The development of infections from mycobacteria and fungi endemic to U.S. regions in patients taking tumor necrosis factor–alpha inhibitors (TNFIs) is rare and is not influenced by prescreening of targeted infections, research suggests.

A case-control study of 30,772 patients taking TNFIs showed that only 158 (0.51%) patients developed the fungal and/or mycobacterial infections targeted in this study, with tuberculosis and histoplasmosis being the most common infections.

Targeted infections were nontuberculous mycobacterial infection, blastomycosis, coccidioidomyocosis, cryptococcal infection, histoplasmosis, pneumocystosis, tuberculosis disease, and unspecified fungal infection.

Prednisone was the only predictive factor for infection and was associated with a twofold increase in the likelihood of patients seeking medical attention for a fungal or mycobacterial infection, which the authors said was supported by previous research, according to a paper published online in Arthritis & Rheumatology.

“Thus, the question remains if the increased infection rates are related solely to the use of the glucocorticoids or the active disease for which the medication is being prescribed,” wrote Elizabeth Salt, Ph.D., of the University of Kentucky, Lexington, and coauthors (Arthritis Rheumatol. 2015 Oct 16 doi: 10.1002/art.39462).

Researchers also noted that sulfamethoxazole-trimethoprim was associated with a nonsignificant 45% increase in the likelihood of requiring medical care, compared with controls.

“It is possible that providers recognized the infectious risk of this population and made attempts at controlling infectious processes among those most vulnerable.”

The study was supported by the National Institutes of Health. There were no conflicts of interest declared.

The development of infections from mycobacteria and fungi endemic to U.S. regions in patients taking tumor necrosis factor–alpha inhibitors (TNFIs) is rare and is not influenced by prescreening of targeted infections, research suggests.

A case-control study of 30,772 patients taking TNFIs showed that only 158 (0.51%) patients developed the fungal and/or mycobacterial infections targeted in this study, with tuberculosis and histoplasmosis being the most common infections.

Targeted infections were nontuberculous mycobacterial infection, blastomycosis, coccidioidomyocosis, cryptococcal infection, histoplasmosis, pneumocystosis, tuberculosis disease, and unspecified fungal infection.

Prednisone was the only predictive factor for infection and was associated with a twofold increase in the likelihood of patients seeking medical attention for a fungal or mycobacterial infection, which the authors said was supported by previous research, according to a paper published online in Arthritis & Rheumatology.

“Thus, the question remains if the increased infection rates are related solely to the use of the glucocorticoids or the active disease for which the medication is being prescribed,” wrote Elizabeth Salt, Ph.D., of the University of Kentucky, Lexington, and coauthors (Arthritis Rheumatol. 2015 Oct 16 doi: 10.1002/art.39462).

Researchers also noted that sulfamethoxazole-trimethoprim was associated with a nonsignificant 45% increase in the likelihood of requiring medical care, compared with controls.

“It is possible that providers recognized the infectious risk of this population and made attempts at controlling infectious processes among those most vulnerable.”

The study was supported by the National Institutes of Health. There were no conflicts of interest declared.

The development of infections from mycobacteria and fungi endemic to U.S. regions in patients taking tumor necrosis factor–alpha inhibitors (TNFIs) is rare and is not influenced by prescreening of targeted infections, research suggests.

A case-control study of 30,772 patients taking TNFIs showed that only 158 (0.51%) patients developed the fungal and/or mycobacterial infections targeted in this study, with tuberculosis and histoplasmosis being the most common infections.

Targeted infections were nontuberculous mycobacterial infection, blastomycosis, coccidioidomyocosis, cryptococcal infection, histoplasmosis, pneumocystosis, tuberculosis disease, and unspecified fungal infection.

Prednisone was the only predictive factor for infection and was associated with a twofold increase in the likelihood of patients seeking medical attention for a fungal or mycobacterial infection, which the authors said was supported by previous research, according to a paper published online in Arthritis & Rheumatology.

“Thus, the question remains if the increased infection rates are related solely to the use of the glucocorticoids or the active disease for which the medication is being prescribed,” wrote Elizabeth Salt, Ph.D., of the University of Kentucky, Lexington, and coauthors (Arthritis Rheumatol. 2015 Oct 16 doi: 10.1002/art.39462).

Researchers also noted that sulfamethoxazole-trimethoprim was associated with a nonsignificant 45% increase in the likelihood of requiring medical care, compared with controls.

“It is possible that providers recognized the infectious risk of this population and made attempts at controlling infectious processes among those most vulnerable.”

The study was supported by the National Institutes of Health. There were no conflicts of interest declared.

The delicate balance involved in providing hospitalized patients with needed anticoagulant, anti-platelet, and thrombolytic therapies for stroke and possible cardiac complications while minimizing bleed risks was explored by several speakers at the University of California San Francisco’s annual Management of the Hospitalized Patient Conference.

“These are dynamic issues and they’re moving all the time,” said Tracy Minichiello, MD, a former hospitalist who now runs the Anticoagulation and Thrombosis Service at the San Francisco VA Medical Center. Dosing and monitoring choices for physicians have grown more complicated with the new oral anticoagulants (apixaban, dabigatran, and rivaroxaban), and she said another balancing act is emerging in hospitals trying to avoid unnecessary and wasteful treatments.

“There is interest on both sides of that question,” Dr. Minichiello said, adding the stakes are high. “We don’t want to miss the diagnosis of pulmonary embolisms, which can be difficult to catch. But now there’s more discussion of the other side of the issue—over-diagnosis and over-treatment—where we’re also trying to avoid, for example, overuse of CT scans.”

Another major thrust of Dr. Minichiello’s presentations involved bridging therapies, the application of a parenteral, short-acting anticoagulant therapy during the temporary interruption of warfarin anticoagulation for an invasive procedure. Bridging decreases stroke and embolism risk, but with an increased risk for bleeding.

“Full intensity bridging therapy for anticoagulation potentially can do more harm than good,” she said, noting a dearth of data to support mortality benefits of bridging therapy.

Literature increasingly recommends hospitalists be more selective about the use of bridging therapies that might have been employed reflexively in the past, she noted.

“[Hospitalists] must be mindful of the risks and benefits,” she said.

Physicians should also think twice about concomitant antiplatelet therapy like aspirin with anticoagulants. “We need to work collaboratively with our cardiology colleagues when a patient is on two or three of these therapies,” she said. “Recommendations in this area are in evolution.”

Elise Bouchard, MD, an internist at Centre Maria-Chapdelaine in Dolbeau-Mistassini, Quebec, attended Dr. Minichiello’s breakout session on challenging cases.

“I learned that we shouldn’t use aspirin with Coumadin or other anticoagulants, except for cases like acute coronary syndrome,” Dr. Bouchard said. She also explained a number of her patients with cancer, for example, need anticoagulation treatment and hate getting another injection, so she tries when possible to offer the oral anticoagulants.

Dr. Minichiello works with hospitalists at the San Francisco VA who seek consults around procedures, anticoagulant choices, and when to restart treatments.

“Most hospitalists don’t have access to a service like ours, although they might be able to call on a hematology consult service [or pharmacist],” she said. She suggested hospitalists trying to develop their own evidenced-based protocols use websites like the University of Washington’s anticoagulation service website, or the American Society of Health System Pharmacists’ anticoagulation resource center. TH

The delicate balance involved in providing hospitalized patients with needed anticoagulant, anti-platelet, and thrombolytic therapies for stroke and possible cardiac complications while minimizing bleed risks was explored by several speakers at the University of California San Francisco’s annual Management of the Hospitalized Patient Conference.

“These are dynamic issues and they’re moving all the time,” said Tracy Minichiello, MD, a former hospitalist who now runs the Anticoagulation and Thrombosis Service at the San Francisco VA Medical Center. Dosing and monitoring choices for physicians have grown more complicated with the new oral anticoagulants (apixaban, dabigatran, and rivaroxaban), and she said another balancing act is emerging in hospitals trying to avoid unnecessary and wasteful treatments.

“There is interest on both sides of that question,” Dr. Minichiello said, adding the stakes are high. “We don’t want to miss the diagnosis of pulmonary embolisms, which can be difficult to catch. But now there’s more discussion of the other side of the issue—over-diagnosis and over-treatment—where we’re also trying to avoid, for example, overuse of CT scans.”

Another major thrust of Dr. Minichiello’s presentations involved bridging therapies, the application of a parenteral, short-acting anticoagulant therapy during the temporary interruption of warfarin anticoagulation for an invasive procedure. Bridging decreases stroke and embolism risk, but with an increased risk for bleeding.

“Full intensity bridging therapy for anticoagulation potentially can do more harm than good,” she said, noting a dearth of data to support mortality benefits of bridging therapy.

Literature increasingly recommends hospitalists be more selective about the use of bridging therapies that might have been employed reflexively in the past, she noted.

“[Hospitalists] must be mindful of the risks and benefits,” she said.

Physicians should also think twice about concomitant antiplatelet therapy like aspirin with anticoagulants. “We need to work collaboratively with our cardiology colleagues when a patient is on two or three of these therapies,” she said. “Recommendations in this area are in evolution.”

Elise Bouchard, MD, an internist at Centre Maria-Chapdelaine in Dolbeau-Mistassini, Quebec, attended Dr. Minichiello’s breakout session on challenging cases.

“I learned that we shouldn’t use aspirin with Coumadin or other anticoagulants, except for cases like acute coronary syndrome,” Dr. Bouchard said. She also explained a number of her patients with cancer, for example, need anticoagulation treatment and hate getting another injection, so she tries when possible to offer the oral anticoagulants.

Dr. Minichiello works with hospitalists at the San Francisco VA who seek consults around procedures, anticoagulant choices, and when to restart treatments.

“Most hospitalists don’t have access to a service like ours, although they might be able to call on a hematology consult service [or pharmacist],” she said. She suggested hospitalists trying to develop their own evidenced-based protocols use websites like the University of Washington’s anticoagulation service website, or the American Society of Health System Pharmacists’ anticoagulation resource center. TH

The delicate balance involved in providing hospitalized patients with needed anticoagulant, anti-platelet, and thrombolytic therapies for stroke and possible cardiac complications while minimizing bleed risks was explored by several speakers at the University of California San Francisco’s annual Management of the Hospitalized Patient Conference.

“These are dynamic issues and they’re moving all the time,” said Tracy Minichiello, MD, a former hospitalist who now runs the Anticoagulation and Thrombosis Service at the San Francisco VA Medical Center. Dosing and monitoring choices for physicians have grown more complicated with the new oral anticoagulants (apixaban, dabigatran, and rivaroxaban), and she said another balancing act is emerging in hospitals trying to avoid unnecessary and wasteful treatments.

“There is interest on both sides of that question,” Dr. Minichiello said, adding the stakes are high. “We don’t want to miss the diagnosis of pulmonary embolisms, which can be difficult to catch. But now there’s more discussion of the other side of the issue—over-diagnosis and over-treatment—where we’re also trying to avoid, for example, overuse of CT scans.”

Another major thrust of Dr. Minichiello’s presentations involved bridging therapies, the application of a parenteral, short-acting anticoagulant therapy during the temporary interruption of warfarin anticoagulation for an invasive procedure. Bridging decreases stroke and embolism risk, but with an increased risk for bleeding.

“Full intensity bridging therapy for anticoagulation potentially can do more harm than good,” she said, noting a dearth of data to support mortality benefits of bridging therapy.

Literature increasingly recommends hospitalists be more selective about the use of bridging therapies that might have been employed reflexively in the past, she noted.

“[Hospitalists] must be mindful of the risks and benefits,” she said.

Physicians should also think twice about concomitant antiplatelet therapy like aspirin with anticoagulants. “We need to work collaboratively with our cardiology colleagues when a patient is on two or three of these therapies,” she said. “Recommendations in this area are in evolution.”

Elise Bouchard, MD, an internist at Centre Maria-Chapdelaine in Dolbeau-Mistassini, Quebec, attended Dr. Minichiello’s breakout session on challenging cases.

“I learned that we shouldn’t use aspirin with Coumadin or other anticoagulants, except for cases like acute coronary syndrome,” Dr. Bouchard said. She also explained a number of her patients with cancer, for example, need anticoagulation treatment and hate getting another injection, so she tries when possible to offer the oral anticoagulants.

Dr. Minichiello works with hospitalists at the San Francisco VA who seek consults around procedures, anticoagulant choices, and when to restart treatments.

“Most hospitalists don’t have access to a service like ours, although they might be able to call on a hematology consult service [or pharmacist],” she said. She suggested hospitalists trying to develop their own evidenced-based protocols use websites like the University of Washington’s anticoagulation service website, or the American Society of Health System Pharmacists’ anticoagulation resource center. TH

The biological transition to puberty has always marked a critical point in a primary care pediatrician’s relationship to a patient. Adolescents’ capacity for abstract reasoning, their movement to autonomy, their nuanced sense of identity, their need for privacy, and their emerging sexuality together give the pediatrician an opportunity and a responsibility to create a safe place to talk. Your office can be an oasis from parents, peers, and a society that seems saturated with sexuality. You can be trusted more than the Internet and offer discussions that are leavened by your long-standing relationship with the patient.

The growing public awareness, acceptance, and legal standing given to gay, lesbian, bisexual, and transgender individuals represents welcome societal progress, and we sense that amidst this richer public conversation, a growing number of children and adolescents are presenting with questions or worries about their own emerging sexual orientation or gender identity. We would like to start with our key takeaway: Discussions about sexual orientation and gender identity do not require that you give answers or predict the future. Focus instead on being a curious, compassionate, and nonjudgmental listener, and you will be effective at helping your patient to better manage new, uncertain, and possibly stressful feelings.

Our focus today is how to create a safe setting and specifically how to ask about and discuss sexual orientation. Most teenagers will wonder at some point about their orientation. Studies suggest that among adults, 5%-10% are attracted to the same sex and 3% describe themselves as gay or bisexual. Such surveys are very challenging, though, and in our experience, these percentages are higher. Sexual orientation is believed to exist on a continuum rather than in a simple binary state – some people identify as purely homosexual or heterosexual, and the rest exist somewhere in the middle. Sharing this fact alone can offer a very helpful perspective to young people who are feeling pressure to “figure out” if they are gay or straight.

While sexual orientation describes whom a person is attracted to, gender identity is a person’s internal sense of his or her own gender. It emerges in childhood and becomes more rich and nuanced in adolescence and adulthood, and, like sexual orientation, it is also believed to exist on a continuum rather than in a simple binary state. Less than 0.1% of youth will experience gender dysphoria, or the pressing feeling that their gender identity is not the same as their phenotypic sex. While questions about gender identity should be approached with the same curious, compassionate, and nonjudgmental style, we will not discuss the management of patients with gender dysphoria here. It is a very complex (and controversial) topic. And, as a practical matter, sexual orientation will likely be a more common issue with your patients, whereas questions about gender identity will come up much less frequently.

It is worth knowing that there is a range of mental health issues that are associated with the stress of feeling comfortable with one’s sexual identity. There is some evidence that young people who identify as gay or bisexual have elevated risk for mood disorders (depression), anxiety disorders, conduct disorder, and substance use disorders, but this finding has not been consistent (Am J Public Health. 2010:100[12]; 2426-32). However, there is unequivocal evidence that there is an elevated risk for suicide attempts in lesbian, gay, or bisexual (LGB) youth above their heterosexual peers. One survey found that 9th-12th grade students who identified as LGB were up to seven times as likely to have a suicide attempt as were their peers who identify as heterosexual. This risk is especially pronounced in male adolescents and continues into adulthood, when there is an elevated risk for suicide completion among adult males who identify as homosexual, although not in adult females (J Homosex. 2011 Jan;58[1]:10-51). Importantly, the risk for suicide attempt in LGB adolescents remains elevated even in those adolescents without any diagnosable mental illness, likely attributable to the stresses of isolation, family conflict, stigmatization, or bullying that LGB adolescents are likely to experience.

Asking your early-adolescent patients in a calm and comfortable manner about sexual feelings builds an environment in which thoughts, feelings, and questions about sex and sexuality are more easily shared. It is important to find language that feels like yours, which you can use with ease. Perhaps starting with, “At about your age, I ask every patient of mine whether they are beginning to have sexual feelings. This is when you really want to be around someone, in a way that’s more powerful and different from even your favorite friend. Some people call it getting butterflies in your stomach.” If your patient recognizes what you are talking about, you might continue, “Do you feel attracted to boys or girls or both? Do you have those feelings about kids in your class or people you know, like a teacher? Perhaps about a celebrity in a TV show or a band?” You should absolutely reassure them, “You don’t have to talk about anything you do not want to, but you should know that this is a normal part of becoming a teenager. I talk about this a lot with patients who are younger and older than you are. I keep what we talk about very private, and sometimes this is the only place a teenager feels safe to ask questions.” If you start this process early enough – by the start of middle school – the patient will probably be a bit embarrassed or giggle and not talk much. But, by the next annual physical or the one after that, the issue will be more familiar and less charged. A meaningful discussion may start.

With patients who do describe feeling attracted to people of the same sex, more specific questions may be appropriate. You should expect these feelings to exist on a continuum: You may encounter a school-age child with great clarity about exactly whom she is attracted to and what that means, or an older teenager who is far less certain, responding to a less intense interest or having been told by a peer that he is probably gay. It can be powerfully reassuring to remind your patient that adolescence is when we start to figure out to whom we are attracted. They don’t have to decide, but just be aware of these feelings as they emerge, essentially getting to know themselves without any feelings of urgency or pressure. You might ask, “Have you wondered if you were gay or bisexual? Have you spoken to any friends about your feelings or have you experimented with a boy or girl to try and figure this out?” It’s very helpful if you ask if they are worried or stressed by these feelings. Some young people will suffer from internalized homophobia, which may be helped by your accepting stance or may require a referral for more ongoing support. It can be valuable to find out if they are dating people of the same sex, or if their “relationships” have all been online. While this “virtual” dating may seem safer, it may not help them better understand themselves and may expose them to exploitation or predatory behavior. If your patient is sexually active, you should be comfortable talking with them about the risks of unprotected sex and same-sex safe-sex practices.

It is particularly important to ask your adolescent LGB patient about whom they have told, and what responses have they gotten. The presence of good friends and loving family members is critical to all adolescents’ emotional well-being. If they have talked about their sexual orientation with their peers, have their friends been supportive, or has it left them more isolated at school? You should find out if they have been teased or bullied, and ask specifically about online teasing or harassment. If they are being bullied, how have they handled that? Find out also if they feel free to ask or talk about this subject with their parents. If not, try to understand if they are simply embarrassed and unsure how to bring it up, or if there is a strong sense that they will be shamed or even rejected by their parents. If the parents are truly shaming or rejecting, it will be critical to consider what kind of support may be necessary. Teens who are facing isolation or bullying at school may benefit from resources such as a gay-straight student alliance or a community organization dedicated to issues facing LGB youth. For patients who are facing hostile or rejecting parents, it can be protective to connect them with a therapist as well, as you are mindful of their marked isolation and subsequently heightened risk for mood problems and even suicide attempts.

Along a similar vein, it is very important that you are aware of your own comfort level with these issues. While discussing sexual orientation may feel awkward if it is new for you, it is important to be realistic if you cannot be supportive of your patients who are gay. If for religious or other reasons you are not comfortable talking about sexual orientation in an accepting, nonjudgmental manner, you should seek guidance on how to thoughtfully care for your LGB patients or appropriately refer them to someone who can provide a more-supportive treatment setting.

When you create an office that makes sexuality a safe topic for discussion, you should expect that you will hear questions or concerns about which you yourself may not know the answers. Do not panic, just maintain your posture of being a curious, compassionate, and nonjudgmental listener, and then look for the answers. We are delighted this news organization has devoted a column to the optimal care of LGBT youth (LGBT Youth Consult) and encourage the primary care pediatrician to “never to worry alone,” and instead get some advice and expert teammates when dealing with these complex and important issues.

Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton Wellesley Hospital, in Newton, Mass. Dr. Jellinek is professor of psychiatry and of pediatrics at Harvard Medical School, Boston.

The biological transition to puberty has always marked a critical point in a primary care pediatrician’s relationship to a patient. Adolescents’ capacity for abstract reasoning, their movement to autonomy, their nuanced sense of identity, their need for privacy, and their emerging sexuality together give the pediatrician an opportunity and a responsibility to create a safe place to talk. Your office can be an oasis from parents, peers, and a society that seems saturated with sexuality. You can be trusted more than the Internet and offer discussions that are leavened by your long-standing relationship with the patient.

The growing public awareness, acceptance, and legal standing given to gay, lesbian, bisexual, and transgender individuals represents welcome societal progress, and we sense that amidst this richer public conversation, a growing number of children and adolescents are presenting with questions or worries about their own emerging sexual orientation or gender identity. We would like to start with our key takeaway: Discussions about sexual orientation and gender identity do not require that you give answers or predict the future. Focus instead on being a curious, compassionate, and nonjudgmental listener, and you will be effective at helping your patient to better manage new, uncertain, and possibly stressful feelings.

Our focus today is how to create a safe setting and specifically how to ask about and discuss sexual orientation. Most teenagers will wonder at some point about their orientation. Studies suggest that among adults, 5%-10% are attracted to the same sex and 3% describe themselves as gay or bisexual. Such surveys are very challenging, though, and in our experience, these percentages are higher. Sexual orientation is believed to exist on a continuum rather than in a simple binary state – some people identify as purely homosexual or heterosexual, and the rest exist somewhere in the middle. Sharing this fact alone can offer a very helpful perspective to young people who are feeling pressure to “figure out” if they are gay or straight.

While sexual orientation describes whom a person is attracted to, gender identity is a person’s internal sense of his or her own gender. It emerges in childhood and becomes more rich and nuanced in adolescence and adulthood, and, like sexual orientation, it is also believed to exist on a continuum rather than in a simple binary state. Less than 0.1% of youth will experience gender dysphoria, or the pressing feeling that their gender identity is not the same as their phenotypic sex. While questions about gender identity should be approached with the same curious, compassionate, and nonjudgmental style, we will not discuss the management of patients with gender dysphoria here. It is a very complex (and controversial) topic. And, as a practical matter, sexual orientation will likely be a more common issue with your patients, whereas questions about gender identity will come up much less frequently.

It is worth knowing that there is a range of mental health issues that are associated with the stress of feeling comfortable with one’s sexual identity. There is some evidence that young people who identify as gay or bisexual have elevated risk for mood disorders (depression), anxiety disorders, conduct disorder, and substance use disorders, but this finding has not been consistent (Am J Public Health. 2010:100[12]; 2426-32). However, there is unequivocal evidence that there is an elevated risk for suicide attempts in lesbian, gay, or bisexual (LGB) youth above their heterosexual peers. One survey found that 9th-12th grade students who identified as LGB were up to seven times as likely to have a suicide attempt as were their peers who identify as heterosexual. This risk is especially pronounced in male adolescents and continues into adulthood, when there is an elevated risk for suicide completion among adult males who identify as homosexual, although not in adult females (J Homosex. 2011 Jan;58[1]:10-51). Importantly, the risk for suicide attempt in LGB adolescents remains elevated even in those adolescents without any diagnosable mental illness, likely attributable to the stresses of isolation, family conflict, stigmatization, or bullying that LGB adolescents are likely to experience.

Asking your early-adolescent patients in a calm and comfortable manner about sexual feelings builds an environment in which thoughts, feelings, and questions about sex and sexuality are more easily shared. It is important to find language that feels like yours, which you can use with ease. Perhaps starting with, “At about your age, I ask every patient of mine whether they are beginning to have sexual feelings. This is when you really want to be around someone, in a way that’s more powerful and different from even your favorite friend. Some people call it getting butterflies in your stomach.” If your patient recognizes what you are talking about, you might continue, “Do you feel attracted to boys or girls or both? Do you have those feelings about kids in your class or people you know, like a teacher? Perhaps about a celebrity in a TV show or a band?” You should absolutely reassure them, “You don’t have to talk about anything you do not want to, but you should know that this is a normal part of becoming a teenager. I talk about this a lot with patients who are younger and older than you are. I keep what we talk about very private, and sometimes this is the only place a teenager feels safe to ask questions.” If you start this process early enough – by the start of middle school – the patient will probably be a bit embarrassed or giggle and not talk much. But, by the next annual physical or the one after that, the issue will be more familiar and less charged. A meaningful discussion may start.

With patients who do describe feeling attracted to people of the same sex, more specific questions may be appropriate. You should expect these feelings to exist on a continuum: You may encounter a school-age child with great clarity about exactly whom she is attracted to and what that means, or an older teenager who is far less certain, responding to a less intense interest or having been told by a peer that he is probably gay. It can be powerfully reassuring to remind your patient that adolescence is when we start to figure out to whom we are attracted. They don’t have to decide, but just be aware of these feelings as they emerge, essentially getting to know themselves without any feelings of urgency or pressure. You might ask, “Have you wondered if you were gay or bisexual? Have you spoken to any friends about your feelings or have you experimented with a boy or girl to try and figure this out?” It’s very helpful if you ask if they are worried or stressed by these feelings. Some young people will suffer from internalized homophobia, which may be helped by your accepting stance or may require a referral for more ongoing support. It can be valuable to find out if they are dating people of the same sex, or if their “relationships” have all been online. While this “virtual” dating may seem safer, it may not help them better understand themselves and may expose them to exploitation or predatory behavior. If your patient is sexually active, you should be comfortable talking with them about the risks of unprotected sex and same-sex safe-sex practices.

It is particularly important to ask your adolescent LGB patient about whom they have told, and what responses have they gotten. The presence of good friends and loving family members is critical to all adolescents’ emotional well-being. If they have talked about their sexual orientation with their peers, have their friends been supportive, or has it left them more isolated at school? You should find out if they have been teased or bullied, and ask specifically about online teasing or harassment. If they are being bullied, how have they handled that? Find out also if they feel free to ask or talk about this subject with their parents. If not, try to understand if they are simply embarrassed and unsure how to bring it up, or if there is a strong sense that they will be shamed or even rejected by their parents. If the parents are truly shaming or rejecting, it will be critical to consider what kind of support may be necessary. Teens who are facing isolation or bullying at school may benefit from resources such as a gay-straight student alliance or a community organization dedicated to issues facing LGB youth. For patients who are facing hostile or rejecting parents, it can be protective to connect them with a therapist as well, as you are mindful of their marked isolation and subsequently heightened risk for mood problems and even suicide attempts.

Along a similar vein, it is very important that you are aware of your own comfort level with these issues. While discussing sexual orientation may feel awkward if it is new for you, it is important to be realistic if you cannot be supportive of your patients who are gay. If for religious or other reasons you are not comfortable talking about sexual orientation in an accepting, nonjudgmental manner, you should seek guidance on how to thoughtfully care for your LGB patients or appropriately refer them to someone who can provide a more-supportive treatment setting.

When you create an office that makes sexuality a safe topic for discussion, you should expect that you will hear questions or concerns about which you yourself may not know the answers. Do not panic, just maintain your posture of being a curious, compassionate, and nonjudgmental listener, and then look for the answers. We are delighted this news organization has devoted a column to the optimal care of LGBT youth (LGBT Youth Consult) and encourage the primary care pediatrician to “never to worry alone,” and instead get some advice and expert teammates when dealing with these complex and important issues.

Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton Wellesley Hospital, in Newton, Mass. Dr. Jellinek is professor of psychiatry and of pediatrics at Harvard Medical School, Boston.

The biological transition to puberty has always marked a critical point in a primary care pediatrician’s relationship to a patient. Adolescents’ capacity for abstract reasoning, their movement to autonomy, their nuanced sense of identity, their need for privacy, and their emerging sexuality together give the pediatrician an opportunity and a responsibility to create a safe place to talk. Your office can be an oasis from parents, peers, and a society that seems saturated with sexuality. You can be trusted more than the Internet and offer discussions that are leavened by your long-standing relationship with the patient.

The growing public awareness, acceptance, and legal standing given to gay, lesbian, bisexual, and transgender individuals represents welcome societal progress, and we sense that amidst this richer public conversation, a growing number of children and adolescents are presenting with questions or worries about their own emerging sexual orientation or gender identity. We would like to start with our key takeaway: Discussions about sexual orientation and gender identity do not require that you give answers or predict the future. Focus instead on being a curious, compassionate, and nonjudgmental listener, and you will be effective at helping your patient to better manage new, uncertain, and possibly stressful feelings.

Our focus today is how to create a safe setting and specifically how to ask about and discuss sexual orientation. Most teenagers will wonder at some point about their orientation. Studies suggest that among adults, 5%-10% are attracted to the same sex and 3% describe themselves as gay or bisexual. Such surveys are very challenging, though, and in our experience, these percentages are higher. Sexual orientation is believed to exist on a continuum rather than in a simple binary state – some people identify as purely homosexual or heterosexual, and the rest exist somewhere in the middle. Sharing this fact alone can offer a very helpful perspective to young people who are feeling pressure to “figure out” if they are gay or straight.

While sexual orientation describes whom a person is attracted to, gender identity is a person’s internal sense of his or her own gender. It emerges in childhood and becomes more rich and nuanced in adolescence and adulthood, and, like sexual orientation, it is also believed to exist on a continuum rather than in a simple binary state. Less than 0.1% of youth will experience gender dysphoria, or the pressing feeling that their gender identity is not the same as their phenotypic sex. While questions about gender identity should be approached with the same curious, compassionate, and nonjudgmental style, we will not discuss the management of patients with gender dysphoria here. It is a very complex (and controversial) topic. And, as a practical matter, sexual orientation will likely be a more common issue with your patients, whereas questions about gender identity will come up much less frequently.

It is worth knowing that there is a range of mental health issues that are associated with the stress of feeling comfortable with one’s sexual identity. There is some evidence that young people who identify as gay or bisexual have elevated risk for mood disorders (depression), anxiety disorders, conduct disorder, and substance use disorders, but this finding has not been consistent (Am J Public Health. 2010:100[12]; 2426-32). However, there is unequivocal evidence that there is an elevated risk for suicide attempts in lesbian, gay, or bisexual (LGB) youth above their heterosexual peers. One survey found that 9th-12th grade students who identified as LGB were up to seven times as likely to have a suicide attempt as were their peers who identify as heterosexual. This risk is especially pronounced in male adolescents and continues into adulthood, when there is an elevated risk for suicide completion among adult males who identify as homosexual, although not in adult females (J Homosex. 2011 Jan;58[1]:10-51). Importantly, the risk for suicide attempt in LGB adolescents remains elevated even in those adolescents without any diagnosable mental illness, likely attributable to the stresses of isolation, family conflict, stigmatization, or bullying that LGB adolescents are likely to experience.

Asking your early-adolescent patients in a calm and comfortable manner about sexual feelings builds an environment in which thoughts, feelings, and questions about sex and sexuality are more easily shared. It is important to find language that feels like yours, which you can use with ease. Perhaps starting with, “At about your age, I ask every patient of mine whether they are beginning to have sexual feelings. This is when you really want to be around someone, in a way that’s more powerful and different from even your favorite friend. Some people call it getting butterflies in your stomach.” If your patient recognizes what you are talking about, you might continue, “Do you feel attracted to boys or girls or both? Do you have those feelings about kids in your class or people you know, like a teacher? Perhaps about a celebrity in a TV show or a band?” You should absolutely reassure them, “You don’t have to talk about anything you do not want to, but you should know that this is a normal part of becoming a teenager. I talk about this a lot with patients who are younger and older than you are. I keep what we talk about very private, and sometimes this is the only place a teenager feels safe to ask questions.” If you start this process early enough – by the start of middle school – the patient will probably be a bit embarrassed or giggle and not talk much. But, by the next annual physical or the one after that, the issue will be more familiar and less charged. A meaningful discussion may start.

With patients who do describe feeling attracted to people of the same sex, more specific questions may be appropriate. You should expect these feelings to exist on a continuum: You may encounter a school-age child with great clarity about exactly whom she is attracted to and what that means, or an older teenager who is far less certain, responding to a less intense interest or having been told by a peer that he is probably gay. It can be powerfully reassuring to remind your patient that adolescence is when we start to figure out to whom we are attracted. They don’t have to decide, but just be aware of these feelings as they emerge, essentially getting to know themselves without any feelings of urgency or pressure. You might ask, “Have you wondered if you were gay or bisexual? Have you spoken to any friends about your feelings or have you experimented with a boy or girl to try and figure this out?” It’s very helpful if you ask if they are worried or stressed by these feelings. Some young people will suffer from internalized homophobia, which may be helped by your accepting stance or may require a referral for more ongoing support. It can be valuable to find out if they are dating people of the same sex, or if their “relationships” have all been online. While this “virtual” dating may seem safer, it may not help them better understand themselves and may expose them to exploitation or predatory behavior. If your patient is sexually active, you should be comfortable talking with them about the risks of unprotected sex and same-sex safe-sex practices.

It is particularly important to ask your adolescent LGB patient about whom they have told, and what responses have they gotten. The presence of good friends and loving family members is critical to all adolescents’ emotional well-being. If they have talked about their sexual orientation with their peers, have their friends been supportive, or has it left them more isolated at school? You should find out if they have been teased or bullied, and ask specifically about online teasing or harassment. If they are being bullied, how have they handled that? Find out also if they feel free to ask or talk about this subject with their parents. If not, try to understand if they are simply embarrassed and unsure how to bring it up, or if there is a strong sense that they will be shamed or even rejected by their parents. If the parents are truly shaming or rejecting, it will be critical to consider what kind of support may be necessary. Teens who are facing isolation or bullying at school may benefit from resources such as a gay-straight student alliance or a community organization dedicated to issues facing LGB youth. For patients who are facing hostile or rejecting parents, it can be protective to connect them with a therapist as well, as you are mindful of their marked isolation and subsequently heightened risk for mood problems and even suicide attempts.

Along a similar vein, it is very important that you are aware of your own comfort level with these issues. While discussing sexual orientation may feel awkward if it is new for you, it is important to be realistic if you cannot be supportive of your patients who are gay. If for religious or other reasons you are not comfortable talking about sexual orientation in an accepting, nonjudgmental manner, you should seek guidance on how to thoughtfully care for your LGB patients or appropriately refer them to someone who can provide a more-supportive treatment setting.

When you create an office that makes sexuality a safe topic for discussion, you should expect that you will hear questions or concerns about which you yourself may not know the answers. Do not panic, just maintain your posture of being a curious, compassionate, and nonjudgmental listener, and then look for the answers. We are delighted this news organization has devoted a column to the optimal care of LGBT youth (LGBT Youth Consult) and encourage the primary care pediatrician to “never to worry alone,” and instead get some advice and expert teammates when dealing with these complex and important issues.

Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton Wellesley Hospital, in Newton, Mass. Dr. Jellinek is professor of psychiatry and of pediatrics at Harvard Medical School, Boston.

COPENHAGEN – Back pain is surprisingly common in patients with hidradenitis suppurativa, and more than half of affected patients showed MRI evidence of axial spondyloarthropathy, Dr. Sylke Schneider-Burrus reported at the Annual Congress of the European Academy of Dermatology and Venereology.

“Our study demonstrates that back pain and spondyloarthropathy are very common among hidradenitis suppurativa patients and that neither history nor clinical parameters provide any hints for the presence of spondyloarthropathy. Therefore, we strongly suggest that hidradenitis suppurativa patients should be evaluated for spondyloarthropathy and affected patients should be treated systemically with TNF-alpha blockers in order to avoid chronic joint alterations,” said Dr. Schneider-Burrus, a dermatologist at Charite University Hospital in Berlin.

Bruce Jancin/Frontline Medical News

Hidradenitis suppurativa (HS) is a chronic, recurrent, scarring, inflammatory skin disease of the hair follicles. It causes painful, purulent, foul-smelling fistulating sinuses in the axillae, groin, and perianal region.

Because several other chronic inflammatory diseases affecting epithelial tissue have been associated with increased rates of axial spondyloarthropathy – notably, Crohn’s disease, ulcerative colitis, and psoriasis – Dr. Schneider-Burrus and coinvestigators wondered whether that might true of HS as well.

She presented a survey of 100 HS patients. To her surprise, fully 71% indicated they suffer from back pain, with lower back complaints predominating.

Forty-eight HS patients with back pain consented to undergo a pelvic MRI exam. Fifteen of the 48 (32%) showed clear MRI evidence of spondyloarthropathy, including sacroiliac erosions and subchondral sclerosis, while another 12 showed active sacroiliac synovitis and other acute inflammatory changes.

No significant differences were found between HS patients with and without axial spondyloarthropathy in terms of age at onset of HS, disease duration, HS severity as reflected in Sartorius score, age at MRI, body mass index, or smoking status.

Dr. Schneider-Burrus reported serving as a paid investigator for and consultant to Novartis and AbbVie.

bjancin@frontlinemedcom.com

COPENHAGEN – Back pain is surprisingly common in patients with hidradenitis suppurativa, and more than half of affected patients showed MRI evidence of axial spondyloarthropathy, Dr. Sylke Schneider-Burrus reported at the Annual Congress of the European Academy of Dermatology and Venereology.

“Our study demonstrates that back pain and spondyloarthropathy are very common among hidradenitis suppurativa patients and that neither history nor clinical parameters provide any hints for the presence of spondyloarthropathy. Therefore, we strongly suggest that hidradenitis suppurativa patients should be evaluated for spondyloarthropathy and affected patients should be treated systemically with TNF-alpha blockers in order to avoid chronic joint alterations,” said Dr. Schneider-Burrus, a dermatologist at Charite University Hospital in Berlin.

Bruce Jancin/Frontline Medical News

Hidradenitis suppurativa (HS) is a chronic, recurrent, scarring, inflammatory skin disease of the hair follicles. It causes painful, purulent, foul-smelling fistulating sinuses in the axillae, groin, and perianal region.

Because several other chronic inflammatory diseases affecting epithelial tissue have been associated with increased rates of axial spondyloarthropathy – notably, Crohn’s disease, ulcerative colitis, and psoriasis – Dr. Schneider-Burrus and coinvestigators wondered whether that might true of HS as well.

She presented a survey of 100 HS patients. To her surprise, fully 71% indicated they suffer from back pain, with lower back complaints predominating.

Forty-eight HS patients with back pain consented to undergo a pelvic MRI exam. Fifteen of the 48 (32%) showed clear MRI evidence of spondyloarthropathy, including sacroiliac erosions and subchondral sclerosis, while another 12 showed active sacroiliac synovitis and other acute inflammatory changes.

No significant differences were found between HS patients with and without axial spondyloarthropathy in terms of age at onset of HS, disease duration, HS severity as reflected in Sartorius score, age at MRI, body mass index, or smoking status.

Dr. Schneider-Burrus reported serving as a paid investigator for and consultant to Novartis and AbbVie.

bjancin@frontlinemedcom.com

COPENHAGEN – Back pain is surprisingly common in patients with hidradenitis suppurativa, and more than half of affected patients showed MRI evidence of axial spondyloarthropathy, Dr. Sylke Schneider-Burrus reported at the Annual Congress of the European Academy of Dermatology and Venereology.

“Our study demonstrates that back pain and spondyloarthropathy are very common among hidradenitis suppurativa patients and that neither history nor clinical parameters provide any hints for the presence of spondyloarthropathy. Therefore, we strongly suggest that hidradenitis suppurativa patients should be evaluated for spondyloarthropathy and affected patients should be treated systemically with TNF-alpha blockers in order to avoid chronic joint alterations,” said Dr. Schneider-Burrus, a dermatologist at Charite University Hospital in Berlin.

Bruce Jancin/Frontline Medical News

Hidradenitis suppurativa (HS) is a chronic, recurrent, scarring, inflammatory skin disease of the hair follicles. It causes painful, purulent, foul-smelling fistulating sinuses in the axillae, groin, and perianal region.

Because several other chronic inflammatory diseases affecting epithelial tissue have been associated with increased rates of axial spondyloarthropathy – notably, Crohn’s disease, ulcerative colitis, and psoriasis – Dr. Schneider-Burrus and coinvestigators wondered whether that might true of HS as well.

She presented a survey of 100 HS patients. To her surprise, fully 71% indicated they suffer from back pain, with lower back complaints predominating.

Forty-eight HS patients with back pain consented to undergo a pelvic MRI exam. Fifteen of the 48 (32%) showed clear MRI evidence of spondyloarthropathy, including sacroiliac erosions and subchondral sclerosis, while another 12 showed active sacroiliac synovitis and other acute inflammatory changes.

No significant differences were found between HS patients with and without axial spondyloarthropathy in terms of age at onset of HS, disease duration, HS severity as reflected in Sartorius score, age at MRI, body mass index, or smoking status.

Dr. Schneider-Burrus reported serving as a paid investigator for and consultant to Novartis and AbbVie.

bjancin@frontlinemedcom.com

Compared to the general population, women with mutations in the BRCA1 or BRCA2 genes have a significantly higher lifetime risk of ovarian and breast cancers (Science. 2003 Oct 24;302[5645]:643-6). Since the occurrence of ovarian and breast cancer in BRCA carriers is often prior to menopause, and because we have no screening test to detect early stage ovarian cancer, risk-reducing salpingo-oophorectomy has been recommended around age 40.

It has been shown that risk-reducing salpingo-oophorectomy significantly reduces ovarian cancer risk by 85%-95% in BRCA-affected women. Also, this surgery can reduce breast cancer risk by 53%-68% (N Engl J Med. 2002 May 23;346[21]:1609-15). The 2008 Practice Bulletin from the American College of Obstetricians and Gynecologists recommends that risk-reducing salpingo-oophorectomy should be performed in women with BRCA1 or BRCA2 mutations after the completion of childbearing or age 40 (Obstet Gynecol. 2008 Jan;111[1]:231-41).

Health implications

Nearly 60% of women who have a BRCA1 or BRCA2 mutation will elect to undergo risk-reducing salpingo-oophorectomy between the ages of 35 and 40 years (Open Med. 2007 Aug 13;1[2]:e92-8). As such, surgical menopause can result in hot flashes, vaginal dryness, sexual dysfunction, sleep disturbances, and cognitive changes, which may significantly impact a woman’s quality of life. In addition, increased risk of cardiovascular disease and osteoporosis following bilateral salpingo-oophorectomy may have a significant impact on a woman’s health.

Since these women undergo surgical menopause as opposed to natural menopause, they have an abrupt loss in hormones, and due to their younger age at the time of surgery, they may also have a longer exposure period to the detrimental effects of hypoestrogenism.

Symptom management

Various treatment options exist for relief of menopausal symptoms, including nonhormonal therapies and hormone replacement therapies (HT).

Nonhormonal therapies include serotonin receptor inhibitors (venlafaxine and paroxetine) and alpha-2 adrenergic agonists (clonidine), which are most appropriate for the treatment of vasomotor symptoms. Unfortunately, these options have proved to be as effective as HT. Also, women should be adequately counseled regarding the various side effects of these nonhormonal medications. Alternative approaches such as phytoestrogens are unproven and are still undergoing investigation. As such, HT remains the standard for treatment of menopausal symptoms, and many trials have confirmed that HT can effectively treat menopausal symptoms following risk-reducing salpingo-oophorectomy.

This then raises the question of safety regarding use of HT in this patient population; especially the possibility of increased risk of breast cancer. Interestingly, only 10%-25% of BRCA1 carriers will have estrogen receptor–positive breast cancer, while 65%-79% of BRCA2-associated breast cancers will be positive for the receptor (Clin Cancer Res. 2004 Mar 15;10[6]:2029-34).

Unfortunately, we do not have adequate trials or studies with sufficient long-term follow-up to validate whether HT increases the risk of breast cancer or recurrence. However, the PROSE Study Group did report on a prospective cohort of 462 women with BRCA1 or BRCA2 mutations. In this study, HT did not alter the reduction in breast cancer risk from risk-reducing salpingo-oophorectomy (J Clin Oncol. 2005 Nov 1;23[31]:7804-10). In addition to a paucity of data regarding systemic HT, there is little data in the BRCA-positive population to confirm the safety of local vaginal estrogen for treatment of vaginal atrophy (J Clin Oncol. 2004 Mar 15;22[6]:1045-54).

Understanding the options

Use of HT in women with BRCA1 and BRCA2 mutations requires further investigation. There should be shared decision making between the patient and provider when counseling on the management of menopausal symptoms following risk-reducing salpingo-oophorectomy. Most importantly, women should understand the options of nonhormonal therapies and their specific side effects. They should also understand the lack of significant data regarding use of systemic HT, and that if use is elected, there may be an increased risk of breast cancer.

Women who do elect to use systemic HT following risk-reducing salpingo-oophorectomy have options that can help reduce the risk of HT-associated breast cancer, including a shorter duration of systemic HT or concurrent hysterectomy to allow for estrogen-only HT, which has a decreased risk of breast cancer compared with combined therapies that include progestins. These women may also be considering prophylactic mastectomy, which would change the concerns regarding HT and an increased risk of breast cancer.

Increased awareness of these options among physicians and patients alike can help to decrease unsatisfactory symptoms and improve quality of life in women undergoing risk-reducing salpingo-oophorectomy.

Dr. Staley is a resident physician in the department of obstetrics and gynecology at the University of North Carolina at Chapel Hill. Dr. Gehrig is professor and director of gynecologic oncology at the university. They reported having no relevant financial disclosures. Email them at obnews@frontlinemedcom.com.

Compared to the general population, women with mutations in the BRCA1 or BRCA2 genes have a significantly higher lifetime risk of ovarian and breast cancers (Science. 2003 Oct 24;302[5645]:643-6). Since the occurrence of ovarian and breast cancer in BRCA carriers is often prior to menopause, and because we have no screening test to detect early stage ovarian cancer, risk-reducing salpingo-oophorectomy has been recommended around age 40.

It has been shown that risk-reducing salpingo-oophorectomy significantly reduces ovarian cancer risk by 85%-95% in BRCA-affected women. Also, this surgery can reduce breast cancer risk by 53%-68% (N Engl J Med. 2002 May 23;346[21]:1609-15). The 2008 Practice Bulletin from the American College of Obstetricians and Gynecologists recommends that risk-reducing salpingo-oophorectomy should be performed in women with BRCA1 or BRCA2 mutations after the completion of childbearing or age 40 (Obstet Gynecol. 2008 Jan;111[1]:231-41).

Health implications

Nearly 60% of women who have a BRCA1 or BRCA2 mutation will elect to undergo risk-reducing salpingo-oophorectomy between the ages of 35 and 40 years (Open Med. 2007 Aug 13;1[2]:e92-8). As such, surgical menopause can result in hot flashes, vaginal dryness, sexual dysfunction, sleep disturbances, and cognitive changes, which may significantly impact a woman’s quality of life. In addition, increased risk of cardiovascular disease and osteoporosis following bilateral salpingo-oophorectomy may have a significant impact on a woman’s health.

Since these women undergo surgical menopause as opposed to natural menopause, they have an abrupt loss in hormones, and due to their younger age at the time of surgery, they may also have a longer exposure period to the detrimental effects of hypoestrogenism.

Symptom management

Various treatment options exist for relief of menopausal symptoms, including nonhormonal therapies and hormone replacement therapies (HT).

Nonhormonal therapies include serotonin receptor inhibitors (venlafaxine and paroxetine) and alpha-2 adrenergic agonists (clonidine), which are most appropriate for the treatment of vasomotor symptoms. Unfortunately, these options have proved to be as effective as HT. Also, women should be adequately counseled regarding the various side effects of these nonhormonal medications. Alternative approaches such as phytoestrogens are unproven and are still undergoing investigation. As such, HT remains the standard for treatment of menopausal symptoms, and many trials have confirmed that HT can effectively treat menopausal symptoms following risk-reducing salpingo-oophorectomy.

This then raises the question of safety regarding use of HT in this patient population; especially the possibility of increased risk of breast cancer. Interestingly, only 10%-25% of BRCA1 carriers will have estrogen receptor–positive breast cancer, while 65%-79% of BRCA2-associated breast cancers will be positive for the receptor (Clin Cancer Res. 2004 Mar 15;10[6]:2029-34).

Unfortunately, we do not have adequate trials or studies with sufficient long-term follow-up to validate whether HT increases the risk of breast cancer or recurrence. However, the PROSE Study Group did report on a prospective cohort of 462 women with BRCA1 or BRCA2 mutations. In this study, HT did not alter the reduction in breast cancer risk from risk-reducing salpingo-oophorectomy (J Clin Oncol. 2005 Nov 1;23[31]:7804-10). In addition to a paucity of data regarding systemic HT, there is little data in the BRCA-positive population to confirm the safety of local vaginal estrogen for treatment of vaginal atrophy (J Clin Oncol. 2004 Mar 15;22[6]:1045-54).

Understanding the options

Use of HT in women with BRCA1 and BRCA2 mutations requires further investigation. There should be shared decision making between the patient and provider when counseling on the management of menopausal symptoms following risk-reducing salpingo-oophorectomy. Most importantly, women should understand the options of nonhormonal therapies and their specific side effects. They should also understand the lack of significant data regarding use of systemic HT, and that if use is elected, there may be an increased risk of breast cancer.

Women who do elect to use systemic HT following risk-reducing salpingo-oophorectomy have options that can help reduce the risk of HT-associated breast cancer, including a shorter duration of systemic HT or concurrent hysterectomy to allow for estrogen-only HT, which has a decreased risk of breast cancer compared with combined therapies that include progestins. These women may also be considering prophylactic mastectomy, which would change the concerns regarding HT and an increased risk of breast cancer.

Increased awareness of these options among physicians and patients alike can help to decrease unsatisfactory symptoms and improve quality of life in women undergoing risk-reducing salpingo-oophorectomy.

Dr. Staley is a resident physician in the department of obstetrics and gynecology at the University of North Carolina at Chapel Hill. Dr. Gehrig is professor and director of gynecologic oncology at the university. They reported having no relevant financial disclosures. Email them at obnews@frontlinemedcom.com.

Compared to the general population, women with mutations in the BRCA1 or BRCA2 genes have a significantly higher lifetime risk of ovarian and breast cancers (Science. 2003 Oct 24;302[5645]:643-6). Since the occurrence of ovarian and breast cancer in BRCA carriers is often prior to menopause, and because we have no screening test to detect early stage ovarian cancer, risk-reducing salpingo-oophorectomy has been recommended around age 40.

It has been shown that risk-reducing salpingo-oophorectomy significantly reduces ovarian cancer risk by 85%-95% in BRCA-affected women. Also, this surgery can reduce breast cancer risk by 53%-68% (N Engl J Med. 2002 May 23;346[21]:1609-15). The 2008 Practice Bulletin from the American College of Obstetricians and Gynecologists recommends that risk-reducing salpingo-oophorectomy should be performed in women with BRCA1 or BRCA2 mutations after the completion of childbearing or age 40 (Obstet Gynecol. 2008 Jan;111[1]:231-41).

Health implications

Nearly 60% of women who have a BRCA1 or BRCA2 mutation will elect to undergo risk-reducing salpingo-oophorectomy between the ages of 35 and 40 years (Open Med. 2007 Aug 13;1[2]:e92-8). As such, surgical menopause can result in hot flashes, vaginal dryness, sexual dysfunction, sleep disturbances, and cognitive changes, which may significantly impact a woman’s quality of life. In addition, increased risk of cardiovascular disease and osteoporosis following bilateral salpingo-oophorectomy may have a significant impact on a woman’s health.

Since these women undergo surgical menopause as opposed to natural menopause, they have an abrupt loss in hormones, and due to their younger age at the time of surgery, they may also have a longer exposure period to the detrimental effects of hypoestrogenism.

Symptom management

Various treatment options exist for relief of menopausal symptoms, including nonhormonal therapies and hormone replacement therapies (HT).

Nonhormonal therapies include serotonin receptor inhibitors (venlafaxine and paroxetine) and alpha-2 adrenergic agonists (clonidine), which are most appropriate for the treatment of vasomotor symptoms. Unfortunately, these options have proved to be as effective as HT. Also, women should be adequately counseled regarding the various side effects of these nonhormonal medications. Alternative approaches such as phytoestrogens are unproven and are still undergoing investigation. As such, HT remains the standard for treatment of menopausal symptoms, and many trials have confirmed that HT can effectively treat menopausal symptoms following risk-reducing salpingo-oophorectomy.

This then raises the question of safety regarding use of HT in this patient population; especially the possibility of increased risk of breast cancer. Interestingly, only 10%-25% of BRCA1 carriers will have estrogen receptor–positive breast cancer, while 65%-79% of BRCA2-associated breast cancers will be positive for the receptor (Clin Cancer Res. 2004 Mar 15;10[6]:2029-34).

Unfortunately, we do not have adequate trials or studies with sufficient long-term follow-up to validate whether HT increases the risk of breast cancer or recurrence. However, the PROSE Study Group did report on a prospective cohort of 462 women with BRCA1 or BRCA2 mutations. In this study, HT did not alter the reduction in breast cancer risk from risk-reducing salpingo-oophorectomy (J Clin Oncol. 2005 Nov 1;23[31]:7804-10). In addition to a paucity of data regarding systemic HT, there is little data in the BRCA-positive population to confirm the safety of local vaginal estrogen for treatment of vaginal atrophy (J Clin Oncol. 2004 Mar 15;22[6]:1045-54).

Understanding the options

Use of HT in women with BRCA1 and BRCA2 mutations requires further investigation. There should be shared decision making between the patient and provider when counseling on the management of menopausal symptoms following risk-reducing salpingo-oophorectomy. Most importantly, women should understand the options of nonhormonal therapies and their specific side effects. They should also understand the lack of significant data regarding use of systemic HT, and that if use is elected, there may be an increased risk of breast cancer.

Women who do elect to use systemic HT following risk-reducing salpingo-oophorectomy have options that can help reduce the risk of HT-associated breast cancer, including a shorter duration of systemic HT or concurrent hysterectomy to allow for estrogen-only HT, which has a decreased risk of breast cancer compared with combined therapies that include progestins. These women may also be considering prophylactic mastectomy, which would change the concerns regarding HT and an increased risk of breast cancer.

Increased awareness of these options among physicians and patients alike can help to decrease unsatisfactory symptoms and improve quality of life in women undergoing risk-reducing salpingo-oophorectomy.

Dr. Staley is a resident physician in the department of obstetrics and gynecology at the University of North Carolina at Chapel Hill. Dr. Gehrig is professor and director of gynecologic oncology at the university. They reported having no relevant financial disclosures. Email them at obnews@frontlinemedcom.com.

Completely percutaneous endovascular aortic aneurysm repair (PEVAR) has become more common, using the suture-mediated “preclose” technique. The rate of periprocedural, iatrogenic, acute deep vein thrombosis (DVT), hitherto unknown, was found to be low for this approach, according to a study reported by Dr. Courtney E. Morgan and her colleagues at the Northwestern University, Chicago.

The researchers assessed 52 consecutive patients (44 men) with a mean age of 73 years, who underwent PEVAR at their center. Only 6% had a prior history of DVT (J Vasc Surg. 2015 Aug; 62:351-4).

© Sebastian Kaulitzki/Thinkstock

Acute DVT was seen in four patients on postoperative day 1. These four DVTs comprised one femoropopliteal, and three calf DVTs. Three of these patients had associated risk factors: history of DVT (two patients); active smokers (one patient); and obesity (body mass index greater than 30 kg/m² in all three patients).

At 2 weeks postoperatively, 75% of the DVTs had resolved.

“We found an overall rate of proximal DVT of 4% after PEVAR, which increased to 13% when calf-vein DVTs were included. Most patients with postoperative DVT had preexisting risk factors, which suggests that routine duplex ultrasound screening after PEVAR is not necessary unless there exist preclinical risk factors or postprocedural clinical indications suggestive of DVT,” the authors concluded.

Two of the researchers have received funding and/or served as speakers/consultants for device companies involved in EVAR.

Read the full study online in the Journal of Vascular Surgery.

mlesney@frontlinemedcom.com

Completely percutaneous endovascular aortic aneurysm repair (PEVAR) has become more common, using the suture-mediated “preclose” technique. The rate of periprocedural, iatrogenic, acute deep vein thrombosis (DVT), hitherto unknown, was found to be low for this approach, according to a study reported by Dr. Courtney E. Morgan and her colleagues at the Northwestern University, Chicago.

The researchers assessed 52 consecutive patients (44 men) with a mean age of 73 years, who underwent PEVAR at their center. Only 6% had a prior history of DVT (J Vasc Surg. 2015 Aug; 62:351-4).

© Sebastian Kaulitzki/Thinkstock

Acute DVT was seen in four patients on postoperative day 1. These four DVTs comprised one femoropopliteal, and three calf DVTs. Three of these patients had associated risk factors: history of DVT (two patients); active smokers (one patient); and obesity (body mass index greater than 30 kg/m² in all three patients).

At 2 weeks postoperatively, 75% of the DVTs had resolved.

“We found an overall rate of proximal DVT of 4% after PEVAR, which increased to 13% when calf-vein DVTs were included. Most patients with postoperative DVT had preexisting risk factors, which suggests that routine duplex ultrasound screening after PEVAR is not necessary unless there exist preclinical risk factors or postprocedural clinical indications suggestive of DVT,” the authors concluded.

Two of the researchers have received funding and/or served as speakers/consultants for device companies involved in EVAR.

Read the full study online in the Journal of Vascular Surgery.

mlesney@frontlinemedcom.com

Completely percutaneous endovascular aortic aneurysm repair (PEVAR) has become more common, using the suture-mediated “preclose” technique. The rate of periprocedural, iatrogenic, acute deep vein thrombosis (DVT), hitherto unknown, was found to be low for this approach, according to a study reported by Dr. Courtney E. Morgan and her colleagues at the Northwestern University, Chicago.

The researchers assessed 52 consecutive patients (44 men) with a mean age of 73 years, who underwent PEVAR at their center. Only 6% had a prior history of DVT (J Vasc Surg. 2015 Aug; 62:351-4).

© Sebastian Kaulitzki/Thinkstock

Acute DVT was seen in four patients on postoperative day 1. These four DVTs comprised one femoropopliteal, and three calf DVTs. Three of these patients had associated risk factors: history of DVT (two patients); active smokers (one patient); and obesity (body mass index greater than 30 kg/m² in all three patients).

At 2 weeks postoperatively, 75% of the DVTs had resolved.

“We found an overall rate of proximal DVT of 4% after PEVAR, which increased to 13% when calf-vein DVTs were included. Most patients with postoperative DVT had preexisting risk factors, which suggests that routine duplex ultrasound screening after PEVAR is not necessary unless there exist preclinical risk factors or postprocedural clinical indications suggestive of DVT,” the authors concluded.

Two of the researchers have received funding and/or served as speakers/consultants for device companies involved in EVAR.

Read the full study online in the Journal of Vascular Surgery.

mlesney@frontlinemedcom.com

The new American Cancer Society (ACS) policy for mammography screening now recommends annual mammograms from age 45 until age 54, suggesting a less aggressive approach to screening than in the 2003 guidelines. The recommendation is for asymptomatic women at average risk of developing breast cancer.

Related: How Much Is Too Much Cancer Screening?

“These recommendations are made with the intent of maximizing reductions in breast cancer mortality and years of life saved while being attentive to the need to minimize harms associated with screening,” said Dr. Kevin C. Oeffinger, chairman of the breast cancer guideline panel.

Related: Advances in Targeted Therapy for Breast Cancer

The guideline, developed by a panel of outside experts, was published October 20, 2015, in The Journal of the American Medical Association.

Other important recommendation changes include:

• ŸWomen aged 45 to 54 years should receive annual screening mammography and at age 55 women should transition to biennial screening.
• ŸWomen should continue screening mammography as long as their overall health is good and they have a life expectancy of 10 years or longer.
• ŸClinical breast examination is no longer recommended at any age.
• ŸThe panel noted that the recommendations are an effort to avoid false positive findings, which can take an emotional toll.

The current VHA recommendations state:

• Mammography is not recommended for women aged 13 to 39 years.
• Women aged 40 to 49 years should talk with their health care providers about screening.
• ŸMammograms are recommended every 2 years for women aged 50 to 74 years.
• ŸWomen aged > 75 years should talk with their health care providers.

According to Anita Aggarwal, DO, PhD, president of the Association of VA Hematology and Oncology (AVAHO), the VHA recommendations leave a lot of wiggle room; every year starting at age 40 is still acceptable practice at the VA.

Related: Breast Cancer Research Group Aims to Improve Veteran Survival Rates

“Keep in mind that recommendations are just recommendations,” Dr. Aggarwal told Federal Practitioner. “One size may not fit all. I believe we should use our sound judgment based on valid research to recommend what is best for the patient. Based on my literature search, annual screening starting at 40 saves the most lives via early detection.”

The new American Cancer Society (ACS) policy for mammography screening now recommends annual mammograms from age 45 until age 54, suggesting a less aggressive approach to screening than in the 2003 guidelines. The recommendation is for asymptomatic women at average risk of developing breast cancer.

Related: How Much Is Too Much Cancer Screening?

“These recommendations are made with the intent of maximizing reductions in breast cancer mortality and years of life saved while being attentive to the need to minimize harms associated with screening,” said Dr. Kevin C. Oeffinger, chairman of the breast cancer guideline panel.

Related: Advances in Targeted Therapy for Breast Cancer

The guideline, developed by a panel of outside experts, was published October 20, 2015, in The Journal of the American Medical Association.

Other important recommendation changes include:

• ŸWomen aged 45 to 54 years should receive annual screening mammography and at age 55 women should transition to biennial screening.
• ŸWomen should continue screening mammography as long as their overall health is good and they have a life expectancy of 10 years or longer.
• ŸClinical breast examination is no longer recommended at any age.
• ŸThe panel noted that the recommendations are an effort to avoid false positive findings, which can take an emotional toll.

The current VHA recommendations state:

• Mammography is not recommended for women aged 13 to 39 years.
• Women aged 40 to 49 years should talk with their health care providers about screening.
• ŸMammograms are recommended every 2 years for women aged 50 to 74 years.
• ŸWomen aged > 75 years should talk with their health care providers.

According to Anita Aggarwal, DO, PhD, president of the Association of VA Hematology and Oncology (AVAHO), the VHA recommendations leave a lot of wiggle room; every year starting at age 40 is still acceptable practice at the VA.

Related: Breast Cancer Research Group Aims to Improve Veteran Survival Rates

“Keep in mind that recommendations are just recommendations,” Dr. Aggarwal told Federal Practitioner. “One size may not fit all. I believe we should use our sound judgment based on valid research to recommend what is best for the patient. Based on my literature search, annual screening starting at 40 saves the most lives via early detection.”

The new American Cancer Society (ACS) policy for mammography screening now recommends annual mammograms from age 45 until age 54, suggesting a less aggressive approach to screening than in the 2003 guidelines. The recommendation is for asymptomatic women at average risk of developing breast cancer.

Related: How Much Is Too Much Cancer Screening?

“These recommendations are made with the intent of maximizing reductions in breast cancer mortality and years of life saved while being attentive to the need to minimize harms associated with screening,” said Dr. Kevin C. Oeffinger, chairman of the breast cancer guideline panel.

Related: Advances in Targeted Therapy for Breast Cancer

The guideline, developed by a panel of outside experts, was published October 20, 2015, in The Journal of the American Medical Association.

Other important recommendation changes include:

• ŸWomen aged 45 to 54 years should receive annual screening mammography and at age 55 women should transition to biennial screening.
• ŸWomen should continue screening mammography as long as their overall health is good and they have a life expectancy of 10 years or longer.
• ŸClinical breast examination is no longer recommended at any age.
• ŸThe panel noted that the recommendations are an effort to avoid false positive findings, which can take an emotional toll.

The current VHA recommendations state:

• Mammography is not recommended for women aged 13 to 39 years.
• Women aged 40 to 49 years should talk with their health care providers about screening.
• ŸMammograms are recommended every 2 years for women aged 50 to 74 years.
• ŸWomen aged > 75 years should talk with their health care providers.

According to Anita Aggarwal, DO, PhD, president of the Association of VA Hematology and Oncology (AVAHO), the VHA recommendations leave a lot of wiggle room; every year starting at age 40 is still acceptable practice at the VA.

Related: Breast Cancer Research Group Aims to Improve Veteran Survival Rates

“Keep in mind that recommendations are just recommendations,” Dr. Aggarwal told Federal Practitioner. “One size may not fit all. I believe we should use our sound judgment based on valid research to recommend what is best for the patient. Based on my literature search, annual screening starting at 40 saves the most lives via early detection.”

A 35-year-old woman with asthma presents for a follow-up visit in October. You recommend that she receive the influenza vaccine. She tells you that she cannot take the influenza vaccine because she is allergic to eggs.

What do you recommend?

A. Give her the influenza vaccine.

B. Give her an oseltamivir prescription, and have her start it if any flu-like symptoms appear.

C. Give her the nasal influenza vaccine.

D. Give her the cell-based influenza vaccine.

The clinic I work in asks all patients if they have allergy to eggs before giving the influenza vaccine. If the patient replies yes, then the vaccine is not given and the physician is consulted.

For many years, allergy to egg was considered a contraindication to receiving the influenza vaccine. This contraindication was based on the fear that administering a vaccine that was grown in eggs and could contain egg protein might cause anaphylaxis in patients with immunoglobulin E antibodies against egg proteins.

Fortunately, there is a good evidence base that shows that administering influenza vaccine to patients with egg allergy is safe.

This is extremely important information, because it is estimated that there are about 200,000-300,000 hospitalizations annually because of influenza. For the 2012-2013 influenza season, the CDC estimated that the flu vaccine prevented 6.6 million cases of influenza, 3.2 million doctor visits, and 79,000 hospitalizations. There were 170 pediatric deaths from the flu during the 2012-2013 influenza season (MMWR Morb Mortal Wkly Rep. 2013 Dec 13;62[49]:997-1000). The need for widespread vaccination is great, and decreasing the number of people unable to receive the vaccine is an important goal.

Raquel Camacho Gómez/Thinkstock

There are many studies in children and adults that show that those with egg allergy can be safely vaccinated with influenza vaccine. Dr. John M. James and colleagues reported a study of mostly children with egg allergy confirmed with skin testing (average age of the study group was 3 years) receiving influenza vaccine (J Pediatr. 1998 Nov;133[5]:624-8). A total of 83 patients with egg allergy received the vaccine (including 27 patients with a history of anaphylaxis or severe reactions after egg ingestion). No patients suffered severe reactions with the vaccine, with only four patients having mild, self-limited symptoms.

In another study, Dr. Anne Des Roches and colleagues performed a prospective, cohort study recruiting and vaccinating egg-allergic patients with trivalent inactivated influenza vaccine between 2010 and 2012 (J Allergy Clin Immunol. 2012 Nov;130[5]:1213-1216.e1). In the second year of the study, the focus was on recruiting patients with a history of anaphylaxis or severe cardiopulmonary symptoms upon egg ingestion. In addition, a retrospective study of all egg-allergic patients who had received an influenza vaccine between 2007 and 2010 was included.

A total of 457 doses of vaccine were administered to 367 patients with egg allergy, of whom 132 had a history of severe allergy. No patients developed anaphylaxis, and 13 patients developed mild allergiclike symptoms in the 24 hours after vaccination.

In an authoritative review on the subject of influenza vaccination in egg-allergic patients, Dr. John Kelso reported on 28 studies with a total of 4,315 patients with egg allergy, including 656 with history of anaphylaxis with egg ingestion (Expert Rev Vaccines. 2014 Aug;13[8]:1049-57). None of these patients developed a serious reaction when they received influenza vaccine.

Dr. Des Roches and colleagues reported on a prospective, cohort study in which 68 children with previous egg allergy received intranasal live attenuated influenza vaccine (J Allergy Clin Immunol Pract. 2015 Jan-Feb;3[1]:138-9). No patients had anaphylaxis or a severe allergic reaction. There were more adverse reactions in the patients with egg (7 patients) than in the control group (1 patient), but these were mild and nonspecific (abdominal pain, nasal congestion, headache, and cough).

The 2012 adverse reactions to vaccines practice parameter update recommended that patients with egg allergy should receive influenza vaccinations (trivalent influenza vaccine), because the risks of vaccinating are outweighed by the risks of not vaccinating (J Allergy Clin Immunol. 2012 Jul;130[1]:25-43).

A subsequent recommendation takes this a step further, recommending that all patients with egg allergy of any severity should receive inactivated influenza vaccine annually, using any age-approved brand (Ann Allergy Asthma Immunol. 2013 Oct;111[4]:301-2). In addition, there are no special waiting periods after vaccination of egg allergic patients beyond what is standard practice for any vaccine.

I think that we have plenty of evidence now to immunize all patients who report egg allergy, and to do so in the primary care setting.

Dr. Paauw is professor of medicine in the division of general internal medicine at the University of Washington, Seattle, and he serves as third-year medical student clerkship director at the University of Washington. Contact Dr. Paauw at dpaauw@uw.edu.

A 35-year-old woman with asthma presents for a follow-up visit in October. You recommend that she receive the influenza vaccine. She tells you that she cannot take the influenza vaccine because she is allergic to eggs.

What do you recommend?

A. Give her the influenza vaccine.

B. Give her an oseltamivir prescription, and have her start it if any flu-like symptoms appear.

C. Give her the nasal influenza vaccine.

D. Give her the cell-based influenza vaccine.

The clinic I work in asks all patients if they have allergy to eggs before giving the influenza vaccine. If the patient replies yes, then the vaccine is not given and the physician is consulted.

For many years, allergy to egg was considered a contraindication to receiving the influenza vaccine. This contraindication was based on the fear that administering a vaccine that was grown in eggs and could contain egg protein might cause anaphylaxis in patients with immunoglobulin E antibodies against egg proteins.

Fortunately, there is a good evidence base that shows that administering influenza vaccine to patients with egg allergy is safe.

This is extremely important information, because it is estimated that there are about 200,000-300,000 hospitalizations annually because of influenza. For the 2012-2013 influenza season, the CDC estimated that the flu vaccine prevented 6.6 million cases of influenza, 3.2 million doctor visits, and 79,000 hospitalizations. There were 170 pediatric deaths from the flu during the 2012-2013 influenza season (MMWR Morb Mortal Wkly Rep. 2013 Dec 13;62[49]:997-1000). The need for widespread vaccination is great, and decreasing the number of people unable to receive the vaccine is an important goal.

Raquel Camacho Gómez/Thinkstock

There are many studies in children and adults that show that those with egg allergy can be safely vaccinated with influenza vaccine. Dr. John M. James and colleagues reported a study of mostly children with egg allergy confirmed with skin testing (average age of the study group was 3 years) receiving influenza vaccine (J Pediatr. 1998 Nov;133[5]:624-8). A total of 83 patients with egg allergy received the vaccine (including 27 patients with a history of anaphylaxis or severe reactions after egg ingestion). No patients suffered severe reactions with the vaccine, with only four patients having mild, self-limited symptoms.

In another study, Dr. Anne Des Roches and colleagues performed a prospective, cohort study recruiting and vaccinating egg-allergic patients with trivalent inactivated influenza vaccine between 2010 and 2012 (J Allergy Clin Immunol. 2012 Nov;130[5]:1213-1216.e1). In the second year of the study, the focus was on recruiting patients with a history of anaphylaxis or severe cardiopulmonary symptoms upon egg ingestion. In addition, a retrospective study of all egg-allergic patients who had received an influenza vaccine between 2007 and 2010 was included.

A total of 457 doses of vaccine were administered to 367 patients with egg allergy, of whom 132 had a history of severe allergy. No patients developed anaphylaxis, and 13 patients developed mild allergiclike symptoms in the 24 hours after vaccination.

In an authoritative review on the subject of influenza vaccination in egg-allergic patients, Dr. John Kelso reported on 28 studies with a total of 4,315 patients with egg allergy, including 656 with history of anaphylaxis with egg ingestion (Expert Rev Vaccines. 2014 Aug;13[8]:1049-57). None of these patients developed a serious reaction when they received influenza vaccine.

Dr. Des Roches and colleagues reported on a prospective, cohort study in which 68 children with previous egg allergy received intranasal live attenuated influenza vaccine (J Allergy Clin Immunol Pract. 2015 Jan-Feb;3[1]:138-9). No patients had anaphylaxis or a severe allergic reaction. There were more adverse reactions in the patients with egg (7 patients) than in the control group (1 patient), but these were mild and nonspecific (abdominal pain, nasal congestion, headache, and cough).

The 2012 adverse reactions to vaccines practice parameter update recommended that patients with egg allergy should receive influenza vaccinations (trivalent influenza vaccine), because the risks of vaccinating are outweighed by the risks of not vaccinating (J Allergy Clin Immunol. 2012 Jul;130[1]:25-43).

A subsequent recommendation takes this a step further, recommending that all patients with egg allergy of any severity should receive inactivated influenza vaccine annually, using any age-approved brand (Ann Allergy Asthma Immunol. 2013 Oct;111[4]:301-2). In addition, there are no special waiting periods after vaccination of egg allergic patients beyond what is standard practice for any vaccine.

I think that we have plenty of evidence now to immunize all patients who report egg allergy, and to do so in the primary care setting.

Dr. Paauw is professor of medicine in the division of general internal medicine at the University of Washington, Seattle, and he serves as third-year medical student clerkship director at the University of Washington. Contact Dr. Paauw at dpaauw@uw.edu.

A 35-year-old woman with asthma presents for a follow-up visit in October. You recommend that she receive the influenza vaccine. She tells you that she cannot take the influenza vaccine because she is allergic to eggs.

What do you recommend?

A. Give her the influenza vaccine.

B. Give her an oseltamivir prescription, and have her start it if any flu-like symptoms appear.

C. Give her the nasal influenza vaccine.

D. Give her the cell-based influenza vaccine.

The clinic I work in asks all patients if they have allergy to eggs before giving the influenza vaccine. If the patient replies yes, then the vaccine is not given and the physician is consulted.

For many years, allergy to egg was considered a contraindication to receiving the influenza vaccine. This contraindication was based on the fear that administering a vaccine that was grown in eggs and could contain egg protein might cause anaphylaxis in patients with immunoglobulin E antibodies against egg proteins.

Fortunately, there is a good evidence base that shows that administering influenza vaccine to patients with egg allergy is safe.

This is extremely important information, because it is estimated that there are about 200,000-300,000 hospitalizations annually because of influenza. For the 2012-2013 influenza season, the CDC estimated that the flu vaccine prevented 6.6 million cases of influenza, 3.2 million doctor visits, and 79,000 hospitalizations. There were 170 pediatric deaths from the flu during the 2012-2013 influenza season (MMWR Morb Mortal Wkly Rep. 2013 Dec 13;62[49]:997-1000). The need for widespread vaccination is great, and decreasing the number of people unable to receive the vaccine is an important goal.

Raquel Camacho Gómez/Thinkstock

There are many studies in children and adults that show that those with egg allergy can be safely vaccinated with influenza vaccine. Dr. John M. James and colleagues reported a study of mostly children with egg allergy confirmed with skin testing (average age of the study group was 3 years) receiving influenza vaccine (J Pediatr. 1998 Nov;133[5]:624-8). A total of 83 patients with egg allergy received the vaccine (including 27 patients with a history of anaphylaxis or severe reactions after egg ingestion). No patients suffered severe reactions with the vaccine, with only four patients having mild, self-limited symptoms.

In another study, Dr. Anne Des Roches and colleagues performed a prospective, cohort study recruiting and vaccinating egg-allergic patients with trivalent inactivated influenza vaccine between 2010 and 2012 (J Allergy Clin Immunol. 2012 Nov;130[5]:1213-1216.e1). In the second year of the study, the focus was on recruiting patients with a history of anaphylaxis or severe cardiopulmonary symptoms upon egg ingestion. In addition, a retrospective study of all egg-allergic patients who had received an influenza vaccine between 2007 and 2010 was included.

A total of 457 doses of vaccine were administered to 367 patients with egg allergy, of whom 132 had a history of severe allergy. No patients developed anaphylaxis, and 13 patients developed mild allergiclike symptoms in the 24 hours after vaccination.

In an authoritative review on the subject of influenza vaccination in egg-allergic patients, Dr. John Kelso reported on 28 studies with a total of 4,315 patients with egg allergy, including 656 with history of anaphylaxis with egg ingestion (Expert Rev Vaccines. 2014 Aug;13[8]:1049-57). None of these patients developed a serious reaction when they received influenza vaccine.

Dr. Des Roches and colleagues reported on a prospective, cohort study in which 68 children with previous egg allergy received intranasal live attenuated influenza vaccine (J Allergy Clin Immunol Pract. 2015 Jan-Feb;3[1]:138-9). No patients had anaphylaxis or a severe allergic reaction. There were more adverse reactions in the patients with egg (7 patients) than in the control group (1 patient), but these were mild and nonspecific (abdominal pain, nasal congestion, headache, and cough).

The 2012 adverse reactions to vaccines practice parameter update recommended that patients with egg allergy should receive influenza vaccinations (trivalent influenza vaccine), because the risks of vaccinating are outweighed by the risks of not vaccinating (J Allergy Clin Immunol. 2012 Jul;130[1]:25-43).

A subsequent recommendation takes this a step further, recommending that all patients with egg allergy of any severity should receive inactivated influenza vaccine annually, using any age-approved brand (Ann Allergy Asthma Immunol. 2013 Oct;111[4]:301-2). In addition, there are no special waiting periods after vaccination of egg allergic patients beyond what is standard practice for any vaccine.

I think that we have plenty of evidence now to immunize all patients who report egg allergy, and to do so in the primary care setting.

Dr. Paauw is professor of medicine in the division of general internal medicine at the University of Washington, Seattle, and he serves as third-year medical student clerkship director at the University of Washington. Contact Dr. Paauw at dpaauw@uw.edu.

LAKE BUENA VISTA, FLA. – An outpatient procedure may represent an efficacious and safe alternative to surgery for those patients with small papillary thyroid cancers who prefer definitive treatment over the “wait and watch” approach. Further, at one institution, the cost-effective alternative to surgery saved almost $40,000 per patient.

Ultrasound-guided percutaneous ethanol injection (UPEA) of small (cT1N0) intrathyroidal papillary thyroid cancer (SIPC) successfully reduced tumor volume by a median of 92%, eliminated tumor blood flow, and was very well tolerated by a series of 13 patients who received UPEA at the Mayo Clinic, Rochester, Minn.

Dr. Ian D. Hay, a consultant in Mayo’s division of endocrinology, diabetes, metabolism, and nutrition, presented the findings during a poster session at the International Thyroid Congress.

Dr. Hay and his colleagues treated 13 patients with a total of 15 tumors with injections of percutaneous ethanol. The first patient received just one injection; the remaining patients received one injection to each tumor site on each of 2 consecutive days. Five of the tumor foci had less than a 50% reduction in tumor volume at the first follow-up visit, so those tumors were injected a third time.

Patients in the series ranged from 38 to 86 years old (median 45), and five patients had significant comorbidities: one had congestive heart failure and the other four had concomitant unrelated cancers. Tumors were a median 8 mm in size, with volumes ranging from 25 to 676 mm³ (median 140 mm³).

All of the injections were performed under ultrasound guidance, and a median of 0.9 cc of ethanol was injected into each tumor. Ultrasound examination was performed at each follow-up visit to evaluate tumor volume and blood flow. Dr. Hay reported that the procedure was well tolerated: Local neck tenderness resolved within a day or two, and there were no reports of hoarseness or laryngeal nerve palsy.

Patients were followed for a mean 2.0 years (range, 0.4-5.7 years), with a median tumor reduction of 92% (range 46%-100%). For the nine tumors that were still identifiable on ultrasound at the time of reporting, the mean volume had decreased by 73%. Six tumor foci had completely disappeared, and no tumor had detectable blood flow on Doppler exam. Tumor thyroglobulin levels remained stable in all patients, and no nodal metastases were identified, Dr. Hay reported at the meeting, which was held by the American Thyroid Association, Asia-Oceania Thyroid Association, European Thyroid Association, and Latin American Thyroid Society.

Internationally, the approach to managing SIPC varies from lobectomy to near-total thyroidectomy to active surveillance. For patients who prefer definitive management of their tumors but are reluctant to have surgery or who may have significant comorbidities, UPEA may represent a safe alternative, and at significant cost savings compared to surgery: Dr. Hay and his colleagues reported that they estimated the average cost savings at their institution to be over $38,000 per patient. “If prospective trials of observation vs. surgery for SIPC are to occur in the USA, perhaps it could be included as a ‘third arm’ in such trials,” Dr. Hay and his colleagues said.

koakes@frontlinemedcom.com

On Twitter @karioakes

LAKE BUENA VISTA, FLA. – An outpatient procedure may represent an efficacious and safe alternative to surgery for those patients with small papillary thyroid cancers who prefer definitive treatment over the “wait and watch” approach. Further, at one institution, the cost-effective alternative to surgery saved almost $40,000 per patient.

Ultrasound-guided percutaneous ethanol injection (UPEA) of small (cT1N0) intrathyroidal papillary thyroid cancer (SIPC) successfully reduced tumor volume by a median of 92%, eliminated tumor blood flow, and was very well tolerated by a series of 13 patients who received UPEA at the Mayo Clinic, Rochester, Minn.

Dr. Ian D. Hay, a consultant in Mayo’s division of endocrinology, diabetes, metabolism, and nutrition, presented the findings during a poster session at the International Thyroid Congress.

Dr. Hay and his colleagues treated 13 patients with a total of 15 tumors with injections of percutaneous ethanol. The first patient received just one injection; the remaining patients received one injection to each tumor site on each of 2 consecutive days. Five of the tumor foci had less than a 50% reduction in tumor volume at the first follow-up visit, so those tumors were injected a third time.

Patients in the series ranged from 38 to 86 years old (median 45), and five patients had significant comorbidities: one had congestive heart failure and the other four had concomitant unrelated cancers. Tumors were a median 8 mm in size, with volumes ranging from 25 to 676 mm³ (median 140 mm³).

All of the injections were performed under ultrasound guidance, and a median of 0.9 cc of ethanol was injected into each tumor. Ultrasound examination was performed at each follow-up visit to evaluate tumor volume and blood flow. Dr. Hay reported that the procedure was well tolerated: Local neck tenderness resolved within a day or two, and there were no reports of hoarseness or laryngeal nerve palsy.

Patients were followed for a mean 2.0 years (range, 0.4-5.7 years), with a median tumor reduction of 92% (range 46%-100%). For the nine tumors that were still identifiable on ultrasound at the time of reporting, the mean volume had decreased by 73%. Six tumor foci had completely disappeared, and no tumor had detectable blood flow on Doppler exam. Tumor thyroglobulin levels remained stable in all patients, and no nodal metastases were identified, Dr. Hay reported at the meeting, which was held by the American Thyroid Association, Asia-Oceania Thyroid Association, European Thyroid Association, and Latin American Thyroid Society.

Internationally, the approach to managing SIPC varies from lobectomy to near-total thyroidectomy to active surveillance. For patients who prefer definitive management of their tumors but are reluctant to have surgery or who may have significant comorbidities, UPEA may represent a safe alternative, and at significant cost savings compared to surgery: Dr. Hay and his colleagues reported that they estimated the average cost savings at their institution to be over $38,000 per patient. “If prospective trials of observation vs. surgery for SIPC are to occur in the USA, perhaps it could be included as a ‘third arm’ in such trials,” Dr. Hay and his colleagues said.

koakes@frontlinemedcom.com

On Twitter @karioakes

LAKE BUENA VISTA, FLA. – An outpatient procedure may represent an efficacious and safe alternative to surgery for those patients with small papillary thyroid cancers who prefer definitive treatment over the “wait and watch” approach. Further, at one institution, the cost-effective alternative to surgery saved almost $40,000 per patient.

Ultrasound-guided percutaneous ethanol injection (UPEA) of small (cT1N0) intrathyroidal papillary thyroid cancer (SIPC) successfully reduced tumor volume by a median of 92%, eliminated tumor blood flow, and was very well tolerated by a series of 13 patients who received UPEA at the Mayo Clinic, Rochester, Minn.

Dr. Ian D. Hay, a consultant in Mayo’s division of endocrinology, diabetes, metabolism, and nutrition, presented the findings during a poster session at the International Thyroid Congress.

Dr. Hay and his colleagues treated 13 patients with a total of 15 tumors with injections of percutaneous ethanol. The first patient received just one injection; the remaining patients received one injection to each tumor site on each of 2 consecutive days. Five of the tumor foci had less than a 50% reduction in tumor volume at the first follow-up visit, so those tumors were injected a third time.

Patients in the series ranged from 38 to 86 years old (median 45), and five patients had significant comorbidities: one had congestive heart failure and the other four had concomitant unrelated cancers. Tumors were a median 8 mm in size, with volumes ranging from 25 to 676 mm³ (median 140 mm³).

All of the injections were performed under ultrasound guidance, and a median of 0.9 cc of ethanol was injected into each tumor. Ultrasound examination was performed at each follow-up visit to evaluate tumor volume and blood flow. Dr. Hay reported that the procedure was well tolerated: Local neck tenderness resolved within a day or two, and there were no reports of hoarseness or laryngeal nerve palsy.

Patients were followed for a mean 2.0 years (range, 0.4-5.7 years), with a median tumor reduction of 92% (range 46%-100%). For the nine tumors that were still identifiable on ultrasound at the time of reporting, the mean volume had decreased by 73%. Six tumor foci had completely disappeared, and no tumor had detectable blood flow on Doppler exam. Tumor thyroglobulin levels remained stable in all patients, and no nodal metastases were identified, Dr. Hay reported at the meeting, which was held by the American Thyroid Association, Asia-Oceania Thyroid Association, European Thyroid Association, and Latin American Thyroid Society.

Internationally, the approach to managing SIPC varies from lobectomy to near-total thyroidectomy to active surveillance. For patients who prefer definitive management of their tumors but are reluctant to have surgery or who may have significant comorbidities, UPEA may represent a safe alternative, and at significant cost savings compared to surgery: Dr. Hay and his colleagues reported that they estimated the average cost savings at their institution to be over $38,000 per patient. “If prospective trials of observation vs. surgery for SIPC are to occur in the USA, perhaps it could be included as a ‘third arm’ in such trials,” Dr. Hay and his colleagues said.

koakes@frontlinemedcom.com

On Twitter @karioakes