DALLAS – A smartphone can be a valuable extension of clinician assessment in multiple sclerosis and other neurologic disorders, affording the opportunity for patients to complete some assessments at home.

Alexandra Boukhvalova, a medical student at the University of Maryland School of Medicine, Baltimore, and her collaborators developed an interactive smartphone app to assess some aspects of cognitive and motor function for patients with multiple sclerosis (MS). Their findings were reported during a poster session at the meeting held by the American Society for Prevention and Treatment in Multiple Sclerosis.

“The clinician assessment is an hour-long assessment; it requires a trained neurologist,” Ms. Boukhvalova pointed out. In thinking about how app-based assessment could augment the clinical exam, she and her collaborators realized that “a lot of the neurologic exam is still quite subjective – so is there a way that we can make that exam more objective and quantifiable and also add a little bit of ease with accessibility and mobility?

“We created a suite of test apps ... to assess different neurological systems, ranging from motor function, cognitive and visual dysfunction, general fatigue, and strength,” she said. The apps included tapping tests and balloon-popping tasks, along with measures to give some indication of spasticity by assessing the smoothness of movements.

Participants completed the testing both in the clinic and from home. “We did not need an investigator present for patients to be able to complete the tests,” said Ms. Boukhvalova.

Ms. Boukhvalova and her colleagues compared performance on the gamified tasks between patients with MS and healthy controls. For all tasks, the participants with MS could clearly be differentiated from the healthy participants.

A further plus was that “The patients almost viewed these tests as games.” They reported that they enjoyed completing them, said Ms. Boukhvalova, adding that app-based assessments also offer an additional point of connection between MS patients and specialists, whom they may only see annually or semiannually.

Further app development may focus on utilizing sensor and accelerometer functions in smartphones to perform more natural and sophisticated motor analysis to look at gait and gross motor functioning, she said.

koakes@mdedge.com

DALLAS – A smartphone can be a valuable extension of clinician assessment in multiple sclerosis and other neurologic disorders, affording the opportunity for patients to complete some assessments at home.

Alexandra Boukhvalova, a medical student at the University of Maryland School of Medicine, Baltimore, and her collaborators developed an interactive smartphone app to assess some aspects of cognitive and motor function for patients with multiple sclerosis (MS). Their findings were reported during a poster session at the meeting held by the American Society for Prevention and Treatment in Multiple Sclerosis.

“The clinician assessment is an hour-long assessment; it requires a trained neurologist,” Ms. Boukhvalova pointed out. In thinking about how app-based assessment could augment the clinical exam, she and her collaborators realized that “a lot of the neurologic exam is still quite subjective – so is there a way that we can make that exam more objective and quantifiable and also add a little bit of ease with accessibility and mobility?

“We created a suite of test apps ... to assess different neurological systems, ranging from motor function, cognitive and visual dysfunction, general fatigue, and strength,” she said. The apps included tapping tests and balloon-popping tasks, along with measures to give some indication of spasticity by assessing the smoothness of movements.

Participants completed the testing both in the clinic and from home. “We did not need an investigator present for patients to be able to complete the tests,” said Ms. Boukhvalova.

Ms. Boukhvalova and her colleagues compared performance on the gamified tasks between patients with MS and healthy controls. For all tasks, the participants with MS could clearly be differentiated from the healthy participants.

A further plus was that “The patients almost viewed these tests as games.” They reported that they enjoyed completing them, said Ms. Boukhvalova, adding that app-based assessments also offer an additional point of connection between MS patients and specialists, whom they may only see annually or semiannually.

Further app development may focus on utilizing sensor and accelerometer functions in smartphones to perform more natural and sophisticated motor analysis to look at gait and gross motor functioning, she said.

koakes@mdedge.com

DALLAS – A smartphone can be a valuable extension of clinician assessment in multiple sclerosis and other neurologic disorders, affording the opportunity for patients to complete some assessments at home.

Alexandra Boukhvalova, a medical student at the University of Maryland School of Medicine, Baltimore, and her collaborators developed an interactive smartphone app to assess some aspects of cognitive and motor function for patients with multiple sclerosis (MS). Their findings were reported during a poster session at the meeting held by the American Society for Prevention and Treatment in Multiple Sclerosis.

“The clinician assessment is an hour-long assessment; it requires a trained neurologist,” Ms. Boukhvalova pointed out. In thinking about how app-based assessment could augment the clinical exam, she and her collaborators realized that “a lot of the neurologic exam is still quite subjective – so is there a way that we can make that exam more objective and quantifiable and also add a little bit of ease with accessibility and mobility?

“We created a suite of test apps ... to assess different neurological systems, ranging from motor function, cognitive and visual dysfunction, general fatigue, and strength,” she said. The apps included tapping tests and balloon-popping tasks, along with measures to give some indication of spasticity by assessing the smoothness of movements.

Participants completed the testing both in the clinic and from home. “We did not need an investigator present for patients to be able to complete the tests,” said Ms. Boukhvalova.

Ms. Boukhvalova and her colleagues compared performance on the gamified tasks between patients with MS and healthy controls. For all tasks, the participants with MS could clearly be differentiated from the healthy participants.

A further plus was that “The patients almost viewed these tests as games.” They reported that they enjoyed completing them, said Ms. Boukhvalova, adding that app-based assessments also offer an additional point of connection between MS patients and specialists, whom they may only see annually or semiannually.

Further app development may focus on utilizing sensor and accelerometer functions in smartphones to perform more natural and sophisticated motor analysis to look at gait and gross motor functioning, she said.

koakes@mdedge.com

LAS VEGAS – A text messaging program connected black women at risk of postnatal hypertension with the care they needed to avoid blood pressure complications, Adi Hirshberg, MD, reported at the Pregnancy Meeting.

Violet Karyn

The text messaging system increased the compliance rate to 93%, compared with just 30% of those asked to return to the office after hospital discharge. Just as importantly, it completely erased racial disparity in compliance rates, compared with white women, with more than 90% of both groups complying, said Dr. Hirshberg of the University of Pennsylvania, Philadelphia.

“Our study shows that text-based monitoring eliminated the observed racial disparity in postpregnancy hypertension care,” she said at the meeting sponsored by the Society for Maternal-Fetal Medicine. “Using texts as a standard of care would have likely led to medication initiation or adjustment for an additional 20% or more women who missed an office visit. This is an innovative way to equally engage all women in the postpregnancy period.”

Dr. Hirshberg presented a preplanned subanalysis of the Remote Surveillance of Hypertension (TextBP) trial, published last year (BMJ Qual Saf. 2018;27:871-7). The publication gave overall data; this analysis broke results down by race.

TextBP equally randomized 206 postpartum women with pregnancy-induced hypertension to the usual practice of office-based BP monitoring, or to 2 weeks of text-based surveillance using a home BP cuff. It was open to all women with pregnancy-related hypertension who delivered in the Hospital of the University of Pennsylvania. Hypertension classes included gestational hypertension, preeclampsia, chronic hypertension with superimposed preeclampsia, and HELLP syndrome before or during the delivery admission. Women were randomized to usual care or to an office-based BP check within the first postpartum week.

The texting platform was developed through Way to Health, a web-based platform within the institution, with secure technological infrastructure. A starting introductory text message was sent by the Way to Health platform to the phone number provided on day of discharge.

Patients received reminders to text message their blood pressure twice daily for 2 weeks post partum, starting on the day after discharge. If the patient reported a systolic BP of more than 160 mm Hg or diastolic more than 110 mm Hg, the clinician received an alert.

The overall results showed that significantly more women in the texting group reported their blood pressure (92% vs. 44%), compared with the controls. Almost everyone in the texting group (84%) met the established criteria for BP measurement.

Dr. Hirshberg and her colleagues wanted to zero in on black women, to discover if the text reminders could help boost their compliance. This is important for a couple of reasons, she said. For one thing, black women face a higher baseline risk of hypertensive disorders and cardiovascular disease, both in general and during and after pregnancy. Second, “for every 100 black women who require postpartum hypertension surveillance, only about a third are likely to attended an office visit after discharge,” leaving them vulnerable to potentially preventable complications of hypertension.

Even in the original analysis, return rates for postpregnancy BP checks were low in both groups and, in fact, seemed to be declining over several years. In 2012, 56% of nonblack and 33% of black women returned for their checks. By 2014, that number had declined to 34% and 20%. The numbers parallel the increasing disparity in U.S. maternal death rate between black women and nonblack women. From 1989 to 2013, the death rate for black mothers doubled, jumping from 20 to 40 deaths per 100,000 live births. During the same period, the death rate for nonblack mothers increased from about 8 to about 11 per 10,000. Dr. Hirshberg said.

In the subanalysis, the primary outcomes were the percentage of patients in whom a blood pressure was obtained in the first 10 days following discharge. In the control office visit group, about 33% of black women had a measurement, compared with 70% of nonblack women – a significant difference. Text messaging, however, completely eliminated the disparity. In the texting group, 91% of nonblack women and 93% of black women had a BP measurement.

There were no hypertension readmissions in the texting arm; there were four in the office-visit arm, three of which occurred in black women.

“This suggests that the traditional office-based follow-up may have resulted in missed opportunities to start an antihypertensive in about 10 of the 55 women who missed their office visit,” Dr. Hirshberg said, adding that “these kinds of early interventions can reduce maternal morbidity and mortality and increase overall health in all.”

She reported no relevant financial disclosures.

msullivan@mdedge.com

SOURCE: Hirshberg A et al. Am J Obstet Gynecol. 2019 Jan;220(1):S6, Abstract 7.

LAS VEGAS – A text messaging program connected black women at risk of postnatal hypertension with the care they needed to avoid blood pressure complications, Adi Hirshberg, MD, reported at the Pregnancy Meeting.

Violet Karyn

The text messaging system increased the compliance rate to 93%, compared with just 30% of those asked to return to the office after hospital discharge. Just as importantly, it completely erased racial disparity in compliance rates, compared with white women, with more than 90% of both groups complying, said Dr. Hirshberg of the University of Pennsylvania, Philadelphia.

“Our study shows that text-based monitoring eliminated the observed racial disparity in postpregnancy hypertension care,” she said at the meeting sponsored by the Society for Maternal-Fetal Medicine. “Using texts as a standard of care would have likely led to medication initiation or adjustment for an additional 20% or more women who missed an office visit. This is an innovative way to equally engage all women in the postpregnancy period.”

Dr. Hirshberg presented a preplanned subanalysis of the Remote Surveillance of Hypertension (TextBP) trial, published last year (BMJ Qual Saf. 2018;27:871-7). The publication gave overall data; this analysis broke results down by race.

TextBP equally randomized 206 postpartum women with pregnancy-induced hypertension to the usual practice of office-based BP monitoring, or to 2 weeks of text-based surveillance using a home BP cuff. It was open to all women with pregnancy-related hypertension who delivered in the Hospital of the University of Pennsylvania. Hypertension classes included gestational hypertension, preeclampsia, chronic hypertension with superimposed preeclampsia, and HELLP syndrome before or during the delivery admission. Women were randomized to usual care or to an office-based BP check within the first postpartum week.

The texting platform was developed through Way to Health, a web-based platform within the institution, with secure technological infrastructure. A starting introductory text message was sent by the Way to Health platform to the phone number provided on day of discharge.

Patients received reminders to text message their blood pressure twice daily for 2 weeks post partum, starting on the day after discharge. If the patient reported a systolic BP of more than 160 mm Hg or diastolic more than 110 mm Hg, the clinician received an alert.

The overall results showed that significantly more women in the texting group reported their blood pressure (92% vs. 44%), compared with the controls. Almost everyone in the texting group (84%) met the established criteria for BP measurement.

Dr. Hirshberg and her colleagues wanted to zero in on black women, to discover if the text reminders could help boost their compliance. This is important for a couple of reasons, she said. For one thing, black women face a higher baseline risk of hypertensive disorders and cardiovascular disease, both in general and during and after pregnancy. Second, “for every 100 black women who require postpartum hypertension surveillance, only about a third are likely to attended an office visit after discharge,” leaving them vulnerable to potentially preventable complications of hypertension.

Even in the original analysis, return rates for postpregnancy BP checks were low in both groups and, in fact, seemed to be declining over several years. In 2012, 56% of nonblack and 33% of black women returned for their checks. By 2014, that number had declined to 34% and 20%. The numbers parallel the increasing disparity in U.S. maternal death rate between black women and nonblack women. From 1989 to 2013, the death rate for black mothers doubled, jumping from 20 to 40 deaths per 100,000 live births. During the same period, the death rate for nonblack mothers increased from about 8 to about 11 per 10,000. Dr. Hirshberg said.

In the subanalysis, the primary outcomes were the percentage of patients in whom a blood pressure was obtained in the first 10 days following discharge. In the control office visit group, about 33% of black women had a measurement, compared with 70% of nonblack women – a significant difference. Text messaging, however, completely eliminated the disparity. In the texting group, 91% of nonblack women and 93% of black women had a BP measurement.

There were no hypertension readmissions in the texting arm; there were four in the office-visit arm, three of which occurred in black women.

“This suggests that the traditional office-based follow-up may have resulted in missed opportunities to start an antihypertensive in about 10 of the 55 women who missed their office visit,” Dr. Hirshberg said, adding that “these kinds of early interventions can reduce maternal morbidity and mortality and increase overall health in all.”

She reported no relevant financial disclosures.

msullivan@mdedge.com

SOURCE: Hirshberg A et al. Am J Obstet Gynecol. 2019 Jan;220(1):S6, Abstract 7.

LAS VEGAS – A text messaging program connected black women at risk of postnatal hypertension with the care they needed to avoid blood pressure complications, Adi Hirshberg, MD, reported at the Pregnancy Meeting.

Violet Karyn

The text messaging system increased the compliance rate to 93%, compared with just 30% of those asked to return to the office after hospital discharge. Just as importantly, it completely erased racial disparity in compliance rates, compared with white women, with more than 90% of both groups complying, said Dr. Hirshberg of the University of Pennsylvania, Philadelphia.

“Our study shows that text-based monitoring eliminated the observed racial disparity in postpregnancy hypertension care,” she said at the meeting sponsored by the Society for Maternal-Fetal Medicine. “Using texts as a standard of care would have likely led to medication initiation or adjustment for an additional 20% or more women who missed an office visit. This is an innovative way to equally engage all women in the postpregnancy period.”

Dr. Hirshberg presented a preplanned subanalysis of the Remote Surveillance of Hypertension (TextBP) trial, published last year (BMJ Qual Saf. 2018;27:871-7). The publication gave overall data; this analysis broke results down by race.

TextBP equally randomized 206 postpartum women with pregnancy-induced hypertension to the usual practice of office-based BP monitoring, or to 2 weeks of text-based surveillance using a home BP cuff. It was open to all women with pregnancy-related hypertension who delivered in the Hospital of the University of Pennsylvania. Hypertension classes included gestational hypertension, preeclampsia, chronic hypertension with superimposed preeclampsia, and HELLP syndrome before or during the delivery admission. Women were randomized to usual care or to an office-based BP check within the first postpartum week.

The texting platform was developed through Way to Health, a web-based platform within the institution, with secure technological infrastructure. A starting introductory text message was sent by the Way to Health platform to the phone number provided on day of discharge.

Patients received reminders to text message their blood pressure twice daily for 2 weeks post partum, starting on the day after discharge. If the patient reported a systolic BP of more than 160 mm Hg or diastolic more than 110 mm Hg, the clinician received an alert.

The overall results showed that significantly more women in the texting group reported their blood pressure (92% vs. 44%), compared with the controls. Almost everyone in the texting group (84%) met the established criteria for BP measurement.

Dr. Hirshberg and her colleagues wanted to zero in on black women, to discover if the text reminders could help boost their compliance. This is important for a couple of reasons, she said. For one thing, black women face a higher baseline risk of hypertensive disorders and cardiovascular disease, both in general and during and after pregnancy. Second, “for every 100 black women who require postpartum hypertension surveillance, only about a third are likely to attended an office visit after discharge,” leaving them vulnerable to potentially preventable complications of hypertension.

Even in the original analysis, return rates for postpregnancy BP checks were low in both groups and, in fact, seemed to be declining over several years. In 2012, 56% of nonblack and 33% of black women returned for their checks. By 2014, that number had declined to 34% and 20%. The numbers parallel the increasing disparity in U.S. maternal death rate between black women and nonblack women. From 1989 to 2013, the death rate for black mothers doubled, jumping from 20 to 40 deaths per 100,000 live births. During the same period, the death rate for nonblack mothers increased from about 8 to about 11 per 10,000. Dr. Hirshberg said.

In the subanalysis, the primary outcomes were the percentage of patients in whom a blood pressure was obtained in the first 10 days following discharge. In the control office visit group, about 33% of black women had a measurement, compared with 70% of nonblack women – a significant difference. Text messaging, however, completely eliminated the disparity. In the texting group, 91% of nonblack women and 93% of black women had a BP measurement.

There were no hypertension readmissions in the texting arm; there were four in the office-visit arm, three of which occurred in black women.

“This suggests that the traditional office-based follow-up may have resulted in missed opportunities to start an antihypertensive in about 10 of the 55 women who missed their office visit,” Dr. Hirshberg said, adding that “these kinds of early interventions can reduce maternal morbidity and mortality and increase overall health in all.”

She reported no relevant financial disclosures.

msullivan@mdedge.com

SOURCE: Hirshberg A et al. Am J Obstet Gynecol. 2019 Jan;220(1):S6, Abstract 7.

DALLAS – Patients with multiple sclerosis (MS) have a nearly 100% higher incidence of new treated depression, compared with matched patients without MS, according to an analysis of data from patients in the United Kingdom.

After a diagnosis of MS, the incidence of new treated depression is 229 per 10,000 person-years. In comparison, the incidence of new treated depression among matched patients without MS is 121 per 10,000 person-years, Neil Minton, MD, drug safety head at Celgene, reported at the meeting held by the Americas Committee for Treatment and Research in Multiple Sclerosis.

MS causes changes in the CNS that are associated with depression, but “data on rates of incident depression after MS diagnosis ... are limited,” Dr. Minton and his research colleagues said. To examine rates of treated incident depression in patients with MS after an MS diagnosis, compared with rates in a matched population of patients without MS, the researchers analyzed data from the U.K. Clinical Practice Research Datalink.

Their analysis included patients with MS who received a diagnosis of MS between 2001 and 2016, had at least 1 year of history available before the MS diagnosis, and had no history of treated depression. The researchers matched these patients with as many as 10 patients without MS by age, sex, general practice, record history length, and no history of treated depression. Treated depression was defined as a diagnosis code for depression and a prescription for an antidepressant treatment within 90 days. They used Byar’s method to estimate incidence rates and incidence rate ratios, the Kaplan-Meier method to generate cumulative incidence curves, and a log-rank test to compare the curves.

In all, 5,456 patients with MS and 45,712 matched patients without MS were included in the study. Patients’ median age was 42 years; 65% were female. Compared with patients without MS, patients with MS were more likely to have a history of untreated depression (9.6% vs. 7.5%) and to have received an antidepressant treatment for any indication before cohort entry (28.0% vs. 15.5%). Diagnoses for other psychiatric conditions were similar between the groups.

Incidence rates of treated depression were higher among women with MS, compared with men with MS – 241 versus 202 per 10,000 person-years. Compared with patients without MS, however, men with MS had a higher relative risk of treated depression (2.40 vs. 1.73).

The incidence rate ratios were similar in sensitivity analyses that excluded patients with a history of any psychiatric disorder at cohort entry and that did not require treatment to confirm a depression diagnosis.

The study was funded by a grant from Celgene.

jremaly@mdedge.com

SOURCE: Minton N et al. ACTRIMS Forum 2019, Abstract 82.

DALLAS – Patients with multiple sclerosis (MS) have a nearly 100% higher incidence of new treated depression, compared with matched patients without MS, according to an analysis of data from patients in the United Kingdom.

After a diagnosis of MS, the incidence of new treated depression is 229 per 10,000 person-years. In comparison, the incidence of new treated depression among matched patients without MS is 121 per 10,000 person-years, Neil Minton, MD, drug safety head at Celgene, reported at the meeting held by the Americas Committee for Treatment and Research in Multiple Sclerosis.

MS causes changes in the CNS that are associated with depression, but “data on rates of incident depression after MS diagnosis ... are limited,” Dr. Minton and his research colleagues said. To examine rates of treated incident depression in patients with MS after an MS diagnosis, compared with rates in a matched population of patients without MS, the researchers analyzed data from the U.K. Clinical Practice Research Datalink.

Their analysis included patients with MS who received a diagnosis of MS between 2001 and 2016, had at least 1 year of history available before the MS diagnosis, and had no history of treated depression. The researchers matched these patients with as many as 10 patients without MS by age, sex, general practice, record history length, and no history of treated depression. Treated depression was defined as a diagnosis code for depression and a prescription for an antidepressant treatment within 90 days. They used Byar’s method to estimate incidence rates and incidence rate ratios, the Kaplan-Meier method to generate cumulative incidence curves, and a log-rank test to compare the curves.

In all, 5,456 patients with MS and 45,712 matched patients without MS were included in the study. Patients’ median age was 42 years; 65% were female. Compared with patients without MS, patients with MS were more likely to have a history of untreated depression (9.6% vs. 7.5%) and to have received an antidepressant treatment for any indication before cohort entry (28.0% vs. 15.5%). Diagnoses for other psychiatric conditions were similar between the groups.

Incidence rates of treated depression were higher among women with MS, compared with men with MS – 241 versus 202 per 10,000 person-years. Compared with patients without MS, however, men with MS had a higher relative risk of treated depression (2.40 vs. 1.73).

The incidence rate ratios were similar in sensitivity analyses that excluded patients with a history of any psychiatric disorder at cohort entry and that did not require treatment to confirm a depression diagnosis.

The study was funded by a grant from Celgene.

jremaly@mdedge.com

SOURCE: Minton N et al. ACTRIMS Forum 2019, Abstract 82.

DALLAS – Patients with multiple sclerosis (MS) have a nearly 100% higher incidence of new treated depression, compared with matched patients without MS, according to an analysis of data from patients in the United Kingdom.

After a diagnosis of MS, the incidence of new treated depression is 229 per 10,000 person-years. In comparison, the incidence of new treated depression among matched patients without MS is 121 per 10,000 person-years, Neil Minton, MD, drug safety head at Celgene, reported at the meeting held by the Americas Committee for Treatment and Research in Multiple Sclerosis.

MS causes changes in the CNS that are associated with depression, but “data on rates of incident depression after MS diagnosis ... are limited,” Dr. Minton and his research colleagues said. To examine rates of treated incident depression in patients with MS after an MS diagnosis, compared with rates in a matched population of patients without MS, the researchers analyzed data from the U.K. Clinical Practice Research Datalink.

Their analysis included patients with MS who received a diagnosis of MS between 2001 and 2016, had at least 1 year of history available before the MS diagnosis, and had no history of treated depression. The researchers matched these patients with as many as 10 patients without MS by age, sex, general practice, record history length, and no history of treated depression. Treated depression was defined as a diagnosis code for depression and a prescription for an antidepressant treatment within 90 days. They used Byar’s method to estimate incidence rates and incidence rate ratios, the Kaplan-Meier method to generate cumulative incidence curves, and a log-rank test to compare the curves.

In all, 5,456 patients with MS and 45,712 matched patients without MS were included in the study. Patients’ median age was 42 years; 65% were female. Compared with patients without MS, patients with MS were more likely to have a history of untreated depression (9.6% vs. 7.5%) and to have received an antidepressant treatment for any indication before cohort entry (28.0% vs. 15.5%). Diagnoses for other psychiatric conditions were similar between the groups.

Incidence rates of treated depression were higher among women with MS, compared with men with MS – 241 versus 202 per 10,000 person-years. Compared with patients without MS, however, men with MS had a higher relative risk of treated depression (2.40 vs. 1.73).

The incidence rate ratios were similar in sensitivity analyses that excluded patients with a history of any psychiatric disorder at cohort entry and that did not require treatment to confirm a depression diagnosis.

The study was funded by a grant from Celgene.

jremaly@mdedge.com

SOURCE: Minton N et al. ACTRIMS Forum 2019, Abstract 82.

WASHINGTON – When repigmentation therapy fails, dermatologists may offer depigmentation therapy to patients with vitiligo, Seemal Desai, MD, said at the annual meeting of the American Academy of Dermatology.

Depigmentation therapy is “an underutilized resource for those patients who have recalcitrant disease or whose disease is so bad that you have not been able to improve their clinical, visible outcome,” said Dr. Desai, clinical assistant professor of dermatology at the University of Texas, Dallas. “Some of these patients simply desire to be one uniform color.”

Therapy is administered through medications that destroy residual melanocytes with the goal of achieving a uniform appearance of the skin. Monobenzyl ether of hydroquinone (MBEH) is the most common drug used in depigmentation therapy, according to Dr. Desai. It is available in concentrations of 20% and 40% and can be compounded in other concentrations. At first, patients should apply MBEH to a nickel-sized area of the skin (such as the forearm, the back of the hand, or the thigh) for 3 or 4 days. Treatment is administered in the morning and evening, but not at bedtime. A common side effect is irritant contact dermatitis.

When the patient is able to tolerate the medication in the first area, he or she can apply it to larger areas of the skin. Parts of the body are treated one at a time, and successful treatment takes time, he noted. Hair may become depigmented, but patients can be assured that the eyes will not.

Repigmentation has been reported after sun exposure. For all patients undergoing depigmentation therapy, dermatologists should provide extensive counseling about the need for lifelong photoprotection, said Dr. Desai. Protective measures can include wide-brimmed hats and broad-spectrum sunscreen. Paradoxical repigmentation can be treated with a stronger concentration of MBEH, liquid nitrogen therapy, microdermabrasion, and peels.

For patients with vitiligo, which results from the immune-mediated destruction of melanocytes, dermatologists should assess the patient’s psychological status and discuss “the impact that the disease has on not only the patient, but also the family,” Dr. Desai said. “The psychological trauma from this disease, especially for our patients who have rapidly progressing vitiligo or who have failed multiple therapies, is something that we cannot discount.”

Patients with vitiligo often have comorbid depression, and evening of the skin tone that depigmentation provides can benefit the patient’s mental state, he observed. Patients with severe depression related to vitiligo should be referred to a psychologist or psychiatrist. Finally, counseling and appropriate patient selection for depigmentation is of paramount importance.

During the presentation, he noted that hair dyes, resin products and adhesives, detergents, and leather preservatives have been associated with vitiligo. Dermatologic drugs such as imiquimod, chemotherapeutic agents, and interferon also may cause the condition.

He referred to the thousands of reported cases of vitiligo related to rhododenol, a phenolic compound that has been used in cosmetics and topical products. Most cases resolved when those affected stopped using the product, but some developed vitiligo vulgaris. Cosmetics containing rhododenol have been recalled in Japan since 2013, but over-the-counter products in Asia and Africa have been found to contain similar compounds, so dermatologists should ask patients about their travel history and about what products they are using for their skin, Dr. Desai advised.

He reported receiving grants and research funding from AbbVie, Dermira, Dr. Reddy’s Laboratories, and Menlo Therapeutics and serving as a consultant for several pharmaceutical companies.

egreb@mdedge.com

WASHINGTON – When repigmentation therapy fails, dermatologists may offer depigmentation therapy to patients with vitiligo, Seemal Desai, MD, said at the annual meeting of the American Academy of Dermatology.

Depigmentation therapy is “an underutilized resource for those patients who have recalcitrant disease or whose disease is so bad that you have not been able to improve their clinical, visible outcome,” said Dr. Desai, clinical assistant professor of dermatology at the University of Texas, Dallas. “Some of these patients simply desire to be one uniform color.”

Therapy is administered through medications that destroy residual melanocytes with the goal of achieving a uniform appearance of the skin. Monobenzyl ether of hydroquinone (MBEH) is the most common drug used in depigmentation therapy, according to Dr. Desai. It is available in concentrations of 20% and 40% and can be compounded in other concentrations. At first, patients should apply MBEH to a nickel-sized area of the skin (such as the forearm, the back of the hand, or the thigh) for 3 or 4 days. Treatment is administered in the morning and evening, but not at bedtime. A common side effect is irritant contact dermatitis.

When the patient is able to tolerate the medication in the first area, he or she can apply it to larger areas of the skin. Parts of the body are treated one at a time, and successful treatment takes time, he noted. Hair may become depigmented, but patients can be assured that the eyes will not.

Repigmentation has been reported after sun exposure. For all patients undergoing depigmentation therapy, dermatologists should provide extensive counseling about the need for lifelong photoprotection, said Dr. Desai. Protective measures can include wide-brimmed hats and broad-spectrum sunscreen. Paradoxical repigmentation can be treated with a stronger concentration of MBEH, liquid nitrogen therapy, microdermabrasion, and peels.

For patients with vitiligo, which results from the immune-mediated destruction of melanocytes, dermatologists should assess the patient’s psychological status and discuss “the impact that the disease has on not only the patient, but also the family,” Dr. Desai said. “The psychological trauma from this disease, especially for our patients who have rapidly progressing vitiligo or who have failed multiple therapies, is something that we cannot discount.”

Patients with vitiligo often have comorbid depression, and evening of the skin tone that depigmentation provides can benefit the patient’s mental state, he observed. Patients with severe depression related to vitiligo should be referred to a psychologist or psychiatrist. Finally, counseling and appropriate patient selection for depigmentation is of paramount importance.

During the presentation, he noted that hair dyes, resin products and adhesives, detergents, and leather preservatives have been associated with vitiligo. Dermatologic drugs such as imiquimod, chemotherapeutic agents, and interferon also may cause the condition.

He referred to the thousands of reported cases of vitiligo related to rhododenol, a phenolic compound that has been used in cosmetics and topical products. Most cases resolved when those affected stopped using the product, but some developed vitiligo vulgaris. Cosmetics containing rhododenol have been recalled in Japan since 2013, but over-the-counter products in Asia and Africa have been found to contain similar compounds, so dermatologists should ask patients about their travel history and about what products they are using for their skin, Dr. Desai advised.

He reported receiving grants and research funding from AbbVie, Dermira, Dr. Reddy’s Laboratories, and Menlo Therapeutics and serving as a consultant for several pharmaceutical companies.

egreb@mdedge.com

WASHINGTON – When repigmentation therapy fails, dermatologists may offer depigmentation therapy to patients with vitiligo, Seemal Desai, MD, said at the annual meeting of the American Academy of Dermatology.

Depigmentation therapy is “an underutilized resource for those patients who have recalcitrant disease or whose disease is so bad that you have not been able to improve their clinical, visible outcome,” said Dr. Desai, clinical assistant professor of dermatology at the University of Texas, Dallas. “Some of these patients simply desire to be one uniform color.”

Therapy is administered through medications that destroy residual melanocytes with the goal of achieving a uniform appearance of the skin. Monobenzyl ether of hydroquinone (MBEH) is the most common drug used in depigmentation therapy, according to Dr. Desai. It is available in concentrations of 20% and 40% and can be compounded in other concentrations. At first, patients should apply MBEH to a nickel-sized area of the skin (such as the forearm, the back of the hand, or the thigh) for 3 or 4 days. Treatment is administered in the morning and evening, but not at bedtime. A common side effect is irritant contact dermatitis.

When the patient is able to tolerate the medication in the first area, he or she can apply it to larger areas of the skin. Parts of the body are treated one at a time, and successful treatment takes time, he noted. Hair may become depigmented, but patients can be assured that the eyes will not.

Repigmentation has been reported after sun exposure. For all patients undergoing depigmentation therapy, dermatologists should provide extensive counseling about the need for lifelong photoprotection, said Dr. Desai. Protective measures can include wide-brimmed hats and broad-spectrum sunscreen. Paradoxical repigmentation can be treated with a stronger concentration of MBEH, liquid nitrogen therapy, microdermabrasion, and peels.

For patients with vitiligo, which results from the immune-mediated destruction of melanocytes, dermatologists should assess the patient’s psychological status and discuss “the impact that the disease has on not only the patient, but also the family,” Dr. Desai said. “The psychological trauma from this disease, especially for our patients who have rapidly progressing vitiligo or who have failed multiple therapies, is something that we cannot discount.”

Patients with vitiligo often have comorbid depression, and evening of the skin tone that depigmentation provides can benefit the patient’s mental state, he observed. Patients with severe depression related to vitiligo should be referred to a psychologist or psychiatrist. Finally, counseling and appropriate patient selection for depigmentation is of paramount importance.

During the presentation, he noted that hair dyes, resin products and adhesives, detergents, and leather preservatives have been associated with vitiligo. Dermatologic drugs such as imiquimod, chemotherapeutic agents, and interferon also may cause the condition.

He referred to the thousands of reported cases of vitiligo related to rhododenol, a phenolic compound that has been used in cosmetics and topical products. Most cases resolved when those affected stopped using the product, but some developed vitiligo vulgaris. Cosmetics containing rhododenol have been recalled in Japan since 2013, but over-the-counter products in Asia and Africa have been found to contain similar compounds, so dermatologists should ask patients about their travel history and about what products they are using for their skin, Dr. Desai advised.

He reported receiving grants and research funding from AbbVie, Dermira, Dr. Reddy’s Laboratories, and Menlo Therapeutics and serving as a consultant for several pharmaceutical companies.

egreb@mdedge.com

DALLAS – Patients with relapsing emitting multiple sclerosis who discontinued treatment after a period of disease inactivity had a similar time to next event, compared with those who remained on treatment, results from a single-center study showed.

In addition, being over the age of 45 years was associated with a better disease course after treatment discontinuation.

“Being clinically and radiologically stable for more than 2 years can be a potential milestone to regard the discontinuation of DMT [disease-modifying therapy] as a reasonable option in a subset of patients, especially patients who are nondisabled,” lead study author Hajime Yano, MD, said in an interview at the Americas Committee for Treatment and Research in Multiple Sclerosis.

According to Dr. Yano, a research fellow at the Ann Romney Center for Neurologic Diseases and Partners Multiple Sclerosis Center in Boston, relapsing remitting multiple sclerosis (RRMS) patients without relapse for long periods on treatment may consider discontinuing DMT, but there is limited information regarding the impact of discontinuation, especially in terms of MRI activity.

In an effort to investigate the impact of DMT discontinuation on clinical and radiologic outcomes in RRMS patients, he and his colleagues identified 70 patients from the Comprehensive Longitudinal Investigation of Multiple Sclerosis at the Brigham and Women’s Hospital (CLIMB) study, which was initiated in 2000 and has enrolled more than 2,400 patients cared for at the Partners Multiple Sclerosis Center. Relapse date, symptoms, and Expanded Disability Status Scale (EDSS) were evaluated at 6-month intervals for each patient during the time of clinic visits by the treating neurologist. Additionally, brain MRIs were performed annually.

Next, the researchers matched the patients with 70 patients who remained on DMT identified by age, sex, treatment, treatment duration, disease duration, and EDSS. They used univariate and multivariable Cox proportional hazard models to test the differences between DMT discontinuation status with time to clinical relapse, MRI event, disability progression, and any inflammatory event (either clinical relapse or MRI event).

The mean age of patients was 45 years, 87% were female, their mean disease duration was about 13 years, and they had been receiving treatment for a mean of about 6 years. In adjusted analyses, the 70 pairs of patients who discontinued DMT and patients who continued DMT had similar outcomes in time to clinical relapse (hazard ratio, 0.93; P = .84), MRI event (HR, 1.01; P = .98), disability progression (HR, 1.33; P = .43), and any inflammatory event (HR, 0.93; P = .85). In a subgroup analysis, which compared the impact of DMT discontinuation between patients over the age of 45 years and those aged 45 years and younger, the researchers observed a statistically significant difference in effect of discontinuation on time to clinical relapse (P = .032), time to MRI event (P = .013), and time to any inflammatory event (P = .0005), all favoring patients over the age of 45 years.

“This finding makes sense since age has been reported as one of the factors that negatively impacts on the inflammatory activity in patients with RRMS,” Dr. Yano said. “However, our study is the first study [to find] that the impact of discontinuing DMT on RRMS patient prognosis may differ based on the age at the discontinuation. In short, stopping DMT at a younger age has a statistically significant higher risk on inflammatory activities, compared to [stopping DMT at an] older age.”

He acknowledged certain limitations of the study, including its small sample size and single-center design. However, Dr. Yano said that a key strength of the analysis was the inclusion of MRI activity prior to DMT as the definition of stable state, “which is an integral piece of information when physicians and patients consider DMT discontinuation in a ‘real world’ clinical setting. We also used MRI activity as an outcome measure, which is lacking in prior discontinuation studies.”

Dr. Yano reported that he has received a research grant from Yoshida Scholarship Foundation in Japan. His coauthors reported having numerous financial ties to industry.

dbrunk@mdedge.com

SOURCE: Yano H et al. ACTRIMS Forum 2019, Poster 061.

DALLAS – Patients with relapsing emitting multiple sclerosis who discontinued treatment after a period of disease inactivity had a similar time to next event, compared with those who remained on treatment, results from a single-center study showed.

In addition, being over the age of 45 years was associated with a better disease course after treatment discontinuation.

“Being clinically and radiologically stable for more than 2 years can be a potential milestone to regard the discontinuation of DMT [disease-modifying therapy] as a reasonable option in a subset of patients, especially patients who are nondisabled,” lead study author Hajime Yano, MD, said in an interview at the Americas Committee for Treatment and Research in Multiple Sclerosis.

According to Dr. Yano, a research fellow at the Ann Romney Center for Neurologic Diseases and Partners Multiple Sclerosis Center in Boston, relapsing remitting multiple sclerosis (RRMS) patients without relapse for long periods on treatment may consider discontinuing DMT, but there is limited information regarding the impact of discontinuation, especially in terms of MRI activity.

In an effort to investigate the impact of DMT discontinuation on clinical and radiologic outcomes in RRMS patients, he and his colleagues identified 70 patients from the Comprehensive Longitudinal Investigation of Multiple Sclerosis at the Brigham and Women’s Hospital (CLIMB) study, which was initiated in 2000 and has enrolled more than 2,400 patients cared for at the Partners Multiple Sclerosis Center. Relapse date, symptoms, and Expanded Disability Status Scale (EDSS) were evaluated at 6-month intervals for each patient during the time of clinic visits by the treating neurologist. Additionally, brain MRIs were performed annually.

Next, the researchers matched the patients with 70 patients who remained on DMT identified by age, sex, treatment, treatment duration, disease duration, and EDSS. They used univariate and multivariable Cox proportional hazard models to test the differences between DMT discontinuation status with time to clinical relapse, MRI event, disability progression, and any inflammatory event (either clinical relapse or MRI event).

The mean age of patients was 45 years, 87% were female, their mean disease duration was about 13 years, and they had been receiving treatment for a mean of about 6 years. In adjusted analyses, the 70 pairs of patients who discontinued DMT and patients who continued DMT had similar outcomes in time to clinical relapse (hazard ratio, 0.93; P = .84), MRI event (HR, 1.01; P = .98), disability progression (HR, 1.33; P = .43), and any inflammatory event (HR, 0.93; P = .85). In a subgroup analysis, which compared the impact of DMT discontinuation between patients over the age of 45 years and those aged 45 years and younger, the researchers observed a statistically significant difference in effect of discontinuation on time to clinical relapse (P = .032), time to MRI event (P = .013), and time to any inflammatory event (P = .0005), all favoring patients over the age of 45 years.

“This finding makes sense since age has been reported as one of the factors that negatively impacts on the inflammatory activity in patients with RRMS,” Dr. Yano said. “However, our study is the first study [to find] that the impact of discontinuing DMT on RRMS patient prognosis may differ based on the age at the discontinuation. In short, stopping DMT at a younger age has a statistically significant higher risk on inflammatory activities, compared to [stopping DMT at an] older age.”

He acknowledged certain limitations of the study, including its small sample size and single-center design. However, Dr. Yano said that a key strength of the analysis was the inclusion of MRI activity prior to DMT as the definition of stable state, “which is an integral piece of information when physicians and patients consider DMT discontinuation in a ‘real world’ clinical setting. We also used MRI activity as an outcome measure, which is lacking in prior discontinuation studies.”

Dr. Yano reported that he has received a research grant from Yoshida Scholarship Foundation in Japan. His coauthors reported having numerous financial ties to industry.

dbrunk@mdedge.com

SOURCE: Yano H et al. ACTRIMS Forum 2019, Poster 061.

DALLAS – Patients with relapsing emitting multiple sclerosis who discontinued treatment after a period of disease inactivity had a similar time to next event, compared with those who remained on treatment, results from a single-center study showed.

In addition, being over the age of 45 years was associated with a better disease course after treatment discontinuation.

“Being clinically and radiologically stable for more than 2 years can be a potential milestone to regard the discontinuation of DMT [disease-modifying therapy] as a reasonable option in a subset of patients, especially patients who are nondisabled,” lead study author Hajime Yano, MD, said in an interview at the Americas Committee for Treatment and Research in Multiple Sclerosis.

According to Dr. Yano, a research fellow at the Ann Romney Center for Neurologic Diseases and Partners Multiple Sclerosis Center in Boston, relapsing remitting multiple sclerosis (RRMS) patients without relapse for long periods on treatment may consider discontinuing DMT, but there is limited information regarding the impact of discontinuation, especially in terms of MRI activity.

In an effort to investigate the impact of DMT discontinuation on clinical and radiologic outcomes in RRMS patients, he and his colleagues identified 70 patients from the Comprehensive Longitudinal Investigation of Multiple Sclerosis at the Brigham and Women’s Hospital (CLIMB) study, which was initiated in 2000 and has enrolled more than 2,400 patients cared for at the Partners Multiple Sclerosis Center. Relapse date, symptoms, and Expanded Disability Status Scale (EDSS) were evaluated at 6-month intervals for each patient during the time of clinic visits by the treating neurologist. Additionally, brain MRIs were performed annually.

Next, the researchers matched the patients with 70 patients who remained on DMT identified by age, sex, treatment, treatment duration, disease duration, and EDSS. They used univariate and multivariable Cox proportional hazard models to test the differences between DMT discontinuation status with time to clinical relapse, MRI event, disability progression, and any inflammatory event (either clinical relapse or MRI event).

The mean age of patients was 45 years, 87% were female, their mean disease duration was about 13 years, and they had been receiving treatment for a mean of about 6 years. In adjusted analyses, the 70 pairs of patients who discontinued DMT and patients who continued DMT had similar outcomes in time to clinical relapse (hazard ratio, 0.93; P = .84), MRI event (HR, 1.01; P = .98), disability progression (HR, 1.33; P = .43), and any inflammatory event (HR, 0.93; P = .85). In a subgroup analysis, which compared the impact of DMT discontinuation between patients over the age of 45 years and those aged 45 years and younger, the researchers observed a statistically significant difference in effect of discontinuation on time to clinical relapse (P = .032), time to MRI event (P = .013), and time to any inflammatory event (P = .0005), all favoring patients over the age of 45 years.

“This finding makes sense since age has been reported as one of the factors that negatively impacts on the inflammatory activity in patients with RRMS,” Dr. Yano said. “However, our study is the first study [to find] that the impact of discontinuing DMT on RRMS patient prognosis may differ based on the age at the discontinuation. In short, stopping DMT at a younger age has a statistically significant higher risk on inflammatory activities, compared to [stopping DMT at an] older age.”

He acknowledged certain limitations of the study, including its small sample size and single-center design. However, Dr. Yano said that a key strength of the analysis was the inclusion of MRI activity prior to DMT as the definition of stable state, “which is an integral piece of information when physicians and patients consider DMT discontinuation in a ‘real world’ clinical setting. We also used MRI activity as an outcome measure, which is lacking in prior discontinuation studies.”

Dr. Yano reported that he has received a research grant from Yoshida Scholarship Foundation in Japan. His coauthors reported having numerous financial ties to industry.

dbrunk@mdedge.com

SOURCE: Yano H et al. ACTRIMS Forum 2019, Poster 061.

New research suggests a gene expression signature can distinguish high-grade diffuse large B-cell lymphomas (DLBCLs) from other germinal center B-cell–like (GCB) DLBCLs.

Gio_tto/Thinkstock

Researchers identified GCB DLBCL patients with this 104-gene signature who had a “distinct mutational landscape” and inferior treatment outcomes. David W. Scott, MBChB, PhD, of the British Columbia Cancer Research Centre in Vancouver, and his colleagues described these patients in the Journal of Clinical Oncology.

The findings were published alongside a related editorial and a similar study from another group.

Dr. Scott and his colleagues began their study by analyzing data from 157 patients with de novo GCB DLBCL. Twenty-five of these patients had double- or triple-hit high-grade B-cell lymphoma with BCL2 translocations (HGBL-DH/TH-BCL2).

The researchers identified 104 genes that were the “most significantly differentially expressed between HGBL-DH/TH-BCL2 and other GCB DLBCLs” to create their double-hit gene signature (DHITsig).

The signature divided the patients into two groups — 42 patients (27%) whose tumors were positive for the DHITsig and 115 (73%) whose tumors were negative. Notably, 22 of the 25 HGBL-DH/TH-BCL2 tumors were DHITsig-positive and 3 were negative.

The DHITsig was not associated with clinical variables such as tumor volume, but it was associated with prognosis. Treatment outcomes were inferior in patients who were DHITsig-positive.

The 5-year time to progression rate was 81% in patients who were DHITsig-negative and 57% in those who were positive (P less than .001). The 5-year overall survival rate was 81% and 60%, respectively (P = .001).

The researchers observed similar results in a validation cohort of 262 patients with GCB-DLBCL who received rituximab-based therapy. The 5-year overall survival rate was 76% in patients who were DHITsig-negative and 49% in those who were positive (P less than .001).

Dr. Scott and his colleagues also evaluated the DHITsig in a second validation cohort of 162 patients with GCB DLBCL.

In analyzing data from all three cohorts, the researchers found that mutations in MYC, BCL2, CREBBP, EZH2^Y646, DDX3X, TP53, and KMT2D were more frequent in DHITsig-positive patients and mutations in TNFAIP3, KLHL6, NFKBIE, TET2, CD58, and STAT3 were more common in DHITsig-negative patients.

Additional analyses suggested the cell of origin for DHITsig-positive tumors comes from the intermediate zone or dark zone of the germinal center.

Finally, the researchers found they could use a “clinically relevant assay” to detect the DHITsig. They added a 30-gene module to the Lymph3Cx assay to create a NanoString-based assay called DLBCL90.

The team tested DLBCL90 in 171 GCB DLBCL patients. In this group, 26% of patients were DHITsig-positive, 64% were negative, and 10% were indeterminate. The prognostic significance of the signature was maintained with the assay results, according to the researchers.

Dr. Scott and his colleagues also wanted to validate the association between the DHITsig and HGBL-DH/TH-BCL2, so they tested the DLBCL90 assay in two additional groups of patients.

First, the assay was used in 88 patients who had transformed follicular lymphoma with DLBCL morphology. Eleven of the 25 DHITsig-positive tumors and 4 of the 13 DHITsig-indeterminate tumors were HGBL-DH/TH-BCL2. However, none of the 50 DHITsig-negative tumors were HGBL-DH/TH-BCL2.

The researchers then used the DLBCL90 assay on 26 HGBL tumors. Twenty-three of these were DHITsig-positive and 3 were indeterminate.

This research was supported by the Canadian Cancer Society Research Institute and other organizations. The researchers reported relationships with Seattle Genetics, Roche, Janssen, Celgene, and various other companies.

jensmith@mdedge.com

SOURCE: Scott DW et al. J Clin Oncol. 2019 Jan 20;37(3):190-201.
 

New research suggests a gene expression signature can distinguish high-grade diffuse large B-cell lymphomas (DLBCLs) from other germinal center B-cell–like (GCB) DLBCLs.

Gio_tto/Thinkstock

Researchers identified GCB DLBCL patients with this 104-gene signature who had a “distinct mutational landscape” and inferior treatment outcomes. David W. Scott, MBChB, PhD, of the British Columbia Cancer Research Centre in Vancouver, and his colleagues described these patients in the Journal of Clinical Oncology.

The findings were published alongside a related editorial and a similar study from another group.

Dr. Scott and his colleagues began their study by analyzing data from 157 patients with de novo GCB DLBCL. Twenty-five of these patients had double- or triple-hit high-grade B-cell lymphoma with BCL2 translocations (HGBL-DH/TH-BCL2).

The researchers identified 104 genes that were the “most significantly differentially expressed between HGBL-DH/TH-BCL2 and other GCB DLBCLs” to create their double-hit gene signature (DHITsig).

The signature divided the patients into two groups — 42 patients (27%) whose tumors were positive for the DHITsig and 115 (73%) whose tumors were negative. Notably, 22 of the 25 HGBL-DH/TH-BCL2 tumors were DHITsig-positive and 3 were negative.

The DHITsig was not associated with clinical variables such as tumor volume, but it was associated with prognosis. Treatment outcomes were inferior in patients who were DHITsig-positive.

The 5-year time to progression rate was 81% in patients who were DHITsig-negative and 57% in those who were positive (P less than .001). The 5-year overall survival rate was 81% and 60%, respectively (P = .001).

The researchers observed similar results in a validation cohort of 262 patients with GCB-DLBCL who received rituximab-based therapy. The 5-year overall survival rate was 76% in patients who were DHITsig-negative and 49% in those who were positive (P less than .001).

Dr. Scott and his colleagues also evaluated the DHITsig in a second validation cohort of 162 patients with GCB DLBCL.

In analyzing data from all three cohorts, the researchers found that mutations in MYC, BCL2, CREBBP, EZH2^Y646, DDX3X, TP53, and KMT2D were more frequent in DHITsig-positive patients and mutations in TNFAIP3, KLHL6, NFKBIE, TET2, CD58, and STAT3 were more common in DHITsig-negative patients.

Additional analyses suggested the cell of origin for DHITsig-positive tumors comes from the intermediate zone or dark zone of the germinal center.

Finally, the researchers found they could use a “clinically relevant assay” to detect the DHITsig. They added a 30-gene module to the Lymph3Cx assay to create a NanoString-based assay called DLBCL90.

The team tested DLBCL90 in 171 GCB DLBCL patients. In this group, 26% of patients were DHITsig-positive, 64% were negative, and 10% were indeterminate. The prognostic significance of the signature was maintained with the assay results, according to the researchers.

Dr. Scott and his colleagues also wanted to validate the association between the DHITsig and HGBL-DH/TH-BCL2, so they tested the DLBCL90 assay in two additional groups of patients.

First, the assay was used in 88 patients who had transformed follicular lymphoma with DLBCL morphology. Eleven of the 25 DHITsig-positive tumors and 4 of the 13 DHITsig-indeterminate tumors were HGBL-DH/TH-BCL2. However, none of the 50 DHITsig-negative tumors were HGBL-DH/TH-BCL2.

The researchers then used the DLBCL90 assay on 26 HGBL tumors. Twenty-three of these were DHITsig-positive and 3 were indeterminate.

This research was supported by the Canadian Cancer Society Research Institute and other organizations. The researchers reported relationships with Seattle Genetics, Roche, Janssen, Celgene, and various other companies.

jensmith@mdedge.com

SOURCE: Scott DW et al. J Clin Oncol. 2019 Jan 20;37(3):190-201.
 

New research suggests a gene expression signature can distinguish high-grade diffuse large B-cell lymphomas (DLBCLs) from other germinal center B-cell–like (GCB) DLBCLs.

Gio_tto/Thinkstock

Researchers identified GCB DLBCL patients with this 104-gene signature who had a “distinct mutational landscape” and inferior treatment outcomes. David W. Scott, MBChB, PhD, of the British Columbia Cancer Research Centre in Vancouver, and his colleagues described these patients in the Journal of Clinical Oncology.

The findings were published alongside a related editorial and a similar study from another group.

Dr. Scott and his colleagues began their study by analyzing data from 157 patients with de novo GCB DLBCL. Twenty-five of these patients had double- or triple-hit high-grade B-cell lymphoma with BCL2 translocations (HGBL-DH/TH-BCL2).

The researchers identified 104 genes that were the “most significantly differentially expressed between HGBL-DH/TH-BCL2 and other GCB DLBCLs” to create their double-hit gene signature (DHITsig).

The signature divided the patients into two groups — 42 patients (27%) whose tumors were positive for the DHITsig and 115 (73%) whose tumors were negative. Notably, 22 of the 25 HGBL-DH/TH-BCL2 tumors were DHITsig-positive and 3 were negative.

The DHITsig was not associated with clinical variables such as tumor volume, but it was associated with prognosis. Treatment outcomes were inferior in patients who were DHITsig-positive.

The 5-year time to progression rate was 81% in patients who were DHITsig-negative and 57% in those who were positive (P less than .001). The 5-year overall survival rate was 81% and 60%, respectively (P = .001).

The researchers observed similar results in a validation cohort of 262 patients with GCB-DLBCL who received rituximab-based therapy. The 5-year overall survival rate was 76% in patients who were DHITsig-negative and 49% in those who were positive (P less than .001).

Dr. Scott and his colleagues also evaluated the DHITsig in a second validation cohort of 162 patients with GCB DLBCL.

In analyzing data from all three cohorts, the researchers found that mutations in MYC, BCL2, CREBBP, EZH2^Y646, DDX3X, TP53, and KMT2D were more frequent in DHITsig-positive patients and mutations in TNFAIP3, KLHL6, NFKBIE, TET2, CD58, and STAT3 were more common in DHITsig-negative patients.

Additional analyses suggested the cell of origin for DHITsig-positive tumors comes from the intermediate zone or dark zone of the germinal center.

Finally, the researchers found they could use a “clinically relevant assay” to detect the DHITsig. They added a 30-gene module to the Lymph3Cx assay to create a NanoString-based assay called DLBCL90.

The team tested DLBCL90 in 171 GCB DLBCL patients. In this group, 26% of patients were DHITsig-positive, 64% were negative, and 10% were indeterminate. The prognostic significance of the signature was maintained with the assay results, according to the researchers.

Dr. Scott and his colleagues also wanted to validate the association between the DHITsig and HGBL-DH/TH-BCL2, so they tested the DLBCL90 assay in two additional groups of patients.

First, the assay was used in 88 patients who had transformed follicular lymphoma with DLBCL morphology. Eleven of the 25 DHITsig-positive tumors and 4 of the 13 DHITsig-indeterminate tumors were HGBL-DH/TH-BCL2. However, none of the 50 DHITsig-negative tumors were HGBL-DH/TH-BCL2.

The researchers then used the DLBCL90 assay on 26 HGBL tumors. Twenty-three of these were DHITsig-positive and 3 were indeterminate.

This research was supported by the Canadian Cancer Society Research Institute and other organizations. The researchers reported relationships with Seattle Genetics, Roche, Janssen, Celgene, and various other companies.

jensmith@mdedge.com

SOURCE: Scott DW et al. J Clin Oncol. 2019 Jan 20;37(3):190-201.
 

WASHINGTON – Noninvasive diagnostic devices may increasingly play a part in which lesions you choose to biopsy, Darrell S. Rigel, MD, said at the annual meeting of the American Academy of Dermatology.

Jeff Craven/MDedge News

“If you incorporate the data from these devices into the biopsy decision, you can improve biopsy sensitivity and accuracy of selection. I think there’s no question with these technologies that’s a true statement,” said Dr. Rigel, of New York University Langone Health.

When considering diagnostic devices, evaluate whether they produce results that outperform dermatologists, are low cost, user-friendly, time-efficient and have a high sensitivity and specificity, Dr. Rigel advised. But since no device has a perfect sensitivity and specificity, they cannot be followed blindly. The data from these devices should be used to inform, but not replace, clinical decisions made by dermatologists.

“They’re basically additional information to integrate into the biopsy decision,” he said. “At the end of the day, if you see something with a low score but it really looks funky, the reality is you have to really consider it for biopsy.”

Dr. Rigel discussed five device types that were used to analyze a number of preselected, noninvasive melanoma lesions. The devices required little training to use and a dermatologist would be required to correctly identify the lesions in a deeper analysis.

• Multispectral digital skin lesion analysis (MDSLA) uses 10 spectral wavelengths to measure the light reflected from the tissue, generating a score from a proprietary algorithm that predicts the risk of melanoma. Use of MDSLA improved the biopsy sensitivity for melanoma from 65% to 93% among 179 dermatologists who reviewed images of 24 lesions, 5 of which were melanoma (Arch Dermatol. 2012;148(4):541-3).
• Spectrophotometric intracutaneous analysis scope uses a similar analytic method as the MDSLA device but is difficult to find in the United States; however, one recent study cited a sensitivity of 81.4% and a specificity of 86.4%, indicating it has value for diagnosing melanoma.
• Raman spectroscopy uses monochromatic laser light to analyze the vibratory patterns of cells and examines the shifts in the light to identify a “molecular fingerprint” of potentially cancerous cells, has a high sensitivity and a “relatively reasonable specificity,” Dr. Rigel said.
• Elastic scattering spectroscopy, a newer technology that uses a smartphone-sized device to measure the difference in light scattered from different cellular structures, holds promise to reduce the number of negative biopsies when differentiating between malignant and benign skin conditions. It is currently pending approval with the Food and Drug Administration.
• Electrical impedance spectroscopy (EIS), which uses an electrical alternating current to detect the electrical resistance of potentially cancerous tissue, generates a score with a high negative predictive value and a higher positive predictive value as the score increases. In a study of melanoma diagnoses made by dermatology trainees, use of EIS decreased the number of missed melanomas by 23.4% and resulted in fewer benign biopsies. (J Amer Acad Dermatol. 2019;80:285-7).

All these technologies have been proven effective, but have encountered various economic roadblocks, including delays in regulatory approval, which are partly responsible for why some are no longer on the market, Dr. Rigel said. “If you have to wait 5 years or 7 years to get approval of these devices, by the time they’re approved, the technology is already passed by.”

There are also issues with reimbursements, Dr. Rigel noted, which can further reduce the clinical implementation of these technologies.

Dr. Rigel reported relationships with Derm Tech International, Scibase (maker of EIS) and a number of dermatologic drug companies.

WASHINGTON – Noninvasive diagnostic devices may increasingly play a part in which lesions you choose to biopsy, Darrell S. Rigel, MD, said at the annual meeting of the American Academy of Dermatology.

Jeff Craven/MDedge News

“If you incorporate the data from these devices into the biopsy decision, you can improve biopsy sensitivity and accuracy of selection. I think there’s no question with these technologies that’s a true statement,” said Dr. Rigel, of New York University Langone Health.

When considering diagnostic devices, evaluate whether they produce results that outperform dermatologists, are low cost, user-friendly, time-efficient and have a high sensitivity and specificity, Dr. Rigel advised. But since no device has a perfect sensitivity and specificity, they cannot be followed blindly. The data from these devices should be used to inform, but not replace, clinical decisions made by dermatologists.

“They’re basically additional information to integrate into the biopsy decision,” he said. “At the end of the day, if you see something with a low score but it really looks funky, the reality is you have to really consider it for biopsy.”

Dr. Rigel discussed five device types that were used to analyze a number of preselected, noninvasive melanoma lesions. The devices required little training to use and a dermatologist would be required to correctly identify the lesions in a deeper analysis.

• Multispectral digital skin lesion analysis (MDSLA) uses 10 spectral wavelengths to measure the light reflected from the tissue, generating a score from a proprietary algorithm that predicts the risk of melanoma. Use of MDSLA improved the biopsy sensitivity for melanoma from 65% to 93% among 179 dermatologists who reviewed images of 24 lesions, 5 of which were melanoma (Arch Dermatol. 2012;148(4):541-3).
• Spectrophotometric intracutaneous analysis scope uses a similar analytic method as the MDSLA device but is difficult to find in the United States; however, one recent study cited a sensitivity of 81.4% and a specificity of 86.4%, indicating it has value for diagnosing melanoma.
• Raman spectroscopy uses monochromatic laser light to analyze the vibratory patterns of cells and examines the shifts in the light to identify a “molecular fingerprint” of potentially cancerous cells, has a high sensitivity and a “relatively reasonable specificity,” Dr. Rigel said.
• Elastic scattering spectroscopy, a newer technology that uses a smartphone-sized device to measure the difference in light scattered from different cellular structures, holds promise to reduce the number of negative biopsies when differentiating between malignant and benign skin conditions. It is currently pending approval with the Food and Drug Administration.
• Electrical impedance spectroscopy (EIS), which uses an electrical alternating current to detect the electrical resistance of potentially cancerous tissue, generates a score with a high negative predictive value and a higher positive predictive value as the score increases. In a study of melanoma diagnoses made by dermatology trainees, use of EIS decreased the number of missed melanomas by 23.4% and resulted in fewer benign biopsies. (J Amer Acad Dermatol. 2019;80:285-7).

All these technologies have been proven effective, but have encountered various economic roadblocks, including delays in regulatory approval, which are partly responsible for why some are no longer on the market, Dr. Rigel said. “If you have to wait 5 years or 7 years to get approval of these devices, by the time they’re approved, the technology is already passed by.”

There are also issues with reimbursements, Dr. Rigel noted, which can further reduce the clinical implementation of these technologies.

Dr. Rigel reported relationships with Derm Tech International, Scibase (maker of EIS) and a number of dermatologic drug companies.

WASHINGTON – Noninvasive diagnostic devices may increasingly play a part in which lesions you choose to biopsy, Darrell S. Rigel, MD, said at the annual meeting of the American Academy of Dermatology.

Jeff Craven/MDedge News

“If you incorporate the data from these devices into the biopsy decision, you can improve biopsy sensitivity and accuracy of selection. I think there’s no question with these technologies that’s a true statement,” said Dr. Rigel, of New York University Langone Health.

When considering diagnostic devices, evaluate whether they produce results that outperform dermatologists, are low cost, user-friendly, time-efficient and have a high sensitivity and specificity, Dr. Rigel advised. But since no device has a perfect sensitivity and specificity, they cannot be followed blindly. The data from these devices should be used to inform, but not replace, clinical decisions made by dermatologists.

“They’re basically additional information to integrate into the biopsy decision,” he said. “At the end of the day, if you see something with a low score but it really looks funky, the reality is you have to really consider it for biopsy.”

Dr. Rigel discussed five device types that were used to analyze a number of preselected, noninvasive melanoma lesions. The devices required little training to use and a dermatologist would be required to correctly identify the lesions in a deeper analysis.

• Multispectral digital skin lesion analysis (MDSLA) uses 10 spectral wavelengths to measure the light reflected from the tissue, generating a score from a proprietary algorithm that predicts the risk of melanoma. Use of MDSLA improved the biopsy sensitivity for melanoma from 65% to 93% among 179 dermatologists who reviewed images of 24 lesions, 5 of which were melanoma (Arch Dermatol. 2012;148(4):541-3).
• Spectrophotometric intracutaneous analysis scope uses a similar analytic method as the MDSLA device but is difficult to find in the United States; however, one recent study cited a sensitivity of 81.4% and a specificity of 86.4%, indicating it has value for diagnosing melanoma.
• Raman spectroscopy uses monochromatic laser light to analyze the vibratory patterns of cells and examines the shifts in the light to identify a “molecular fingerprint” of potentially cancerous cells, has a high sensitivity and a “relatively reasonable specificity,” Dr. Rigel said.
• Elastic scattering spectroscopy, a newer technology that uses a smartphone-sized device to measure the difference in light scattered from different cellular structures, holds promise to reduce the number of negative biopsies when differentiating between malignant and benign skin conditions. It is currently pending approval with the Food and Drug Administration.
• Electrical impedance spectroscopy (EIS), which uses an electrical alternating current to detect the electrical resistance of potentially cancerous tissue, generates a score with a high negative predictive value and a higher positive predictive value as the score increases. In a study of melanoma diagnoses made by dermatology trainees, use of EIS decreased the number of missed melanomas by 23.4% and resulted in fewer benign biopsies. (J Amer Acad Dermatol. 2019;80:285-7).

All these technologies have been proven effective, but have encountered various economic roadblocks, including delays in regulatory approval, which are partly responsible for why some are no longer on the market, Dr. Rigel said. “If you have to wait 5 years or 7 years to get approval of these devices, by the time they’re approved, the technology is already passed by.”

There are also issues with reimbursements, Dr. Rigel noted, which can further reduce the clinical implementation of these technologies.

Dr. Rigel reported relationships with Derm Tech International, Scibase (maker of EIS) and a number of dermatologic drug companies.

The American Academy of Pediatrics has released new guidance about how you can protect yourself from liability risks when caring for children during disasters.

In a 2019 technical report, the AAP outlines common claims that can arise when treating children during disasters and how certain circumstances can force you to deviate from routine medical practices. In an accompanying policy statement by the AAP committee on medical liability and risk management, recommendations are offered for how to prepare for and prevent such legal risks.

During disasters, liability dangers can increase when circumstances “devolve into an environment of limited choices for both patients and providers,” and you have fewer treatment options available to you, according to the guidance authored by New York pediatrician Dr. Robin L. Altman and her associates.

Common claims that stem from treating patients during disasters are negligence, abandonment, and lack of informed consent. The AAP technical report offers examples about how these accusations can occur, including:

• When during a disaster, you are forced to alter treatment because of scarce medical supplies or equipment, you may later be accused of negligence if the patient’s outcome is negatively affected by the modified treatment.
• When a disaster progresses to overwhelming conditions, and you must practice in an altered health care environment that demands atypical actions, such actions may later be questioned and be accused of providing suboptimal care. Documentation of medical decision making for instance, a primary defense for one’s actions, may be compromised because of an inoperable electronic medical record. Similarly, past medical history may be unavailable, which may impact the appropriateness of care provision.
• In chaotic conditions, you may have to stop treating some patients to focus their time and resources elsewhere, which may lead to an abandonment claim, defined as unilateral termination of a physician-patient relationship – without proper patient notice – when treatment is still required. An abandonment claim also may arise when you have to make decisions in extreme conditions about which patients to transfer or evacuate first and whom to leave behind.
• When providing medical care to children during disasters, a lack of informed consent claim can arise if adequate parental permission is unattainable. This may result from families that are separated or displaced children in need of medical care.

Other claims that can arise from providing care during disasters include HIPAA breaches, licensing violations, discrimination claims, and Emergency Medical Treatment and Labor Act (EMTALA) violations, among others.

To reduce liability risks, you should strive to understand liability risks and limitations during disasters and take steps to mitigate them by crafting a disaster readiness plan, according to the AAP policy statement. The plan should include provider and staff education on improving medical care during disasters and how best to document medical decisions made in disaster-affected health care environments. Proactively identifying obstacles to care during disasters also is key. You can use the AAP division of state government affairs as a resource; it can provide current information on disaster liability in the different states.

You also should understand potential limits to your medical malpractice insurance coverage during disasters and take steps to add coverage for identified gaps, according to the AAP guidelines.

merznatalia/Thinkstock

AAP recommends that you advocate for your health center to have active disaster plans that cover children’s needs and for your hospital to conduct regular drills that test pediatric capabilities. Throughout the guidelines, the AAP calls on the U.S. Department of Health and Human Services to review current state and federal liability laws, and for the agency to recommend new laws that address disaster-response liability protections for doctors. HHS also should assess the liability coverage needs of physicians during crisis times and take action to reduce inconsistencies in state malpractice protections for volunteer physicians and nonvolunteer physicians, according to AAP.

The AAP policy statement is timely because of the number of recent disasters in the United States, said Dr. Altman, lead author of the two papers.

Citing the Federal Emergency Management Agency, Dr. Altman said there were 59 major disaster declarations and 16 emergency declarations in 2017, along with more than 300 mass shooting incidents and more than 110 other man-made disasters such as fires and industrial accidents.

“Disaster conditions can result in pediatric health care providers being faced with the need to address medical conditions outside of their scope of training and experience, without access to the usual fund of patient history and background information, without the usual input or consent from parents or guardians, without the usual assistance of data such as laboratory values or physiologic monitoring, and without knowledge of how long dire conditions will last,” Dr. Altman said in an AAP News statement. “In addition, this can occur within the backdrop of one’s own physical exhaustion, concerns for the safety of one’s own family members, and the risk of loss of valuable and expensive professional property and supplies.”

The AAP guidance can help pediatricians understand the unique professional liability risks that may occur when caring for pediatric patients and families during a disaster, she said.

“It is the hope that this will raise awareness, improve preparedness, and reduce potential deficiencies in professional liability protections for health care providers trying to do their best to care for patients during these infrequent, yet debilitating, events,” Dr. Altman said in the statement.

There was no external funding, and the authors indicated they had no relevant financial disclosures.

SOURCES: Pediatrics. 2019. doi: 10.1542/peds.2018-3892; Pediatrics. 2019. doi: 10.1542/peds.2018-3893.

The American Academy of Pediatrics has released new guidance about how you can protect yourself from liability risks when caring for children during disasters.

In a 2019 technical report, the AAP outlines common claims that can arise when treating children during disasters and how certain circumstances can force you to deviate from routine medical practices. In an accompanying policy statement by the AAP committee on medical liability and risk management, recommendations are offered for how to prepare for and prevent such legal risks.

During disasters, liability dangers can increase when circumstances “devolve into an environment of limited choices for both patients and providers,” and you have fewer treatment options available to you, according to the guidance authored by New York pediatrician Dr. Robin L. Altman and her associates.

Common claims that stem from treating patients during disasters are negligence, abandonment, and lack of informed consent. The AAP technical report offers examples about how these accusations can occur, including:

• When during a disaster, you are forced to alter treatment because of scarce medical supplies or equipment, you may later be accused of negligence if the patient’s outcome is negatively affected by the modified treatment.
• When a disaster progresses to overwhelming conditions, and you must practice in an altered health care environment that demands atypical actions, such actions may later be questioned and be accused of providing suboptimal care. Documentation of medical decision making for instance, a primary defense for one’s actions, may be compromised because of an inoperable electronic medical record. Similarly, past medical history may be unavailable, which may impact the appropriateness of care provision.
• In chaotic conditions, you may have to stop treating some patients to focus their time and resources elsewhere, which may lead to an abandonment claim, defined as unilateral termination of a physician-patient relationship – without proper patient notice – when treatment is still required. An abandonment claim also may arise when you have to make decisions in extreme conditions about which patients to transfer or evacuate first and whom to leave behind.
• When providing medical care to children during disasters, a lack of informed consent claim can arise if adequate parental permission is unattainable. This may result from families that are separated or displaced children in need of medical care.

Other claims that can arise from providing care during disasters include HIPAA breaches, licensing violations, discrimination claims, and Emergency Medical Treatment and Labor Act (EMTALA) violations, among others.

To reduce liability risks, you should strive to understand liability risks and limitations during disasters and take steps to mitigate them by crafting a disaster readiness plan, according to the AAP policy statement. The plan should include provider and staff education on improving medical care during disasters and how best to document medical decisions made in disaster-affected health care environments. Proactively identifying obstacles to care during disasters also is key. You can use the AAP division of state government affairs as a resource; it can provide current information on disaster liability in the different states.

You also should understand potential limits to your medical malpractice insurance coverage during disasters and take steps to add coverage for identified gaps, according to the AAP guidelines.

merznatalia/Thinkstock

AAP recommends that you advocate for your health center to have active disaster plans that cover children’s needs and for your hospital to conduct regular drills that test pediatric capabilities. Throughout the guidelines, the AAP calls on the U.S. Department of Health and Human Services to review current state and federal liability laws, and for the agency to recommend new laws that address disaster-response liability protections for doctors. HHS also should assess the liability coverage needs of physicians during crisis times and take action to reduce inconsistencies in state malpractice protections for volunteer physicians and nonvolunteer physicians, according to AAP.

The AAP policy statement is timely because of the number of recent disasters in the United States, said Dr. Altman, lead author of the two papers.

Citing the Federal Emergency Management Agency, Dr. Altman said there were 59 major disaster declarations and 16 emergency declarations in 2017, along with more than 300 mass shooting incidents and more than 110 other man-made disasters such as fires and industrial accidents.

“Disaster conditions can result in pediatric health care providers being faced with the need to address medical conditions outside of their scope of training and experience, without access to the usual fund of patient history and background information, without the usual input or consent from parents or guardians, without the usual assistance of data such as laboratory values or physiologic monitoring, and without knowledge of how long dire conditions will last,” Dr. Altman said in an AAP News statement. “In addition, this can occur within the backdrop of one’s own physical exhaustion, concerns for the safety of one’s own family members, and the risk of loss of valuable and expensive professional property and supplies.”

The AAP guidance can help pediatricians understand the unique professional liability risks that may occur when caring for pediatric patients and families during a disaster, she said.

“It is the hope that this will raise awareness, improve preparedness, and reduce potential deficiencies in professional liability protections for health care providers trying to do their best to care for patients during these infrequent, yet debilitating, events,” Dr. Altman said in the statement.

There was no external funding, and the authors indicated they had no relevant financial disclosures.

SOURCES: Pediatrics. 2019. doi: 10.1542/peds.2018-3892; Pediatrics. 2019. doi: 10.1542/peds.2018-3893.

The American Academy of Pediatrics has released new guidance about how you can protect yourself from liability risks when caring for children during disasters.

In a 2019 technical report, the AAP outlines common claims that can arise when treating children during disasters and how certain circumstances can force you to deviate from routine medical practices. In an accompanying policy statement by the AAP committee on medical liability and risk management, recommendations are offered for how to prepare for and prevent such legal risks.

During disasters, liability dangers can increase when circumstances “devolve into an environment of limited choices for both patients and providers,” and you have fewer treatment options available to you, according to the guidance authored by New York pediatrician Dr. Robin L. Altman and her associates.

Common claims that stem from treating patients during disasters are negligence, abandonment, and lack of informed consent. The AAP technical report offers examples about how these accusations can occur, including:

• When during a disaster, you are forced to alter treatment because of scarce medical supplies or equipment, you may later be accused of negligence if the patient’s outcome is negatively affected by the modified treatment.
• When a disaster progresses to overwhelming conditions, and you must practice in an altered health care environment that demands atypical actions, such actions may later be questioned and be accused of providing suboptimal care. Documentation of medical decision making for instance, a primary defense for one’s actions, may be compromised because of an inoperable electronic medical record. Similarly, past medical history may be unavailable, which may impact the appropriateness of care provision.
• In chaotic conditions, you may have to stop treating some patients to focus their time and resources elsewhere, which may lead to an abandonment claim, defined as unilateral termination of a physician-patient relationship – without proper patient notice – when treatment is still required. An abandonment claim also may arise when you have to make decisions in extreme conditions about which patients to transfer or evacuate first and whom to leave behind.
• When providing medical care to children during disasters, a lack of informed consent claim can arise if adequate parental permission is unattainable. This may result from families that are separated or displaced children in need of medical care.

Other claims that can arise from providing care during disasters include HIPAA breaches, licensing violations, discrimination claims, and Emergency Medical Treatment and Labor Act (EMTALA) violations, among others.

To reduce liability risks, you should strive to understand liability risks and limitations during disasters and take steps to mitigate them by crafting a disaster readiness plan, according to the AAP policy statement. The plan should include provider and staff education on improving medical care during disasters and how best to document medical decisions made in disaster-affected health care environments. Proactively identifying obstacles to care during disasters also is key. You can use the AAP division of state government affairs as a resource; it can provide current information on disaster liability in the different states.

You also should understand potential limits to your medical malpractice insurance coverage during disasters and take steps to add coverage for identified gaps, according to the AAP guidelines.

merznatalia/Thinkstock

AAP recommends that you advocate for your health center to have active disaster plans that cover children’s needs and for your hospital to conduct regular drills that test pediatric capabilities. Throughout the guidelines, the AAP calls on the U.S. Department of Health and Human Services to review current state and federal liability laws, and for the agency to recommend new laws that address disaster-response liability protections for doctors. HHS also should assess the liability coverage needs of physicians during crisis times and take action to reduce inconsistencies in state malpractice protections for volunteer physicians and nonvolunteer physicians, according to AAP.

The AAP policy statement is timely because of the number of recent disasters in the United States, said Dr. Altman, lead author of the two papers.

Citing the Federal Emergency Management Agency, Dr. Altman said there were 59 major disaster declarations and 16 emergency declarations in 2017, along with more than 300 mass shooting incidents and more than 110 other man-made disasters such as fires and industrial accidents.

“Disaster conditions can result in pediatric health care providers being faced with the need to address medical conditions outside of their scope of training and experience, without access to the usual fund of patient history and background information, without the usual input or consent from parents or guardians, without the usual assistance of data such as laboratory values or physiologic monitoring, and without knowledge of how long dire conditions will last,” Dr. Altman said in an AAP News statement. “In addition, this can occur within the backdrop of one’s own physical exhaustion, concerns for the safety of one’s own family members, and the risk of loss of valuable and expensive professional property and supplies.”

The AAP guidance can help pediatricians understand the unique professional liability risks that may occur when caring for pediatric patients and families during a disaster, she said.

“It is the hope that this will raise awareness, improve preparedness, and reduce potential deficiencies in professional liability protections for health care providers trying to do their best to care for patients during these infrequent, yet debilitating, events,” Dr. Altman said in the statement.

There was no external funding, and the authors indicated they had no relevant financial disclosures.

SOURCES: Pediatrics. 2019. doi: 10.1542/peds.2018-3892; Pediatrics. 2019. doi: 10.1542/peds.2018-3893.

The Food and Drug Administration has granted priority review to a supplemental new drug application (sNDA) for lenalidomide (Revlimid).

Celgene is seeking approval for lenalidomide in combination with rituximab to treat patients with previously treated follicular lymphoma (FL) or marginal zone lymphoma (MZL).

The FDA plans to make a decision on the sNDA by June 27, 2019.

The FDA aims to take action on a priority review application within 6 months of receiving it rather than the standard 10 months. The FDA grants priority review to applications for products that are expected to provide significant improvements in the treatment, diagnosis, or prevention of serious conditions.

The sNDA for lenalidomide is supported by the phase 3 AUGMENT study (NCT01938001) in which researchers compared rituximab plus lenalidomide to rituximab plus placebo in patients with relapsed/refractory FL or MZL.

Results from AUGMENT were presented at the 2018 annual meeting of the American Society of Hematology (Blood 2018 Nov 29;132:445).

According to the ASH abstract, the trial included 358 patients who were randomized to receive rituximab plus lenalidomide (n = 178) or rituximab plus placebo (n = 180).

At a median follow-up of 28.3 months, the overall response rate was 78% in the lenalidomide arm and 53% in the placebo arm (P less than .0001). The complete response rate was 34% and 18%, respectively (P = .001).

The median progression-free survival was 39.4 months in the lenalidomide arm and 14.1 months in the placebo arm. Overall survival data were not mature, but there were 16 deaths reported in the lenalidomide arm and 26 deaths in the placebo arm.

Treatment-emergent adverse events that were more common in the lenalidomide arm than the placebo arm included infections, cutaneous reactions, constipation, thrombocytopenia, and tumor flare reaction.

jensmith@mdedge.com

The Food and Drug Administration has granted priority review to a supplemental new drug application (sNDA) for lenalidomide (Revlimid).

Celgene is seeking approval for lenalidomide in combination with rituximab to treat patients with previously treated follicular lymphoma (FL) or marginal zone lymphoma (MZL).

The FDA plans to make a decision on the sNDA by June 27, 2019.

The FDA aims to take action on a priority review application within 6 months of receiving it rather than the standard 10 months. The FDA grants priority review to applications for products that are expected to provide significant improvements in the treatment, diagnosis, or prevention of serious conditions.

The sNDA for lenalidomide is supported by the phase 3 AUGMENT study (NCT01938001) in which researchers compared rituximab plus lenalidomide to rituximab plus placebo in patients with relapsed/refractory FL or MZL.

Results from AUGMENT were presented at the 2018 annual meeting of the American Society of Hematology (Blood 2018 Nov 29;132:445).

According to the ASH abstract, the trial included 358 patients who were randomized to receive rituximab plus lenalidomide (n = 178) or rituximab plus placebo (n = 180).

At a median follow-up of 28.3 months, the overall response rate was 78% in the lenalidomide arm and 53% in the placebo arm (P less than .0001). The complete response rate was 34% and 18%, respectively (P = .001).

The median progression-free survival was 39.4 months in the lenalidomide arm and 14.1 months in the placebo arm. Overall survival data were not mature, but there were 16 deaths reported in the lenalidomide arm and 26 deaths in the placebo arm.

Treatment-emergent adverse events that were more common in the lenalidomide arm than the placebo arm included infections, cutaneous reactions, constipation, thrombocytopenia, and tumor flare reaction.

jensmith@mdedge.com

The Food and Drug Administration has granted priority review to a supplemental new drug application (sNDA) for lenalidomide (Revlimid).

Celgene is seeking approval for lenalidomide in combination with rituximab to treat patients with previously treated follicular lymphoma (FL) or marginal zone lymphoma (MZL).

The FDA plans to make a decision on the sNDA by June 27, 2019.

The FDA aims to take action on a priority review application within 6 months of receiving it rather than the standard 10 months. The FDA grants priority review to applications for products that are expected to provide significant improvements in the treatment, diagnosis, or prevention of serious conditions.

The sNDA for lenalidomide is supported by the phase 3 AUGMENT study (NCT01938001) in which researchers compared rituximab plus lenalidomide to rituximab plus placebo in patients with relapsed/refractory FL or MZL.

Results from AUGMENT were presented at the 2018 annual meeting of the American Society of Hematology (Blood 2018 Nov 29;132:445).

According to the ASH abstract, the trial included 358 patients who were randomized to receive rituximab plus lenalidomide (n = 178) or rituximab plus placebo (n = 180).

At a median follow-up of 28.3 months, the overall response rate was 78% in the lenalidomide arm and 53% in the placebo arm (P less than .0001). The complete response rate was 34% and 18%, respectively (P = .001).

The median progression-free survival was 39.4 months in the lenalidomide arm and 14.1 months in the placebo arm. Overall survival data were not mature, but there were 16 deaths reported in the lenalidomide arm and 26 deaths in the placebo arm.

Treatment-emergent adverse events that were more common in the lenalidomide arm than the placebo arm included infections, cutaneous reactions, constipation, thrombocytopenia, and tumor flare reaction.

jensmith@mdedge.com

DALLAS – An iPad-based series of neuroperformance tests and patient-reported outcomes along with fully automated MRI analysis may facilitate the clinical evaluation of patients with multiple sclerosis, according to research described at the meeting held by the Americas Committee for Treatment and Research in Multiple Sclerosis.

An analysis of data collected using these methods found that patient-reported outcomes and MRI measures correlate with neuroperformance test results, said Laura Baldassari, MD, a clinical neuroimmunology fellow at the Mellen Center for Multiple Sclerosis at the Cleveland Clinic. Such assessments “could potentially enable us to better tune in to disability worsening and treatment response in our patients.”

The Multiple Sclerosis Performance Test (MSPT) collects patient-reported outcomes and tests patients’ processing speed, contrast sensitivity, manual dexterity, and walking speed. The MSPT is designed for supervised or independent administration with an assistant and has been “incorporated into routine clinical care at the Mellen Center,” Dr. Baldassari said. Before seeing their provider, patients complete the MSPT with a biomedical assistant, which usually takes 30-40 minutes. The data are scored instantly and “integrated into the electronic medical record for use during the clinical encounter.”

Dr. Baldassari and her research colleagues analyzed associations between the neuroperformance metrics, patient-reported outcome measures, and quantitative MRI metrics. The analysis included 976 patients who completed the MSPT between December 2015 and December 2017 and had an MRI within 3 months of a clinical encounter. T2 lesion volume, normalized whole brain volume or whole brain fraction, thalamic volume, and cross-sectional upper cervical spinal cord area at the level of C2 on MRI were calculated using a fully automated method.

Patient-reported outcomes included Quality of Life in Neurological Disorders (Neuro-QoL) upper and lower extremity function, Patient-Reported Outcomes Measurement Information System (PROMIS) physical, and Patient Determined Disease Steps (PDDS).

The researchers used Spearman correlation coefficients to examine the relationships between each neuroperformance test, patient-reported outcome, and MRI measure. Linear regression models determined which clinical demographic, patient-reported outcome, or MRI characteristic predicted neuroperformance test results.

Patients had a mean age of about 48 years, and the population was predominantly female and white with relapsing remitting MS.

“There were significant correlations between all neuroperformance tests and all patient-reported outcomes except for the contrast sensitivity test and PROMIS physical,” Dr. Baldassari said. “The processing speed test was most strongly correlated with the PDDS as well as the Neuro-QoL lower extremity. The contrast sensitivity test was correlated with Neuro-QoL lower extremity as well.” The manual dexterity test correlated with PDDS and Neuro-QoL upper and lower extremity and the walking speed test correlated with PDDS and Neuro-QoL lower extremity.

“With worsening self-reported functions, these neuroperformance test results demonstrated impairment as well,” she said.

The neuroperformance tests and all MRI metrics had significant, moderate correlations. “The strongest correlations here are between the processing speed test and whole brain fraction and T2 lesion volume; contrast sensitivity and T2 lesion volume, whole brain fraction, and thalamic volume; manual dexterity test and T2 lesion volume and whole brain fraction; and walking speed test and whole brain fraction and cord area,” she said.

“The strongest predictors of each neuroperformance test varied, which highlights the unique complementary contribution of each patient-reported outcome measure and MRI metric to the complex domains of disability in MS,” Dr. Baldassari said.

Comprehensive, quantitative MS assessments may lead to detailed patient profiles, which could support more precise clinical care and observational studies. In future studies, the researchers plan to examine how these measures relate over time.

The MSPT was developed by the Cleveland Clinic in partnership with Biogen. Dr. Baldassari reported receiving funding through the National Multiple Sclerosis Society and personal fees for serving on a scientific advisory board for Teva. His coauthors’ disclosures included the contribution of intellectual property to the MSPT, for which they could receive royalties.

jremaly@mdedge.com

SOURCE: Baldassari L et al. ACTRIMS Forum 2019, Abstract 32.

DALLAS – An iPad-based series of neuroperformance tests and patient-reported outcomes along with fully automated MRI analysis may facilitate the clinical evaluation of patients with multiple sclerosis, according to research described at the meeting held by the Americas Committee for Treatment and Research in Multiple Sclerosis.

An analysis of data collected using these methods found that patient-reported outcomes and MRI measures correlate with neuroperformance test results, said Laura Baldassari, MD, a clinical neuroimmunology fellow at the Mellen Center for Multiple Sclerosis at the Cleveland Clinic. Such assessments “could potentially enable us to better tune in to disability worsening and treatment response in our patients.”

The Multiple Sclerosis Performance Test (MSPT) collects patient-reported outcomes and tests patients’ processing speed, contrast sensitivity, manual dexterity, and walking speed. The MSPT is designed for supervised or independent administration with an assistant and has been “incorporated into routine clinical care at the Mellen Center,” Dr. Baldassari said. Before seeing their provider, patients complete the MSPT with a biomedical assistant, which usually takes 30-40 minutes. The data are scored instantly and “integrated into the electronic medical record for use during the clinical encounter.”

Dr. Baldassari and her research colleagues analyzed associations between the neuroperformance metrics, patient-reported outcome measures, and quantitative MRI metrics. The analysis included 976 patients who completed the MSPT between December 2015 and December 2017 and had an MRI within 3 months of a clinical encounter. T2 lesion volume, normalized whole brain volume or whole brain fraction, thalamic volume, and cross-sectional upper cervical spinal cord area at the level of C2 on MRI were calculated using a fully automated method.

Patient-reported outcomes included Quality of Life in Neurological Disorders (Neuro-QoL) upper and lower extremity function, Patient-Reported Outcomes Measurement Information System (PROMIS) physical, and Patient Determined Disease Steps (PDDS).

The researchers used Spearman correlation coefficients to examine the relationships between each neuroperformance test, patient-reported outcome, and MRI measure. Linear regression models determined which clinical demographic, patient-reported outcome, or MRI characteristic predicted neuroperformance test results.

Patients had a mean age of about 48 years, and the population was predominantly female and white with relapsing remitting MS.

“There were significant correlations between all neuroperformance tests and all patient-reported outcomes except for the contrast sensitivity test and PROMIS physical,” Dr. Baldassari said. “The processing speed test was most strongly correlated with the PDDS as well as the Neuro-QoL lower extremity. The contrast sensitivity test was correlated with Neuro-QoL lower extremity as well.” The manual dexterity test correlated with PDDS and Neuro-QoL upper and lower extremity and the walking speed test correlated with PDDS and Neuro-QoL lower extremity.

“With worsening self-reported functions, these neuroperformance test results demonstrated impairment as well,” she said.

The neuroperformance tests and all MRI metrics had significant, moderate correlations. “The strongest correlations here are between the processing speed test and whole brain fraction and T2 lesion volume; contrast sensitivity and T2 lesion volume, whole brain fraction, and thalamic volume; manual dexterity test and T2 lesion volume and whole brain fraction; and walking speed test and whole brain fraction and cord area,” she said.

“The strongest predictors of each neuroperformance test varied, which highlights the unique complementary contribution of each patient-reported outcome measure and MRI metric to the complex domains of disability in MS,” Dr. Baldassari said.

Comprehensive, quantitative MS assessments may lead to detailed patient profiles, which could support more precise clinical care and observational studies. In future studies, the researchers plan to examine how these measures relate over time.

The MSPT was developed by the Cleveland Clinic in partnership with Biogen. Dr. Baldassari reported receiving funding through the National Multiple Sclerosis Society and personal fees for serving on a scientific advisory board for Teva. His coauthors’ disclosures included the contribution of intellectual property to the MSPT, for which they could receive royalties.

jremaly@mdedge.com

SOURCE: Baldassari L et al. ACTRIMS Forum 2019, Abstract 32.

DALLAS – An iPad-based series of neuroperformance tests and patient-reported outcomes along with fully automated MRI analysis may facilitate the clinical evaluation of patients with multiple sclerosis, according to research described at the meeting held by the Americas Committee for Treatment and Research in Multiple Sclerosis.

An analysis of data collected using these methods found that patient-reported outcomes and MRI measures correlate with neuroperformance test results, said Laura Baldassari, MD, a clinical neuroimmunology fellow at the Mellen Center for Multiple Sclerosis at the Cleveland Clinic. Such assessments “could potentially enable us to better tune in to disability worsening and treatment response in our patients.”

The Multiple Sclerosis Performance Test (MSPT) collects patient-reported outcomes and tests patients’ processing speed, contrast sensitivity, manual dexterity, and walking speed. The MSPT is designed for supervised or independent administration with an assistant and has been “incorporated into routine clinical care at the Mellen Center,” Dr. Baldassari said. Before seeing their provider, patients complete the MSPT with a biomedical assistant, which usually takes 30-40 minutes. The data are scored instantly and “integrated into the electronic medical record for use during the clinical encounter.”

Dr. Baldassari and her research colleagues analyzed associations between the neuroperformance metrics, patient-reported outcome measures, and quantitative MRI metrics. The analysis included 976 patients who completed the MSPT between December 2015 and December 2017 and had an MRI within 3 months of a clinical encounter. T2 lesion volume, normalized whole brain volume or whole brain fraction, thalamic volume, and cross-sectional upper cervical spinal cord area at the level of C2 on MRI were calculated using a fully automated method.

Patient-reported outcomes included Quality of Life in Neurological Disorders (Neuro-QoL) upper and lower extremity function, Patient-Reported Outcomes Measurement Information System (PROMIS) physical, and Patient Determined Disease Steps (PDDS).

The researchers used Spearman correlation coefficients to examine the relationships between each neuroperformance test, patient-reported outcome, and MRI measure. Linear regression models determined which clinical demographic, patient-reported outcome, or MRI characteristic predicted neuroperformance test results.

Patients had a mean age of about 48 years, and the population was predominantly female and white with relapsing remitting MS.

“There were significant correlations between all neuroperformance tests and all patient-reported outcomes except for the contrast sensitivity test and PROMIS physical,” Dr. Baldassari said. “The processing speed test was most strongly correlated with the PDDS as well as the Neuro-QoL lower extremity. The contrast sensitivity test was correlated with Neuro-QoL lower extremity as well.” The manual dexterity test correlated with PDDS and Neuro-QoL upper and lower extremity and the walking speed test correlated with PDDS and Neuro-QoL lower extremity.

“With worsening self-reported functions, these neuroperformance test results demonstrated impairment as well,” she said.

The neuroperformance tests and all MRI metrics had significant, moderate correlations. “The strongest correlations here are between the processing speed test and whole brain fraction and T2 lesion volume; contrast sensitivity and T2 lesion volume, whole brain fraction, and thalamic volume; manual dexterity test and T2 lesion volume and whole brain fraction; and walking speed test and whole brain fraction and cord area,” she said.

“The strongest predictors of each neuroperformance test varied, which highlights the unique complementary contribution of each patient-reported outcome measure and MRI metric to the complex domains of disability in MS,” Dr. Baldassari said.

Comprehensive, quantitative MS assessments may lead to detailed patient profiles, which could support more precise clinical care and observational studies. In future studies, the researchers plan to examine how these measures relate over time.

The MSPT was developed by the Cleveland Clinic in partnership with Biogen. Dr. Baldassari reported receiving funding through the National Multiple Sclerosis Society and personal fees for serving on a scientific advisory board for Teva. His coauthors’ disclosures included the contribution of intellectual property to the MSPT, for which they could receive royalties.

jremaly@mdedge.com

SOURCE: Baldassari L et al. ACTRIMS Forum 2019, Abstract 32.