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Data overwhelmingly support use of dermoscopy in practice
LAHAINA, HAWAII – Multiple but there are still some “nonbelievers,” Ashfaq A. Marghoob, MD, said at the Hawaii Dermatology Seminar provided by Global Academy for Medical Education/Skin Disease Education Foundation.
In fact, not one study has shown that dermoscopy is less sensitive than the naked eye alone, and at clinics where dermoscopy is used, “two-thirds of the melanomas being detected now lack the classic ABCD features of melanoma,” added Dr. Marghoob, director of clinical dermatology at Memorial Sloan Kettering in Hauppauge, N.Y.
Dr. Marghoob cited a meta-analysis of 9 prospective trials, which concluded that dermoscopy was more accurate in diagnosing melanoma than the naked eye alone and did not lower specificity, with a sensitivity and specificity of 90%, compared with 71% and 81%, respectively for the naked eye (Br J Dermatol. 2008 Sep;159[3]:669-76).
“And at least from an evidence-based standpoint ... the Cochrane library has basically endorsed that, yes, dermoscopy does indeed improve your diagnostic accuracy,” Dr. Marghoob said.
He referred to a 2018 Cochrane review on 104 dermoscopy studies, with and without visual inspection, for diagnosing melanoma in adults (Cochrane Database Syst Rev. 2018 Dec 4;12:CD011902). The review authors concluded that “the evidence suggests that melanomas will be missed if visual inspection is used on its own,” and despite limitations in the evidence, “dermoscopy is a valuable tool to support the visual inspection of a suspicious skin lesion for the detection of melanoma and atypical intraepidermal melanocytic variants.”
As for the question of specificity, Dr. Marghoob said studies have found that dermoscopy results in the detection of more melanomas and reduces the number of biopsies of benign lesions and “every study looking into this has shown that, yes, it does improve” specificity.
A 10-year multicenter survey of about 300,000 cases, which included 17,172 melanomas and 283,043 melanocytic nevi, found that the number-needed-to-excise (NNE) values improved over time in specialized clinics where newer diagnostic techniques like dermoscopy were used (from 12.8 to 6.8), but the NNE did not appear to change in the nonspecialized settings (J Am Acad Dermatol. 2012 Jul;67[1]:54-9).
Looking at the benign-to-malignant ratio, there was no change among those not using dermoscopy, where the ratio remained at about 30 to 1. When dermoscopy was used, this ratio started to improve over the 10-year period, to about 5 to 1. In addition, “the dermoscopy users were finding many more melanomas than the non–dermoscopy users,” Dr. Marghoob added. And over the 10 years, the number of nevi being removed did not change among those not using dermoscopy but dropped among those using dermoscopy.
Adding photography with the ability to digitally monitor patients helps bring this ratio down further, Dr. Marghoob noted. He referred to a study that instead evaluated the ratio of melanoma to nonmelanomas diagnosed among dermatologists in three groups: those with no digital dermoscopy with little dermoscopy training (group A, the reference group), no digital dermoscopy but more dermoscopy training (group B), and those using digital dermoscopy (group C). In the group that used digital dermoscopy, that ratio was about 1 to 2.4, compared with about 1 to 8 in group B, and about 1 to 10.7 in group A (Br J Dermatol. 2012;167[4]778-86).
The use of dermoscopy is also associated with thinner tumors. Among dermoscopy users, the thickness of the tumors detected drops, and the proportion of thin to thick lesions detected increases, Dr. Marghoob said.
For example, in one study, the mean thickness in melanomas detected with dermoscopy was 1.4 mm versus 2.59 mm when dermoscopy was not used (J Eur Acad Dermatol Venereol. 2015 Jan; 29[1]:102-8). About 55% of the tumors detected with dermoscopic examination were 1 mm or less in thickness versus 23.4% of those detected without dermoscopy, “so the dermoscopy users from a proportion standpoint were also finding thinner tumors,” Dr. Marghoob said. Dermoscopy was also identified as an independent predictor of finding thinner tumors.
Even without a study, it could be assumed that the use of dermoscopy would reduce costs, since dermoscopy increases sensitivity and the total number of melanomas detected, decreases the number of benign nevi removed, and helps detect disease earlier. But there are data showing that dermoscopy reduces health care costs, Dr. Marghoob said.* For example, a Belgian study that looked at dermoscopy in two cohorts of melanoma patients concluded that adequate dermoscopy training was cost effective (Eur J Cancer. 2016 Nov;67:38-45).
It has also been shown that adding dermoscopy to a primary care setting has cost benefits, Dr. Marghoob said. He cited a study of Dutch general practices that found that the probability of a correct diagnosis was 1.25 times higher when dermoscopy was used to evaluate suspicious skin lesions and concluded that the use of dermoscopy appeared to be cost effective (J Eur Acad Dermatol Venereol. 2014 Nov;28[11]:1442-9).
Dr. Marghoob had no disclosures relevant to this presentation.
SDEF/Global Academy for Medical Education and this news organization are owned by the same parent company.
*Correction, 2/28/20: An earlier version of this article mischaracterized the cost implications of dermoscopy use.
LAHAINA, HAWAII – Multiple but there are still some “nonbelievers,” Ashfaq A. Marghoob, MD, said at the Hawaii Dermatology Seminar provided by Global Academy for Medical Education/Skin Disease Education Foundation.
In fact, not one study has shown that dermoscopy is less sensitive than the naked eye alone, and at clinics where dermoscopy is used, “two-thirds of the melanomas being detected now lack the classic ABCD features of melanoma,” added Dr. Marghoob, director of clinical dermatology at Memorial Sloan Kettering in Hauppauge, N.Y.
Dr. Marghoob cited a meta-analysis of 9 prospective trials, which concluded that dermoscopy was more accurate in diagnosing melanoma than the naked eye alone and did not lower specificity, with a sensitivity and specificity of 90%, compared with 71% and 81%, respectively for the naked eye (Br J Dermatol. 2008 Sep;159[3]:669-76).
“And at least from an evidence-based standpoint ... the Cochrane library has basically endorsed that, yes, dermoscopy does indeed improve your diagnostic accuracy,” Dr. Marghoob said.
He referred to a 2018 Cochrane review on 104 dermoscopy studies, with and without visual inspection, for diagnosing melanoma in adults (Cochrane Database Syst Rev. 2018 Dec 4;12:CD011902). The review authors concluded that “the evidence suggests that melanomas will be missed if visual inspection is used on its own,” and despite limitations in the evidence, “dermoscopy is a valuable tool to support the visual inspection of a suspicious skin lesion for the detection of melanoma and atypical intraepidermal melanocytic variants.”
As for the question of specificity, Dr. Marghoob said studies have found that dermoscopy results in the detection of more melanomas and reduces the number of biopsies of benign lesions and “every study looking into this has shown that, yes, it does improve” specificity.
A 10-year multicenter survey of about 300,000 cases, which included 17,172 melanomas and 283,043 melanocytic nevi, found that the number-needed-to-excise (NNE) values improved over time in specialized clinics where newer diagnostic techniques like dermoscopy were used (from 12.8 to 6.8), but the NNE did not appear to change in the nonspecialized settings (J Am Acad Dermatol. 2012 Jul;67[1]:54-9).
Looking at the benign-to-malignant ratio, there was no change among those not using dermoscopy, where the ratio remained at about 30 to 1. When dermoscopy was used, this ratio started to improve over the 10-year period, to about 5 to 1. In addition, “the dermoscopy users were finding many more melanomas than the non–dermoscopy users,” Dr. Marghoob added. And over the 10 years, the number of nevi being removed did not change among those not using dermoscopy but dropped among those using dermoscopy.
Adding photography with the ability to digitally monitor patients helps bring this ratio down further, Dr. Marghoob noted. He referred to a study that instead evaluated the ratio of melanoma to nonmelanomas diagnosed among dermatologists in three groups: those with no digital dermoscopy with little dermoscopy training (group A, the reference group), no digital dermoscopy but more dermoscopy training (group B), and those using digital dermoscopy (group C). In the group that used digital dermoscopy, that ratio was about 1 to 2.4, compared with about 1 to 8 in group B, and about 1 to 10.7 in group A (Br J Dermatol. 2012;167[4]778-86).
The use of dermoscopy is also associated with thinner tumors. Among dermoscopy users, the thickness of the tumors detected drops, and the proportion of thin to thick lesions detected increases, Dr. Marghoob said.
For example, in one study, the mean thickness in melanomas detected with dermoscopy was 1.4 mm versus 2.59 mm when dermoscopy was not used (J Eur Acad Dermatol Venereol. 2015 Jan; 29[1]:102-8). About 55% of the tumors detected with dermoscopic examination were 1 mm or less in thickness versus 23.4% of those detected without dermoscopy, “so the dermoscopy users from a proportion standpoint were also finding thinner tumors,” Dr. Marghoob said. Dermoscopy was also identified as an independent predictor of finding thinner tumors.
Even without a study, it could be assumed that the use of dermoscopy would reduce costs, since dermoscopy increases sensitivity and the total number of melanomas detected, decreases the number of benign nevi removed, and helps detect disease earlier. But there are data showing that dermoscopy reduces health care costs, Dr. Marghoob said.* For example, a Belgian study that looked at dermoscopy in two cohorts of melanoma patients concluded that adequate dermoscopy training was cost effective (Eur J Cancer. 2016 Nov;67:38-45).
It has also been shown that adding dermoscopy to a primary care setting has cost benefits, Dr. Marghoob said. He cited a study of Dutch general practices that found that the probability of a correct diagnosis was 1.25 times higher when dermoscopy was used to evaluate suspicious skin lesions and concluded that the use of dermoscopy appeared to be cost effective (J Eur Acad Dermatol Venereol. 2014 Nov;28[11]:1442-9).
Dr. Marghoob had no disclosures relevant to this presentation.
SDEF/Global Academy for Medical Education and this news organization are owned by the same parent company.
*Correction, 2/28/20: An earlier version of this article mischaracterized the cost implications of dermoscopy use.
LAHAINA, HAWAII – Multiple but there are still some “nonbelievers,” Ashfaq A. Marghoob, MD, said at the Hawaii Dermatology Seminar provided by Global Academy for Medical Education/Skin Disease Education Foundation.
In fact, not one study has shown that dermoscopy is less sensitive than the naked eye alone, and at clinics where dermoscopy is used, “two-thirds of the melanomas being detected now lack the classic ABCD features of melanoma,” added Dr. Marghoob, director of clinical dermatology at Memorial Sloan Kettering in Hauppauge, N.Y.
Dr. Marghoob cited a meta-analysis of 9 prospective trials, which concluded that dermoscopy was more accurate in diagnosing melanoma than the naked eye alone and did not lower specificity, with a sensitivity and specificity of 90%, compared with 71% and 81%, respectively for the naked eye (Br J Dermatol. 2008 Sep;159[3]:669-76).
“And at least from an evidence-based standpoint ... the Cochrane library has basically endorsed that, yes, dermoscopy does indeed improve your diagnostic accuracy,” Dr. Marghoob said.
He referred to a 2018 Cochrane review on 104 dermoscopy studies, with and without visual inspection, for diagnosing melanoma in adults (Cochrane Database Syst Rev. 2018 Dec 4;12:CD011902). The review authors concluded that “the evidence suggests that melanomas will be missed if visual inspection is used on its own,” and despite limitations in the evidence, “dermoscopy is a valuable tool to support the visual inspection of a suspicious skin lesion for the detection of melanoma and atypical intraepidermal melanocytic variants.”
As for the question of specificity, Dr. Marghoob said studies have found that dermoscopy results in the detection of more melanomas and reduces the number of biopsies of benign lesions and “every study looking into this has shown that, yes, it does improve” specificity.
A 10-year multicenter survey of about 300,000 cases, which included 17,172 melanomas and 283,043 melanocytic nevi, found that the number-needed-to-excise (NNE) values improved over time in specialized clinics where newer diagnostic techniques like dermoscopy were used (from 12.8 to 6.8), but the NNE did not appear to change in the nonspecialized settings (J Am Acad Dermatol. 2012 Jul;67[1]:54-9).
Looking at the benign-to-malignant ratio, there was no change among those not using dermoscopy, where the ratio remained at about 30 to 1. When dermoscopy was used, this ratio started to improve over the 10-year period, to about 5 to 1. In addition, “the dermoscopy users were finding many more melanomas than the non–dermoscopy users,” Dr. Marghoob added. And over the 10 years, the number of nevi being removed did not change among those not using dermoscopy but dropped among those using dermoscopy.
Adding photography with the ability to digitally monitor patients helps bring this ratio down further, Dr. Marghoob noted. He referred to a study that instead evaluated the ratio of melanoma to nonmelanomas diagnosed among dermatologists in three groups: those with no digital dermoscopy with little dermoscopy training (group A, the reference group), no digital dermoscopy but more dermoscopy training (group B), and those using digital dermoscopy (group C). In the group that used digital dermoscopy, that ratio was about 1 to 2.4, compared with about 1 to 8 in group B, and about 1 to 10.7 in group A (Br J Dermatol. 2012;167[4]778-86).
The use of dermoscopy is also associated with thinner tumors. Among dermoscopy users, the thickness of the tumors detected drops, and the proportion of thin to thick lesions detected increases, Dr. Marghoob said.
For example, in one study, the mean thickness in melanomas detected with dermoscopy was 1.4 mm versus 2.59 mm when dermoscopy was not used (J Eur Acad Dermatol Venereol. 2015 Jan; 29[1]:102-8). About 55% of the tumors detected with dermoscopic examination were 1 mm or less in thickness versus 23.4% of those detected without dermoscopy, “so the dermoscopy users from a proportion standpoint were also finding thinner tumors,” Dr. Marghoob said. Dermoscopy was also identified as an independent predictor of finding thinner tumors.
Even without a study, it could be assumed that the use of dermoscopy would reduce costs, since dermoscopy increases sensitivity and the total number of melanomas detected, decreases the number of benign nevi removed, and helps detect disease earlier. But there are data showing that dermoscopy reduces health care costs, Dr. Marghoob said.* For example, a Belgian study that looked at dermoscopy in two cohorts of melanoma patients concluded that adequate dermoscopy training was cost effective (Eur J Cancer. 2016 Nov;67:38-45).
It has also been shown that adding dermoscopy to a primary care setting has cost benefits, Dr. Marghoob said. He cited a study of Dutch general practices that found that the probability of a correct diagnosis was 1.25 times higher when dermoscopy was used to evaluate suspicious skin lesions and concluded that the use of dermoscopy appeared to be cost effective (J Eur Acad Dermatol Venereol. 2014 Nov;28[11]:1442-9).
Dr. Marghoob had no disclosures relevant to this presentation.
SDEF/Global Academy for Medical Education and this news organization are owned by the same parent company.
*Correction, 2/28/20: An earlier version of this article mischaracterized the cost implications of dermoscopy use.
EXPERT ANALYSIS FROM SDEF HAWAII DERMATOLOGY SEMINAR
Obesity expert: Time to embrace growing array of options
MAUI, HAWAII – Specialists who study obesity and embrace the increasing number of treatment options are poised to lead the way in stemming the disease, which Andres Acosta, MD, PhD, calls the “epidemic of the century.”
“Gastroenterologists are in the first line of treatment for obesity management,” said Acosta, who runs the precision medicine for obesity lab at the Mayo Clinic in Rochester, Minn.
“Patients with obesity are already in our clinics,” he said in an interview. And too many physicians “are ignoring the problem.”
The vast majority of people with acid reflux have obesity, as do those with nonalcoholic fatty liver disease, he explained. “By targeting those two areas, we’ll be targeting more than 50% of our patients.” Recurring polyps and colon cancer are also often associated with obesity, he said.
Because of their skill as endoscopists, internists, and nutrition experts, gastroenterologists are uniquely positioned to care for obesity, said Acosta, who is first author of a white paper – Practice Guide on Obesity and Weight Management, Education and Resources – developed by the American Gastroenterological Association with input from nine medical societies.
More treatment choices
Physicians heard an update on options available in the continuum of obesity care from Christopher Thompson, MD, director of endoscopy at Brigham and Women’s Hospital in Boston, at the Gastroenterology Updates IBD Liver Disease Conference 2020. He discussed the potential weight-loss range and safety profile of each.
Some medications result in a body-weight loss of 5%, whereas gastric bypass surgeries can result in a loss of up to 40%, he said in an interview. And weight loss is typically 10% with intragastric balloon, 15%-20% with aspiration therapies and with endoscopic suturing techniques, and 25%-30% with sleeve gastrectomy.
“It’s nice to be able to offer all of those to patients,” he said, adding that he wants to get the message across to hesitant physicians that obesity management “is not as difficult as they think.”
Physicians can be reluctant to address obesity because of the social stigma associated with excess weight and a discomfort in talking about it.
But “there are ways to open that conversation, and it needs to start happening more,” said Thompson, who pointed out that obesity is the underlying cause of many other illnesses, including diabetes and heart diseases.
And new strategies are in the offing, he explained. His team at Brigham is currently involved in clinical trials to test whether the diversion of food and bile to the lower part of the bowel will generate a metabolic signal that affects insulin resistance and weight, he reported.
They are also testing whether gastric procedures can be combined with small bowel procedures to achieve the weight loss seen with bariatric surgery.
As treatment options for obesity increase, precision medicine will help maximize their potential, said Acosta.
Precision medicine will amp up treatments
Acosta outlined the four categories that patients who are obese generally fall into: those with a “hungry brain,” who think they need to eat more than they do; those with a “hungry gut,” whose gut is not sending the proper signal to the brain that it is full; those with “emotional hunger”; and those with abnormal metabolism.
“For each of those, there are genetic circumstances, metabolism, a hormonal profile, as well as pathophysiologic aspects of obesity, that make these groups unique,” he said.
Deciding which patients should get which treatment is the next frontier, he explained. “For example, if you give an intragastric balloon to all comers, patients will lose about 12% of their body weight. But if you separate responders from nonresponders and you select the right intervention, you can achieve an 18% loss of body weight in the right responders.”
At Mayo, they are working on a blood test to break down phenotypes and identify who will respond best to which treatment, he reported. That could lead to a much more efficient use of scarce resources.
“At the same time, I hope that more insurance companies will cover more obesity treatments,” said Acosta.
This article first appeared on Medscape.com.
MAUI, HAWAII – Specialists who study obesity and embrace the increasing number of treatment options are poised to lead the way in stemming the disease, which Andres Acosta, MD, PhD, calls the “epidemic of the century.”
“Gastroenterologists are in the first line of treatment for obesity management,” said Acosta, who runs the precision medicine for obesity lab at the Mayo Clinic in Rochester, Minn.
“Patients with obesity are already in our clinics,” he said in an interview. And too many physicians “are ignoring the problem.”
The vast majority of people with acid reflux have obesity, as do those with nonalcoholic fatty liver disease, he explained. “By targeting those two areas, we’ll be targeting more than 50% of our patients.” Recurring polyps and colon cancer are also often associated with obesity, he said.
Because of their skill as endoscopists, internists, and nutrition experts, gastroenterologists are uniquely positioned to care for obesity, said Acosta, who is first author of a white paper – Practice Guide on Obesity and Weight Management, Education and Resources – developed by the American Gastroenterological Association with input from nine medical societies.
More treatment choices
Physicians heard an update on options available in the continuum of obesity care from Christopher Thompson, MD, director of endoscopy at Brigham and Women’s Hospital in Boston, at the Gastroenterology Updates IBD Liver Disease Conference 2020. He discussed the potential weight-loss range and safety profile of each.
Some medications result in a body-weight loss of 5%, whereas gastric bypass surgeries can result in a loss of up to 40%, he said in an interview. And weight loss is typically 10% with intragastric balloon, 15%-20% with aspiration therapies and with endoscopic suturing techniques, and 25%-30% with sleeve gastrectomy.
“It’s nice to be able to offer all of those to patients,” he said, adding that he wants to get the message across to hesitant physicians that obesity management “is not as difficult as they think.”
Physicians can be reluctant to address obesity because of the social stigma associated with excess weight and a discomfort in talking about it.
But “there are ways to open that conversation, and it needs to start happening more,” said Thompson, who pointed out that obesity is the underlying cause of many other illnesses, including diabetes and heart diseases.
And new strategies are in the offing, he explained. His team at Brigham is currently involved in clinical trials to test whether the diversion of food and bile to the lower part of the bowel will generate a metabolic signal that affects insulin resistance and weight, he reported.
They are also testing whether gastric procedures can be combined with small bowel procedures to achieve the weight loss seen with bariatric surgery.
As treatment options for obesity increase, precision medicine will help maximize their potential, said Acosta.
Precision medicine will amp up treatments
Acosta outlined the four categories that patients who are obese generally fall into: those with a “hungry brain,” who think they need to eat more than they do; those with a “hungry gut,” whose gut is not sending the proper signal to the brain that it is full; those with “emotional hunger”; and those with abnormal metabolism.
“For each of those, there are genetic circumstances, metabolism, a hormonal profile, as well as pathophysiologic aspects of obesity, that make these groups unique,” he said.
Deciding which patients should get which treatment is the next frontier, he explained. “For example, if you give an intragastric balloon to all comers, patients will lose about 12% of their body weight. But if you separate responders from nonresponders and you select the right intervention, you can achieve an 18% loss of body weight in the right responders.”
At Mayo, they are working on a blood test to break down phenotypes and identify who will respond best to which treatment, he reported. That could lead to a much more efficient use of scarce resources.
“At the same time, I hope that more insurance companies will cover more obesity treatments,” said Acosta.
This article first appeared on Medscape.com.
MAUI, HAWAII – Specialists who study obesity and embrace the increasing number of treatment options are poised to lead the way in stemming the disease, which Andres Acosta, MD, PhD, calls the “epidemic of the century.”
“Gastroenterologists are in the first line of treatment for obesity management,” said Acosta, who runs the precision medicine for obesity lab at the Mayo Clinic in Rochester, Minn.
“Patients with obesity are already in our clinics,” he said in an interview. And too many physicians “are ignoring the problem.”
The vast majority of people with acid reflux have obesity, as do those with nonalcoholic fatty liver disease, he explained. “By targeting those two areas, we’ll be targeting more than 50% of our patients.” Recurring polyps and colon cancer are also often associated with obesity, he said.
Because of their skill as endoscopists, internists, and nutrition experts, gastroenterologists are uniquely positioned to care for obesity, said Acosta, who is first author of a white paper – Practice Guide on Obesity and Weight Management, Education and Resources – developed by the American Gastroenterological Association with input from nine medical societies.
More treatment choices
Physicians heard an update on options available in the continuum of obesity care from Christopher Thompson, MD, director of endoscopy at Brigham and Women’s Hospital in Boston, at the Gastroenterology Updates IBD Liver Disease Conference 2020. He discussed the potential weight-loss range and safety profile of each.
Some medications result in a body-weight loss of 5%, whereas gastric bypass surgeries can result in a loss of up to 40%, he said in an interview. And weight loss is typically 10% with intragastric balloon, 15%-20% with aspiration therapies and with endoscopic suturing techniques, and 25%-30% with sleeve gastrectomy.
“It’s nice to be able to offer all of those to patients,” he said, adding that he wants to get the message across to hesitant physicians that obesity management “is not as difficult as they think.”
Physicians can be reluctant to address obesity because of the social stigma associated with excess weight and a discomfort in talking about it.
But “there are ways to open that conversation, and it needs to start happening more,” said Thompson, who pointed out that obesity is the underlying cause of many other illnesses, including diabetes and heart diseases.
And new strategies are in the offing, he explained. His team at Brigham is currently involved in clinical trials to test whether the diversion of food and bile to the lower part of the bowel will generate a metabolic signal that affects insulin resistance and weight, he reported.
They are also testing whether gastric procedures can be combined with small bowel procedures to achieve the weight loss seen with bariatric surgery.
As treatment options for obesity increase, precision medicine will help maximize their potential, said Acosta.
Precision medicine will amp up treatments
Acosta outlined the four categories that patients who are obese generally fall into: those with a “hungry brain,” who think they need to eat more than they do; those with a “hungry gut,” whose gut is not sending the proper signal to the brain that it is full; those with “emotional hunger”; and those with abnormal metabolism.
“For each of those, there are genetic circumstances, metabolism, a hormonal profile, as well as pathophysiologic aspects of obesity, that make these groups unique,” he said.
Deciding which patients should get which treatment is the next frontier, he explained. “For example, if you give an intragastric balloon to all comers, patients will lose about 12% of their body weight. But if you separate responders from nonresponders and you select the right intervention, you can achieve an 18% loss of body weight in the right responders.”
At Mayo, they are working on a blood test to break down phenotypes and identify who will respond best to which treatment, he reported. That could lead to a much more efficient use of scarce resources.
“At the same time, I hope that more insurance companies will cover more obesity treatments,” said Acosta.
This article first appeared on Medscape.com.
EXPERT ANALYSIS FROM GUILD 2020
Older adults with IBD often undertreated
MAUI, HAWAII – said Christina Ha, MD, from the Inflammatory Bowel Disease Center at Cedars-Sinai in Los Angeles.
Clinicians sometimes fall back on steroids because they are typically inexpensive and because there are fears that the new anti-TNF biologics can cause adverse events in older patients, Ha said at the Gastroenterology Updates, IBD, Liver Disease Conference.
“There are not a lot of safety data for the age group, which is not well represented in clinical trials,” she explained. “We can’t necessarily extrapolate data from a study of people with an average age in the 40s to someone in their 70s.”
But, she emphasized, steroid use for more than 3 months is potentially inappropriate.
“If we have a patient on steroids, we should be saying which steroid-sparing strategy will be incorporated into their regimen when we start them on their course of steroids,” she explained.
Ha said she gets asked frequently whether the man-made steroid budesonide, which is readily available, should be considered an acceptable alternative to prednisone.
“Steroids are not maintenance therapies,” she pointed out. “One could argue that maybe someone who has symptomatic mild Crohn’s disease could be kept on low doses of budesonide. But I would argue whether it is really the budesonide that’s helping them or some other disease process related to polypharmacy.”
There are no long-term safety or efficacy data for budesonide in patients with ulcerative colitis or Crohn’s disease, she added.
Special considerations
Older patients with IBD have a decreased ability to handle disease activity; they have more comorbidities and a susceptibility to falls, said Ha. Early control of the disease is therefore essential.
Sarcopenia, an inherent part of aging when muscle mass decreases over time, is central to physiologic changes, which have implications for older adults with IBD, she said.
“We’re learning that sarcopenia is also prevalent in our patients with moderate to severe inflammatory bowel disease,” she explained. “Sarcopenia is associated with increased risk of infections, hospitalizations, and postoperative complications.”
Other changes occur in the intestines as patients age, Ha reported. “Recent studies have shown that there are changes in the intestinal barrier in terms of the junctions within the mucosal lining that increase intestinal permeability, which may help explain why some patients respond to treatments and others don’t.”
Physical therapy underused
Other treatment options, such as physical therapy, have also been underused in older patients with IBD. For example, there’s often considerable pushback against doing a physical therapy assessment on a hospitalized older patient, said Ha.
Medicare covers up to 80% of those services, but referral wording is key. “They’re not going to cover it for a primary diagnosis of ulcerative colitis or Crohn’s,” she explained. However, “they will cover it for a primary diagnosis of deconditioning with a secondary diagnoses of steroid exposure, anemia, Crohn’s disease, or ulcerative colitis.”
Physical therapy can improve muscle function, decrease muscle pain, potentially decrease analgesics, improve bone mass, and decrease joint pain, stress, fatigue, and debility. Fatigue is prevalent in patients with IBD, Ha explained.
Another underused resource is psychosocial assessment, she added. Although depression is not part of the aging process, it is common in those with chronic conditions.
Visits with licensed psychiatrists and clinical psychologists are covered under Medicare Part B, Ha pointed out, as are psychiatric evaluation and testing and individual and group therapy.
Older patients with IBD are often not receiving the care they need, said Uma Mahadevan, MD, a gastroenterologist at UCSF Health in San Francisco.
The need for awareness of polypharmacy, which Ha also discussed, is a concern in all older patients, but especially those with IBD, Mahadevan said in an interview. Clinicians need to be aware of the cascading effect of pharmacy, in which one drug’s adverse effect leads to the prescription of another drug, with different adverse effects.
Ha gave the example of a patient with IBD who started to have diarrhea as an adverse effect of a medication. A clinician might then prescribe a medication for Clostridium difficile, but that might lead to nausea, leading to the prescription of an antinausea medicine.
A multidisciplinary team is needed to perform medication reconciliation, Ha noted.
Correcting anemia important for IBD
Anemia is also underidentified and undertreated in older patients with IBD, Ha said.
“Across the board with inflammatory bowel disease, we don’t do a great job of being aggressive and correcting anemia. That has implications for fatigue and implications with functional status and circulating volume,” she said.
In older patients, it might be that the decline in hemoglobin over time is more important to outcomes than the number itself, she said. “A hemoglobin of 8 g/dL is one thing, but if it was at 12 g/dL 6 months ago, that’s a different story.”
“For older patients, anemia is associated with a high incidence of cardiovascular disease, cognitive impairment, increased risks of falls and fractures, longer hospitalizations (and thus increased costs of care), increased frailty and dementia, and increased risk of mortality,” Ha said. But, she pointed out, Medicare benefits do cover intravenous iron formulations.
This article originally appeared on Medscape.com.
MAUI, HAWAII – said Christina Ha, MD, from the Inflammatory Bowel Disease Center at Cedars-Sinai in Los Angeles.
Clinicians sometimes fall back on steroids because they are typically inexpensive and because there are fears that the new anti-TNF biologics can cause adverse events in older patients, Ha said at the Gastroenterology Updates, IBD, Liver Disease Conference.
“There are not a lot of safety data for the age group, which is not well represented in clinical trials,” she explained. “We can’t necessarily extrapolate data from a study of people with an average age in the 40s to someone in their 70s.”
But, she emphasized, steroid use for more than 3 months is potentially inappropriate.
“If we have a patient on steroids, we should be saying which steroid-sparing strategy will be incorporated into their regimen when we start them on their course of steroids,” she explained.
Ha said she gets asked frequently whether the man-made steroid budesonide, which is readily available, should be considered an acceptable alternative to prednisone.
“Steroids are not maintenance therapies,” she pointed out. “One could argue that maybe someone who has symptomatic mild Crohn’s disease could be kept on low doses of budesonide. But I would argue whether it is really the budesonide that’s helping them or some other disease process related to polypharmacy.”
There are no long-term safety or efficacy data for budesonide in patients with ulcerative colitis or Crohn’s disease, she added.
Special considerations
Older patients with IBD have a decreased ability to handle disease activity; they have more comorbidities and a susceptibility to falls, said Ha. Early control of the disease is therefore essential.
Sarcopenia, an inherent part of aging when muscle mass decreases over time, is central to physiologic changes, which have implications for older adults with IBD, she said.
“We’re learning that sarcopenia is also prevalent in our patients with moderate to severe inflammatory bowel disease,” she explained. “Sarcopenia is associated with increased risk of infections, hospitalizations, and postoperative complications.”
Other changes occur in the intestines as patients age, Ha reported. “Recent studies have shown that there are changes in the intestinal barrier in terms of the junctions within the mucosal lining that increase intestinal permeability, which may help explain why some patients respond to treatments and others don’t.”
Physical therapy underused
Other treatment options, such as physical therapy, have also been underused in older patients with IBD. For example, there’s often considerable pushback against doing a physical therapy assessment on a hospitalized older patient, said Ha.
Medicare covers up to 80% of those services, but referral wording is key. “They’re not going to cover it for a primary diagnosis of ulcerative colitis or Crohn’s,” she explained. However, “they will cover it for a primary diagnosis of deconditioning with a secondary diagnoses of steroid exposure, anemia, Crohn’s disease, or ulcerative colitis.”
Physical therapy can improve muscle function, decrease muscle pain, potentially decrease analgesics, improve bone mass, and decrease joint pain, stress, fatigue, and debility. Fatigue is prevalent in patients with IBD, Ha explained.
Another underused resource is psychosocial assessment, she added. Although depression is not part of the aging process, it is common in those with chronic conditions.
Visits with licensed psychiatrists and clinical psychologists are covered under Medicare Part B, Ha pointed out, as are psychiatric evaluation and testing and individual and group therapy.
Older patients with IBD are often not receiving the care they need, said Uma Mahadevan, MD, a gastroenterologist at UCSF Health in San Francisco.
The need for awareness of polypharmacy, which Ha also discussed, is a concern in all older patients, but especially those with IBD, Mahadevan said in an interview. Clinicians need to be aware of the cascading effect of pharmacy, in which one drug’s adverse effect leads to the prescription of another drug, with different adverse effects.
Ha gave the example of a patient with IBD who started to have diarrhea as an adverse effect of a medication. A clinician might then prescribe a medication for Clostridium difficile, but that might lead to nausea, leading to the prescription of an antinausea medicine.
A multidisciplinary team is needed to perform medication reconciliation, Ha noted.
Correcting anemia important for IBD
Anemia is also underidentified and undertreated in older patients with IBD, Ha said.
“Across the board with inflammatory bowel disease, we don’t do a great job of being aggressive and correcting anemia. That has implications for fatigue and implications with functional status and circulating volume,” she said.
In older patients, it might be that the decline in hemoglobin over time is more important to outcomes than the number itself, she said. “A hemoglobin of 8 g/dL is one thing, but if it was at 12 g/dL 6 months ago, that’s a different story.”
“For older patients, anemia is associated with a high incidence of cardiovascular disease, cognitive impairment, increased risks of falls and fractures, longer hospitalizations (and thus increased costs of care), increased frailty and dementia, and increased risk of mortality,” Ha said. But, she pointed out, Medicare benefits do cover intravenous iron formulations.
This article originally appeared on Medscape.com.
MAUI, HAWAII – said Christina Ha, MD, from the Inflammatory Bowel Disease Center at Cedars-Sinai in Los Angeles.
Clinicians sometimes fall back on steroids because they are typically inexpensive and because there are fears that the new anti-TNF biologics can cause adverse events in older patients, Ha said at the Gastroenterology Updates, IBD, Liver Disease Conference.
“There are not a lot of safety data for the age group, which is not well represented in clinical trials,” she explained. “We can’t necessarily extrapolate data from a study of people with an average age in the 40s to someone in their 70s.”
But, she emphasized, steroid use for more than 3 months is potentially inappropriate.
“If we have a patient on steroids, we should be saying which steroid-sparing strategy will be incorporated into their regimen when we start them on their course of steroids,” she explained.
Ha said she gets asked frequently whether the man-made steroid budesonide, which is readily available, should be considered an acceptable alternative to prednisone.
“Steroids are not maintenance therapies,” she pointed out. “One could argue that maybe someone who has symptomatic mild Crohn’s disease could be kept on low doses of budesonide. But I would argue whether it is really the budesonide that’s helping them or some other disease process related to polypharmacy.”
There are no long-term safety or efficacy data for budesonide in patients with ulcerative colitis or Crohn’s disease, she added.
Special considerations
Older patients with IBD have a decreased ability to handle disease activity; they have more comorbidities and a susceptibility to falls, said Ha. Early control of the disease is therefore essential.
Sarcopenia, an inherent part of aging when muscle mass decreases over time, is central to physiologic changes, which have implications for older adults with IBD, she said.
“We’re learning that sarcopenia is also prevalent in our patients with moderate to severe inflammatory bowel disease,” she explained. “Sarcopenia is associated with increased risk of infections, hospitalizations, and postoperative complications.”
Other changes occur in the intestines as patients age, Ha reported. “Recent studies have shown that there are changes in the intestinal barrier in terms of the junctions within the mucosal lining that increase intestinal permeability, which may help explain why some patients respond to treatments and others don’t.”
Physical therapy underused
Other treatment options, such as physical therapy, have also been underused in older patients with IBD. For example, there’s often considerable pushback against doing a physical therapy assessment on a hospitalized older patient, said Ha.
Medicare covers up to 80% of those services, but referral wording is key. “They’re not going to cover it for a primary diagnosis of ulcerative colitis or Crohn’s,” she explained. However, “they will cover it for a primary diagnosis of deconditioning with a secondary diagnoses of steroid exposure, anemia, Crohn’s disease, or ulcerative colitis.”
Physical therapy can improve muscle function, decrease muscle pain, potentially decrease analgesics, improve bone mass, and decrease joint pain, stress, fatigue, and debility. Fatigue is prevalent in patients with IBD, Ha explained.
Another underused resource is psychosocial assessment, she added. Although depression is not part of the aging process, it is common in those with chronic conditions.
Visits with licensed psychiatrists and clinical psychologists are covered under Medicare Part B, Ha pointed out, as are psychiatric evaluation and testing and individual and group therapy.
Older patients with IBD are often not receiving the care they need, said Uma Mahadevan, MD, a gastroenterologist at UCSF Health in San Francisco.
The need for awareness of polypharmacy, which Ha also discussed, is a concern in all older patients, but especially those with IBD, Mahadevan said in an interview. Clinicians need to be aware of the cascading effect of pharmacy, in which one drug’s adverse effect leads to the prescription of another drug, with different adverse effects.
Ha gave the example of a patient with IBD who started to have diarrhea as an adverse effect of a medication. A clinician might then prescribe a medication for Clostridium difficile, but that might lead to nausea, leading to the prescription of an antinausea medicine.
A multidisciplinary team is needed to perform medication reconciliation, Ha noted.
Correcting anemia important for IBD
Anemia is also underidentified and undertreated in older patients with IBD, Ha said.
“Across the board with inflammatory bowel disease, we don’t do a great job of being aggressive and correcting anemia. That has implications for fatigue and implications with functional status and circulating volume,” she said.
In older patients, it might be that the decline in hemoglobin over time is more important to outcomes than the number itself, she said. “A hemoglobin of 8 g/dL is one thing, but if it was at 12 g/dL 6 months ago, that’s a different story.”
“For older patients, anemia is associated with a high incidence of cardiovascular disease, cognitive impairment, increased risks of falls and fractures, longer hospitalizations (and thus increased costs of care), increased frailty and dementia, and increased risk of mortality,” Ha said. But, she pointed out, Medicare benefits do cover intravenous iron formulations.
This article originally appeared on Medscape.com.
EXPERT ANALYSIS FROM GUILD 2020
A case is building for proactive anti-TNF monitoring in IBD
MAUI, HAWAII – Gastroenterologists are starting to embrace proactive therapeutic drug monitoring for inflammatory bowel disease patients on tumor necrosis factor inhibitors, according to reports at the Gastroenterology Updates, IBD, and Liver Disease conference.
Proactive therapeutic drug monitoring (TDM) is an alternative to standard combination therapy for inflammatory bowel disease, which involves giving a tumor necrosis factor inhibitor (TNFi) with an immunomodulator, usually azathioprine.
The immunomodulator is meant to prevent antibodies from forming against the TNFi and short-circuiting its effect. Growing evidence suggests that proactive TDM can do the same thing without the second drug and its sometimes fatal adverse events.
Serum TNFi levels are checked during induction, when the risk of antibody formation is highest if levels are too low, and increased upward if they are. Levels are also checked to make sure they aren’t too high, and sometimes followed during maintenance, speakers said at the meeting.
Commercially available serum assays make it easy; the turnaround time is a few days.
Reactive testing is too late
Reactive, instead of proactive, TNFi level testing is standard at the moment, which means levels are checked when people stop responding, but by then it’s often too late. “Why wait until a patient isn’t doing well and potentially has antibodies you can’t overcome before optimizing them? Why not deal with dose optimizing [tumor necrosis factor inhibitors] as opposed to using another drug like a thiopurine? This is common sense,” said gastroenterologist Adam Cheifetz, MD, director of the Center for Inflammatory Bowel Disease at Beth Israel Deaconess Medical Center and professor of medicine at Harvard Medical School, Boston, and a long-time advocate for proactive TDM.
Not too long ago, Edward Loftus, MD, a professor and consultant in the division of gastroenterology and hepatology at the Mayo Clinic in Rochester, Minn., doubted the approach, but he’s since come around “now that we are starting to see higher level data.” In his own practice, he said he now checks infliximab levels at week 14, before the fourth infusion. Other clinicians check at week 6 before the third infusion.
Whatever the timing, “If we are going to put somebody into remission, it’s going to be in that first 3-month window, so I think early optimization is important. Once you’ve adjusted the dose and optimized it, it might be something you want to check once a year. In my own practice, I’ve been inclined to do more combination therapy, but we’ll see how this goes,” Dr. Loftus said.
The evidence
Both presenters reviewed a recent randomized trial from Israel in pediatric Crohn’s patients induced with adalimumab. Trough levels were checked and adjusted as necessary to concentrations of 5 mcg/mL at weeks 4 and 8, and every 8 weeks thereafter, in 38 children; 40 others were randomized to reactive monitoring, with adjustments to the same trough level. Most of the children in the proactive group had dose intensifications, versus fewer than two-thirds in the reactive group.
At week 72, 31 children (82%) in the proactive group, but only 19 children (48%) in the reactive group, met the study’s primary endpoint, sustained corticosteroid-free clinical remission at all visits (Gastroenterology. 2019 Oct;157[4]:985-96.e2).
In short, “proactive TDM was far superior to reactive testing,” Dr. Cheifetz said.
There’s a question if the results would translate to adults, but, Dr. Loftus said, they beg “the issue of if I should be checking adalimumab trough levels at weeks 4 and 8. It certainly gives you pause to think about doing that.”
Among other reports, Dr. Cheifetz also reviewed a retrospective study of 264 patients – almost two-thirds with Crohn’s disease, the rest with ulcerative colitis - on infliximab maintenance therapy; half had proactive TDM, and the rest reactive monitoring. The target trough concentration was 5-10 mcg/mL; median follow-up was 2.4 years. He was the senior investigator.
On multiple Cox regression analysis, the proactive group had an 84% lower risk of treatment failure, an 84% lower risk of IBD hospitalization, a 75% lower risk of antibody formation, an 83% lower risk of serious infusion reactions, and a 70% lower risk of IBD surgery (Clin Gastroenterol Hepatol. 2017 Oct;15[10]:1580-8.e3).
Dr. Cheifetz said he uses assays from Prometheus Laboratories for proactive TDM, but there are other options. Prometheus turnaround times are a few days. He and his colleagues also have a website – www.bridgeibd.com – where doctors can plug in patient characteristics and get proactive TDM advice.
Dr. Cheifetz is a consultant for Prometheus, as well as Janssen, Abbvie and other companies. He disclosed research funding form Inform Diagnostics. Dr. Loftus is a consultant and/or has research funding from Abbott, Pfizer, and other companies.
MAUI, HAWAII – Gastroenterologists are starting to embrace proactive therapeutic drug monitoring for inflammatory bowel disease patients on tumor necrosis factor inhibitors, according to reports at the Gastroenterology Updates, IBD, and Liver Disease conference.
Proactive therapeutic drug monitoring (TDM) is an alternative to standard combination therapy for inflammatory bowel disease, which involves giving a tumor necrosis factor inhibitor (TNFi) with an immunomodulator, usually azathioprine.
The immunomodulator is meant to prevent antibodies from forming against the TNFi and short-circuiting its effect. Growing evidence suggests that proactive TDM can do the same thing without the second drug and its sometimes fatal adverse events.
Serum TNFi levels are checked during induction, when the risk of antibody formation is highest if levels are too low, and increased upward if they are. Levels are also checked to make sure they aren’t too high, and sometimes followed during maintenance, speakers said at the meeting.
Commercially available serum assays make it easy; the turnaround time is a few days.
Reactive testing is too late
Reactive, instead of proactive, TNFi level testing is standard at the moment, which means levels are checked when people stop responding, but by then it’s often too late. “Why wait until a patient isn’t doing well and potentially has antibodies you can’t overcome before optimizing them? Why not deal with dose optimizing [tumor necrosis factor inhibitors] as opposed to using another drug like a thiopurine? This is common sense,” said gastroenterologist Adam Cheifetz, MD, director of the Center for Inflammatory Bowel Disease at Beth Israel Deaconess Medical Center and professor of medicine at Harvard Medical School, Boston, and a long-time advocate for proactive TDM.
Not too long ago, Edward Loftus, MD, a professor and consultant in the division of gastroenterology and hepatology at the Mayo Clinic in Rochester, Minn., doubted the approach, but he’s since come around “now that we are starting to see higher level data.” In his own practice, he said he now checks infliximab levels at week 14, before the fourth infusion. Other clinicians check at week 6 before the third infusion.
Whatever the timing, “If we are going to put somebody into remission, it’s going to be in that first 3-month window, so I think early optimization is important. Once you’ve adjusted the dose and optimized it, it might be something you want to check once a year. In my own practice, I’ve been inclined to do more combination therapy, but we’ll see how this goes,” Dr. Loftus said.
The evidence
Both presenters reviewed a recent randomized trial from Israel in pediatric Crohn’s patients induced with adalimumab. Trough levels were checked and adjusted as necessary to concentrations of 5 mcg/mL at weeks 4 and 8, and every 8 weeks thereafter, in 38 children; 40 others were randomized to reactive monitoring, with adjustments to the same trough level. Most of the children in the proactive group had dose intensifications, versus fewer than two-thirds in the reactive group.
At week 72, 31 children (82%) in the proactive group, but only 19 children (48%) in the reactive group, met the study’s primary endpoint, sustained corticosteroid-free clinical remission at all visits (Gastroenterology. 2019 Oct;157[4]:985-96.e2).
In short, “proactive TDM was far superior to reactive testing,” Dr. Cheifetz said.
There’s a question if the results would translate to adults, but, Dr. Loftus said, they beg “the issue of if I should be checking adalimumab trough levels at weeks 4 and 8. It certainly gives you pause to think about doing that.”
Among other reports, Dr. Cheifetz also reviewed a retrospective study of 264 patients – almost two-thirds with Crohn’s disease, the rest with ulcerative colitis - on infliximab maintenance therapy; half had proactive TDM, and the rest reactive monitoring. The target trough concentration was 5-10 mcg/mL; median follow-up was 2.4 years. He was the senior investigator.
On multiple Cox regression analysis, the proactive group had an 84% lower risk of treatment failure, an 84% lower risk of IBD hospitalization, a 75% lower risk of antibody formation, an 83% lower risk of serious infusion reactions, and a 70% lower risk of IBD surgery (Clin Gastroenterol Hepatol. 2017 Oct;15[10]:1580-8.e3).
Dr. Cheifetz said he uses assays from Prometheus Laboratories for proactive TDM, but there are other options. Prometheus turnaround times are a few days. He and his colleagues also have a website – www.bridgeibd.com – where doctors can plug in patient characteristics and get proactive TDM advice.
Dr. Cheifetz is a consultant for Prometheus, as well as Janssen, Abbvie and other companies. He disclosed research funding form Inform Diagnostics. Dr. Loftus is a consultant and/or has research funding from Abbott, Pfizer, and other companies.
MAUI, HAWAII – Gastroenterologists are starting to embrace proactive therapeutic drug monitoring for inflammatory bowel disease patients on tumor necrosis factor inhibitors, according to reports at the Gastroenterology Updates, IBD, and Liver Disease conference.
Proactive therapeutic drug monitoring (TDM) is an alternative to standard combination therapy for inflammatory bowel disease, which involves giving a tumor necrosis factor inhibitor (TNFi) with an immunomodulator, usually azathioprine.
The immunomodulator is meant to prevent antibodies from forming against the TNFi and short-circuiting its effect. Growing evidence suggests that proactive TDM can do the same thing without the second drug and its sometimes fatal adverse events.
Serum TNFi levels are checked during induction, when the risk of antibody formation is highest if levels are too low, and increased upward if they are. Levels are also checked to make sure they aren’t too high, and sometimes followed during maintenance, speakers said at the meeting.
Commercially available serum assays make it easy; the turnaround time is a few days.
Reactive testing is too late
Reactive, instead of proactive, TNFi level testing is standard at the moment, which means levels are checked when people stop responding, but by then it’s often too late. “Why wait until a patient isn’t doing well and potentially has antibodies you can’t overcome before optimizing them? Why not deal with dose optimizing [tumor necrosis factor inhibitors] as opposed to using another drug like a thiopurine? This is common sense,” said gastroenterologist Adam Cheifetz, MD, director of the Center for Inflammatory Bowel Disease at Beth Israel Deaconess Medical Center and professor of medicine at Harvard Medical School, Boston, and a long-time advocate for proactive TDM.
Not too long ago, Edward Loftus, MD, a professor and consultant in the division of gastroenterology and hepatology at the Mayo Clinic in Rochester, Minn., doubted the approach, but he’s since come around “now that we are starting to see higher level data.” In his own practice, he said he now checks infliximab levels at week 14, before the fourth infusion. Other clinicians check at week 6 before the third infusion.
Whatever the timing, “If we are going to put somebody into remission, it’s going to be in that first 3-month window, so I think early optimization is important. Once you’ve adjusted the dose and optimized it, it might be something you want to check once a year. In my own practice, I’ve been inclined to do more combination therapy, but we’ll see how this goes,” Dr. Loftus said.
The evidence
Both presenters reviewed a recent randomized trial from Israel in pediatric Crohn’s patients induced with adalimumab. Trough levels were checked and adjusted as necessary to concentrations of 5 mcg/mL at weeks 4 and 8, and every 8 weeks thereafter, in 38 children; 40 others were randomized to reactive monitoring, with adjustments to the same trough level. Most of the children in the proactive group had dose intensifications, versus fewer than two-thirds in the reactive group.
At week 72, 31 children (82%) in the proactive group, but only 19 children (48%) in the reactive group, met the study’s primary endpoint, sustained corticosteroid-free clinical remission at all visits (Gastroenterology. 2019 Oct;157[4]:985-96.e2).
In short, “proactive TDM was far superior to reactive testing,” Dr. Cheifetz said.
There’s a question if the results would translate to adults, but, Dr. Loftus said, they beg “the issue of if I should be checking adalimumab trough levels at weeks 4 and 8. It certainly gives you pause to think about doing that.”
Among other reports, Dr. Cheifetz also reviewed a retrospective study of 264 patients – almost two-thirds with Crohn’s disease, the rest with ulcerative colitis - on infliximab maintenance therapy; half had proactive TDM, and the rest reactive monitoring. The target trough concentration was 5-10 mcg/mL; median follow-up was 2.4 years. He was the senior investigator.
On multiple Cox regression analysis, the proactive group had an 84% lower risk of treatment failure, an 84% lower risk of IBD hospitalization, a 75% lower risk of antibody formation, an 83% lower risk of serious infusion reactions, and a 70% lower risk of IBD surgery (Clin Gastroenterol Hepatol. 2017 Oct;15[10]:1580-8.e3).
Dr. Cheifetz said he uses assays from Prometheus Laboratories for proactive TDM, but there are other options. Prometheus turnaround times are a few days. He and his colleagues also have a website – www.bridgeibd.com – where doctors can plug in patient characteristics and get proactive TDM advice.
Dr. Cheifetz is a consultant for Prometheus, as well as Janssen, Abbvie and other companies. He disclosed research funding form Inform Diagnostics. Dr. Loftus is a consultant and/or has research funding from Abbott, Pfizer, and other companies.
REPORTING FROM GUILD 2020
Pembrolizumab plus chemoradiotherapy shows early promise in NSCLC
Combination pembrolizumab and chemoradiotherapy appears safe and active for patients with locally advanced non–small cell lung cancer (NSCLC), results from a phase 1 trial suggest.
Nearly 90% of evaluable patients responded to the combination, and the 12-month progression-free survival rate was 69.7%. Pneumonitis was common, but most patients responded to high-dose corticosteroids.
Salma K. Jabbour, MD, of Rutgers Cancer Institute of New Jersey, in New Brunswick, and colleagues reported these results in JAMA Oncology.
The phase 1 study included 21 patients with locally advanced, unresectable, stage III NSCLC. Planned treatment consisted of pembrolizumab (Keytruda) at various dosing schedules, chemotherapy (weekly carboplatin and paclitaxel), and radiation (2 Gy/day, 60 Gy total).
The researchers used a standard 3 + 3 design to evaluate the safety and tolerability of pembrolizumab in five dosing cohorts.
In cohort 1, patients received pembrolizumab at 200 mg every 21 days within 2-6 weeks of completing chemoradiotherapy. In cohort 2, patients received pembrolizumab at 100 mg every 21 days, starting on day 29 of chemoradiotherapy. Cohort 3 received the 200 mg dose of pembrolizumab, starting on day 29.
Pembrolizumab was started on day 1 of chemoradiotherapy at the 100-mg dose in cohort 4 and at the 200-mg dose in cohort 5. An additional six-patient safety expansion cohort received the same treatment as cohort 5.
The median follow-up was 16 months. There was one dose-limiting toxicity – grade 5 pneumonitis, which occurred in the safety expansion cohort.
Grade 2 or higher immune-related toxicities were observed in 14 patients (67%), and grade 2 or higher pneumonitis occurred in 7 patients (33%).
“Although we observed an increased rate of pneumonitis, most patients had pneumonitis that responded to high-dose corticosteroid treatment,” the researchers noted.
There were 19 patients who received at least two cycles of pembrolizumab and were evaluable for response. The best response was complete response in 3 patients (16%), partial response in 14 patients (74%), and stable disease in 1 patient (5%).
The progression-free survival rate was 81.0% at 6 months and 69.7% at 12 months. The overall survival rate was 95.2% at 6 months and 85.2% at 12 months.
The researchers acknowledged that two key limitations of this study were the small sample size and short duration of follow-up.
“Pembrolizumab with concurrent chemoradiotherapy is tolerable for patients with locally advanced, unresectable NSCLC, although the risk of pneumonitis and long-term outcomes should be evaluated in additional studies,” commented Enriqueta Felip, MD, PhD, of Vall D’Hebron Institute of Oncology in Barcelona, who was not involved in this study.
The study was funded by Merck. The authors and Dr. Felip disclosed relationships with Merck and other companies.
SOURCE: Jabbour SK et al. JAMA Oncol. 2020 Feb 20. doi: 10.1001/jamaoncol.2019.6731.
Combination pembrolizumab and chemoradiotherapy appears safe and active for patients with locally advanced non–small cell lung cancer (NSCLC), results from a phase 1 trial suggest.
Nearly 90% of evaluable patients responded to the combination, and the 12-month progression-free survival rate was 69.7%. Pneumonitis was common, but most patients responded to high-dose corticosteroids.
Salma K. Jabbour, MD, of Rutgers Cancer Institute of New Jersey, in New Brunswick, and colleagues reported these results in JAMA Oncology.
The phase 1 study included 21 patients with locally advanced, unresectable, stage III NSCLC. Planned treatment consisted of pembrolizumab (Keytruda) at various dosing schedules, chemotherapy (weekly carboplatin and paclitaxel), and radiation (2 Gy/day, 60 Gy total).
The researchers used a standard 3 + 3 design to evaluate the safety and tolerability of pembrolizumab in five dosing cohorts.
In cohort 1, patients received pembrolizumab at 200 mg every 21 days within 2-6 weeks of completing chemoradiotherapy. In cohort 2, patients received pembrolizumab at 100 mg every 21 days, starting on day 29 of chemoradiotherapy. Cohort 3 received the 200 mg dose of pembrolizumab, starting on day 29.
Pembrolizumab was started on day 1 of chemoradiotherapy at the 100-mg dose in cohort 4 and at the 200-mg dose in cohort 5. An additional six-patient safety expansion cohort received the same treatment as cohort 5.
The median follow-up was 16 months. There was one dose-limiting toxicity – grade 5 pneumonitis, which occurred in the safety expansion cohort.
Grade 2 or higher immune-related toxicities were observed in 14 patients (67%), and grade 2 or higher pneumonitis occurred in 7 patients (33%).
“Although we observed an increased rate of pneumonitis, most patients had pneumonitis that responded to high-dose corticosteroid treatment,” the researchers noted.
There were 19 patients who received at least two cycles of pembrolizumab and were evaluable for response. The best response was complete response in 3 patients (16%), partial response in 14 patients (74%), and stable disease in 1 patient (5%).
The progression-free survival rate was 81.0% at 6 months and 69.7% at 12 months. The overall survival rate was 95.2% at 6 months and 85.2% at 12 months.
The researchers acknowledged that two key limitations of this study were the small sample size and short duration of follow-up.
“Pembrolizumab with concurrent chemoradiotherapy is tolerable for patients with locally advanced, unresectable NSCLC, although the risk of pneumonitis and long-term outcomes should be evaluated in additional studies,” commented Enriqueta Felip, MD, PhD, of Vall D’Hebron Institute of Oncology in Barcelona, who was not involved in this study.
The study was funded by Merck. The authors and Dr. Felip disclosed relationships with Merck and other companies.
SOURCE: Jabbour SK et al. JAMA Oncol. 2020 Feb 20. doi: 10.1001/jamaoncol.2019.6731.
Combination pembrolizumab and chemoradiotherapy appears safe and active for patients with locally advanced non–small cell lung cancer (NSCLC), results from a phase 1 trial suggest.
Nearly 90% of evaluable patients responded to the combination, and the 12-month progression-free survival rate was 69.7%. Pneumonitis was common, but most patients responded to high-dose corticosteroids.
Salma K. Jabbour, MD, of Rutgers Cancer Institute of New Jersey, in New Brunswick, and colleagues reported these results in JAMA Oncology.
The phase 1 study included 21 patients with locally advanced, unresectable, stage III NSCLC. Planned treatment consisted of pembrolizumab (Keytruda) at various dosing schedules, chemotherapy (weekly carboplatin and paclitaxel), and radiation (2 Gy/day, 60 Gy total).
The researchers used a standard 3 + 3 design to evaluate the safety and tolerability of pembrolizumab in five dosing cohorts.
In cohort 1, patients received pembrolizumab at 200 mg every 21 days within 2-6 weeks of completing chemoradiotherapy. In cohort 2, patients received pembrolizumab at 100 mg every 21 days, starting on day 29 of chemoradiotherapy. Cohort 3 received the 200 mg dose of pembrolizumab, starting on day 29.
Pembrolizumab was started on day 1 of chemoradiotherapy at the 100-mg dose in cohort 4 and at the 200-mg dose in cohort 5. An additional six-patient safety expansion cohort received the same treatment as cohort 5.
The median follow-up was 16 months. There was one dose-limiting toxicity – grade 5 pneumonitis, which occurred in the safety expansion cohort.
Grade 2 or higher immune-related toxicities were observed in 14 patients (67%), and grade 2 or higher pneumonitis occurred in 7 patients (33%).
“Although we observed an increased rate of pneumonitis, most patients had pneumonitis that responded to high-dose corticosteroid treatment,” the researchers noted.
There were 19 patients who received at least two cycles of pembrolizumab and were evaluable for response. The best response was complete response in 3 patients (16%), partial response in 14 patients (74%), and stable disease in 1 patient (5%).
The progression-free survival rate was 81.0% at 6 months and 69.7% at 12 months. The overall survival rate was 95.2% at 6 months and 85.2% at 12 months.
The researchers acknowledged that two key limitations of this study were the small sample size and short duration of follow-up.
“Pembrolizumab with concurrent chemoradiotherapy is tolerable for patients with locally advanced, unresectable NSCLC, although the risk of pneumonitis and long-term outcomes should be evaluated in additional studies,” commented Enriqueta Felip, MD, PhD, of Vall D’Hebron Institute of Oncology in Barcelona, who was not involved in this study.
The study was funded by Merck. The authors and Dr. Felip disclosed relationships with Merck and other companies.
SOURCE: Jabbour SK et al. JAMA Oncol. 2020 Feb 20. doi: 10.1001/jamaoncol.2019.6731.
FROM JAMA ONCOLOGY
Secondary bile acid deficiency may be culprit in UC inflammation
Researchers have found three potential gut mechanisms linked to secondary bile acid (SBA) deficiencies implicated in intestinal inflammation in ulcerative colitis (UC), and reported that supplementation may aid in restoring bile acid levels and potentially treating intestinal inflammation, according to a study published in Cell Host & Microbe.
The study identified lower levels of the following gut components in SBA deficiency in colectomy patients with UC, compared with those with familial adenomatous polyposis (FAP): deoxycholic and lithocholic acids (DCA and LCA), the most abundant gut secondary bile acids (SBAs); expression of the genes needed to convert primary bile acids (PBAs) into SBAs; and the number of Ruminococcaceae, one of the few taxa that include bacteria that generate SBAs.
“Our findings confirm that significant changes in bacterial diversity and composition occur in UC versus FAP pouches,” wrote Sidhartha R. Sinha, MD, of Stanford (Calif.) University, and coauthors. “Notably, our finding of decreased Ruminococcaceae in UC, compared to FAP pouch stool, requires further exploration.” They added that this is the first study to identify Ruminococcaceae as a key contributor to the production of LCA or DCA from PBAs.
The study found average DCA counts of 60,957 in FAP versus 1,593 in UC (P = .002), and average LCA counts of 30,644 and 282.9, respectively (P = .001). The study profiled stools from ileal pouches in colectomy patients who had UC (17) or FAP (7), a noninflammatory disease. “Remarkably, our data identify LCA and DCA to be almost undetectable in UC pouch patients,” Dr. Sinha and coauthors wrote. “This striking finding in patients who underwent colectomy suggests that SBAs may play a role in dysregulated metabolism-induced intestinal inflammation.”
The study found that UC pouches demonstrated less bacterial diversity, or alpha-diversity, than FAP pouches, which is in line with previously reported findings (J Inflamm Res. 2017;10:63-73), and had significantly lower expression of bile-acid inducible genes that encode enzymes that transform PBA to SBA.
The researchers also demonstrated that LCA and DCA supplementation reduced intestinal inflammation in mice with UC.
“Our results show that LCA and DCA treatments caused a remarkable and significant decrease in multiple chemokines and cytokines associated with inflammation, including those often increased in intestinal inflammation,” Dr. Sinha and coauthors wrote. However, they found that LCA had no protective effect on dextran sodium sulfate–induced colitis in mice with TGR5-deficient immune cells. The TGR5 bile acid receptor influences the anti-inflammatory effect in SBA supplementation, the study reported.
The researchers have initiated a clinical study (NCT03724175) to investigate the role of SBAs in patients with pouchitis that doesn’t respond to antibiotic therapy. “Insights from this study will further inform our understanding of the role of SBAs in intestinal inflammation and hold promise to provide an effective treatment,” Dr. Sinha and coauthors wrote.
Christian Jobin, PhD, of the University of Florida, Gainesville, said in an interview these findings are consistent with a recent paper that found a correlation between production of SBAs such as DCA and disease remission (ISME J. 2020;14:702-13). Dr. Jobin coauthored a 2018 study that similarly found SBAs have a role in intestinal inflammation (Gastroenterology. 2018;154:1751-63).
“For a long time, secondary bile acid, especially DCA was linked to cell injury, toxicity and even cancer,” he said. “It’s time to rehabilitate this important signaling molecule and recognize its important role in regulating host homeostasis.” The 2018 paper he coauthored showed that injection of DCA into germ-free mice did not promote intestinal pathology. “Actually, DCA was critical in preventing Campylobacter jejune–induced colitis,” he added.
Dr. Sinha received funding from the Crohn’s & Colitis Foundation, Stanford Clinical and Translational Science Award, and Kenneth Rainin Foundation Synergy Award. Coauthors received funding from the National Institutes of Health, the Ann and Bill Swindells Charitable Trust, Leslie and Douglas Ballinger, and the Kenneth Rainin Foundation.
SOURCE: Sinha SR et al. Cell Host Microbe. 2020 Feb 25. doi: 10.1016/j.chom.2020.01.021.
Researchers have found three potential gut mechanisms linked to secondary bile acid (SBA) deficiencies implicated in intestinal inflammation in ulcerative colitis (UC), and reported that supplementation may aid in restoring bile acid levels and potentially treating intestinal inflammation, according to a study published in Cell Host & Microbe.
The study identified lower levels of the following gut components in SBA deficiency in colectomy patients with UC, compared with those with familial adenomatous polyposis (FAP): deoxycholic and lithocholic acids (DCA and LCA), the most abundant gut secondary bile acids (SBAs); expression of the genes needed to convert primary bile acids (PBAs) into SBAs; and the number of Ruminococcaceae, one of the few taxa that include bacteria that generate SBAs.
“Our findings confirm that significant changes in bacterial diversity and composition occur in UC versus FAP pouches,” wrote Sidhartha R. Sinha, MD, of Stanford (Calif.) University, and coauthors. “Notably, our finding of decreased Ruminococcaceae in UC, compared to FAP pouch stool, requires further exploration.” They added that this is the first study to identify Ruminococcaceae as a key contributor to the production of LCA or DCA from PBAs.
The study found average DCA counts of 60,957 in FAP versus 1,593 in UC (P = .002), and average LCA counts of 30,644 and 282.9, respectively (P = .001). The study profiled stools from ileal pouches in colectomy patients who had UC (17) or FAP (7), a noninflammatory disease. “Remarkably, our data identify LCA and DCA to be almost undetectable in UC pouch patients,” Dr. Sinha and coauthors wrote. “This striking finding in patients who underwent colectomy suggests that SBAs may play a role in dysregulated metabolism-induced intestinal inflammation.”
The study found that UC pouches demonstrated less bacterial diversity, or alpha-diversity, than FAP pouches, which is in line with previously reported findings (J Inflamm Res. 2017;10:63-73), and had significantly lower expression of bile-acid inducible genes that encode enzymes that transform PBA to SBA.
The researchers also demonstrated that LCA and DCA supplementation reduced intestinal inflammation in mice with UC.
“Our results show that LCA and DCA treatments caused a remarkable and significant decrease in multiple chemokines and cytokines associated with inflammation, including those often increased in intestinal inflammation,” Dr. Sinha and coauthors wrote. However, they found that LCA had no protective effect on dextran sodium sulfate–induced colitis in mice with TGR5-deficient immune cells. The TGR5 bile acid receptor influences the anti-inflammatory effect in SBA supplementation, the study reported.
The researchers have initiated a clinical study (NCT03724175) to investigate the role of SBAs in patients with pouchitis that doesn’t respond to antibiotic therapy. “Insights from this study will further inform our understanding of the role of SBAs in intestinal inflammation and hold promise to provide an effective treatment,” Dr. Sinha and coauthors wrote.
Christian Jobin, PhD, of the University of Florida, Gainesville, said in an interview these findings are consistent with a recent paper that found a correlation between production of SBAs such as DCA and disease remission (ISME J. 2020;14:702-13). Dr. Jobin coauthored a 2018 study that similarly found SBAs have a role in intestinal inflammation (Gastroenterology. 2018;154:1751-63).
“For a long time, secondary bile acid, especially DCA was linked to cell injury, toxicity and even cancer,” he said. “It’s time to rehabilitate this important signaling molecule and recognize its important role in regulating host homeostasis.” The 2018 paper he coauthored showed that injection of DCA into germ-free mice did not promote intestinal pathology. “Actually, DCA was critical in preventing Campylobacter jejune–induced colitis,” he added.
Dr. Sinha received funding from the Crohn’s & Colitis Foundation, Stanford Clinical and Translational Science Award, and Kenneth Rainin Foundation Synergy Award. Coauthors received funding from the National Institutes of Health, the Ann and Bill Swindells Charitable Trust, Leslie and Douglas Ballinger, and the Kenneth Rainin Foundation.
SOURCE: Sinha SR et al. Cell Host Microbe. 2020 Feb 25. doi: 10.1016/j.chom.2020.01.021.
Researchers have found three potential gut mechanisms linked to secondary bile acid (SBA) deficiencies implicated in intestinal inflammation in ulcerative colitis (UC), and reported that supplementation may aid in restoring bile acid levels and potentially treating intestinal inflammation, according to a study published in Cell Host & Microbe.
The study identified lower levels of the following gut components in SBA deficiency in colectomy patients with UC, compared with those with familial adenomatous polyposis (FAP): deoxycholic and lithocholic acids (DCA and LCA), the most abundant gut secondary bile acids (SBAs); expression of the genes needed to convert primary bile acids (PBAs) into SBAs; and the number of Ruminococcaceae, one of the few taxa that include bacteria that generate SBAs.
“Our findings confirm that significant changes in bacterial diversity and composition occur in UC versus FAP pouches,” wrote Sidhartha R. Sinha, MD, of Stanford (Calif.) University, and coauthors. “Notably, our finding of decreased Ruminococcaceae in UC, compared to FAP pouch stool, requires further exploration.” They added that this is the first study to identify Ruminococcaceae as a key contributor to the production of LCA or DCA from PBAs.
The study found average DCA counts of 60,957 in FAP versus 1,593 in UC (P = .002), and average LCA counts of 30,644 and 282.9, respectively (P = .001). The study profiled stools from ileal pouches in colectomy patients who had UC (17) or FAP (7), a noninflammatory disease. “Remarkably, our data identify LCA and DCA to be almost undetectable in UC pouch patients,” Dr. Sinha and coauthors wrote. “This striking finding in patients who underwent colectomy suggests that SBAs may play a role in dysregulated metabolism-induced intestinal inflammation.”
The study found that UC pouches demonstrated less bacterial diversity, or alpha-diversity, than FAP pouches, which is in line with previously reported findings (J Inflamm Res. 2017;10:63-73), and had significantly lower expression of bile-acid inducible genes that encode enzymes that transform PBA to SBA.
The researchers also demonstrated that LCA and DCA supplementation reduced intestinal inflammation in mice with UC.
“Our results show that LCA and DCA treatments caused a remarkable and significant decrease in multiple chemokines and cytokines associated with inflammation, including those often increased in intestinal inflammation,” Dr. Sinha and coauthors wrote. However, they found that LCA had no protective effect on dextran sodium sulfate–induced colitis in mice with TGR5-deficient immune cells. The TGR5 bile acid receptor influences the anti-inflammatory effect in SBA supplementation, the study reported.
The researchers have initiated a clinical study (NCT03724175) to investigate the role of SBAs in patients with pouchitis that doesn’t respond to antibiotic therapy. “Insights from this study will further inform our understanding of the role of SBAs in intestinal inflammation and hold promise to provide an effective treatment,” Dr. Sinha and coauthors wrote.
Christian Jobin, PhD, of the University of Florida, Gainesville, said in an interview these findings are consistent with a recent paper that found a correlation between production of SBAs such as DCA and disease remission (ISME J. 2020;14:702-13). Dr. Jobin coauthored a 2018 study that similarly found SBAs have a role in intestinal inflammation (Gastroenterology. 2018;154:1751-63).
“For a long time, secondary bile acid, especially DCA was linked to cell injury, toxicity and even cancer,” he said. “It’s time to rehabilitate this important signaling molecule and recognize its important role in regulating host homeostasis.” The 2018 paper he coauthored showed that injection of DCA into germ-free mice did not promote intestinal pathology. “Actually, DCA was critical in preventing Campylobacter jejune–induced colitis,” he added.
Dr. Sinha received funding from the Crohn’s & Colitis Foundation, Stanford Clinical and Translational Science Award, and Kenneth Rainin Foundation Synergy Award. Coauthors received funding from the National Institutes of Health, the Ann and Bill Swindells Charitable Trust, Leslie and Douglas Ballinger, and the Kenneth Rainin Foundation.
SOURCE: Sinha SR et al. Cell Host Microbe. 2020 Feb 25. doi: 10.1016/j.chom.2020.01.021.
FROM CELL HOST & MICROBE
Abbreviated MRI bests digital breast tomosynthesis in finding cancer in dense breasts
For women with dense breasts, abbreviated magnetic resonance imaging was more effective than was digital breast tomosynthesis for detecting invasive breast cancer in a cross-sectional study of 1,444 women who underwent both procedures.
Dense breasts are a common reason for failed early diagnosis of breast cancer, wrote Christopher E. Comstock, MD, of Memorial Sloan Kettering Cancer Center, New York, and colleagues. Digital breast tomosynthesis (DBT) and abbreviated breast magnetic resonance imaging (MRI) are becoming more popular as safe and cost-effective breast cancer screening options, but their effectiveness in women with dense breasts and average breast cancer risk has not been compared.
The researchers reviewed data from 1,444 women aged 40-75 years at 47 institutions in the United States and 1 in Germany. The women underwent both DBT and MRI. The primary endpoint was the detection of invasive cancers, of which 17 were identified at baseline screening. Abbreviated breast MRI detected all 17 cases of invasive cancer, compared with 7 detected by DBT. In addition, MRI detected six of seven women with ductal carcinoma in situ, while DBT identified two of the seven cases, according to the study, which was published in JAMA.
Overall, the invasive cancer detection rate was 11.8 per 1,000 women for MRI compared with 4.8 per 1,000 women for DBT. Sensitivity for MRI and DBT was 96% vs. 39%, and specificity was 87% vs. 97%.
The rate of recommendation for further screening was not significantly different between the procedures (8% for MRI and 10% for DBT). The most common adverse events were three cases of mild allergic reactions and two cases of anxiety.
The study findings were limited by several factors including the inability to show an association between abbreviated breast MRI and breast cancer mortality and the lack of cost-effectiveness comparisons for the two procedures. Because eligibility criteria required a prior breast mammogram to see if the breasts were dense, the study compared an incidence DBT screen to a prevalence abbreviated MRI screen, Dr. Comstock and associates noted.
However, the results show a significantly increased breast cancer detection rate with abbreviated MRI, which merits additional research to examine the relationship between screening strategies and clinical outcomes for women with dense breasts, they said.
The study was supported in part by the National Cancer Institute of the National Institutes of Health, and by Bracco Diagnostics through funding to the ECOG-ACRIN Cancer Research Group. Dr. Comstock disclosed financial relationships with Bracco Diagnostics and Bayer, and three coauthors disclosed financial relationships with other imaging companies. The remaining coauthors had no relevant financial disclosures.
SOURCE: Comstock CK et al. JAMA. 2020 Feb 25. doi: 10.1001/jama.2020.0572.
For women with dense breasts, abbreviated magnetic resonance imaging was more effective than was digital breast tomosynthesis for detecting invasive breast cancer in a cross-sectional study of 1,444 women who underwent both procedures.
Dense breasts are a common reason for failed early diagnosis of breast cancer, wrote Christopher E. Comstock, MD, of Memorial Sloan Kettering Cancer Center, New York, and colleagues. Digital breast tomosynthesis (DBT) and abbreviated breast magnetic resonance imaging (MRI) are becoming more popular as safe and cost-effective breast cancer screening options, but their effectiveness in women with dense breasts and average breast cancer risk has not been compared.
The researchers reviewed data from 1,444 women aged 40-75 years at 47 institutions in the United States and 1 in Germany. The women underwent both DBT and MRI. The primary endpoint was the detection of invasive cancers, of which 17 were identified at baseline screening. Abbreviated breast MRI detected all 17 cases of invasive cancer, compared with 7 detected by DBT. In addition, MRI detected six of seven women with ductal carcinoma in situ, while DBT identified two of the seven cases, according to the study, which was published in JAMA.
Overall, the invasive cancer detection rate was 11.8 per 1,000 women for MRI compared with 4.8 per 1,000 women for DBT. Sensitivity for MRI and DBT was 96% vs. 39%, and specificity was 87% vs. 97%.
The rate of recommendation for further screening was not significantly different between the procedures (8% for MRI and 10% for DBT). The most common adverse events were three cases of mild allergic reactions and two cases of anxiety.
The study findings were limited by several factors including the inability to show an association between abbreviated breast MRI and breast cancer mortality and the lack of cost-effectiveness comparisons for the two procedures. Because eligibility criteria required a prior breast mammogram to see if the breasts were dense, the study compared an incidence DBT screen to a prevalence abbreviated MRI screen, Dr. Comstock and associates noted.
However, the results show a significantly increased breast cancer detection rate with abbreviated MRI, which merits additional research to examine the relationship between screening strategies and clinical outcomes for women with dense breasts, they said.
The study was supported in part by the National Cancer Institute of the National Institutes of Health, and by Bracco Diagnostics through funding to the ECOG-ACRIN Cancer Research Group. Dr. Comstock disclosed financial relationships with Bracco Diagnostics and Bayer, and three coauthors disclosed financial relationships with other imaging companies. The remaining coauthors had no relevant financial disclosures.
SOURCE: Comstock CK et al. JAMA. 2020 Feb 25. doi: 10.1001/jama.2020.0572.
For women with dense breasts, abbreviated magnetic resonance imaging was more effective than was digital breast tomosynthesis for detecting invasive breast cancer in a cross-sectional study of 1,444 women who underwent both procedures.
Dense breasts are a common reason for failed early diagnosis of breast cancer, wrote Christopher E. Comstock, MD, of Memorial Sloan Kettering Cancer Center, New York, and colleagues. Digital breast tomosynthesis (DBT) and abbreviated breast magnetic resonance imaging (MRI) are becoming more popular as safe and cost-effective breast cancer screening options, but their effectiveness in women with dense breasts and average breast cancer risk has not been compared.
The researchers reviewed data from 1,444 women aged 40-75 years at 47 institutions in the United States and 1 in Germany. The women underwent both DBT and MRI. The primary endpoint was the detection of invasive cancers, of which 17 were identified at baseline screening. Abbreviated breast MRI detected all 17 cases of invasive cancer, compared with 7 detected by DBT. In addition, MRI detected six of seven women with ductal carcinoma in situ, while DBT identified two of the seven cases, according to the study, which was published in JAMA.
Overall, the invasive cancer detection rate was 11.8 per 1,000 women for MRI compared with 4.8 per 1,000 women for DBT. Sensitivity for MRI and DBT was 96% vs. 39%, and specificity was 87% vs. 97%.
The rate of recommendation for further screening was not significantly different between the procedures (8% for MRI and 10% for DBT). The most common adverse events were three cases of mild allergic reactions and two cases of anxiety.
The study findings were limited by several factors including the inability to show an association between abbreviated breast MRI and breast cancer mortality and the lack of cost-effectiveness comparisons for the two procedures. Because eligibility criteria required a prior breast mammogram to see if the breasts were dense, the study compared an incidence DBT screen to a prevalence abbreviated MRI screen, Dr. Comstock and associates noted.
However, the results show a significantly increased breast cancer detection rate with abbreviated MRI, which merits additional research to examine the relationship between screening strategies and clinical outcomes for women with dense breasts, they said.
The study was supported in part by the National Cancer Institute of the National Institutes of Health, and by Bracco Diagnostics through funding to the ECOG-ACRIN Cancer Research Group. Dr. Comstock disclosed financial relationships with Bracco Diagnostics and Bayer, and three coauthors disclosed financial relationships with other imaging companies. The remaining coauthors had no relevant financial disclosures.
SOURCE: Comstock CK et al. JAMA. 2020 Feb 25. doi: 10.1001/jama.2020.0572.
FROM JAMA
It is time to separate the O from the G
Two very different specialties, obstetrics (O) and gynecology (G), were fused into one in 1889. It is difficult to conceive that, with the expansion of both specialties in knowledge, procedures, and subspecialties, they still remain as one after 130 years. The American College of Obstetricians and Gynecologists was founded in 1952, and after 68 years no major changes have been made to accept or incorporate that there is a need to consider O and G as two different specialties.
Obstetrics and gynecology are the only specialties dedicated exclusively to women but with a very different purpose: the O is for reproduction, the G is for prevention and management of genital diseases. The specialties of O and G are so different the only thing in common is the patient.
It is time to separate the O from the G.
Are we training surgically competent residents?
No, we are not. There is an adequate volume for training and practice in O with close to 3.8 million births a year (the number cited by the Centers for Disease Control and Prevention in 2018). Not surprisingly, there is a need for trainees and also for practitioners in rural areas. As a result, the surgical training and practice in G is not optimal. If the number of hysterectomies was even near that of deliveries, there would be an adequate volume for everyone in training and in practice. But this is not the case.
The Accreditation Council for Graduate Medical Education (ACGME) mandates OG residents to graduate with a minimum of 70 minimally invasive hysterectomies (MIH), including laparoscopic (LH), vaginal (VH), and laparoscopic vaginally assisted (LAVH). In 2017, 51% of graduating residents fell below the minimum of 70 MIH.1 Because the learning curve of LH ranges from 30 to 80 cases,2 it is not surprising most residents feel surgically inadequate at graduation to function independently.
Increased procedures and technologies with reduced training hours
Let’s look at hysterectomies. From two techniques, vaginal and abdominal, they have expanded to LH, LAVH, robotic, single-site LH, single-site robotic, and recently single-port robotic. In addition, different and new technologies for hysteroscopy and myomectomy procedures have been developed.
All these operations are supposed to be part of any training program as ACGME demands “OG residents must be able to competently perform all medical, diagnostic, and surgical procedures considered essential for the area of practice.”3 In addition, primary care has been added to OG residency training: “Primary health care management from adolescence through reproductive age to midlife and beyond is integral to any ob.gyn.’s practice” and “Obstetrician-gynecologists are viewed by some entities as being primary care physicians for women, especially as coordinators of care among most reproductive-aged women,” according to ACOG.4
All this with reduced training hours.
The number of training hours a week has been reduced to 80, while it used to be over 100 hours. If you do the math, 20 fewer hours a week for 4 years amounts to 4,240 hours, equivalent to 180 days, equal to 6 months.
Graduating residents must pass a written and an oral exam for certification and with this are approved to enter the operating room and operate on women without a surgical skills test.
A simple test shows that elimination of the O for 1 year improves laparoscopic performance
We compared the time to perform three basic laparoscopic skills by fourth-year OG residents with that of fellows at the end of their first year in a minimally invasive G fellowship.5 The mean time for the residents completing the three tasks within the allotted time was 16 minutes, compared with 3.5 minutes for fellows: a four times faster performance.
Are there enough patients to maintain surgical skills after residency?
No, there are not.
Consider the following reality after residency. Decreasing number of surgeries and increasing numbers of OGs results in what you have already guessed: a lower surgical volume per OG.
Since 1979, the number of G surgeries has decreased by almost half (46%) while the number of OGs has doubled (54%) resulting in an 81% decrease of number of surgeries per OG, from 132 in 1979 to 25 in 2007.6 For hysterectomies, there has been a continuous yearly decline per G from 28 in 1980 to 9.8 in 2007 and to 8.5 in 2010.7,8
Would any mother feel comfortable having an obstetrician for her pregnancy and delivery performing only 8.5 deliveries a year?
Where do we go from here?
Separate the training and practice of O and G, an initiative already started in some residency programs and in some institutions in the United States. The O and the G both include a medical and a surgical practice.
We need to start accepting there is a need for different practices: medical O, medical G, surgical O, and surgical G. It is not new, it is already happening, it is the case in our institution since inception, and it is expanding across the country because it is needed. Graduating residents recognize this need as noticed by the increasing number seeking subspecialty training, from 7% in 2000 to 19.5% in 2012.4
Will this require some patients to drive away from home to obtain the best possible care? Yes. It is not a new concept, and it already is occurring for patients traveling to specialized centers away from home for certain conditions. In some countries, the practice is restricted to only a few centers. In Sweden, for instance, patients diagnosed with gynecologic cancer must travel to one of only seven centers subspecialized in gynecologic malignancies.
Conclusion
We need to start someday. We already are late after 130 years. We need to provide optimal care for women. They are our mothers. They deserve it. Let the O deliver O care, let the G provide G care, and we will reap improved results.
Dr. Magrina is with the department of medical and surgical gynecology at the Mayo Clinic in Phoenix. The author has no conflict of interest or financial involvement with this manuscript.
References
1. Am J Obstet Gynecol. 2019 Nov 22. doi: 10.1016/j.ajog.2019.11.1258.
2. Clin Obstet Gynecol. 2011 Sep;54(3):376-81.
3. Accreditation Council for Graduate Medical Education. Program requirements for GME in Obstetrics and Gynecology 2017.
4. “The obstetrician-gynecologist workforce in the United States: Facts, figures, and implications, 2017” (Washington, D.C.: ACOG, 2017).
5. J Minim Invasive Gynecol. 2008 Jul-Aug;15(4):410-3.
6. J Minim Invasive Gynecol. 2014 Jul-Aug;21(4):501-3.
7. National Health Statistics Report. Hysterectomy in the U.S. and oophorectomy 1979-2007. http://www.cdc.gov/nchs/products/nhsr.htm.
8. The Healthcare Cost and Utilization Project – Nationwide Inpatient Sample: Agency for Health Care Research Quality. 2013.
Two very different specialties, obstetrics (O) and gynecology (G), were fused into one in 1889. It is difficult to conceive that, with the expansion of both specialties in knowledge, procedures, and subspecialties, they still remain as one after 130 years. The American College of Obstetricians and Gynecologists was founded in 1952, and after 68 years no major changes have been made to accept or incorporate that there is a need to consider O and G as two different specialties.
Obstetrics and gynecology are the only specialties dedicated exclusively to women but with a very different purpose: the O is for reproduction, the G is for prevention and management of genital diseases. The specialties of O and G are so different the only thing in common is the patient.
It is time to separate the O from the G.
Are we training surgically competent residents?
No, we are not. There is an adequate volume for training and practice in O with close to 3.8 million births a year (the number cited by the Centers for Disease Control and Prevention in 2018). Not surprisingly, there is a need for trainees and also for practitioners in rural areas. As a result, the surgical training and practice in G is not optimal. If the number of hysterectomies was even near that of deliveries, there would be an adequate volume for everyone in training and in practice. But this is not the case.
The Accreditation Council for Graduate Medical Education (ACGME) mandates OG residents to graduate with a minimum of 70 minimally invasive hysterectomies (MIH), including laparoscopic (LH), vaginal (VH), and laparoscopic vaginally assisted (LAVH). In 2017, 51% of graduating residents fell below the minimum of 70 MIH.1 Because the learning curve of LH ranges from 30 to 80 cases,2 it is not surprising most residents feel surgically inadequate at graduation to function independently.
Increased procedures and technologies with reduced training hours
Let’s look at hysterectomies. From two techniques, vaginal and abdominal, they have expanded to LH, LAVH, robotic, single-site LH, single-site robotic, and recently single-port robotic. In addition, different and new technologies for hysteroscopy and myomectomy procedures have been developed.
All these operations are supposed to be part of any training program as ACGME demands “OG residents must be able to competently perform all medical, diagnostic, and surgical procedures considered essential for the area of practice.”3 In addition, primary care has been added to OG residency training: “Primary health care management from adolescence through reproductive age to midlife and beyond is integral to any ob.gyn.’s practice” and “Obstetrician-gynecologists are viewed by some entities as being primary care physicians for women, especially as coordinators of care among most reproductive-aged women,” according to ACOG.4
All this with reduced training hours.
The number of training hours a week has been reduced to 80, while it used to be over 100 hours. If you do the math, 20 fewer hours a week for 4 years amounts to 4,240 hours, equivalent to 180 days, equal to 6 months.
Graduating residents must pass a written and an oral exam for certification and with this are approved to enter the operating room and operate on women without a surgical skills test.
A simple test shows that elimination of the O for 1 year improves laparoscopic performance
We compared the time to perform three basic laparoscopic skills by fourth-year OG residents with that of fellows at the end of their first year in a minimally invasive G fellowship.5 The mean time for the residents completing the three tasks within the allotted time was 16 minutes, compared with 3.5 minutes for fellows: a four times faster performance.
Are there enough patients to maintain surgical skills after residency?
No, there are not.
Consider the following reality after residency. Decreasing number of surgeries and increasing numbers of OGs results in what you have already guessed: a lower surgical volume per OG.
Since 1979, the number of G surgeries has decreased by almost half (46%) while the number of OGs has doubled (54%) resulting in an 81% decrease of number of surgeries per OG, from 132 in 1979 to 25 in 2007.6 For hysterectomies, there has been a continuous yearly decline per G from 28 in 1980 to 9.8 in 2007 and to 8.5 in 2010.7,8
Would any mother feel comfortable having an obstetrician for her pregnancy and delivery performing only 8.5 deliveries a year?
Where do we go from here?
Separate the training and practice of O and G, an initiative already started in some residency programs and in some institutions in the United States. The O and the G both include a medical and a surgical practice.
We need to start accepting there is a need for different practices: medical O, medical G, surgical O, and surgical G. It is not new, it is already happening, it is the case in our institution since inception, and it is expanding across the country because it is needed. Graduating residents recognize this need as noticed by the increasing number seeking subspecialty training, from 7% in 2000 to 19.5% in 2012.4
Will this require some patients to drive away from home to obtain the best possible care? Yes. It is not a new concept, and it already is occurring for patients traveling to specialized centers away from home for certain conditions. In some countries, the practice is restricted to only a few centers. In Sweden, for instance, patients diagnosed with gynecologic cancer must travel to one of only seven centers subspecialized in gynecologic malignancies.
Conclusion
We need to start someday. We already are late after 130 years. We need to provide optimal care for women. They are our mothers. They deserve it. Let the O deliver O care, let the G provide G care, and we will reap improved results.
Dr. Magrina is with the department of medical and surgical gynecology at the Mayo Clinic in Phoenix. The author has no conflict of interest or financial involvement with this manuscript.
References
1. Am J Obstet Gynecol. 2019 Nov 22. doi: 10.1016/j.ajog.2019.11.1258.
2. Clin Obstet Gynecol. 2011 Sep;54(3):376-81.
3. Accreditation Council for Graduate Medical Education. Program requirements for GME in Obstetrics and Gynecology 2017.
4. “The obstetrician-gynecologist workforce in the United States: Facts, figures, and implications, 2017” (Washington, D.C.: ACOG, 2017).
5. J Minim Invasive Gynecol. 2008 Jul-Aug;15(4):410-3.
6. J Minim Invasive Gynecol. 2014 Jul-Aug;21(4):501-3.
7. National Health Statistics Report. Hysterectomy in the U.S. and oophorectomy 1979-2007. http://www.cdc.gov/nchs/products/nhsr.htm.
8. The Healthcare Cost and Utilization Project – Nationwide Inpatient Sample: Agency for Health Care Research Quality. 2013.
Two very different specialties, obstetrics (O) and gynecology (G), were fused into one in 1889. It is difficult to conceive that, with the expansion of both specialties in knowledge, procedures, and subspecialties, they still remain as one after 130 years. The American College of Obstetricians and Gynecologists was founded in 1952, and after 68 years no major changes have been made to accept or incorporate that there is a need to consider O and G as two different specialties.
Obstetrics and gynecology are the only specialties dedicated exclusively to women but with a very different purpose: the O is for reproduction, the G is for prevention and management of genital diseases. The specialties of O and G are so different the only thing in common is the patient.
It is time to separate the O from the G.
Are we training surgically competent residents?
No, we are not. There is an adequate volume for training and practice in O with close to 3.8 million births a year (the number cited by the Centers for Disease Control and Prevention in 2018). Not surprisingly, there is a need for trainees and also for practitioners in rural areas. As a result, the surgical training and practice in G is not optimal. If the number of hysterectomies was even near that of deliveries, there would be an adequate volume for everyone in training and in practice. But this is not the case.
The Accreditation Council for Graduate Medical Education (ACGME) mandates OG residents to graduate with a minimum of 70 minimally invasive hysterectomies (MIH), including laparoscopic (LH), vaginal (VH), and laparoscopic vaginally assisted (LAVH). In 2017, 51% of graduating residents fell below the minimum of 70 MIH.1 Because the learning curve of LH ranges from 30 to 80 cases,2 it is not surprising most residents feel surgically inadequate at graduation to function independently.
Increased procedures and technologies with reduced training hours
Let’s look at hysterectomies. From two techniques, vaginal and abdominal, they have expanded to LH, LAVH, robotic, single-site LH, single-site robotic, and recently single-port robotic. In addition, different and new technologies for hysteroscopy and myomectomy procedures have been developed.
All these operations are supposed to be part of any training program as ACGME demands “OG residents must be able to competently perform all medical, diagnostic, and surgical procedures considered essential for the area of practice.”3 In addition, primary care has been added to OG residency training: “Primary health care management from adolescence through reproductive age to midlife and beyond is integral to any ob.gyn.’s practice” and “Obstetrician-gynecologists are viewed by some entities as being primary care physicians for women, especially as coordinators of care among most reproductive-aged women,” according to ACOG.4
All this with reduced training hours.
The number of training hours a week has been reduced to 80, while it used to be over 100 hours. If you do the math, 20 fewer hours a week for 4 years amounts to 4,240 hours, equivalent to 180 days, equal to 6 months.
Graduating residents must pass a written and an oral exam for certification and with this are approved to enter the operating room and operate on women without a surgical skills test.
A simple test shows that elimination of the O for 1 year improves laparoscopic performance
We compared the time to perform three basic laparoscopic skills by fourth-year OG residents with that of fellows at the end of their first year in a minimally invasive G fellowship.5 The mean time for the residents completing the three tasks within the allotted time was 16 minutes, compared with 3.5 minutes for fellows: a four times faster performance.
Are there enough patients to maintain surgical skills after residency?
No, there are not.
Consider the following reality after residency. Decreasing number of surgeries and increasing numbers of OGs results in what you have already guessed: a lower surgical volume per OG.
Since 1979, the number of G surgeries has decreased by almost half (46%) while the number of OGs has doubled (54%) resulting in an 81% decrease of number of surgeries per OG, from 132 in 1979 to 25 in 2007.6 For hysterectomies, there has been a continuous yearly decline per G from 28 in 1980 to 9.8 in 2007 and to 8.5 in 2010.7,8
Would any mother feel comfortable having an obstetrician for her pregnancy and delivery performing only 8.5 deliveries a year?
Where do we go from here?
Separate the training and practice of O and G, an initiative already started in some residency programs and in some institutions in the United States. The O and the G both include a medical and a surgical practice.
We need to start accepting there is a need for different practices: medical O, medical G, surgical O, and surgical G. It is not new, it is already happening, it is the case in our institution since inception, and it is expanding across the country because it is needed. Graduating residents recognize this need as noticed by the increasing number seeking subspecialty training, from 7% in 2000 to 19.5% in 2012.4
Will this require some patients to drive away from home to obtain the best possible care? Yes. It is not a new concept, and it already is occurring for patients traveling to specialized centers away from home for certain conditions. In some countries, the practice is restricted to only a few centers. In Sweden, for instance, patients diagnosed with gynecologic cancer must travel to one of only seven centers subspecialized in gynecologic malignancies.
Conclusion
We need to start someday. We already are late after 130 years. We need to provide optimal care for women. They are our mothers. They deserve it. Let the O deliver O care, let the G provide G care, and we will reap improved results.
Dr. Magrina is with the department of medical and surgical gynecology at the Mayo Clinic in Phoenix. The author has no conflict of interest or financial involvement with this manuscript.
References
1. Am J Obstet Gynecol. 2019 Nov 22. doi: 10.1016/j.ajog.2019.11.1258.
2. Clin Obstet Gynecol. 2011 Sep;54(3):376-81.
3. Accreditation Council for Graduate Medical Education. Program requirements for GME in Obstetrics and Gynecology 2017.
4. “The obstetrician-gynecologist workforce in the United States: Facts, figures, and implications, 2017” (Washington, D.C.: ACOG, 2017).
5. J Minim Invasive Gynecol. 2008 Jul-Aug;15(4):410-3.
6. J Minim Invasive Gynecol. 2014 Jul-Aug;21(4):501-3.
7. National Health Statistics Report. Hysterectomy in the U.S. and oophorectomy 1979-2007. http://www.cdc.gov/nchs/products/nhsr.htm.
8. The Healthcare Cost and Utilization Project – Nationwide Inpatient Sample: Agency for Health Care Research Quality. 2013.
A bladder brewery and a neurosurgical violin solo
One bikram, one shakti, one beer
Novelty yoga is a thing, and there’s no stopping it now.
There’s cat yoga, aerial yoga (performed in a harness or hammock suspended above the ground), karaoke yoga, laughter yoga (done while listening to the LOTME podcast, no doubt), snake yoga, toega (yoga for toes), and, of course, goat yoga. So what’s next, beer yoga?
Why, yes, it is beer yoga.
In our travels around the dark, deserted corners of the Internet, we came across an article on Educatedbox.com that said a beer yoga class “involves picking up a beer, drinking it, and putting it back down again, in many different ways.”
Pretty straightforward. Then we saw a photo on Germany’s Bieryoga.de that showed all of the participants doing the tree pose while balancing a beer bottle on their heads. Not so straightforward. Trust us, we tried.
Bieryoga explains that “the exuberance that comes with drinking beer and the body awareness of yoga can be combined into an energizing experience. In the beer and now.”
How can we say no to “in the beer and now”? Well, we can’t, but we do have one teeny tiny problem: We’ve gotten into “downward-facing dog with IPA on rump,” and now we can’t get up.
Little help … anyone?
A surgical symphony
A patient playing the violin during her own brain surgery? That sounds way more interesting than paying hundreds of dollars to attend any old normal concert.
Violinist Dagmar Turner found out in 2013 that she had a brain tumor that was gradually advancing in size. After learning the tumor needed to be removed, Ms. Turner worried she might lose her talents if the parts of her brain crucial to playing the violin were destroyed.
Luckily, her well-orchestrated surgical team composed a plan to ensure they spared the vital parts of the brain used when playing the violin: They would wake their patient during brain surgery and have her play her violin. Yes, you read that right – she played the violin during surgery to help her surgeons make certain there was no damage to the violin-related areas of her brain.
Personally, we here at the profit-minded Bureau of LOTME believe the surgical team missed a perfect opportunity to sell tickets to this event. Ms. Turner successfully made it through the surgery both 90% tumor free and fully able to play her violin. We love a happy ending! Bravo! Though maybe not “Encore!”
Belly up to the bar, boys
Quick, what would be the worst superpower? No doubt your head is flooding with ideas, each more comical than the last. But did you think of “able to pee beer?”
That’s right, it’s the return of an old LOTME favorite – auto-brewery syndrome. But this time, there’s a twist.
Our daring hero in today’s exciting case report from Annals of Internal Medicine is a 61-year-old woman from Pittsburgh who presented with liver damage and poorly controlled diabetes, and who sought placement on the liver transplant list.
But hang on, the woman’s history seemed to indicate her liver problems stemmed from alcohol addiction, because her urine tests were always positive for alcohol, and the current tests said the same. Hmm, this is sounding slightly villainous!
There were, however, some discrepancies. The woman didn’t appear to be intoxicated during clinic visits, tests for ethanol metabolites were negative while urine tests for ethanol were positive, and there were large quantities of glucose and budding yeast in the urine. Something strange was going on, so the doctors decided to dig deeper.
The yeast in question was Candida glabrata, which is closely related to brewer’s yeast. The doctors found high levels of ethanol production in the urine, suggesting that the yeast was fermenting sugar inside the bladder. The patient was quite literally urinating alcohol, becoming the first documented case in a living person of what the doctors dubbed “urinary auto-brewery syndrome.”
As much as we love a good drink here at LOTME world headquarters, we’ll have to pass on the urine cocktail. Just don’t tell all the beer yoga enthusiasts, this seems right up their alley. You know, positive natural energy flow or something like that.
One bikram, one shakti, one beer
Novelty yoga is a thing, and there’s no stopping it now.
There’s cat yoga, aerial yoga (performed in a harness or hammock suspended above the ground), karaoke yoga, laughter yoga (done while listening to the LOTME podcast, no doubt), snake yoga, toega (yoga for toes), and, of course, goat yoga. So what’s next, beer yoga?
Why, yes, it is beer yoga.
In our travels around the dark, deserted corners of the Internet, we came across an article on Educatedbox.com that said a beer yoga class “involves picking up a beer, drinking it, and putting it back down again, in many different ways.”
Pretty straightforward. Then we saw a photo on Germany’s Bieryoga.de that showed all of the participants doing the tree pose while balancing a beer bottle on their heads. Not so straightforward. Trust us, we tried.
Bieryoga explains that “the exuberance that comes with drinking beer and the body awareness of yoga can be combined into an energizing experience. In the beer and now.”
How can we say no to “in the beer and now”? Well, we can’t, but we do have one teeny tiny problem: We’ve gotten into “downward-facing dog with IPA on rump,” and now we can’t get up.
Little help … anyone?
A surgical symphony
A patient playing the violin during her own brain surgery? That sounds way more interesting than paying hundreds of dollars to attend any old normal concert.
Violinist Dagmar Turner found out in 2013 that she had a brain tumor that was gradually advancing in size. After learning the tumor needed to be removed, Ms. Turner worried she might lose her talents if the parts of her brain crucial to playing the violin were destroyed.
Luckily, her well-orchestrated surgical team composed a plan to ensure they spared the vital parts of the brain used when playing the violin: They would wake their patient during brain surgery and have her play her violin. Yes, you read that right – she played the violin during surgery to help her surgeons make certain there was no damage to the violin-related areas of her brain.
Personally, we here at the profit-minded Bureau of LOTME believe the surgical team missed a perfect opportunity to sell tickets to this event. Ms. Turner successfully made it through the surgery both 90% tumor free and fully able to play her violin. We love a happy ending! Bravo! Though maybe not “Encore!”
Belly up to the bar, boys
Quick, what would be the worst superpower? No doubt your head is flooding with ideas, each more comical than the last. But did you think of “able to pee beer?”
That’s right, it’s the return of an old LOTME favorite – auto-brewery syndrome. But this time, there’s a twist.
Our daring hero in today’s exciting case report from Annals of Internal Medicine is a 61-year-old woman from Pittsburgh who presented with liver damage and poorly controlled diabetes, and who sought placement on the liver transplant list.
But hang on, the woman’s history seemed to indicate her liver problems stemmed from alcohol addiction, because her urine tests were always positive for alcohol, and the current tests said the same. Hmm, this is sounding slightly villainous!
There were, however, some discrepancies. The woman didn’t appear to be intoxicated during clinic visits, tests for ethanol metabolites were negative while urine tests for ethanol were positive, and there were large quantities of glucose and budding yeast in the urine. Something strange was going on, so the doctors decided to dig deeper.
The yeast in question was Candida glabrata, which is closely related to brewer’s yeast. The doctors found high levels of ethanol production in the urine, suggesting that the yeast was fermenting sugar inside the bladder. The patient was quite literally urinating alcohol, becoming the first documented case in a living person of what the doctors dubbed “urinary auto-brewery syndrome.”
As much as we love a good drink here at LOTME world headquarters, we’ll have to pass on the urine cocktail. Just don’t tell all the beer yoga enthusiasts, this seems right up their alley. You know, positive natural energy flow or something like that.
One bikram, one shakti, one beer
Novelty yoga is a thing, and there’s no stopping it now.
There’s cat yoga, aerial yoga (performed in a harness or hammock suspended above the ground), karaoke yoga, laughter yoga (done while listening to the LOTME podcast, no doubt), snake yoga, toega (yoga for toes), and, of course, goat yoga. So what’s next, beer yoga?
Why, yes, it is beer yoga.
In our travels around the dark, deserted corners of the Internet, we came across an article on Educatedbox.com that said a beer yoga class “involves picking up a beer, drinking it, and putting it back down again, in many different ways.”
Pretty straightforward. Then we saw a photo on Germany’s Bieryoga.de that showed all of the participants doing the tree pose while balancing a beer bottle on their heads. Not so straightforward. Trust us, we tried.
Bieryoga explains that “the exuberance that comes with drinking beer and the body awareness of yoga can be combined into an energizing experience. In the beer and now.”
How can we say no to “in the beer and now”? Well, we can’t, but we do have one teeny tiny problem: We’ve gotten into “downward-facing dog with IPA on rump,” and now we can’t get up.
Little help … anyone?
A surgical symphony
A patient playing the violin during her own brain surgery? That sounds way more interesting than paying hundreds of dollars to attend any old normal concert.
Violinist Dagmar Turner found out in 2013 that she had a brain tumor that was gradually advancing in size. After learning the tumor needed to be removed, Ms. Turner worried she might lose her talents if the parts of her brain crucial to playing the violin were destroyed.
Luckily, her well-orchestrated surgical team composed a plan to ensure they spared the vital parts of the brain used when playing the violin: They would wake their patient during brain surgery and have her play her violin. Yes, you read that right – she played the violin during surgery to help her surgeons make certain there was no damage to the violin-related areas of her brain.
Personally, we here at the profit-minded Bureau of LOTME believe the surgical team missed a perfect opportunity to sell tickets to this event. Ms. Turner successfully made it through the surgery both 90% tumor free and fully able to play her violin. We love a happy ending! Bravo! Though maybe not “Encore!”
Belly up to the bar, boys
Quick, what would be the worst superpower? No doubt your head is flooding with ideas, each more comical than the last. But did you think of “able to pee beer?”
That’s right, it’s the return of an old LOTME favorite – auto-brewery syndrome. But this time, there’s a twist.
Our daring hero in today’s exciting case report from Annals of Internal Medicine is a 61-year-old woman from Pittsburgh who presented with liver damage and poorly controlled diabetes, and who sought placement on the liver transplant list.
But hang on, the woman’s history seemed to indicate her liver problems stemmed from alcohol addiction, because her urine tests were always positive for alcohol, and the current tests said the same. Hmm, this is sounding slightly villainous!
There were, however, some discrepancies. The woman didn’t appear to be intoxicated during clinic visits, tests for ethanol metabolites were negative while urine tests for ethanol were positive, and there were large quantities of glucose and budding yeast in the urine. Something strange was going on, so the doctors decided to dig deeper.
The yeast in question was Candida glabrata, which is closely related to brewer’s yeast. The doctors found high levels of ethanol production in the urine, suggesting that the yeast was fermenting sugar inside the bladder. The patient was quite literally urinating alcohol, becoming the first documented case in a living person of what the doctors dubbed “urinary auto-brewery syndrome.”
As much as we love a good drink here at LOTME world headquarters, we’ll have to pass on the urine cocktail. Just don’t tell all the beer yoga enthusiasts, this seems right up their alley. You know, positive natural energy flow or something like that.
Rising number of young people dying after heavy drinking
MAUI, HAWAII – Alcohol use and deaths related to alcohol-use disorders are increasing, and young adults might be the group to watch, said Norah Terrault, MD, MPH, professor at the Keck School of Medicine of USC in Los Angeles.
“A lot of young people are drinking large amounts and they don’t know they’re at risk. They may not drink much during the week but then drink 30 drinks on the weekend,” Dr. Terrault told Medscape Medical News.
The largest relative increase in deaths from alcoholic cirrhosis – 10.5% from 2009 to 2016 – was in the 25- to 34-year age group, she reported here at the Gastroenterology Updates IBD Liver Disease Conference 2020.
This highlights the importance of asking for details about alcohol use during primary care visits; not only how much, but also what time of day, for instance, she explained.
Dr. Terrault’s team at Keck is part of the ACCELERATE-AH consortium, a group of 12 transplant centers looking at patterns of alcohol use before and after liver transplantation.
In their retrospective study of 147 consecutive transplant patients from 2006 to 2018, they found that young age, a history of multiple rehab attempts, and overt encephalopathy at time of transplantation were predictors of alcohol use after the procedure.
Corticosteroids remain the only proven therapy for alcoholic hepatitis. “We have not seen a new therapy in this arena in decades,” said Dr. Terrault. “We really have nothing to offer these patients, yet it’s an incredibly common presentation with a high mortality.”
More treatment options
The good news is that some phase 2 data look promising for new therapies, she reported.
“Some of them are targeting injury and regeneration primarily. Others are looking at the anti-inflammatory and antifibrotic effects. Some are also looking at how gut permeability and the microbiome are influencing outcomes,” she explained.
Transplantation has become very important for patients who do not respond to current therapy, and selection criteria have evolved over the years to take this into account, she pointed out.
In the early 1980s, alcoholic hepatitis was considered an inappropriate indication for liver transplantation. In the early 2000s, the guidance moved to setting 6 months of alcohol abstinence as a criterion for transplantation. The 6-month rule effectively eliminated patients with severe alcoholic hepatitis, who, by the time they needed a new liver, would not have 6 months to live.
Recently, guidelines have added the option of transplantation for patients with alcoholic hepatitis. The option was always there for people who developed alcohol cirrhosis or liver cancer, but now alcoholic hepatitis is recognized as a potential indication for transplantation, Dr. Terrault explained.
Today, transplant centers are moving away from the 6-month rule for two main reasons, she said. One is that few data support the 6-month time period as the duration that makes a difference.
“There is nothing magical about 6 months vs. 3 months or 12 months,” she said, adding that studies have shown that other factors might be better indicators, such as family support and whether the person is employed.
Second, recent studies have shown that rates of 3-year survival are similar in people who did not abstain at all before the procedure and those who undergo transplantation for other reasons.
The ACCELERATE-AH consortium also found that 70% of patients with severe alcoholic hepatitis remained abstinent up to 3 years after transplantation.
Anytime we give an organ to anyone on the list, someone else may die without one. Every year, 20% of patients on the list die without a transplant.
The selection process remains complicated and controversial, Dr. Terrault acknowledged.
“Anytime we give an organ to anyone on the list, someone else may die without one. Every year, 20% of patients on the list die without a transplant,” she said.
And there is concern that because patients with severe alcoholic hepatitis present with severe illness, they get moved to the top of the wait list. The rationale for that, she explained, is that it is done that way in other acute situations.
“We transplant individuals who have an acetaminophen overdose, for example. That’s common in many programs,” she said.
“My issue is that some patients with acute alcoholic hepatitis that have a very high severity score, but some of them, just with abstinence, will get better,” said Guadalupe Garcia-Tsao, MD, professor of medicine at Yale University in New Haven, Conn.
There are cases in which acute alcoholic hepatitis will resolve with abstinence, “and patients can return to an entirely compensated state of cirrhosis, in which they are entirely asymptomatic and they can live,” she told Medscape Medical News.
But it’s hard to know without a control group which patients would have that kind of success with just abstinence, she acknowledged.
Terrault said she agreed, and added that “our tools are not that good,” so determining which patients can be “pulled back from the brink” without transplantation is a challenge.
“There’s still a lot to learn about how we do this, and how we do it well,” she said.
Alcoholic hepatitis as an indication for liver transplantation is rare – less than 1% – but growing.
“This is a potential therapy for your patient who is sick in the ICU with a high severity of disease who has failed steroids. We should call out to see if there’s a transplant program that might be willing to evaluate them,” she said.
This article first appeared on Medscape.com.
MAUI, HAWAII – Alcohol use and deaths related to alcohol-use disorders are increasing, and young adults might be the group to watch, said Norah Terrault, MD, MPH, professor at the Keck School of Medicine of USC in Los Angeles.
“A lot of young people are drinking large amounts and they don’t know they’re at risk. They may not drink much during the week but then drink 30 drinks on the weekend,” Dr. Terrault told Medscape Medical News.
The largest relative increase in deaths from alcoholic cirrhosis – 10.5% from 2009 to 2016 – was in the 25- to 34-year age group, she reported here at the Gastroenterology Updates IBD Liver Disease Conference 2020.
This highlights the importance of asking for details about alcohol use during primary care visits; not only how much, but also what time of day, for instance, she explained.
Dr. Terrault’s team at Keck is part of the ACCELERATE-AH consortium, a group of 12 transplant centers looking at patterns of alcohol use before and after liver transplantation.
In their retrospective study of 147 consecutive transplant patients from 2006 to 2018, they found that young age, a history of multiple rehab attempts, and overt encephalopathy at time of transplantation were predictors of alcohol use after the procedure.
Corticosteroids remain the only proven therapy for alcoholic hepatitis. “We have not seen a new therapy in this arena in decades,” said Dr. Terrault. “We really have nothing to offer these patients, yet it’s an incredibly common presentation with a high mortality.”
More treatment options
The good news is that some phase 2 data look promising for new therapies, she reported.
“Some of them are targeting injury and regeneration primarily. Others are looking at the anti-inflammatory and antifibrotic effects. Some are also looking at how gut permeability and the microbiome are influencing outcomes,” she explained.
Transplantation has become very important for patients who do not respond to current therapy, and selection criteria have evolved over the years to take this into account, she pointed out.
In the early 1980s, alcoholic hepatitis was considered an inappropriate indication for liver transplantation. In the early 2000s, the guidance moved to setting 6 months of alcohol abstinence as a criterion for transplantation. The 6-month rule effectively eliminated patients with severe alcoholic hepatitis, who, by the time they needed a new liver, would not have 6 months to live.
Recently, guidelines have added the option of transplantation for patients with alcoholic hepatitis. The option was always there for people who developed alcohol cirrhosis or liver cancer, but now alcoholic hepatitis is recognized as a potential indication for transplantation, Dr. Terrault explained.
Today, transplant centers are moving away from the 6-month rule for two main reasons, she said. One is that few data support the 6-month time period as the duration that makes a difference.
“There is nothing magical about 6 months vs. 3 months or 12 months,” she said, adding that studies have shown that other factors might be better indicators, such as family support and whether the person is employed.
Second, recent studies have shown that rates of 3-year survival are similar in people who did not abstain at all before the procedure and those who undergo transplantation for other reasons.
The ACCELERATE-AH consortium also found that 70% of patients with severe alcoholic hepatitis remained abstinent up to 3 years after transplantation.
Anytime we give an organ to anyone on the list, someone else may die without one. Every year, 20% of patients on the list die without a transplant.
The selection process remains complicated and controversial, Dr. Terrault acknowledged.
“Anytime we give an organ to anyone on the list, someone else may die without one. Every year, 20% of patients on the list die without a transplant,” she said.
And there is concern that because patients with severe alcoholic hepatitis present with severe illness, they get moved to the top of the wait list. The rationale for that, she explained, is that it is done that way in other acute situations.
“We transplant individuals who have an acetaminophen overdose, for example. That’s common in many programs,” she said.
“My issue is that some patients with acute alcoholic hepatitis that have a very high severity score, but some of them, just with abstinence, will get better,” said Guadalupe Garcia-Tsao, MD, professor of medicine at Yale University in New Haven, Conn.
There are cases in which acute alcoholic hepatitis will resolve with abstinence, “and patients can return to an entirely compensated state of cirrhosis, in which they are entirely asymptomatic and they can live,” she told Medscape Medical News.
But it’s hard to know without a control group which patients would have that kind of success with just abstinence, she acknowledged.
Terrault said she agreed, and added that “our tools are not that good,” so determining which patients can be “pulled back from the brink” without transplantation is a challenge.
“There’s still a lot to learn about how we do this, and how we do it well,” she said.
Alcoholic hepatitis as an indication for liver transplantation is rare – less than 1% – but growing.
“This is a potential therapy for your patient who is sick in the ICU with a high severity of disease who has failed steroids. We should call out to see if there’s a transplant program that might be willing to evaluate them,” she said.
This article first appeared on Medscape.com.
MAUI, HAWAII – Alcohol use and deaths related to alcohol-use disorders are increasing, and young adults might be the group to watch, said Norah Terrault, MD, MPH, professor at the Keck School of Medicine of USC in Los Angeles.
“A lot of young people are drinking large amounts and they don’t know they’re at risk. They may not drink much during the week but then drink 30 drinks on the weekend,” Dr. Terrault told Medscape Medical News.
The largest relative increase in deaths from alcoholic cirrhosis – 10.5% from 2009 to 2016 – was in the 25- to 34-year age group, she reported here at the Gastroenterology Updates IBD Liver Disease Conference 2020.
This highlights the importance of asking for details about alcohol use during primary care visits; not only how much, but also what time of day, for instance, she explained.
Dr. Terrault’s team at Keck is part of the ACCELERATE-AH consortium, a group of 12 transplant centers looking at patterns of alcohol use before and after liver transplantation.
In their retrospective study of 147 consecutive transplant patients from 2006 to 2018, they found that young age, a history of multiple rehab attempts, and overt encephalopathy at time of transplantation were predictors of alcohol use after the procedure.
Corticosteroids remain the only proven therapy for alcoholic hepatitis. “We have not seen a new therapy in this arena in decades,” said Dr. Terrault. “We really have nothing to offer these patients, yet it’s an incredibly common presentation with a high mortality.”
More treatment options
The good news is that some phase 2 data look promising for new therapies, she reported.
“Some of them are targeting injury and regeneration primarily. Others are looking at the anti-inflammatory and antifibrotic effects. Some are also looking at how gut permeability and the microbiome are influencing outcomes,” she explained.
Transplantation has become very important for patients who do not respond to current therapy, and selection criteria have evolved over the years to take this into account, she pointed out.
In the early 1980s, alcoholic hepatitis was considered an inappropriate indication for liver transplantation. In the early 2000s, the guidance moved to setting 6 months of alcohol abstinence as a criterion for transplantation. The 6-month rule effectively eliminated patients with severe alcoholic hepatitis, who, by the time they needed a new liver, would not have 6 months to live.
Recently, guidelines have added the option of transplantation for patients with alcoholic hepatitis. The option was always there for people who developed alcohol cirrhosis or liver cancer, but now alcoholic hepatitis is recognized as a potential indication for transplantation, Dr. Terrault explained.
Today, transplant centers are moving away from the 6-month rule for two main reasons, she said. One is that few data support the 6-month time period as the duration that makes a difference.
“There is nothing magical about 6 months vs. 3 months or 12 months,” she said, adding that studies have shown that other factors might be better indicators, such as family support and whether the person is employed.
Second, recent studies have shown that rates of 3-year survival are similar in people who did not abstain at all before the procedure and those who undergo transplantation for other reasons.
The ACCELERATE-AH consortium also found that 70% of patients with severe alcoholic hepatitis remained abstinent up to 3 years after transplantation.
Anytime we give an organ to anyone on the list, someone else may die without one. Every year, 20% of patients on the list die without a transplant.
The selection process remains complicated and controversial, Dr. Terrault acknowledged.
“Anytime we give an organ to anyone on the list, someone else may die without one. Every year, 20% of patients on the list die without a transplant,” she said.
And there is concern that because patients with severe alcoholic hepatitis present with severe illness, they get moved to the top of the wait list. The rationale for that, she explained, is that it is done that way in other acute situations.
“We transplant individuals who have an acetaminophen overdose, for example. That’s common in many programs,” she said.
“My issue is that some patients with acute alcoholic hepatitis that have a very high severity score, but some of them, just with abstinence, will get better,” said Guadalupe Garcia-Tsao, MD, professor of medicine at Yale University in New Haven, Conn.
There are cases in which acute alcoholic hepatitis will resolve with abstinence, “and patients can return to an entirely compensated state of cirrhosis, in which they are entirely asymptomatic and they can live,” she told Medscape Medical News.
But it’s hard to know without a control group which patients would have that kind of success with just abstinence, she acknowledged.
Terrault said she agreed, and added that “our tools are not that good,” so determining which patients can be “pulled back from the brink” without transplantation is a challenge.
“There’s still a lot to learn about how we do this, and how we do it well,” she said.
Alcoholic hepatitis as an indication for liver transplantation is rare – less than 1% – but growing.
“This is a potential therapy for your patient who is sick in the ICU with a high severity of disease who has failed steroids. We should call out to see if there’s a transplant program that might be willing to evaluate them,” she said.
This article first appeared on Medscape.com.
EXPERT ANALYSIS FROM GUILD 2020