment, but data from previous studies suggest that combination disease-modifying antirheumatic drug therapy may be more effective than hydroxychloroquine monotherapy for chronic joint pain post Chikungunya, the researchers noted.
The researchers had no financial conflicts to disclose. The study was supported in part by the Union Régionale des Médecins Libéraux de La Réunion.
FROM JOINT BONE SPINE
Key clinical point:
Major finding: Approximately 83% of adults with Chikungunya virus infections reported persistent joint pain after an average of 32 months.
Data source: A prospective, multicenter study of 307 adults with a history of Chikungunya virus infections.
Disclosures: The researchers had no financial conflicts to disclose. The study was supported in part by the Union Régionale des Médecins Libéraux de La Réunion.
Electrical stimulation skin patch shows promise in easing migraine pain
A wireless skin patch using electrical stimulation at an intensity lower than pain threshold reduced migraine pain when compared against sham stimulation in a trial of 71 adults with episodic migraine. The findings were published online March 1 in Neurology.
“Our rationale is activation of pain inhibitory centers, via the conditioned pain modulation effect; remote noxious stimuli can exert a generalized analgesic effect,” wrote David Yarnitsky, MD, of the Rambam Healthcare Campus and Technion Faculty of Medicine, Haifa, Israel, and his colleagues.
The devices were randomized to give a nonpainful sham stimulation at a very low frequency (controls) or a nonpainful active stimulation at one of four levels (active treatment). Patients were asked to place the wireless patch on the arm of their choice, regardless of the location of migraine pain, and activate the device for 20 minutes as soon as possible after a migraine attack began. They were instructed to use their smartphones to adjust the stimulation as appropriate during the treatment time. The stimulations were active programs at 80-120 Hz with pulse widths of 200, 150, 100, and 50 microseconds. The sham stimulation was a 0.1-Hz frequency with 45-microsecond pulses.
Overall, 64% of patients at the top three stimuli levels reduced their pain level by at least half 2 hours after the treatment, compared with 26% of patients using the sham stimulation. Average reductions were 46% for the 200-microsecond stimulus, 48% for 150, and 39% for 100.
In addition, 58% of the patients in the 200-microsecond group with moderate to severe pain at baseline reported reductions to mild or no pain, compared with 24% of sham patients.
Treatment with stimulation within 20 minutes of migraine onset was the most helpful, resulting in a 47% pain reduction, compared with a 25% reduction with delayed treatment, the researchers noted.
No patients reported side effects or adverse events related to the device.
The investigators said that complete 20-minute treatments were obtained for 70% of each of the top three stimuli levels, for 58% of treatments at 50-microsecond pulse widths, and for just 28% of placebo treatments. This low rate of completion of placebo stimuli may be the result of a loss of blinding for some of the sham activations, the investigators acknowledged, but they argued that “it is likely that this fact did not lead to falsely improved results; on the contrary, had those incomplete stimuli periods been completed, it is most likely that sham effectiveness results would have been lower than currently reported, making the results even more distinct.”
The study was funded by Theranica, and Dr. Yarnitsky disclosed serving on the company’s medical advisory board.
A wireless skin patch using electrical stimulation at an intensity lower than pain threshold reduced migraine pain when compared against sham stimulation in a trial of 71 adults with episodic migraine. The findings were published online March 1 in Neurology.
“Our rationale is activation of pain inhibitory centers, via the conditioned pain modulation effect; remote noxious stimuli can exert a generalized analgesic effect,” wrote David Yarnitsky, MD, of the Rambam Healthcare Campus and Technion Faculty of Medicine, Haifa, Israel, and his colleagues.
The devices were randomized to give a nonpainful sham stimulation at a very low frequency (controls) or a nonpainful active stimulation at one of four levels (active treatment). Patients were asked to place the wireless patch on the arm of their choice, regardless of the location of migraine pain, and activate the device for 20 minutes as soon as possible after a migraine attack began. They were instructed to use their smartphones to adjust the stimulation as appropriate during the treatment time. The stimulations were active programs at 80-120 Hz with pulse widths of 200, 150, 100, and 50 microseconds. The sham stimulation was a 0.1-Hz frequency with 45-microsecond pulses.
Overall, 64% of patients at the top three stimuli levels reduced their pain level by at least half 2 hours after the treatment, compared with 26% of patients using the sham stimulation. Average reductions were 46% for the 200-microsecond stimulus, 48% for 150, and 39% for 100.
In addition, 58% of the patients in the 200-microsecond group with moderate to severe pain at baseline reported reductions to mild or no pain, compared with 24% of sham patients.
Treatment with stimulation within 20 minutes of migraine onset was the most helpful, resulting in a 47% pain reduction, compared with a 25% reduction with delayed treatment, the researchers noted.
No patients reported side effects or adverse events related to the device.
The investigators said that complete 20-minute treatments were obtained for 70% of each of the top three stimuli levels, for 58% of treatments at 50-microsecond pulse widths, and for just 28% of placebo treatments. This low rate of completion of placebo stimuli may be the result of a loss of blinding for some of the sham activations, the investigators acknowledged, but they argued that “it is likely that this fact did not lead to falsely improved results; on the contrary, had those incomplete stimuli periods been completed, it is most likely that sham effectiveness results would have been lower than currently reported, making the results even more distinct.”
The study was funded by Theranica, and Dr. Yarnitsky disclosed serving on the company’s medical advisory board.
A wireless skin patch using electrical stimulation at an intensity lower than pain threshold reduced migraine pain when compared against sham stimulation in a trial of 71 adults with episodic migraine. The findings were published online March 1 in Neurology.
“Our rationale is activation of pain inhibitory centers, via the conditioned pain modulation effect; remote noxious stimuli can exert a generalized analgesic effect,” wrote David Yarnitsky, MD, of the Rambam Healthcare Campus and Technion Faculty of Medicine, Haifa, Israel, and his colleagues.
The devices were randomized to give a nonpainful sham stimulation at a very low frequency (controls) or a nonpainful active stimulation at one of four levels (active treatment). Patients were asked to place the wireless patch on the arm of their choice, regardless of the location of migraine pain, and activate the device for 20 minutes as soon as possible after a migraine attack began. They were instructed to use their smartphones to adjust the stimulation as appropriate during the treatment time. The stimulations were active programs at 80-120 Hz with pulse widths of 200, 150, 100, and 50 microseconds. The sham stimulation was a 0.1-Hz frequency with 45-microsecond pulses.
Overall, 64% of patients at the top three stimuli levels reduced their pain level by at least half 2 hours after the treatment, compared with 26% of patients using the sham stimulation. Average reductions were 46% for the 200-microsecond stimulus, 48% for 150, and 39% for 100.
In addition, 58% of the patients in the 200-microsecond group with moderate to severe pain at baseline reported reductions to mild or no pain, compared with 24% of sham patients.
Treatment with stimulation within 20 minutes of migraine onset was the most helpful, resulting in a 47% pain reduction, compared with a 25% reduction with delayed treatment, the researchers noted.
No patients reported side effects or adverse events related to the device.
The investigators said that complete 20-minute treatments were obtained for 70% of each of the top three stimuli levels, for 58% of treatments at 50-microsecond pulse widths, and for just 28% of placebo treatments. This low rate of completion of placebo stimuli may be the result of a loss of blinding for some of the sham activations, the investigators acknowledged, but they argued that “it is likely that this fact did not lead to falsely improved results; on the contrary, had those incomplete stimuli periods been completed, it is most likely that sham effectiveness results would have been lower than currently reported, making the results even more distinct.”
The study was funded by Theranica, and Dr. Yarnitsky disclosed serving on the company’s medical advisory board.
FROM NEUROLOGY
Key clinical point:
Major finding: A total of 64% of migraine patients experienced a 50% pain reduction when treated with a skin patch that delivered wireless, painless electrical stimulation, compared with 26% of patients who received sham treatment.
Data source: A prospective, double-blind, randomized, crossover, sham-controlled study including 71 adults and 299 episodes of migraine.
Disclosures: The study was funded by Theranica, and lead author Dr. Yarnitsky disclosed serving on the company’s medical advisory board.
Updated SSI prevention guidance highlights glucose control, MRSA
The guidelines for controlling surgical site infections have been updated to reflect evidence-based findings of a collaboration between surgeons and infection control experts from the American College of Surgeons, the ACS National Surgical Quality Improvement Program, and the Surgical Infection Society.
Updated strategies to reduce the risk of surgical site infections (SSIs) include perioperative glucose control in all patients and the use of oral antibiotics as an element of colon procedures, according to guidelines published in Journal of the American College of Surgeons (J Am Coll Surg. 2017;224:59-74).
Surgical site infections now account for 20% of all hospital-acquired infections, wrote lead author Kristen A. Ban, MD, a surgical resident at Loyola University Medical Center, Maywood, Ill., and her colleagues.
The most recent guidelines for preventing surgical site infections came from the Centers for Disease Control and Prevention in 1999; “the CDC has been working on an update since 2011, but this has been incredibly slow,” E. Patchen Dellinger, MD, of the University of Washington, Seattle, one of the guidelines’ authors, said in an interview. “A publication should be coming out sometime this year, but in the meantime, it was useful to have something for clinicians to refer to,” he said.
The researchers used PubMed to review specific topics in the SSI literature and address knowledge gaps.
Based on their findings, the new guidelines add recommendations to previous versions that address SSI prevention in the prehospital setting, at the hospital, and after discharge. The level of evidence to support each guideline varies; the researchers strongly recommend certain points, such as perioperative glucose control for all patients, not only those with diabetes; other recommendations such as postoperative showering 12 hours after surgery vs. delayed showering are left to the surgeon’s discretion.
“The changes/new recommendations since the 1999 guideline include the recommendation for the use of oral antibiotics with mechanical bowel prep for colon operations (in combination with intravenous prophylactic antibiotics), the control of perioperative glucose levels in ALL patients (not just diabetics), the maintenance of normothermia in the OR, the use of wound protectors for clean-contaminated cases, the use of antimicrobial sutures, and the use of increased FiO2 levels for intubated patients,” Dr. Dellinger said. These new elements also will be recommended when the updated CDC guidelines are released, and already have been recommended in recent guidelines from the World Health Organization, he added.
Guidelines for prehospital interventions include smoking cessation 4-6 weeks before surgery, preoperative bathing with chlorhexidine, glucose control for diabetes patients, MRSA screening, and bowel preparation (combining mechanical and antibiotic) for all elective colectomies.
Recommended hospital interventions include the following:
• Intraoperative normothermia.
• Use of wound protectors in open abdominal surgery.
• Use of triclosan antibiotic sutures.
• Supplemental oxygen.
• Antibiotic prophylaxis when indicated.
• Glucose control for all patients perioperatively.
• Hair removal only when necessary, avoiding a razor if possible.
• Alcohol-based skin preparation when possible.
• Surgical hand scrub.
• Facility scrub laundering and use of a skull cap if minimal hair is exposed.
• Use of double gloves and changing gloves before incision closure in colorectal cases.
• Use of new instruments for closure in colorectal cases.
• Purse string closure of stoma sites.
• Use of topical antibiotics as part of wound care.
• Using wound vacuum therapy over stapled skin.
Data on interventions after hospital discharge that may reduce SSI incidence are limited, the researchers said. No specific wound care protocols or surveillance methods have been identified. However, “promising new methods of surveillance are being explored, many of which use smartphone technology to help patients send their surgeon daily photos or updates,” they noted.
“Strategies to decrease SSI are multimodal and occur across a range of settings under the supervision of numerous providers,” the researchers wrote. “Ensuring high compliance with these risk-reduction strategies is crucial to the success of SSI reduction efforts,” they added.
However, changes to surgical practice don’t happen overnight, Dr. Dellinger said. “If all of these are actually adapted it should decrease SSI rates in all areas,” he noted. “Oral antibiotics for colorectal cases and glucose control for all patients will probably make the biggest benefit if actually adopted,” he said.
“We could use some better studies on the precise timing of parenteral prophylactic antibiotics,” said Dr. Dellinger. “One such study has been submitted from Switzerland and should be published sometime this year. Hard evidence on the best timing is missing although observational data allows some of us to come to conclusions on that,” he said. “Additional studies on perioperative oxygenation where fluid management and temperature management are better controlled would be helpful, and more and better studies are need for antimicrobial sutures,” he added.
The authors had nothing to disclose relevant to the scope of the guidelines. Outside the scope of this work, Dr. Dellinger disclosed serving on the advisory boards for 3M, Melinta, and Theravance, as well as receiving a grant from Motif for a clinical trial of iclaprim vs. vancomycin for the treatment of skin and soft tissue infections.
The guidelines for controlling surgical site infections have been updated to reflect evidence-based findings of a collaboration between surgeons and infection control experts from the American College of Surgeons, the ACS National Surgical Quality Improvement Program, and the Surgical Infection Society.
Updated strategies to reduce the risk of surgical site infections (SSIs) include perioperative glucose control in all patients and the use of oral antibiotics as an element of colon procedures, according to guidelines published in Journal of the American College of Surgeons (J Am Coll Surg. 2017;224:59-74).
Surgical site infections now account for 20% of all hospital-acquired infections, wrote lead author Kristen A. Ban, MD, a surgical resident at Loyola University Medical Center, Maywood, Ill., and her colleagues.
The most recent guidelines for preventing surgical site infections came from the Centers for Disease Control and Prevention in 1999; “the CDC has been working on an update since 2011, but this has been incredibly slow,” E. Patchen Dellinger, MD, of the University of Washington, Seattle, one of the guidelines’ authors, said in an interview. “A publication should be coming out sometime this year, but in the meantime, it was useful to have something for clinicians to refer to,” he said.
The researchers used PubMed to review specific topics in the SSI literature and address knowledge gaps.
Based on their findings, the new guidelines add recommendations to previous versions that address SSI prevention in the prehospital setting, at the hospital, and after discharge. The level of evidence to support each guideline varies; the researchers strongly recommend certain points, such as perioperative glucose control for all patients, not only those with diabetes; other recommendations such as postoperative showering 12 hours after surgery vs. delayed showering are left to the surgeon’s discretion.
“The changes/new recommendations since the 1999 guideline include the recommendation for the use of oral antibiotics with mechanical bowel prep for colon operations (in combination with intravenous prophylactic antibiotics), the control of perioperative glucose levels in ALL patients (not just diabetics), the maintenance of normothermia in the OR, the use of wound protectors for clean-contaminated cases, the use of antimicrobial sutures, and the use of increased FiO2 levels for intubated patients,” Dr. Dellinger said. These new elements also will be recommended when the updated CDC guidelines are released, and already have been recommended in recent guidelines from the World Health Organization, he added.
Guidelines for prehospital interventions include smoking cessation 4-6 weeks before surgery, preoperative bathing with chlorhexidine, glucose control for diabetes patients, MRSA screening, and bowel preparation (combining mechanical and antibiotic) for all elective colectomies.
Recommended hospital interventions include the following:
• Intraoperative normothermia.
• Use of wound protectors in open abdominal surgery.
• Use of triclosan antibiotic sutures.
• Supplemental oxygen.
• Antibiotic prophylaxis when indicated.
• Glucose control for all patients perioperatively.
• Hair removal only when necessary, avoiding a razor if possible.
• Alcohol-based skin preparation when possible.
• Surgical hand scrub.
• Facility scrub laundering and use of a skull cap if minimal hair is exposed.
• Use of double gloves and changing gloves before incision closure in colorectal cases.
• Use of new instruments for closure in colorectal cases.
• Purse string closure of stoma sites.
• Use of topical antibiotics as part of wound care.
• Using wound vacuum therapy over stapled skin.
Data on interventions after hospital discharge that may reduce SSI incidence are limited, the researchers said. No specific wound care protocols or surveillance methods have been identified. However, “promising new methods of surveillance are being explored, many of which use smartphone technology to help patients send their surgeon daily photos or updates,” they noted.
“Strategies to decrease SSI are multimodal and occur across a range of settings under the supervision of numerous providers,” the researchers wrote. “Ensuring high compliance with these risk-reduction strategies is crucial to the success of SSI reduction efforts,” they added.
However, changes to surgical practice don’t happen overnight, Dr. Dellinger said. “If all of these are actually adapted it should decrease SSI rates in all areas,” he noted. “Oral antibiotics for colorectal cases and glucose control for all patients will probably make the biggest benefit if actually adopted,” he said.
“We could use some better studies on the precise timing of parenteral prophylactic antibiotics,” said Dr. Dellinger. “One such study has been submitted from Switzerland and should be published sometime this year. Hard evidence on the best timing is missing although observational data allows some of us to come to conclusions on that,” he said. “Additional studies on perioperative oxygenation where fluid management and temperature management are better controlled would be helpful, and more and better studies are need for antimicrobial sutures,” he added.
The authors had nothing to disclose relevant to the scope of the guidelines. Outside the scope of this work, Dr. Dellinger disclosed serving on the advisory boards for 3M, Melinta, and Theravance, as well as receiving a grant from Motif for a clinical trial of iclaprim vs. vancomycin for the treatment of skin and soft tissue infections.
The guidelines for controlling surgical site infections have been updated to reflect evidence-based findings of a collaboration between surgeons and infection control experts from the American College of Surgeons, the ACS National Surgical Quality Improvement Program, and the Surgical Infection Society.
Updated strategies to reduce the risk of surgical site infections (SSIs) include perioperative glucose control in all patients and the use of oral antibiotics as an element of colon procedures, according to guidelines published in Journal of the American College of Surgeons (J Am Coll Surg. 2017;224:59-74).
Surgical site infections now account for 20% of all hospital-acquired infections, wrote lead author Kristen A. Ban, MD, a surgical resident at Loyola University Medical Center, Maywood, Ill., and her colleagues.
The most recent guidelines for preventing surgical site infections came from the Centers for Disease Control and Prevention in 1999; “the CDC has been working on an update since 2011, but this has been incredibly slow,” E. Patchen Dellinger, MD, of the University of Washington, Seattle, one of the guidelines’ authors, said in an interview. “A publication should be coming out sometime this year, but in the meantime, it was useful to have something for clinicians to refer to,” he said.
The researchers used PubMed to review specific topics in the SSI literature and address knowledge gaps.
Based on their findings, the new guidelines add recommendations to previous versions that address SSI prevention in the prehospital setting, at the hospital, and after discharge. The level of evidence to support each guideline varies; the researchers strongly recommend certain points, such as perioperative glucose control for all patients, not only those with diabetes; other recommendations such as postoperative showering 12 hours after surgery vs. delayed showering are left to the surgeon’s discretion.
“The changes/new recommendations since the 1999 guideline include the recommendation for the use of oral antibiotics with mechanical bowel prep for colon operations (in combination with intravenous prophylactic antibiotics), the control of perioperative glucose levels in ALL patients (not just diabetics), the maintenance of normothermia in the OR, the use of wound protectors for clean-contaminated cases, the use of antimicrobial sutures, and the use of increased FiO2 levels for intubated patients,” Dr. Dellinger said. These new elements also will be recommended when the updated CDC guidelines are released, and already have been recommended in recent guidelines from the World Health Organization, he added.
Guidelines for prehospital interventions include smoking cessation 4-6 weeks before surgery, preoperative bathing with chlorhexidine, glucose control for diabetes patients, MRSA screening, and bowel preparation (combining mechanical and antibiotic) for all elective colectomies.
Recommended hospital interventions include the following:
• Intraoperative normothermia.
• Use of wound protectors in open abdominal surgery.
• Use of triclosan antibiotic sutures.
• Supplemental oxygen.
• Antibiotic prophylaxis when indicated.
• Glucose control for all patients perioperatively.
• Hair removal only when necessary, avoiding a razor if possible.
• Alcohol-based skin preparation when possible.
• Surgical hand scrub.
• Facility scrub laundering and use of a skull cap if minimal hair is exposed.
• Use of double gloves and changing gloves before incision closure in colorectal cases.
• Use of new instruments for closure in colorectal cases.
• Purse string closure of stoma sites.
• Use of topical antibiotics as part of wound care.
• Using wound vacuum therapy over stapled skin.
Data on interventions after hospital discharge that may reduce SSI incidence are limited, the researchers said. No specific wound care protocols or surveillance methods have been identified. However, “promising new methods of surveillance are being explored, many of which use smartphone technology to help patients send their surgeon daily photos or updates,” they noted.
“Strategies to decrease SSI are multimodal and occur across a range of settings under the supervision of numerous providers,” the researchers wrote. “Ensuring high compliance with these risk-reduction strategies is crucial to the success of SSI reduction efforts,” they added.
However, changes to surgical practice don’t happen overnight, Dr. Dellinger said. “If all of these are actually adapted it should decrease SSI rates in all areas,” he noted. “Oral antibiotics for colorectal cases and glucose control for all patients will probably make the biggest benefit if actually adopted,” he said.
“We could use some better studies on the precise timing of parenteral prophylactic antibiotics,” said Dr. Dellinger. “One such study has been submitted from Switzerland and should be published sometime this year. Hard evidence on the best timing is missing although observational data allows some of us to come to conclusions on that,” he said. “Additional studies on perioperative oxygenation where fluid management and temperature management are better controlled would be helpful, and more and better studies are need for antimicrobial sutures,” he added.
The authors had nothing to disclose relevant to the scope of the guidelines. Outside the scope of this work, Dr. Dellinger disclosed serving on the advisory boards for 3M, Melinta, and Theravance, as well as receiving a grant from Motif for a clinical trial of iclaprim vs. vancomycin for the treatment of skin and soft tissue infections.
FROM THE JOURNAL OF THE AMERICAN COLLEGE OF SURGEONS
