Take-Home Points

• Have a high-index of suspicion for MLLs and initiate treatment early.
• Compression needs to occur through short-stretch bandaging over a conventional Ace wrap in order to be successful.
• Apply the short-stretch compression with care to avoid shearing underlying tissue.
• Nonoperative treatment modalities require high patient compliance.
• MLLs need close monitoring until final healing occurs.

Morel-Lavallée lesions (MLLs) are traumatic degloving injuries resulting from separation of subcutaneous fat from underlying fascia. MLLs occur in association with acetabular fractures and are also associated with low-velocity crush injuries.^1,2 Shearing creates a “false” space that is filled with hemorrhaged blood, fat, and lymphatic tissue.³ Disruption of the lymphatics leads to cavity formation and, eventually, a fibrotic pseudocapsule.⁴The pseudocapsule prevents resorption, leading to a chronic fluid collection, which potentiates the risk of infection or tissue necrosis.^3,5,6 Skin necrosis may occur through direct-pressure compromise of the dermal vascular plexus.⁴ Necrotic skin may require multiple débridements, negative-pressure wound therapy or soft-tissue coverage, and may ultimately result in infection. MLLs classically occur in the greater trochanteric region, lateral thigh, buttocks, and back but also appear in the prepatellar region.^1,3 Patients present with soft-tissue swelling, bruising, bulging, decreased cutaneous sensation over the region, and a palpable, fluctuant subcutaneous fluid collection with mobile skin.^2,4,7 The mechanism of injury may cause a concomitant fracture. Magnetic resonance imaging (MRI), the preferred imaging modality, shows a discrete fluid collection between subcutaneous fat and underlying fascia. Ultrasonography may reveal a thickened capsule surrounding either a hypoechoic area or an anechoic area but its accuracy is user-dependent.⁷

Large MLLs may be treated with open serial débridement and healing by secondary intention; infection rates, however, are high. Authors have described several other treatment modalities, including percutaneous débridement with a brush followed by use of a large-bore drain and antibiotics; open débridement with meticulous dead-space closure; elastic compression bandaging; aspiration; and doxycycline sclerodesis.^1,5,6,8,9 Modifications of short-stretch compression bandaging were recently described in edema control for hindfoot trauma, ankle trauma, and total ankle arthroplasty, but not for MLLs.^10,11 Nickerson and colleagues⁴ retrospectively reviewed 87 MLLs, found that fluid aspirate of >50 mL predicted recurrence and failure with conservative measures, and recommended operative intervention for any MLL with >50 mL of fluid aspirated.

We report the case of an MLL that occurred in an unusual anatomical region, and we describe a novel application of a conservative treatment, which was selected on the basis of its success in lymphedema management. The patient provided written informed consent for print and electronic publication of this case report.

Case Report

A 66-year-old man was injured when a parked vehicle began moving, pulled him under, and ran over his lower right leg. In the emergency department, no fractures or major injuries were noted (Figures 1A, 1B), and the patient was discharged.

About 10 days after injury, profuse ecchymosis and swelling were noted running from the distal medial thigh to the proximal medial calf (Figures 2A-2C).

Discussion

Short-stretch bandaging has been performed mainly in lymphedema and ulcer management.

Compression bandaging reduces volume in lymphedematous limbs by reducing capillary filtration, shifting fluid into noncompressed parts of the body, increasing lymphatic reabsorption and lymphatic transport stimulation, improving venous pumping, and breaking down fibrosclerotic tissue.¹⁵ We think containment, improved venous flow, and enhanced muscle contraction contributed to the effectiveness of short-stretch bandaging as treatment for our patient’s MLL. Because MLLs also contain disrupted lymphatics, lymphedema management strategies (eg, short-stretch bandages) can be used. Our patient rapidly improved after conversion to short-stretch bandages.

These bandages are applied with 50% overlap to ensure even pressures throughout.¹⁶ Multiple layers are applied using a combination of spiral and figure-of-8 techniques, first clockwise and then counterclockwise, to avoid shearing underlying tissue.¹⁷ This method is very important in MLL treatment, given the degloving involved and the highly mobile skin and subcutaneous fat.

In standard lymphedema management, a foam padding layer is applied before the short-stretch bandage in order to reshape the limb and avoid proximal constrictions.¹³ In our patient’s case, the short-stretch wrap was applied without padding. Because his condition was acute, and the limb contour was preserved, limb reshaping and thus padding were not necessary.

Given the rapid, high-volume reduction that occurs within the first 1 to 2 weeks, bandages are reapplied daily to effectively adjust for the decreased swelling and altered limb shape.¹⁷ Most improvement is expected within the first few weeks—consistent with our patient’s case. Bandages usually are applied to the entire limb. For partial cases, the bandaging must extend past the area of swelling and incorporate the knee to prevent displacement of fluid into the joint.¹⁷ Feet and ankles are bandaged in dorsiflexion.¹⁷Several factors must be considered with short-stretch wraps. For example, pressure may need to be adjusted in patients with peripheral vascular disease. In patients with ankle-brachial indexes >0.5, it is safe to apply pressure up to 40 mm Hg.¹² Reduced pressure is recommended for patients with arterial disease, sensory disturbance, lipoedema, poor mobility, frailty, or palliative needs.¹³The unusual location of our patient’s MLL accounts for the delay in diagnosis. To our knowledge, no other authors have reported such a large MLL in this location. A few series and case reports have listed MLLs in the calf near the gastrocnemius muscle, in the ankle, in the prepatellar area, and in the suprapatellar region, including the thigh,^1,3,18-20 but there are no reports of MLLs running from medial thigh to proximal calf. MLLs of this size classically are treated surgically, but our patient selected nonoperative management.

To our knowledge, there are no earlier reports of using this nonoperative technique to treat MLLs. Conservative treatment with compression has been discussed, but no case involved short-stretch bandages. Large MLLs are thought to require surgery plus some type of drainage. The success of using short-stretch bandages in our patient’s case should prompt further investigation of use in adherent patients—which could ultimately result in reduced surgical needs, improved wound care (surgery is avoided), and a maintained low risk of infection. Although more work is needed to come to a more definitive verdict on this treatment method, it is a promising option that warrants consideration.

Am J Orthop. 2017;46(4):E213-E218. Copyright Frontline Medical Communications Inc. 2017. All rights reserved.

Take-Home Points

• Have a high-index of suspicion for MLLs and initiate treatment early.
• Compression needs to occur through short-stretch bandaging over a conventional Ace wrap in order to be successful.
• Apply the short-stretch compression with care to avoid shearing underlying tissue.
• Nonoperative treatment modalities require high patient compliance.
• MLLs need close monitoring until final healing occurs.

Morel-Lavallée lesions (MLLs) are traumatic degloving injuries resulting from separation of subcutaneous fat from underlying fascia. MLLs occur in association with acetabular fractures and are also associated with low-velocity crush injuries.^1,2 Shearing creates a “false” space that is filled with hemorrhaged blood, fat, and lymphatic tissue.³ Disruption of the lymphatics leads to cavity formation and, eventually, a fibrotic pseudocapsule.⁴The pseudocapsule prevents resorption, leading to a chronic fluid collection, which potentiates the risk of infection or tissue necrosis.^3,5,6 Skin necrosis may occur through direct-pressure compromise of the dermal vascular plexus.⁴ Necrotic skin may require multiple débridements, negative-pressure wound therapy or soft-tissue coverage, and may ultimately result in infection. MLLs classically occur in the greater trochanteric region, lateral thigh, buttocks, and back but also appear in the prepatellar region.^1,3 Patients present with soft-tissue swelling, bruising, bulging, decreased cutaneous sensation over the region, and a palpable, fluctuant subcutaneous fluid collection with mobile skin.^2,4,7 The mechanism of injury may cause a concomitant fracture. Magnetic resonance imaging (MRI), the preferred imaging modality, shows a discrete fluid collection between subcutaneous fat and underlying fascia. Ultrasonography may reveal a thickened capsule surrounding either a hypoechoic area or an anechoic area but its accuracy is user-dependent.⁷

Large MLLs may be treated with open serial débridement and healing by secondary intention; infection rates, however, are high. Authors have described several other treatment modalities, including percutaneous débridement with a brush followed by use of a large-bore drain and antibiotics; open débridement with meticulous dead-space closure; elastic compression bandaging; aspiration; and doxycycline sclerodesis.^1,5,6,8,9 Modifications of short-stretch compression bandaging were recently described in edema control for hindfoot trauma, ankle trauma, and total ankle arthroplasty, but not for MLLs.^10,11 Nickerson and colleagues⁴ retrospectively reviewed 87 MLLs, found that fluid aspirate of >50 mL predicted recurrence and failure with conservative measures, and recommended operative intervention for any MLL with >50 mL of fluid aspirated.

We report the case of an MLL that occurred in an unusual anatomical region, and we describe a novel application of a conservative treatment, which was selected on the basis of its success in lymphedema management. The patient provided written informed consent for print and electronic publication of this case report.

Case Report

A 66-year-old man was injured when a parked vehicle began moving, pulled him under, and ran over his lower right leg. In the emergency department, no fractures or major injuries were noted (Figures 1A, 1B), and the patient was discharged.

About 10 days after injury, profuse ecchymosis and swelling were noted running from the distal medial thigh to the proximal medial calf (Figures 2A-2C).

Discussion

Short-stretch bandaging has been performed mainly in lymphedema and ulcer management.

Compression bandaging reduces volume in lymphedematous limbs by reducing capillary filtration, shifting fluid into noncompressed parts of the body, increasing lymphatic reabsorption and lymphatic transport stimulation, improving venous pumping, and breaking down fibrosclerotic tissue.¹⁵ We think containment, improved venous flow, and enhanced muscle contraction contributed to the effectiveness of short-stretch bandaging as treatment for our patient’s MLL. Because MLLs also contain disrupted lymphatics, lymphedema management strategies (eg, short-stretch bandages) can be used. Our patient rapidly improved after conversion to short-stretch bandages.

These bandages are applied with 50% overlap to ensure even pressures throughout.¹⁶ Multiple layers are applied using a combination of spiral and figure-of-8 techniques, first clockwise and then counterclockwise, to avoid shearing underlying tissue.¹⁷ This method is very important in MLL treatment, given the degloving involved and the highly mobile skin and subcutaneous fat.

In standard lymphedema management, a foam padding layer is applied before the short-stretch bandage in order to reshape the limb and avoid proximal constrictions.¹³ In our patient’s case, the short-stretch wrap was applied without padding. Because his condition was acute, and the limb contour was preserved, limb reshaping and thus padding were not necessary.

Given the rapid, high-volume reduction that occurs within the first 1 to 2 weeks, bandages are reapplied daily to effectively adjust for the decreased swelling and altered limb shape.¹⁷ Most improvement is expected within the first few weeks—consistent with our patient’s case. Bandages usually are applied to the entire limb. For partial cases, the bandaging must extend past the area of swelling and incorporate the knee to prevent displacement of fluid into the joint.¹⁷ Feet and ankles are bandaged in dorsiflexion.¹⁷Several factors must be considered with short-stretch wraps. For example, pressure may need to be adjusted in patients with peripheral vascular disease. In patients with ankle-brachial indexes >0.5, it is safe to apply pressure up to 40 mm Hg.¹² Reduced pressure is recommended for patients with arterial disease, sensory disturbance, lipoedema, poor mobility, frailty, or palliative needs.¹³The unusual location of our patient’s MLL accounts for the delay in diagnosis. To our knowledge, no other authors have reported such a large MLL in this location. A few series and case reports have listed MLLs in the calf near the gastrocnemius muscle, in the ankle, in the prepatellar area, and in the suprapatellar region, including the thigh,^1,3,18-20 but there are no reports of MLLs running from medial thigh to proximal calf. MLLs of this size classically are treated surgically, but our patient selected nonoperative management.

To our knowledge, there are no earlier reports of using this nonoperative technique to treat MLLs. Conservative treatment with compression has been discussed, but no case involved short-stretch bandages. Large MLLs are thought to require surgery plus some type of drainage. The success of using short-stretch bandages in our patient’s case should prompt further investigation of use in adherent patients—which could ultimately result in reduced surgical needs, improved wound care (surgery is avoided), and a maintained low risk of infection. Although more work is needed to come to a more definitive verdict on this treatment method, it is a promising option that warrants consideration.

Am J Orthop. 2017;46(4):E213-E218. Copyright Frontline Medical Communications Inc. 2017. All rights reserved.

Take-Home Points

• Have a high-index of suspicion for MLLs and initiate treatment early.
• Compression needs to occur through short-stretch bandaging over a conventional Ace wrap in order to be successful.
• Apply the short-stretch compression with care to avoid shearing underlying tissue.
• Nonoperative treatment modalities require high patient compliance.
• MLLs need close monitoring until final healing occurs.

Morel-Lavallée lesions (MLLs) are traumatic degloving injuries resulting from separation of subcutaneous fat from underlying fascia. MLLs occur in association with acetabular fractures and are also associated with low-velocity crush injuries.^1,2 Shearing creates a “false” space that is filled with hemorrhaged blood, fat, and lymphatic tissue.³ Disruption of the lymphatics leads to cavity formation and, eventually, a fibrotic pseudocapsule.⁴The pseudocapsule prevents resorption, leading to a chronic fluid collection, which potentiates the risk of infection or tissue necrosis.^3,5,6 Skin necrosis may occur through direct-pressure compromise of the dermal vascular plexus.⁴ Necrotic skin may require multiple débridements, negative-pressure wound therapy or soft-tissue coverage, and may ultimately result in infection. MLLs classically occur in the greater trochanteric region, lateral thigh, buttocks, and back but also appear in the prepatellar region.^1,3 Patients present with soft-tissue swelling, bruising, bulging, decreased cutaneous sensation over the region, and a palpable, fluctuant subcutaneous fluid collection with mobile skin.^2,4,7 The mechanism of injury may cause a concomitant fracture. Magnetic resonance imaging (MRI), the preferred imaging modality, shows a discrete fluid collection between subcutaneous fat and underlying fascia. Ultrasonography may reveal a thickened capsule surrounding either a hypoechoic area or an anechoic area but its accuracy is user-dependent.⁷

Large MLLs may be treated with open serial débridement and healing by secondary intention; infection rates, however, are high. Authors have described several other treatment modalities, including percutaneous débridement with a brush followed by use of a large-bore drain and antibiotics; open débridement with meticulous dead-space closure; elastic compression bandaging; aspiration; and doxycycline sclerodesis.^1,5,6,8,9 Modifications of short-stretch compression bandaging were recently described in edema control for hindfoot trauma, ankle trauma, and total ankle arthroplasty, but not for MLLs.^10,11 Nickerson and colleagues⁴ retrospectively reviewed 87 MLLs, found that fluid aspirate of >50 mL predicted recurrence and failure with conservative measures, and recommended operative intervention for any MLL with >50 mL of fluid aspirated.

We report the case of an MLL that occurred in an unusual anatomical region, and we describe a novel application of a conservative treatment, which was selected on the basis of its success in lymphedema management. The patient provided written informed consent for print and electronic publication of this case report.

Case Report

A 66-year-old man was injured when a parked vehicle began moving, pulled him under, and ran over his lower right leg. In the emergency department, no fractures or major injuries were noted (Figures 1A, 1B), and the patient was discharged.

About 10 days after injury, profuse ecchymosis and swelling were noted running from the distal medial thigh to the proximal medial calf (Figures 2A-2C).

Discussion

Short-stretch bandaging has been performed mainly in lymphedema and ulcer management.

Compression bandaging reduces volume in lymphedematous limbs by reducing capillary filtration, shifting fluid into noncompressed parts of the body, increasing lymphatic reabsorption and lymphatic transport stimulation, improving venous pumping, and breaking down fibrosclerotic tissue.¹⁵ We think containment, improved venous flow, and enhanced muscle contraction contributed to the effectiveness of short-stretch bandaging as treatment for our patient’s MLL. Because MLLs also contain disrupted lymphatics, lymphedema management strategies (eg, short-stretch bandages) can be used. Our patient rapidly improved after conversion to short-stretch bandages.

These bandages are applied with 50% overlap to ensure even pressures throughout.¹⁶ Multiple layers are applied using a combination of spiral and figure-of-8 techniques, first clockwise and then counterclockwise, to avoid shearing underlying tissue.¹⁷ This method is very important in MLL treatment, given the degloving involved and the highly mobile skin and subcutaneous fat.

In standard lymphedema management, a foam padding layer is applied before the short-stretch bandage in order to reshape the limb and avoid proximal constrictions.¹³ In our patient’s case, the short-stretch wrap was applied without padding. Because his condition was acute, and the limb contour was preserved, limb reshaping and thus padding were not necessary.

Given the rapid, high-volume reduction that occurs within the first 1 to 2 weeks, bandages are reapplied daily to effectively adjust for the decreased swelling and altered limb shape.¹⁷ Most improvement is expected within the first few weeks—consistent with our patient’s case. Bandages usually are applied to the entire limb. For partial cases, the bandaging must extend past the area of swelling and incorporate the knee to prevent displacement of fluid into the joint.¹⁷ Feet and ankles are bandaged in dorsiflexion.¹⁷Several factors must be considered with short-stretch wraps. For example, pressure may need to be adjusted in patients with peripheral vascular disease. In patients with ankle-brachial indexes >0.5, it is safe to apply pressure up to 40 mm Hg.¹² Reduced pressure is recommended for patients with arterial disease, sensory disturbance, lipoedema, poor mobility, frailty, or palliative needs.¹³The unusual location of our patient’s MLL accounts for the delay in diagnosis. To our knowledge, no other authors have reported such a large MLL in this location. A few series and case reports have listed MLLs in the calf near the gastrocnemius muscle, in the ankle, in the prepatellar area, and in the suprapatellar region, including the thigh,^1,3,18-20 but there are no reports of MLLs running from medial thigh to proximal calf. MLLs of this size classically are treated surgically, but our patient selected nonoperative management.

To our knowledge, there are no earlier reports of using this nonoperative technique to treat MLLs. Conservative treatment with compression has been discussed, but no case involved short-stretch bandages. Large MLLs are thought to require surgery plus some type of drainage. The success of using short-stretch bandages in our patient’s case should prompt further investigation of use in adherent patients—which could ultimately result in reduced surgical needs, improved wound care (surgery is avoided), and a maintained low risk of infection. Although more work is needed to come to a more definitive verdict on this treatment method, it is a promising option that warrants consideration.

Am J Orthop. 2017;46(4):E213-E218. Copyright Frontline Medical Communications Inc. 2017. All rights reserved.

A multidirectional gravity-assist device that delivers precise trunk support to stroke and spinal cord injury (SCI) patients via an artificial intelligence algorithm has demonstrated significantly improved locomotor performance beyond treadmill-based systems in a new study.

The harness device used in the study adjusts patients’ balance while they stand still or walk by employing a unique, adaptive multidirectional gravity-assist (MGA) algorithm tailored to the specific needs of the patient, according to Jean-Baptiste Mignardot, PhD, of the Center for Neuroprosthetics and Brain Mind Institute, Swiss Federal Institute of Technology, Lausanne, Switzerland, and fellow investigators.

“The MGA establishes a safe and natural rehabilitation environment wherein individuals with neurological deficits can perform basic and skilled locomotor activities that would not be possible without robotic assistance,” according to the investigators. “The immediate and short-term ameliorations of gait performance during locomotion with MGA illustrate the potential of this environment to augment motor recovery.”

Current gait rehabilitation methods in stroke or SCI patients most commonly involves counterweight mechanisms or force-controlled equipment that apply upward support while walking on a treadmill. However Dr. Mignardot and his colleagues believe these methods are flawed.

ezimmerman@frontlinemedcom.com

On Twitter @eaztweets

A multidirectional gravity-assist device that delivers precise trunk support to stroke and spinal cord injury (SCI) patients via an artificial intelligence algorithm has demonstrated significantly improved locomotor performance beyond treadmill-based systems in a new study.

The harness device used in the study adjusts patients’ balance while they stand still or walk by employing a unique, adaptive multidirectional gravity-assist (MGA) algorithm tailored to the specific needs of the patient, according to Jean-Baptiste Mignardot, PhD, of the Center for Neuroprosthetics and Brain Mind Institute, Swiss Federal Institute of Technology, Lausanne, Switzerland, and fellow investigators.

“The MGA establishes a safe and natural rehabilitation environment wherein individuals with neurological deficits can perform basic and skilled locomotor activities that would not be possible without robotic assistance,” according to the investigators. “The immediate and short-term ameliorations of gait performance during locomotion with MGA illustrate the potential of this environment to augment motor recovery.”

Current gait rehabilitation methods in stroke or SCI patients most commonly involves counterweight mechanisms or force-controlled equipment that apply upward support while walking on a treadmill. However Dr. Mignardot and his colleagues believe these methods are flawed.

ezimmerman@frontlinemedcom.com

On Twitter @eaztweets

A multidirectional gravity-assist device that delivers precise trunk support to stroke and spinal cord injury (SCI) patients via an artificial intelligence algorithm has demonstrated significantly improved locomotor performance beyond treadmill-based systems in a new study.

The harness device used in the study adjusts patients’ balance while they stand still or walk by employing a unique, adaptive multidirectional gravity-assist (MGA) algorithm tailored to the specific needs of the patient, according to Jean-Baptiste Mignardot, PhD, of the Center for Neuroprosthetics and Brain Mind Institute, Swiss Federal Institute of Technology, Lausanne, Switzerland, and fellow investigators.

“The MGA establishes a safe and natural rehabilitation environment wherein individuals with neurological deficits can perform basic and skilled locomotor activities that would not be possible without robotic assistance,” according to the investigators. “The immediate and short-term ameliorations of gait performance during locomotion with MGA illustrate the potential of this environment to augment motor recovery.”

Current gait rehabilitation methods in stroke or SCI patients most commonly involves counterweight mechanisms or force-controlled equipment that apply upward support while walking on a treadmill. However Dr. Mignardot and his colleagues believe these methods are flawed.

ezimmerman@frontlinemedcom.com

On Twitter @eaztweets

Clinically significant bleeding events occurred in two elderly men who were taking ibrutinib and underwent Mohs micrographic surgery for squamous cell carcinomas, Cindy E. Parra and her colleagues reported in JAMA Dermatology.

On day 3 after his Mohs procedure, one 73-year-old man taking ibrutinib for Waldenstrom macroglobulinemia developed extensive bilateral periorbital ecchymosis that extended down to his upper chest. The other patient, an 88-year-old man taking ibrutinib for chronic lymphocytic leukemia, developed ecchymosis down to the chin. The first patient discontinued ibrutinib 3 days before his surgery; the second patient was taking ibrutinib at the time of his surgery.

“The increased incidence of nonmelanoma skin cancer and poorer outcomes in patients with non-Hodgkin lymphoma and CLL is well recognized, as is the importance of aggressive dermatologic management,” the researchers wrote (JAMA Dermatol. 2017 Jul 12. doi: 10.1001/jamadermatol.2017.1877). “It may be prudent to withhold ibrutinib treatment prior to dermatologic surgery to avoid potential bleeding complications.”

The findings argue for close collaboration between the dermatologic surgeon and the patient’s hematologist when scheduling extended-duration dermatologic procedures in patients taking ibrutinib.

Find the full summary here.

acruz@frontlinemedcom.com

Clinically significant bleeding events occurred in two elderly men who were taking ibrutinib and underwent Mohs micrographic surgery for squamous cell carcinomas, Cindy E. Parra and her colleagues reported in JAMA Dermatology.

On day 3 after his Mohs procedure, one 73-year-old man taking ibrutinib for Waldenstrom macroglobulinemia developed extensive bilateral periorbital ecchymosis that extended down to his upper chest. The other patient, an 88-year-old man taking ibrutinib for chronic lymphocytic leukemia, developed ecchymosis down to the chin. The first patient discontinued ibrutinib 3 days before his surgery; the second patient was taking ibrutinib at the time of his surgery.

“The increased incidence of nonmelanoma skin cancer and poorer outcomes in patients with non-Hodgkin lymphoma and CLL is well recognized, as is the importance of aggressive dermatologic management,” the researchers wrote (JAMA Dermatol. 2017 Jul 12. doi: 10.1001/jamadermatol.2017.1877). “It may be prudent to withhold ibrutinib treatment prior to dermatologic surgery to avoid potential bleeding complications.”

The findings argue for close collaboration between the dermatologic surgeon and the patient’s hematologist when scheduling extended-duration dermatologic procedures in patients taking ibrutinib.

Find the full summary here.

acruz@frontlinemedcom.com

Clinically significant bleeding events occurred in two elderly men who were taking ibrutinib and underwent Mohs micrographic surgery for squamous cell carcinomas, Cindy E. Parra and her colleagues reported in JAMA Dermatology.

On day 3 after his Mohs procedure, one 73-year-old man taking ibrutinib for Waldenstrom macroglobulinemia developed extensive bilateral periorbital ecchymosis that extended down to his upper chest. The other patient, an 88-year-old man taking ibrutinib for chronic lymphocytic leukemia, developed ecchymosis down to the chin. The first patient discontinued ibrutinib 3 days before his surgery; the second patient was taking ibrutinib at the time of his surgery.

“The increased incidence of nonmelanoma skin cancer and poorer outcomes in patients with non-Hodgkin lymphoma and CLL is well recognized, as is the importance of aggressive dermatologic management,” the researchers wrote (JAMA Dermatol. 2017 Jul 12. doi: 10.1001/jamadermatol.2017.1877). “It may be prudent to withhold ibrutinib treatment prior to dermatologic surgery to avoid potential bleeding complications.”

The findings argue for close collaboration between the dermatologic surgeon and the patient’s hematologist when scheduling extended-duration dermatologic procedures in patients taking ibrutinib.

Find the full summary here.

acruz@frontlinemedcom.com

A handheld detector that offers noninvasive real-time imaging can help dermatologic surgeons get a better idea of skin cancer dimensions before committing to surgery, according to researchers from National Skin Centre and Singapore Bioimaging Consortium, both in Singapore, and Technical University of Munich and iThera Medical GmbH, both in Germany.

Current imaging technologies can lead to excessive or incomplete removal of the cancer, the researchers say. The multispectral optoacoustic tomography (MSOT) allows the user to differentiate tissue chromophores (the chromophore is the part of the molecule responsible for its color) and exogenous contrast agents based on their spectral signatures.

The researchers performed MSOT imaging with 2- and 3-dimensional handheld scanners on 21 patients with nonmelanoma skin cancers. All the skin lesions had recognizable images on MSOT with both detectors, visualizing the shape and thickness of the lesions. The 2D and 3D detectors also offered images with well-resolved tissue chromophores. But the volumetric probe gave more accurate tumor dimensions compared with those from histology analysis.

Aggressive types of skin cancers can involve deeper structures, such as predominant deep blood vessels, the researchers note—another reason the MSOT detector could be useful. In one case, the depth of the basal cell carcinoma, which included its underlying vasculature, reached beyond 3 mm, which might have gone undetected by other imaging modalities, they say.

The fact that the device is also noninvasive and offers real-time imaging, the researchers suggest, makes volumetric MSOT “an ideal modality for longitudinal monitoring of skin diseases and treatment responses.”

Source:

Attia ABE, Chuah SY, Razansky D, et al. Photoacoustics. 2017;7:20-26.
doi: 10.1016/j.pacs.2017.05.003.

A handheld detector that offers noninvasive real-time imaging can help dermatologic surgeons get a better idea of skin cancer dimensions before committing to surgery, according to researchers from National Skin Centre and Singapore Bioimaging Consortium, both in Singapore, and Technical University of Munich and iThera Medical GmbH, both in Germany.

Current imaging technologies can lead to excessive or incomplete removal of the cancer, the researchers say. The multispectral optoacoustic tomography (MSOT) allows the user to differentiate tissue chromophores (the chromophore is the part of the molecule responsible for its color) and exogenous contrast agents based on their spectral signatures.

The researchers performed MSOT imaging with 2- and 3-dimensional handheld scanners on 21 patients with nonmelanoma skin cancers. All the skin lesions had recognizable images on MSOT with both detectors, visualizing the shape and thickness of the lesions. The 2D and 3D detectors also offered images with well-resolved tissue chromophores. But the volumetric probe gave more accurate tumor dimensions compared with those from histology analysis.

Aggressive types of skin cancers can involve deeper structures, such as predominant deep blood vessels, the researchers note—another reason the MSOT detector could be useful. In one case, the depth of the basal cell carcinoma, which included its underlying vasculature, reached beyond 3 mm, which might have gone undetected by other imaging modalities, they say.

The fact that the device is also noninvasive and offers real-time imaging, the researchers suggest, makes volumetric MSOT “an ideal modality for longitudinal monitoring of skin diseases and treatment responses.”

Source:

Attia ABE, Chuah SY, Razansky D, et al. Photoacoustics. 2017;7:20-26.
doi: 10.1016/j.pacs.2017.05.003.

A handheld detector that offers noninvasive real-time imaging can help dermatologic surgeons get a better idea of skin cancer dimensions before committing to surgery, according to researchers from National Skin Centre and Singapore Bioimaging Consortium, both in Singapore, and Technical University of Munich and iThera Medical GmbH, both in Germany.

Current imaging technologies can lead to excessive or incomplete removal of the cancer, the researchers say. The multispectral optoacoustic tomography (MSOT) allows the user to differentiate tissue chromophores (the chromophore is the part of the molecule responsible for its color) and exogenous contrast agents based on their spectral signatures.

The researchers performed MSOT imaging with 2- and 3-dimensional handheld scanners on 21 patients with nonmelanoma skin cancers. All the skin lesions had recognizable images on MSOT with both detectors, visualizing the shape and thickness of the lesions. The 2D and 3D detectors also offered images with well-resolved tissue chromophores. But the volumetric probe gave more accurate tumor dimensions compared with those from histology analysis.

Aggressive types of skin cancers can involve deeper structures, such as predominant deep blood vessels, the researchers note—another reason the MSOT detector could be useful. In one case, the depth of the basal cell carcinoma, which included its underlying vasculature, reached beyond 3 mm, which might have gone undetected by other imaging modalities, they say.

The fact that the device is also noninvasive and offers real-time imaging, the researchers suggest, makes volumetric MSOT “an ideal modality for longitudinal monitoring of skin diseases and treatment responses.”

Source:

Attia ABE, Chuah SY, Razansky D, et al. Photoacoustics. 2017;7:20-26.
doi: 10.1016/j.pacs.2017.05.003.

A new treatment for amyotrophic lateral sclerosis (ALS), Radicava (edaravone), is on the way for U.S. patients.

“After learning about the use of edaravone to treat ALS in Japan, we rapidly engaged with the drug developer about filing a marketing application in the United States,” said Eric Bastings, MD, deputy director of the Division of Neurology Products in the FDA’s Center for Drug Evaluation and Research. “This is the first new treatment approved by the FDA for ALS in many years, and we are pleased that people with ALS will now have an additional option.”

In a 6-month trial, 137 patients were randomly assigned to edaravone or placebo. At week 24, those receiving edaravone had declined less on a clinical assessment of daily functioning.

Edaravon is given intravenously daily for 14 days to start, followed by 14 days drug free. Subsequent treatment cycles consist of dosing on 10 of 14 days, followed by 14 days drug free.

The most common adverse reactions are bruising and gait disturbance. Edaravon also contains sodium bisulfite, which can cause serious allergic reactions in patients with sulfite sensitivity.

A new treatment for amyotrophic lateral sclerosis (ALS), Radicava (edaravone), is on the way for U.S. patients.

“After learning about the use of edaravone to treat ALS in Japan, we rapidly engaged with the drug developer about filing a marketing application in the United States,” said Eric Bastings, MD, deputy director of the Division of Neurology Products in the FDA’s Center for Drug Evaluation and Research. “This is the first new treatment approved by the FDA for ALS in many years, and we are pleased that people with ALS will now have an additional option.”

In a 6-month trial, 137 patients were randomly assigned to edaravone or placebo. At week 24, those receiving edaravone had declined less on a clinical assessment of daily functioning.

Edaravon is given intravenously daily for 14 days to start, followed by 14 days drug free. Subsequent treatment cycles consist of dosing on 10 of 14 days, followed by 14 days drug free.

The most common adverse reactions are bruising and gait disturbance. Edaravon also contains sodium bisulfite, which can cause serious allergic reactions in patients with sulfite sensitivity.

A new treatment for amyotrophic lateral sclerosis (ALS), Radicava (edaravone), is on the way for U.S. patients.

“After learning about the use of edaravone to treat ALS in Japan, we rapidly engaged with the drug developer about filing a marketing application in the United States,” said Eric Bastings, MD, deputy director of the Division of Neurology Products in the FDA’s Center for Drug Evaluation and Research. “This is the first new treatment approved by the FDA for ALS in many years, and we are pleased that people with ALS will now have an additional option.”

In a 6-month trial, 137 patients were randomly assigned to edaravone or placebo. At week 24, those receiving edaravone had declined less on a clinical assessment of daily functioning.

Edaravon is given intravenously daily for 14 days to start, followed by 14 days drug free. Subsequent treatment cycles consist of dosing on 10 of 14 days, followed by 14 days drug free.

The most common adverse reactions are bruising and gait disturbance. Edaravon also contains sodium bisulfite, which can cause serious allergic reactions in patients with sulfite sensitivity.

Micrograph showing MDS

Research published in Cell Reports helps explain why some patients with myelodysplastic syndrome (MDS) do not respond to treatment with azacitidine.

The study showed that patients who were resistant to the drug had relatively quiescent hematopoietic progenitor cells (HPCs).

A smaller proportion of their HPCs were undergoing active cell-cycle progression when compared to the HPCs of patients who responded to azacitidine.

This discovery could provide the first method to identify non-responders to azacitidine early, according to study author Ashwin Unnikrishnan, PhD, of the University of New South Wales in Sydney, Australia.

“These are early days, but this could avoid what has really been a ‘wait and see’ approach with patients that sometimes results in them receiving futile treatment for 6 months,” Dr Unnikrishnan said.

“By that stage, the patient’s disease has progressed, and there’s no alternative for them.”

Dr Unnikrishnan and his colleagues also found the HPC quiescence in non-responders was mediated by integrin α5 (ITGA5) signaling, and the cells’ hematopoietic potential improved when the team combined azacitidine treatment with an ITGA5 inhibitor.

This suggests a potential avenue for future combination therapies that would improve azacitidine responsiveness.

Lastly, the researchers made discoveries that could explain why some patients who initially respond to azacitidine eventually relapse.

“All of the pernicious mutations that we associate with MDS never disappear in these patients, even after years of treatment,” Dr Unnikrishnan said. “From a clinical perspective, blood cell production is restored in patients, but they are a ticking time bomb, waiting to relapse.”

“[Azacitidine] is not a cure, and we are starting to understand why it does what it does. We need to find better treatments than azacitidine if we want a more durable therapy for MDS, and that’s the basis for our future work.”

Micrograph showing MDS

Research published in Cell Reports helps explain why some patients with myelodysplastic syndrome (MDS) do not respond to treatment with azacitidine.

The study showed that patients who were resistant to the drug had relatively quiescent hematopoietic progenitor cells (HPCs).

A smaller proportion of their HPCs were undergoing active cell-cycle progression when compared to the HPCs of patients who responded to azacitidine.

This discovery could provide the first method to identify non-responders to azacitidine early, according to study author Ashwin Unnikrishnan, PhD, of the University of New South Wales in Sydney, Australia.

“These are early days, but this could avoid what has really been a ‘wait and see’ approach with patients that sometimes results in them receiving futile treatment for 6 months,” Dr Unnikrishnan said.

“By that stage, the patient’s disease has progressed, and there’s no alternative for them.”

Dr Unnikrishnan and his colleagues also found the HPC quiescence in non-responders was mediated by integrin α5 (ITGA5) signaling, and the cells’ hematopoietic potential improved when the team combined azacitidine treatment with an ITGA5 inhibitor.

This suggests a potential avenue for future combination therapies that would improve azacitidine responsiveness.

Lastly, the researchers made discoveries that could explain why some patients who initially respond to azacitidine eventually relapse.

“All of the pernicious mutations that we associate with MDS never disappear in these patients, even after years of treatment,” Dr Unnikrishnan said. “From a clinical perspective, blood cell production is restored in patients, but they are a ticking time bomb, waiting to relapse.”

“[Azacitidine] is not a cure, and we are starting to understand why it does what it does. We need to find better treatments than azacitidine if we want a more durable therapy for MDS, and that’s the basis for our future work.”

Micrograph showing MDS

Research published in Cell Reports helps explain why some patients with myelodysplastic syndrome (MDS) do not respond to treatment with azacitidine.

The study showed that patients who were resistant to the drug had relatively quiescent hematopoietic progenitor cells (HPCs).

A smaller proportion of their HPCs were undergoing active cell-cycle progression when compared to the HPCs of patients who responded to azacitidine.

This discovery could provide the first method to identify non-responders to azacitidine early, according to study author Ashwin Unnikrishnan, PhD, of the University of New South Wales in Sydney, Australia.

“These are early days, but this could avoid what has really been a ‘wait and see’ approach with patients that sometimes results in them receiving futile treatment for 6 months,” Dr Unnikrishnan said.

“By that stage, the patient’s disease has progressed, and there’s no alternative for them.”

Dr Unnikrishnan and his colleagues also found the HPC quiescence in non-responders was mediated by integrin α5 (ITGA5) signaling, and the cells’ hematopoietic potential improved when the team combined azacitidine treatment with an ITGA5 inhibitor.

This suggests a potential avenue for future combination therapies that would improve azacitidine responsiveness.

Lastly, the researchers made discoveries that could explain why some patients who initially respond to azacitidine eventually relapse.

“All of the pernicious mutations that we associate with MDS never disappear in these patients, even after years of treatment,” Dr Unnikrishnan said. “From a clinical perspective, blood cell production is restored in patients, but they are a ticking time bomb, waiting to relapse.”

“[Azacitidine] is not a cure, and we are starting to understand why it does what it does. We need to find better treatments than azacitidine if we want a more durable therapy for MDS, and that’s the basis for our future work.”

Vials and a syringe

BERLIN—Results of a phase 3 study suggest prophylaxis with plasma-derived factor X (pdFX, Coagadex®) prevents or reduces bleeding episodes in children with moderate to severe hereditary factor X deficiency (FXD).

pdFX was well tolerated in this study as well, with no treatment-related adverse events (AEs) reported.

“For the first time, we have data providing physicians with important evidence of the efficacy and safety of Coagadex as a prophylactic regimen for the reduction and prevention of bleeding episodes, as well as potential guidance on dosing for children with hereditary factor X deficiency,” said Michael Gattens, MBChB, a consultant pediatric hematologist at Cambridge University Hospitals in the UK and an investigator involved in this trial.

Data from the trial, known as TEN02, were presented in a poster (PB 818) at the International Society on Thrombosis and Haemostasis (ISTH) 2017 Congress. The trial was sponsored by Bio Products Laboratory Limited.

TEN02 was a prospective study conducted in children younger than 12 years with moderate or severe congenital FXD (basal plasma factor X activity <5 IU/dL at diagnosis) and either a history of severe bleeding or an F10 gene mutation causing a documented severe bleeding type.

The study enrolled 9 patients. Eight had severe FXD (FX:C <1 IU/dL), and 1 had moderate FXD (FX:C 1–5 IU/dL).

The patients’ mean age was 7.3 (range, 2.6 years to 11.9 years). Four patients were in the 0-5 age group, and 5 were in the 6-11 age group. Fifty-six percent of patients were female, 78% were Asian, and 22% were white.

The patients had a total of 21 prior bleeds, including overt (n=10), covert (n=9), and menorrhagic (n=2). The past bleeds were spontaneous (n=16) or caused by injury (n=2), menorrhagia (n=2), or surgery (n=2).

Treatment

Patients received 50 IU/kg of pdFX at visit 1 (baseline), followed 72 hours later by a second dose (visit 2). At the investigator’s discretion, visit 2 may have been conducted 48 hours after the first dose for subjects ages 0 to 5.

Following visit 2, patients used pdFX at 40-50 IU/kg as routine prophylaxis every 72 ± 2 hours or every 48 ± 2 hours for those age 0 to 5, at the investigator’s discretion. Dose and frequency were adjusted over the initial 6 weeks to maintain FX:C levels ≥5 IU/dL (with peak levels ≤120 IU/dL).

Treatment was continued for at least 26 weeks, with a minimum of 50 treatment days.

Following visit 2, patients returned to the study site for 3 additional visits (after 9-28, 29-42, and 50 treatment days/26 weeks; visits 3-5), during which time blood samples were collected to assess FX:C trough levels and vital signs and AEs were checked.

A final bolus dose of 50 IU/kg was administered during visit 5 to assess post-dose incremental recovery.

A dose of 25 IU/kg was recommended to treat minor bleeds, and 50 IU/kg was recommended for major bleeds. Treatment was to be repeated as often as necessary based on FX:C recovery levels and clinical need.

Nine patients completed 11 treatment cycles, including 2 patients who had 50 exposure days but less than 26 study weeks. These patients were re-screened and completed a second, per-protocol treatment cycle.

Results

A total of 537 prophylactic infusions were administered, with a mean dose of 38.6 IU/kg per patient.

Investigators rated the prophylactic efficacy of pdFX as “excellent.”

There were 10 bleeds in 3 patients. Four bleeds in 2 patients (both in the 6-11 age group) required treatment with a single infusion of pdFX (mean dose, 31.7±10.1 IU/kg).

The overall mean 30-minute incremental recovery was 1.66 IU/dL per IU/kg for patients’ baseline visit, 1.82 IU/dL per IU/kg for the end-of-study visit, and 1.74 IU/dL per IU/kg for both visits combined.

Incremental recovery was significantly lower in the 0-5 age group than the 6-11 age group:

• 1.45 vs 1.83 at baseline (P=0.027)
• 1.62 vs 1.99 at end of study (P=0.025)
• 1.53 vs 1.91 combined (P=0.001).

All patients had FX:C trough levels greater than 5% after visit 4 (days 29-42).

There were 28 AEs reported in 8 patients, but none of these events were considered related to treatment.

One patient did have 2 serious treatment-emergent AEs—lower respiratory tract infection and influenza.

There were no other serious AEs, no evidence of factor X inhibitor development, and no deaths.

Vials and a syringe

BERLIN—Results of a phase 3 study suggest prophylaxis with plasma-derived factor X (pdFX, Coagadex®) prevents or reduces bleeding episodes in children with moderate to severe hereditary factor X deficiency (FXD).

pdFX was well tolerated in this study as well, with no treatment-related adverse events (AEs) reported.

“For the first time, we have data providing physicians with important evidence of the efficacy and safety of Coagadex as a prophylactic regimen for the reduction and prevention of bleeding episodes, as well as potential guidance on dosing for children with hereditary factor X deficiency,” said Michael Gattens, MBChB, a consultant pediatric hematologist at Cambridge University Hospitals in the UK and an investigator involved in this trial.

Data from the trial, known as TEN02, were presented in a poster (PB 818) at the International Society on Thrombosis and Haemostasis (ISTH) 2017 Congress. The trial was sponsored by Bio Products Laboratory Limited.

TEN02 was a prospective study conducted in children younger than 12 years with moderate or severe congenital FXD (basal plasma factor X activity <5 IU/dL at diagnosis) and either a history of severe bleeding or an F10 gene mutation causing a documented severe bleeding type.

The study enrolled 9 patients. Eight had severe FXD (FX:C <1 IU/dL), and 1 had moderate FXD (FX:C 1–5 IU/dL).

The patients’ mean age was 7.3 (range, 2.6 years to 11.9 years). Four patients were in the 0-5 age group, and 5 were in the 6-11 age group. Fifty-six percent of patients were female, 78% were Asian, and 22% were white.

The patients had a total of 21 prior bleeds, including overt (n=10), covert (n=9), and menorrhagic (n=2). The past bleeds were spontaneous (n=16) or caused by injury (n=2), menorrhagia (n=2), or surgery (n=2).

Treatment

Patients received 50 IU/kg of pdFX at visit 1 (baseline), followed 72 hours later by a second dose (visit 2). At the investigator’s discretion, visit 2 may have been conducted 48 hours after the first dose for subjects ages 0 to 5.

Following visit 2, patients used pdFX at 40-50 IU/kg as routine prophylaxis every 72 ± 2 hours or every 48 ± 2 hours for those age 0 to 5, at the investigator’s discretion. Dose and frequency were adjusted over the initial 6 weeks to maintain FX:C levels ≥5 IU/dL (with peak levels ≤120 IU/dL).

Treatment was continued for at least 26 weeks, with a minimum of 50 treatment days.

Following visit 2, patients returned to the study site for 3 additional visits (after 9-28, 29-42, and 50 treatment days/26 weeks; visits 3-5), during which time blood samples were collected to assess FX:C trough levels and vital signs and AEs were checked.

A final bolus dose of 50 IU/kg was administered during visit 5 to assess post-dose incremental recovery.

A dose of 25 IU/kg was recommended to treat minor bleeds, and 50 IU/kg was recommended for major bleeds. Treatment was to be repeated as often as necessary based on FX:C recovery levels and clinical need.

Nine patients completed 11 treatment cycles, including 2 patients who had 50 exposure days but less than 26 study weeks. These patients were re-screened and completed a second, per-protocol treatment cycle.

Results

A total of 537 prophylactic infusions were administered, with a mean dose of 38.6 IU/kg per patient.

Investigators rated the prophylactic efficacy of pdFX as “excellent.”

There were 10 bleeds in 3 patients. Four bleeds in 2 patients (both in the 6-11 age group) required treatment with a single infusion of pdFX (mean dose, 31.7±10.1 IU/kg).

The overall mean 30-minute incremental recovery was 1.66 IU/dL per IU/kg for patients’ baseline visit, 1.82 IU/dL per IU/kg for the end-of-study visit, and 1.74 IU/dL per IU/kg for both visits combined.

Incremental recovery was significantly lower in the 0-5 age group than the 6-11 age group:

• 1.45 vs 1.83 at baseline (P=0.027)
• 1.62 vs 1.99 at end of study (P=0.025)
• 1.53 vs 1.91 combined (P=0.001).

All patients had FX:C trough levels greater than 5% after visit 4 (days 29-42).

There were 28 AEs reported in 8 patients, but none of these events were considered related to treatment.

One patient did have 2 serious treatment-emergent AEs—lower respiratory tract infection and influenza.

There were no other serious AEs, no evidence of factor X inhibitor development, and no deaths.

Vials and a syringe

BERLIN—Results of a phase 3 study suggest prophylaxis with plasma-derived factor X (pdFX, Coagadex®) prevents or reduces bleeding episodes in children with moderate to severe hereditary factor X deficiency (FXD).

pdFX was well tolerated in this study as well, with no treatment-related adverse events (AEs) reported.

“For the first time, we have data providing physicians with important evidence of the efficacy and safety of Coagadex as a prophylactic regimen for the reduction and prevention of bleeding episodes, as well as potential guidance on dosing for children with hereditary factor X deficiency,” said Michael Gattens, MBChB, a consultant pediatric hematologist at Cambridge University Hospitals in the UK and an investigator involved in this trial.

Data from the trial, known as TEN02, were presented in a poster (PB 818) at the International Society on Thrombosis and Haemostasis (ISTH) 2017 Congress. The trial was sponsored by Bio Products Laboratory Limited.

TEN02 was a prospective study conducted in children younger than 12 years with moderate or severe congenital FXD (basal plasma factor X activity <5 IU/dL at diagnosis) and either a history of severe bleeding or an F10 gene mutation causing a documented severe bleeding type.

The study enrolled 9 patients. Eight had severe FXD (FX:C <1 IU/dL), and 1 had moderate FXD (FX:C 1–5 IU/dL).

The patients’ mean age was 7.3 (range, 2.6 years to 11.9 years). Four patients were in the 0-5 age group, and 5 were in the 6-11 age group. Fifty-six percent of patients were female, 78% were Asian, and 22% were white.

The patients had a total of 21 prior bleeds, including overt (n=10), covert (n=9), and menorrhagic (n=2). The past bleeds were spontaneous (n=16) or caused by injury (n=2), menorrhagia (n=2), or surgery (n=2).

Treatment

Patients received 50 IU/kg of pdFX at visit 1 (baseline), followed 72 hours later by a second dose (visit 2). At the investigator’s discretion, visit 2 may have been conducted 48 hours after the first dose for subjects ages 0 to 5.

Following visit 2, patients used pdFX at 40-50 IU/kg as routine prophylaxis every 72 ± 2 hours or every 48 ± 2 hours for those age 0 to 5, at the investigator’s discretion. Dose and frequency were adjusted over the initial 6 weeks to maintain FX:C levels ≥5 IU/dL (with peak levels ≤120 IU/dL).

Treatment was continued for at least 26 weeks, with a minimum of 50 treatment days.

Following visit 2, patients returned to the study site for 3 additional visits (after 9-28, 29-42, and 50 treatment days/26 weeks; visits 3-5), during which time blood samples were collected to assess FX:C trough levels and vital signs and AEs were checked.

A final bolus dose of 50 IU/kg was administered during visit 5 to assess post-dose incremental recovery.

A dose of 25 IU/kg was recommended to treat minor bleeds, and 50 IU/kg was recommended for major bleeds. Treatment was to be repeated as often as necessary based on FX:C recovery levels and clinical need.

Nine patients completed 11 treatment cycles, including 2 patients who had 50 exposure days but less than 26 study weeks. These patients were re-screened and completed a second, per-protocol treatment cycle.

Results

A total of 537 prophylactic infusions were administered, with a mean dose of 38.6 IU/kg per patient.

Investigators rated the prophylactic efficacy of pdFX as “excellent.”

There were 10 bleeds in 3 patients. Four bleeds in 2 patients (both in the 6-11 age group) required treatment with a single infusion of pdFX (mean dose, 31.7±10.1 IU/kg).

The overall mean 30-minute incremental recovery was 1.66 IU/dL per IU/kg for patients’ baseline visit, 1.82 IU/dL per IU/kg for the end-of-study visit, and 1.74 IU/dL per IU/kg for both visits combined.

Incremental recovery was significantly lower in the 0-5 age group than the 6-11 age group:

• 1.45 vs 1.83 at baseline (P=0.027)
• 1.62 vs 1.99 at end of study (P=0.025)
• 1.53 vs 1.91 combined (P=0.001).

All patients had FX:C trough levels greater than 5% after visit 4 (days 29-42).

There were 28 AEs reported in 8 patients, but none of these events were considered related to treatment.

One patient did have 2 serious treatment-emergent AEs—lower respiratory tract infection and influenza.

There were no other serious AEs, no evidence of factor X inhibitor development, and no deaths.

Image courtesy of AFIP

MADRID—Long-term maintenance with ropeginterferon alfa-2b is feasible, effective, and well-tolerated in patients with polycythemia vera (PV), according to researchers.

In the ongoing phase 1/2 PEGINVERA study, patients have received ropeginterferon alfa-2b for a median of 4 years.

After the first 2 years, patients switched from bi-weekly dosing to receiving ropeginterferon alfa-2b once every 4 weeks.

None of the patients discontinued treatment after the switch, and many were able to maintain their best response.

Most adverse events (AEs) were mild, although there were several severe treatment-related AEs.

These results were presented in a poster (abstract P707) at the 22nd Congress of the European Hematology Association (EHA). The research was funded by AOP Orphan Pharmaceuticals AG.

The trial enrolled 51 patients, but the researchers reported results in the 29 patients who had completed 2 years of treatment and switched from bi-weekly dosing to receiving treatment once every 4 weeks.

All 29 patients remained on the 4-week schedule with a median observation period of roughly 2 years. The median monthly dose was 308 μg before the switch and 165 μg after.

At study entry, the patients’ median age was 58 (range, 40-80), and 76% were male. Their median spleen length was 12.8 cm (range, 8.0-22.0), and 34% of patients had prior treatment with hydroxyurea.

Patients’ median hematocrit was 45.40% (range, 36.9-53.8), their median platelet count was 431 G/L (range, 225-1016), their median leukocyte count was 11.1 G/L (range, 4.7-30.9), and their median JAKV617F allelic burden was 78% (range, 2-91.5).

Results

More than 80% of patients achieved a hematologic response, with more than 50% achieving a complete hematologic response. The same percentage of patients maintained their best hematologic response before and 6 months after switching to the 4-week schedule—51.7%.

More than 80% of patients achieved a molecular response, with nearly 20% achieving a complete molecular response. The percentage of patients maintaining their best molecular response was 62.1% before switching to the 4-week schedule and 58.6% 6 months after the switch.

The researchers said changes in hematocrit, platelet count, leukocyte count, and spleen size after the switch were “minimal and without clinical relevance.”

The median hematocrit changed from 42.3% to 42.6%, the median platelet count changed from 201.0 x 10⁹/L to 211.9 x 10⁹/L, the median leukocyte count changed from 5.0 x 10⁹/L to 5.6 x 10⁹/L, and the median spleen size changed from 12.8 cm to 12.4 cm.

The need for phlebotomy did not change, with 24.1% of patients requiring phlebotomy both before and 6 months after the switch.

The researchers also noted that ropeginterferon alfa-2b decreased mutant JAK2 allele burden in all of the patients over time, with the strongest effect observed in the second year of treatment.

After 2 years, most patients had a burden below 10%, and this was not affected by the change in dosing.

There were no cases of progression to myelofibrosis or leukemic transformation.

Seventy-one percent of AEs were mild, and 40.4% were considered likely related to ropeginterferon alfa-2b. The most frequent treatment-related AEs were arthralgia (29.4%) and fatigue (21.6%).

There were 34 severe AEs, 11 of which were related to ropeginterferon alfa-2b.

Image courtesy of AFIP

MADRID—Long-term maintenance with ropeginterferon alfa-2b is feasible, effective, and well-tolerated in patients with polycythemia vera (PV), according to researchers.

In the ongoing phase 1/2 PEGINVERA study, patients have received ropeginterferon alfa-2b for a median of 4 years.

After the first 2 years, patients switched from bi-weekly dosing to receiving ropeginterferon alfa-2b once every 4 weeks.

None of the patients discontinued treatment after the switch, and many were able to maintain their best response.

Most adverse events (AEs) were mild, although there were several severe treatment-related AEs.

These results were presented in a poster (abstract P707) at the 22nd Congress of the European Hematology Association (EHA). The research was funded by AOP Orphan Pharmaceuticals AG.

The trial enrolled 51 patients, but the researchers reported results in the 29 patients who had completed 2 years of treatment and switched from bi-weekly dosing to receiving treatment once every 4 weeks.

All 29 patients remained on the 4-week schedule with a median observation period of roughly 2 years. The median monthly dose was 308 μg before the switch and 165 μg after.

At study entry, the patients’ median age was 58 (range, 40-80), and 76% were male. Their median spleen length was 12.8 cm (range, 8.0-22.0), and 34% of patients had prior treatment with hydroxyurea.

Patients’ median hematocrit was 45.40% (range, 36.9-53.8), their median platelet count was 431 G/L (range, 225-1016), their median leukocyte count was 11.1 G/L (range, 4.7-30.9), and their median JAKV617F allelic burden was 78% (range, 2-91.5).

Results

More than 80% of patients achieved a hematologic response, with more than 50% achieving a complete hematologic response. The same percentage of patients maintained their best hematologic response before and 6 months after switching to the 4-week schedule—51.7%.

More than 80% of patients achieved a molecular response, with nearly 20% achieving a complete molecular response. The percentage of patients maintaining their best molecular response was 62.1% before switching to the 4-week schedule and 58.6% 6 months after the switch.

The researchers said changes in hematocrit, platelet count, leukocyte count, and spleen size after the switch were “minimal and without clinical relevance.”

The median hematocrit changed from 42.3% to 42.6%, the median platelet count changed from 201.0 x 10⁹/L to 211.9 x 10⁹/L, the median leukocyte count changed from 5.0 x 10⁹/L to 5.6 x 10⁹/L, and the median spleen size changed from 12.8 cm to 12.4 cm.

The need for phlebotomy did not change, with 24.1% of patients requiring phlebotomy both before and 6 months after the switch.

The researchers also noted that ropeginterferon alfa-2b decreased mutant JAK2 allele burden in all of the patients over time, with the strongest effect observed in the second year of treatment.

After 2 years, most patients had a burden below 10%, and this was not affected by the change in dosing.

There were no cases of progression to myelofibrosis or leukemic transformation.

Seventy-one percent of AEs were mild, and 40.4% were considered likely related to ropeginterferon alfa-2b. The most frequent treatment-related AEs were arthralgia (29.4%) and fatigue (21.6%).

There were 34 severe AEs, 11 of which were related to ropeginterferon alfa-2b.

Image courtesy of AFIP

MADRID—Long-term maintenance with ropeginterferon alfa-2b is feasible, effective, and well-tolerated in patients with polycythemia vera (PV), according to researchers.

In the ongoing phase 1/2 PEGINVERA study, patients have received ropeginterferon alfa-2b for a median of 4 years.

After the first 2 years, patients switched from bi-weekly dosing to receiving ropeginterferon alfa-2b once every 4 weeks.

None of the patients discontinued treatment after the switch, and many were able to maintain their best response.

Most adverse events (AEs) were mild, although there were several severe treatment-related AEs.

These results were presented in a poster (abstract P707) at the 22nd Congress of the European Hematology Association (EHA). The research was funded by AOP Orphan Pharmaceuticals AG.

The trial enrolled 51 patients, but the researchers reported results in the 29 patients who had completed 2 years of treatment and switched from bi-weekly dosing to receiving treatment once every 4 weeks.

All 29 patients remained on the 4-week schedule with a median observation period of roughly 2 years. The median monthly dose was 308 μg before the switch and 165 μg after.

At study entry, the patients’ median age was 58 (range, 40-80), and 76% were male. Their median spleen length was 12.8 cm (range, 8.0-22.0), and 34% of patients had prior treatment with hydroxyurea.

Patients’ median hematocrit was 45.40% (range, 36.9-53.8), their median platelet count was 431 G/L (range, 225-1016), their median leukocyte count was 11.1 G/L (range, 4.7-30.9), and their median JAKV617F allelic burden was 78% (range, 2-91.5).

Results

More than 80% of patients achieved a hematologic response, with more than 50% achieving a complete hematologic response. The same percentage of patients maintained their best hematologic response before and 6 months after switching to the 4-week schedule—51.7%.

More than 80% of patients achieved a molecular response, with nearly 20% achieving a complete molecular response. The percentage of patients maintaining their best molecular response was 62.1% before switching to the 4-week schedule and 58.6% 6 months after the switch.

The researchers said changes in hematocrit, platelet count, leukocyte count, and spleen size after the switch were “minimal and without clinical relevance.”

The median hematocrit changed from 42.3% to 42.6%, the median platelet count changed from 201.0 x 10⁹/L to 211.9 x 10⁹/L, the median leukocyte count changed from 5.0 x 10⁹/L to 5.6 x 10⁹/L, and the median spleen size changed from 12.8 cm to 12.4 cm.

The need for phlebotomy did not change, with 24.1% of patients requiring phlebotomy both before and 6 months after the switch.

The researchers also noted that ropeginterferon alfa-2b decreased mutant JAK2 allele burden in all of the patients over time, with the strongest effect observed in the second year of treatment.

After 2 years, most patients had a burden below 10%, and this was not affected by the change in dosing.

There were no cases of progression to myelofibrosis or leukemic transformation.

Seventy-one percent of AEs were mild, and 40.4% were considered likely related to ropeginterferon alfa-2b. The most frequent treatment-related AEs were arthralgia (29.4%) and fatigue (21.6%).

There were 34 severe AEs, 11 of which were related to ropeginterferon alfa-2b.

The FP diagnosed pruritic urticarial papules and plaques of pregnancy. PUPPP is usually diagnosed by its characteristic findings in the history and physical examination.

PUPPP typically presents as erythematous papules and plaques within striae (with periumbilical sparing) late in the third trimester. Extreme pruritus is a hallmark of PUPPP and is present in all patients. Abdominal striae are the most common initial symptoms. The lesions usually spread to the extremities and coalesce to form urticarial plaques.

General measures such as cool baths, frequent application of emollients, wet soaks, or cool packs applied to the skin provide some symptomatic relief. First-line pharmacologic therapy consists of topical steroids and oral antihistamines to alleviate symptoms.

In this case, the FP prescribed a mid-potency topical corticosteroid, 0.1% triamcinolone cream twice daily (pregnancy class B). The patient was given the choice of steroid vehicle and chose the cream over the ointment. Both vehicles work to treat PUPPP, but the one that will work best is the one the patient will actually use.

The FP also recommended over-the-counter diphenhydramine 25 mg for additional symptomatic relief of pruritus (pregnancy class B). At her following prenatal visit, the patient’s symptoms were about 80% better and she was tolerating the pruritus. She was relieved to learn that this condition would resolve after pregnancy.

Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Mayeaux EJ. Pruritic urticarial papules and plaques of pregnancy. In: Usatine R, Smith M, Mayeaux EJ, et al, eds. Color Atlas of Family Medicine. 2nd ed. New York, NY: McGraw-Hill; 2013: 467-470.

To learn more about the Color Atlas of Family Medicine, see: www.amazon.com/Color-Family-Medicine-Richard-Usatine/dp/0071769641/

You can now get the second edition of the Color Atlas of Family Medicine as an app by clicking on this link: usatinemedia.com

The FP diagnosed pruritic urticarial papules and plaques of pregnancy. PUPPP is usually diagnosed by its characteristic findings in the history and physical examination.

PUPPP typically presents as erythematous papules and plaques within striae (with periumbilical sparing) late in the third trimester. Extreme pruritus is a hallmark of PUPPP and is present in all patients. Abdominal striae are the most common initial symptoms. The lesions usually spread to the extremities and coalesce to form urticarial plaques.

General measures such as cool baths, frequent application of emollients, wet soaks, or cool packs applied to the skin provide some symptomatic relief. First-line pharmacologic therapy consists of topical steroids and oral antihistamines to alleviate symptoms.

In this case, the FP prescribed a mid-potency topical corticosteroid, 0.1% triamcinolone cream twice daily (pregnancy class B). The patient was given the choice of steroid vehicle and chose the cream over the ointment. Both vehicles work to treat PUPPP, but the one that will work best is the one the patient will actually use.

The FP also recommended over-the-counter diphenhydramine 25 mg for additional symptomatic relief of pruritus (pregnancy class B). At her following prenatal visit, the patient’s symptoms were about 80% better and she was tolerating the pruritus. She was relieved to learn that this condition would resolve after pregnancy.

Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Mayeaux EJ. Pruritic urticarial papules and plaques of pregnancy. In: Usatine R, Smith M, Mayeaux EJ, et al, eds. Color Atlas of Family Medicine. 2nd ed. New York, NY: McGraw-Hill; 2013: 467-470.

To learn more about the Color Atlas of Family Medicine, see: www.amazon.com/Color-Family-Medicine-Richard-Usatine/dp/0071769641/

You can now get the second edition of the Color Atlas of Family Medicine as an app by clicking on this link: usatinemedia.com

The FP diagnosed pruritic urticarial papules and plaques of pregnancy. PUPPP is usually diagnosed by its characteristic findings in the history and physical examination.

PUPPP typically presents as erythematous papules and plaques within striae (with periumbilical sparing) late in the third trimester. Extreme pruritus is a hallmark of PUPPP and is present in all patients. Abdominal striae are the most common initial symptoms. The lesions usually spread to the extremities and coalesce to form urticarial plaques.

General measures such as cool baths, frequent application of emollients, wet soaks, or cool packs applied to the skin provide some symptomatic relief. First-line pharmacologic therapy consists of topical steroids and oral antihistamines to alleviate symptoms.

In this case, the FP prescribed a mid-potency topical corticosteroid, 0.1% triamcinolone cream twice daily (pregnancy class B). The patient was given the choice of steroid vehicle and chose the cream over the ointment. Both vehicles work to treat PUPPP, but the one that will work best is the one the patient will actually use.

The FP also recommended over-the-counter diphenhydramine 25 mg for additional symptomatic relief of pruritus (pregnancy class B). At her following prenatal visit, the patient’s symptoms were about 80% better and she was tolerating the pruritus. She was relieved to learn that this condition would resolve after pregnancy.

Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Mayeaux EJ. Pruritic urticarial papules and plaques of pregnancy. In: Usatine R, Smith M, Mayeaux EJ, et al, eds. Color Atlas of Family Medicine. 2nd ed. New York, NY: McGraw-Hill; 2013: 467-470.

To learn more about the Color Atlas of Family Medicine, see: www.amazon.com/Color-Family-Medicine-Richard-Usatine/dp/0071769641/

You can now get the second edition of the Color Atlas of Family Medicine as an app by clicking on this link: usatinemedia.com

Since 2013, over 100 cases of Mycobacterium chimaera prosthetic valve endocarditis and disseminated disease were detected in Europe and the United States, and these were presumptively linked to contaminated heater-cooler units (HCUs) used during cardiac surgery. A molecular epidemiological analysis of microbial isolate genomes detected a “remarkable clonality of isolates” in almost all of the assessed patients with M. chimaera disease, which “strongly points to a common source of infection,” as reported online in The Lancet Infectious Diseases.

The analysis comprised 250 whole-genome sequencing datasets: 24 isolates from 21 cardiac surgery–related patients in Switzerland, Germany, the Netherlands, and the United Kingdom; 36 from 35 unrelated patients; 126 from LivaNova HCUs in use (85 water cultures, 41 air cultures); 13 from LivaNova HCUs returned to the production site in Germany for disinfection; 4 from the LivaNova production site (3 from newly produced HCUs, 1 from a water source); 2 from Maquet extracorporeal membrane oxygenation (ECMO) devices in use; 14 from Maquet HCUs in use; 15 from new Maquet HCUs sampled at the production site; and 7 from hospital water supplies in Switzerland, Germany, and the Netherlands, plus one M. chimaera DSM 44623–type strain, and eight M. intracellulare strains (from four unrelated patients from Germany and four published genomes).

Isolates were analyzed by next-generation whole-genome sequencing and compared with published M. chimaera genomes, according to Jakko van Ingen, PhD, Radboud University Medical Center, Nijmegen, the Netherlands, and his colleagues. Phylogenetic analysis of these 250 isolates revealed two major M. chimaera groups. They found that all cardiac surgery–related patient isolates could be classified into group 1. They then did a subgroup analysis.

“Three distinct strains of M. chimaera appear to have contaminated the water systems of LivaNova HCUs at the production site, belonging to subgroups 1.1, 1.8, and 2.1,” the authors stated. However, most M. chimaera isolates from air samples taken near operating LivaNova HCUs and those of 23 of the 24 related patients belonged to subgroup 1.1.

“This finding further supports the presumed airborne transmission pathway leading to endocarditis, aortic graft infection, disseminated disease, and surgical site infections in the affected patients,” according to the authors (doi: 10.1016/S1473-3099[17]30324-9).

The results suggest “the possibility that the vast majority of cases of cardiothoracic surgery–related severe M. chimaera infections diagnosed in Switzerland, Germany, the Netherlands, the United Kingdom, the United States, and Australia resulted from a single common source of infection: LivaNova HCUs that were most likely contaminated during production in Germany,” the researchers concluded.

The study was partly funded by the EU Horizon 2020 program, its FP7 program, the German Center for Infection Research (DZIF), the Swiss National Science Foundation, the Swiss Federal Office of Public Health, and National Institute of Health Research Oxford Health Protection Research Units on Healthcare Associated Infection and Antimicrobial Resistance. The authors reported having no relevant conflicts.

mlesney@frontlinemedcom.com

Since 2013, over 100 cases of Mycobacterium chimaera prosthetic valve endocarditis and disseminated disease were detected in Europe and the United States, and these were presumptively linked to contaminated heater-cooler units (HCUs) used during cardiac surgery. A molecular epidemiological analysis of microbial isolate genomes detected a “remarkable clonality of isolates” in almost all of the assessed patients with M. chimaera disease, which “strongly points to a common source of infection,” as reported online in The Lancet Infectious Diseases.

The analysis comprised 250 whole-genome sequencing datasets: 24 isolates from 21 cardiac surgery–related patients in Switzerland, Germany, the Netherlands, and the United Kingdom; 36 from 35 unrelated patients; 126 from LivaNova HCUs in use (85 water cultures, 41 air cultures); 13 from LivaNova HCUs returned to the production site in Germany for disinfection; 4 from the LivaNova production site (3 from newly produced HCUs, 1 from a water source); 2 from Maquet extracorporeal membrane oxygenation (ECMO) devices in use; 14 from Maquet HCUs in use; 15 from new Maquet HCUs sampled at the production site; and 7 from hospital water supplies in Switzerland, Germany, and the Netherlands, plus one M. chimaera DSM 44623–type strain, and eight M. intracellulare strains (from four unrelated patients from Germany and four published genomes).

Isolates were analyzed by next-generation whole-genome sequencing and compared with published M. chimaera genomes, according to Jakko van Ingen, PhD, Radboud University Medical Center, Nijmegen, the Netherlands, and his colleagues. Phylogenetic analysis of these 250 isolates revealed two major M. chimaera groups. They found that all cardiac surgery–related patient isolates could be classified into group 1. They then did a subgroup analysis.

“Three distinct strains of M. chimaera appear to have contaminated the water systems of LivaNova HCUs at the production site, belonging to subgroups 1.1, 1.8, and 2.1,” the authors stated. However, most M. chimaera isolates from air samples taken near operating LivaNova HCUs and those of 23 of the 24 related patients belonged to subgroup 1.1.

“This finding further supports the presumed airborne transmission pathway leading to endocarditis, aortic graft infection, disseminated disease, and surgical site infections in the affected patients,” according to the authors (doi: 10.1016/S1473-3099[17]30324-9).

The results suggest “the possibility that the vast majority of cases of cardiothoracic surgery–related severe M. chimaera infections diagnosed in Switzerland, Germany, the Netherlands, the United Kingdom, the United States, and Australia resulted from a single common source of infection: LivaNova HCUs that were most likely contaminated during production in Germany,” the researchers concluded.

The study was partly funded by the EU Horizon 2020 program, its FP7 program, the German Center for Infection Research (DZIF), the Swiss National Science Foundation, the Swiss Federal Office of Public Health, and National Institute of Health Research Oxford Health Protection Research Units on Healthcare Associated Infection and Antimicrobial Resistance. The authors reported having no relevant conflicts.

mlesney@frontlinemedcom.com

Since 2013, over 100 cases of Mycobacterium chimaera prosthetic valve endocarditis and disseminated disease were detected in Europe and the United States, and these were presumptively linked to contaminated heater-cooler units (HCUs) used during cardiac surgery. A molecular epidemiological analysis of microbial isolate genomes detected a “remarkable clonality of isolates” in almost all of the assessed patients with M. chimaera disease, which “strongly points to a common source of infection,” as reported online in The Lancet Infectious Diseases.

The analysis comprised 250 whole-genome sequencing datasets: 24 isolates from 21 cardiac surgery–related patients in Switzerland, Germany, the Netherlands, and the United Kingdom; 36 from 35 unrelated patients; 126 from LivaNova HCUs in use (85 water cultures, 41 air cultures); 13 from LivaNova HCUs returned to the production site in Germany for disinfection; 4 from the LivaNova production site (3 from newly produced HCUs, 1 from a water source); 2 from Maquet extracorporeal membrane oxygenation (ECMO) devices in use; 14 from Maquet HCUs in use; 15 from new Maquet HCUs sampled at the production site; and 7 from hospital water supplies in Switzerland, Germany, and the Netherlands, plus one M. chimaera DSM 44623–type strain, and eight M. intracellulare strains (from four unrelated patients from Germany and four published genomes).

Isolates were analyzed by next-generation whole-genome sequencing and compared with published M. chimaera genomes, according to Jakko van Ingen, PhD, Radboud University Medical Center, Nijmegen, the Netherlands, and his colleagues. Phylogenetic analysis of these 250 isolates revealed two major M. chimaera groups. They found that all cardiac surgery–related patient isolates could be classified into group 1. They then did a subgroup analysis.

“Three distinct strains of M. chimaera appear to have contaminated the water systems of LivaNova HCUs at the production site, belonging to subgroups 1.1, 1.8, and 2.1,” the authors stated. However, most M. chimaera isolates from air samples taken near operating LivaNova HCUs and those of 23 of the 24 related patients belonged to subgroup 1.1.

“This finding further supports the presumed airborne transmission pathway leading to endocarditis, aortic graft infection, disseminated disease, and surgical site infections in the affected patients,” according to the authors (doi: 10.1016/S1473-3099[17]30324-9).

The results suggest “the possibility that the vast majority of cases of cardiothoracic surgery–related severe M. chimaera infections diagnosed in Switzerland, Germany, the Netherlands, the United Kingdom, the United States, and Australia resulted from a single common source of infection: LivaNova HCUs that were most likely contaminated during production in Germany,” the researchers concluded.

The study was partly funded by the EU Horizon 2020 program, its FP7 program, the German Center for Infection Research (DZIF), the Swiss National Science Foundation, the Swiss Federal Office of Public Health, and National Institute of Health Research Oxford Health Protection Research Units on Healthcare Associated Infection and Antimicrobial Resistance. The authors reported having no relevant conflicts.

mlesney@frontlinemedcom.com