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Adenotonsillectomy reduced hypertension in OSA subgroup
after surgery, according to a retrospective analysis.
This is one of the few studies to have ever examined whether adenotonsillectomy for children with OSA had any effects on blood pressure (BP) and was based on “one of the largest cohorts for evaluating postoperative BP changes in nonobese children with OSA,” noted Cho-Hsueh Lee, MD, and colleagues. The report was published in JAMA Otolaryngology–Head & Neck Surgery. Among the previous studies that evaluated BP in children with OSA before and after having this surgery, the results varied, they added.
The researchers analyzed the medical records of 240 nonobese children with clinical symptoms and polysomnography-confirmed OSA (having an apnea-hypopnea index of greater than 1) who underwent adenotonsillectomy. Prior to surgery, 169 patients (70.4%) of the patients were classified as nonhypertensive, while 71 (29.6%) were classified as hypertensive. The children had a mean age of 7.3 years, and 160 were males.
Patients participated in full-night polysomnography (PSG) before surgery and at 3-6 months after adenotonsillectomy in the National Taiwan University Hospital Sleep Center. Apnea episodes were defined as a 90% decrease in airflow for two consecutive breaths. Sleep center staff measured the study participants’ systolic and diastolic BP in a sleep center using an electronic sphygmomanometer, in the evening, prior to the PSG study, and in the morning. Pediatric hypertension was based on the nocturnal BP measurement and was defined as having mean systolic and diastolic BP greater or equal to the 95th percentile for age, sex, and height.
“Postoperatively, hypertensive children had a significant decrease in all BP measures, including nocturnal and morning [systolic] BP ... A total of 47 hypertensive patients (66.2%) became nonhypertensive after surgery,” the researchers said.
For patients who were hypertensive before surgery, the average nocturnal (before PSG) preop systolic BP was 114.3 mm Hg, versus 107.5 mm Hg after surgery. The mean nocturnal diastolic BP for this same group of patients decreased to 65.1 mm Hg from 74.3 mm Hg. Similarly, the average morning (after PSG) systolic BP and diastolic BP were 106.0 mm Hg and 64.4 mm Hg after these patients underwent adenotonsillectomy, compared with 111.8 mm Hg and 71.7 mm Hg prior to surgery, respectively.
The adenotonsillectomy didn’t improve all patients’ BP. For some who were nonhypertensive before surgery, blood pressure increased, with 36 (21.3%) of this group having become hypersensitive after surgery, the researchers acknowledged.
Overall, the cohort experienced significant improvements in several PSG measures, including the average apnea-hypopnea index, which decreased from 12.1 events per hour to 1.7. The total arousal index also declined, going from 6.1 events per hour to 4.2. In addition, the mean oxygen saturation improved from 96.8% to 97.7%.
The investigators described several limitations of the study, including their inability to collect patients’ arterial stiffness, carotid intima thickness, and other cardiovascular measures beyond BP.
They recommended a follow-up study. “Although we observed improvements in BP measures within 6 months after surgery for hypertensive children with OSA, the long-term effects of surgery on BP remain uncertain,” they explained.
The study was supported by grants from the Ministry of Science and Technology, Republic of China (Taiwan). The researchers disclosed no potential conflicts of interest.
SOURCE: Lee, C-H et al. JAMA Otolaryngol Head Neck Surg. 2018 Feb 15. doi: 10.1001/jamaoto.2017.3127.
after surgery, according to a retrospective analysis.
This is one of the few studies to have ever examined whether adenotonsillectomy for children with OSA had any effects on blood pressure (BP) and was based on “one of the largest cohorts for evaluating postoperative BP changes in nonobese children with OSA,” noted Cho-Hsueh Lee, MD, and colleagues. The report was published in JAMA Otolaryngology–Head & Neck Surgery. Among the previous studies that evaluated BP in children with OSA before and after having this surgery, the results varied, they added.
The researchers analyzed the medical records of 240 nonobese children with clinical symptoms and polysomnography-confirmed OSA (having an apnea-hypopnea index of greater than 1) who underwent adenotonsillectomy. Prior to surgery, 169 patients (70.4%) of the patients were classified as nonhypertensive, while 71 (29.6%) were classified as hypertensive. The children had a mean age of 7.3 years, and 160 were males.
Patients participated in full-night polysomnography (PSG) before surgery and at 3-6 months after adenotonsillectomy in the National Taiwan University Hospital Sleep Center. Apnea episodes were defined as a 90% decrease in airflow for two consecutive breaths. Sleep center staff measured the study participants’ systolic and diastolic BP in a sleep center using an electronic sphygmomanometer, in the evening, prior to the PSG study, and in the morning. Pediatric hypertension was based on the nocturnal BP measurement and was defined as having mean systolic and diastolic BP greater or equal to the 95th percentile for age, sex, and height.
“Postoperatively, hypertensive children had a significant decrease in all BP measures, including nocturnal and morning [systolic] BP ... A total of 47 hypertensive patients (66.2%) became nonhypertensive after surgery,” the researchers said.
For patients who were hypertensive before surgery, the average nocturnal (before PSG) preop systolic BP was 114.3 mm Hg, versus 107.5 mm Hg after surgery. The mean nocturnal diastolic BP for this same group of patients decreased to 65.1 mm Hg from 74.3 mm Hg. Similarly, the average morning (after PSG) systolic BP and diastolic BP were 106.0 mm Hg and 64.4 mm Hg after these patients underwent adenotonsillectomy, compared with 111.8 mm Hg and 71.7 mm Hg prior to surgery, respectively.
The adenotonsillectomy didn’t improve all patients’ BP. For some who were nonhypertensive before surgery, blood pressure increased, with 36 (21.3%) of this group having become hypersensitive after surgery, the researchers acknowledged.
Overall, the cohort experienced significant improvements in several PSG measures, including the average apnea-hypopnea index, which decreased from 12.1 events per hour to 1.7. The total arousal index also declined, going from 6.1 events per hour to 4.2. In addition, the mean oxygen saturation improved from 96.8% to 97.7%.
The investigators described several limitations of the study, including their inability to collect patients’ arterial stiffness, carotid intima thickness, and other cardiovascular measures beyond BP.
They recommended a follow-up study. “Although we observed improvements in BP measures within 6 months after surgery for hypertensive children with OSA, the long-term effects of surgery on BP remain uncertain,” they explained.
The study was supported by grants from the Ministry of Science and Technology, Republic of China (Taiwan). The researchers disclosed no potential conflicts of interest.
SOURCE: Lee, C-H et al. JAMA Otolaryngol Head Neck Surg. 2018 Feb 15. doi: 10.1001/jamaoto.2017.3127.
after surgery, according to a retrospective analysis.
This is one of the few studies to have ever examined whether adenotonsillectomy for children with OSA had any effects on blood pressure (BP) and was based on “one of the largest cohorts for evaluating postoperative BP changes in nonobese children with OSA,” noted Cho-Hsueh Lee, MD, and colleagues. The report was published in JAMA Otolaryngology–Head & Neck Surgery. Among the previous studies that evaluated BP in children with OSA before and after having this surgery, the results varied, they added.
The researchers analyzed the medical records of 240 nonobese children with clinical symptoms and polysomnography-confirmed OSA (having an apnea-hypopnea index of greater than 1) who underwent adenotonsillectomy. Prior to surgery, 169 patients (70.4%) of the patients were classified as nonhypertensive, while 71 (29.6%) were classified as hypertensive. The children had a mean age of 7.3 years, and 160 were males.
Patients participated in full-night polysomnography (PSG) before surgery and at 3-6 months after adenotonsillectomy in the National Taiwan University Hospital Sleep Center. Apnea episodes were defined as a 90% decrease in airflow for two consecutive breaths. Sleep center staff measured the study participants’ systolic and diastolic BP in a sleep center using an electronic sphygmomanometer, in the evening, prior to the PSG study, and in the morning. Pediatric hypertension was based on the nocturnal BP measurement and was defined as having mean systolic and diastolic BP greater or equal to the 95th percentile for age, sex, and height.
“Postoperatively, hypertensive children had a significant decrease in all BP measures, including nocturnal and morning [systolic] BP ... A total of 47 hypertensive patients (66.2%) became nonhypertensive after surgery,” the researchers said.
For patients who were hypertensive before surgery, the average nocturnal (before PSG) preop systolic BP was 114.3 mm Hg, versus 107.5 mm Hg after surgery. The mean nocturnal diastolic BP for this same group of patients decreased to 65.1 mm Hg from 74.3 mm Hg. Similarly, the average morning (after PSG) systolic BP and diastolic BP were 106.0 mm Hg and 64.4 mm Hg after these patients underwent adenotonsillectomy, compared with 111.8 mm Hg and 71.7 mm Hg prior to surgery, respectively.
The adenotonsillectomy didn’t improve all patients’ BP. For some who were nonhypertensive before surgery, blood pressure increased, with 36 (21.3%) of this group having become hypersensitive after surgery, the researchers acknowledged.
Overall, the cohort experienced significant improvements in several PSG measures, including the average apnea-hypopnea index, which decreased from 12.1 events per hour to 1.7. The total arousal index also declined, going from 6.1 events per hour to 4.2. In addition, the mean oxygen saturation improved from 96.8% to 97.7%.
The investigators described several limitations of the study, including their inability to collect patients’ arterial stiffness, carotid intima thickness, and other cardiovascular measures beyond BP.
They recommended a follow-up study. “Although we observed improvements in BP measures within 6 months after surgery for hypertensive children with OSA, the long-term effects of surgery on BP remain uncertain,” they explained.
The study was supported by grants from the Ministry of Science and Technology, Republic of China (Taiwan). The researchers disclosed no potential conflicts of interest.
SOURCE: Lee, C-H et al. JAMA Otolaryngol Head Neck Surg. 2018 Feb 15. doi: 10.1001/jamaoto.2017.3127.
FROM JAMA OTOLARYNGOLOGY-HEAD & NECK SURGERY
Key clinical point: Hypertensive children with obstructive sleep apnea (OSA) who had an adenotonsillectomy experienced significant improvements in their blood pressure after surgery.
Major finding: Sixty-six percent of hypertensive patients with OSA became nonhypertensive after adenotonsillectomy.
Study details: A retrospective analysis of 240 nonobese children with OSA who underwent adenotonsillectomy.
Disclosures: The study was supported by grants from the Ministry of Science and Technology, Republic of China (Taiwan). The researchers disclosed no potential conflicts of interest.
Source: Lee, C-H et al. JAMA Otolaryngol Head Neck Surg. 2018 Feb 15. doi: 10.1001/jamaoto.2017.3127.
Sleep disturbance not linked to age or IQ in early ASD
Sleep disturbance is not associated with age and IQ in young children with autism spectrum disorder (ASD) and disruptive behaviors, according to Cynthia R. Johnson, PhD, and her associates.
They assessed 177 children aged 3-7 who were participating in the Research Units on Behavioral Intervention study, a 24-week trial. All of the children had a diagnosis of autism spectrum disorder, based on DSM-IV criteria. The diagnoses were corroborated by the Autism Diagnostic Observation Schedule and the Autism Diagnostic Interview–Revised.
The children were randomized into a parent training group or a parent education group. After getting parents to complete several forms, including the Children’s Sleep Habits Questionnaire, Dr. Johnson and her associates found no age differences between children who fell into the category of “good sleepers” (n = 52), and those characterized as “poor sleepers” (n = 46) (P = .57). In both sleep groups, more than 70% of the children had an IQ of 70 or above, and no significant difference was found in good sleepers, compared with poor sleepers, in IQ variable (P = .87) (Sleep Med. 2018. 44:61-6).
In addition, the researchers found that poor sleepers had significantly higher scores on the Aberrant Behavior Checklist subscales of irritability, hyperactivity, stereotypic behavior, and social withdrawal/lethargy, compared with good sleepers. All subscales of the parenting stress index and the PSI total score also were significantly higher in the poor sleepers group, compared with children in the good sleepers group, reported Dr. Johnson of the University of Florida, Gainesville, and her associates.
Additional studies are needed within a “comprehensive biopsychosocial model” to advance the understanding of why some children with autism experience disrupted sleep patterns and others do not. “, regardless of age and cognitive level,” Dr. Johnson and her associates concluded. “With improved sleep, better outcomes for children with ASD could be expected.”
Read the full study in Sleep Medicine
Sleep disturbance is not associated with age and IQ in young children with autism spectrum disorder (ASD) and disruptive behaviors, according to Cynthia R. Johnson, PhD, and her associates.
They assessed 177 children aged 3-7 who were participating in the Research Units on Behavioral Intervention study, a 24-week trial. All of the children had a diagnosis of autism spectrum disorder, based on DSM-IV criteria. The diagnoses were corroborated by the Autism Diagnostic Observation Schedule and the Autism Diagnostic Interview–Revised.
The children were randomized into a parent training group or a parent education group. After getting parents to complete several forms, including the Children’s Sleep Habits Questionnaire, Dr. Johnson and her associates found no age differences between children who fell into the category of “good sleepers” (n = 52), and those characterized as “poor sleepers” (n = 46) (P = .57). In both sleep groups, more than 70% of the children had an IQ of 70 or above, and no significant difference was found in good sleepers, compared with poor sleepers, in IQ variable (P = .87) (Sleep Med. 2018. 44:61-6).
In addition, the researchers found that poor sleepers had significantly higher scores on the Aberrant Behavior Checklist subscales of irritability, hyperactivity, stereotypic behavior, and social withdrawal/lethargy, compared with good sleepers. All subscales of the parenting stress index and the PSI total score also were significantly higher in the poor sleepers group, compared with children in the good sleepers group, reported Dr. Johnson of the University of Florida, Gainesville, and her associates.
Additional studies are needed within a “comprehensive biopsychosocial model” to advance the understanding of why some children with autism experience disrupted sleep patterns and others do not. “, regardless of age and cognitive level,” Dr. Johnson and her associates concluded. “With improved sleep, better outcomes for children with ASD could be expected.”
Read the full study in Sleep Medicine
Sleep disturbance is not associated with age and IQ in young children with autism spectrum disorder (ASD) and disruptive behaviors, according to Cynthia R. Johnson, PhD, and her associates.
They assessed 177 children aged 3-7 who were participating in the Research Units on Behavioral Intervention study, a 24-week trial. All of the children had a diagnosis of autism spectrum disorder, based on DSM-IV criteria. The diagnoses were corroborated by the Autism Diagnostic Observation Schedule and the Autism Diagnostic Interview–Revised.
The children were randomized into a parent training group or a parent education group. After getting parents to complete several forms, including the Children’s Sleep Habits Questionnaire, Dr. Johnson and her associates found no age differences between children who fell into the category of “good sleepers” (n = 52), and those characterized as “poor sleepers” (n = 46) (P = .57). In both sleep groups, more than 70% of the children had an IQ of 70 or above, and no significant difference was found in good sleepers, compared with poor sleepers, in IQ variable (P = .87) (Sleep Med. 2018. 44:61-6).
In addition, the researchers found that poor sleepers had significantly higher scores on the Aberrant Behavior Checklist subscales of irritability, hyperactivity, stereotypic behavior, and social withdrawal/lethargy, compared with good sleepers. All subscales of the parenting stress index and the PSI total score also were significantly higher in the poor sleepers group, compared with children in the good sleepers group, reported Dr. Johnson of the University of Florida, Gainesville, and her associates.
Additional studies are needed within a “comprehensive biopsychosocial model” to advance the understanding of why some children with autism experience disrupted sleep patterns and others do not. “, regardless of age and cognitive level,” Dr. Johnson and her associates concluded. “With improved sleep, better outcomes for children with ASD could be expected.”
Read the full study in Sleep Medicine
FROM SLEEP MEDICINE
Suicidal behaviors are associated with discordant sexual orientation in teens
Teenagers with discordant sexual orientation are more likely to experience nonfatal suicidal behaviors, according to results of a study published in the American Journal of Preventative Medicine.
“In this study, discordance refers to reporting sexual contact that is inconsistent with a respondent’s sexual identity. ... Discrimination, stigma, prejudice, rejection, and societal norms may put pressure on sexual minorities to present a sexual identity inconsistent with their true sexual identity or to act in a manner inconsistent with their sexual identity,” said Francis Annor, PhD, of the Centers for Disease Control and Prevention, and fellow investigators.
“In considering the health and well-being of youth, sexual identity and sexual behavior and their intersection should be considered for their association with the mental health and well-being of adolescents,” according to Dr. Annor and his colleagues. “Some adolescents reporting discordance may have needs that should be considered when developing and implementing suicide prevention programs.”
For this study, investigators analyzed survey questions from 6,790 high school students queried during the 2015 national Youth Risk Behavior Survey.
Sexual discordance was measured by asking students their sexual orientation and the gender of any sexual partners they may have had. Students who responded as being bisexual or who had not experienced sexual contact before were excluded from final analysis.
Students were majority male (56% vs. 44%), white (54.8%), and heterosexual (97.8%), and sexually concordant (96.1%).
When analyzing suicidal tendencies among students, teens who were sexually discordant were 70% more likely to report thinking about, or planning, suicide. High risk for nonfatal suicidal behaviors was significantly more common among discordant students, compared with concordant students (46.3% vs .22.4%, P less than .0001). Students who were gay or lesbian were significantly more likely to report sexual orientation discordance than heterosexual students (32% vs. 3%, P less than .001).
Sexual discordance also was common among students who were female, black, bullied on school property, used marijuana, or physically forced to have sexual intercourse.
Dr. Annor and fellow investigators theorized that the association between discordance and suicidal ideation may stem from self-discrepancy, which can lead to increased anxiety, stress, or depression.
Another theory was that the stress was induced from being a minority, which is supported by the increased number of nonfatal suicidal behaviors in students who were discordant, female, or gay or lesbian, according to investigators. “The minority stress theory suggests that stigma experienced by sexual minorities may cause chronic, cumulative stress that may negatively impact both mental and physical health,” Dr. Francis and associates explained. “Minority stress has been associated with increased depression, overall poor physical health, and increased risk of chronic disease diagnosis.”
To help prevent these suicidal tendencies, Dr. Annor and colleagues suggested using a multipronged public health approach, including using CDC suicide prevention materials, creating safe spaces for kids to understand their developing sexual identities, and further studies to examine risk among discordant teens and nonfatal suicidal behaviors.
The findings of this study are limited by the use of only high school students, which excludes what may be a significant part of the population. Certain aspects of the survey, including no specific definition of sexual contact, as well as the self-reported nature of the information, might have affected findings. Finally, some of those involved in the study may not have been fully aware of their sexual preference at this age and may have experimented with those of the opposite sex as their reported sexual preference, and this may not have been associated with distress, the researchers said.
Dr. Annor and associates reported no relevant financial disclosures.
ezimmerman@frontlinemedcom.com
SOURCE: Annor F et al. Am J Prev Med. 2018. doi: 10.1016/j.amepre.2018.01.013
Teenagers with discordant sexual orientation are more likely to experience nonfatal suicidal behaviors, according to results of a study published in the American Journal of Preventative Medicine.
“In this study, discordance refers to reporting sexual contact that is inconsistent with a respondent’s sexual identity. ... Discrimination, stigma, prejudice, rejection, and societal norms may put pressure on sexual minorities to present a sexual identity inconsistent with their true sexual identity or to act in a manner inconsistent with their sexual identity,” said Francis Annor, PhD, of the Centers for Disease Control and Prevention, and fellow investigators.
“In considering the health and well-being of youth, sexual identity and sexual behavior and their intersection should be considered for their association with the mental health and well-being of adolescents,” according to Dr. Annor and his colleagues. “Some adolescents reporting discordance may have needs that should be considered when developing and implementing suicide prevention programs.”
For this study, investigators analyzed survey questions from 6,790 high school students queried during the 2015 national Youth Risk Behavior Survey.
Sexual discordance was measured by asking students their sexual orientation and the gender of any sexual partners they may have had. Students who responded as being bisexual or who had not experienced sexual contact before were excluded from final analysis.
Students were majority male (56% vs. 44%), white (54.8%), and heterosexual (97.8%), and sexually concordant (96.1%).
When analyzing suicidal tendencies among students, teens who were sexually discordant were 70% more likely to report thinking about, or planning, suicide. High risk for nonfatal suicidal behaviors was significantly more common among discordant students, compared with concordant students (46.3% vs .22.4%, P less than .0001). Students who were gay or lesbian were significantly more likely to report sexual orientation discordance than heterosexual students (32% vs. 3%, P less than .001).
Sexual discordance also was common among students who were female, black, bullied on school property, used marijuana, or physically forced to have sexual intercourse.
Dr. Annor and fellow investigators theorized that the association between discordance and suicidal ideation may stem from self-discrepancy, which can lead to increased anxiety, stress, or depression.
Another theory was that the stress was induced from being a minority, which is supported by the increased number of nonfatal suicidal behaviors in students who were discordant, female, or gay or lesbian, according to investigators. “The minority stress theory suggests that stigma experienced by sexual minorities may cause chronic, cumulative stress that may negatively impact both mental and physical health,” Dr. Francis and associates explained. “Minority stress has been associated with increased depression, overall poor physical health, and increased risk of chronic disease diagnosis.”
To help prevent these suicidal tendencies, Dr. Annor and colleagues suggested using a multipronged public health approach, including using CDC suicide prevention materials, creating safe spaces for kids to understand their developing sexual identities, and further studies to examine risk among discordant teens and nonfatal suicidal behaviors.
The findings of this study are limited by the use of only high school students, which excludes what may be a significant part of the population. Certain aspects of the survey, including no specific definition of sexual contact, as well as the self-reported nature of the information, might have affected findings. Finally, some of those involved in the study may not have been fully aware of their sexual preference at this age and may have experimented with those of the opposite sex as their reported sexual preference, and this may not have been associated with distress, the researchers said.
Dr. Annor and associates reported no relevant financial disclosures.
ezimmerman@frontlinemedcom.com
SOURCE: Annor F et al. Am J Prev Med. 2018. doi: 10.1016/j.amepre.2018.01.013
Teenagers with discordant sexual orientation are more likely to experience nonfatal suicidal behaviors, according to results of a study published in the American Journal of Preventative Medicine.
“In this study, discordance refers to reporting sexual contact that is inconsistent with a respondent’s sexual identity. ... Discrimination, stigma, prejudice, rejection, and societal norms may put pressure on sexual minorities to present a sexual identity inconsistent with their true sexual identity or to act in a manner inconsistent with their sexual identity,” said Francis Annor, PhD, of the Centers for Disease Control and Prevention, and fellow investigators.
“In considering the health and well-being of youth, sexual identity and sexual behavior and their intersection should be considered for their association with the mental health and well-being of adolescents,” according to Dr. Annor and his colleagues. “Some adolescents reporting discordance may have needs that should be considered when developing and implementing suicide prevention programs.”
For this study, investigators analyzed survey questions from 6,790 high school students queried during the 2015 national Youth Risk Behavior Survey.
Sexual discordance was measured by asking students their sexual orientation and the gender of any sexual partners they may have had. Students who responded as being bisexual or who had not experienced sexual contact before were excluded from final analysis.
Students were majority male (56% vs. 44%), white (54.8%), and heterosexual (97.8%), and sexually concordant (96.1%).
When analyzing suicidal tendencies among students, teens who were sexually discordant were 70% more likely to report thinking about, or planning, suicide. High risk for nonfatal suicidal behaviors was significantly more common among discordant students, compared with concordant students (46.3% vs .22.4%, P less than .0001). Students who were gay or lesbian were significantly more likely to report sexual orientation discordance than heterosexual students (32% vs. 3%, P less than .001).
Sexual discordance also was common among students who were female, black, bullied on school property, used marijuana, or physically forced to have sexual intercourse.
Dr. Annor and fellow investigators theorized that the association between discordance and suicidal ideation may stem from self-discrepancy, which can lead to increased anxiety, stress, or depression.
Another theory was that the stress was induced from being a minority, which is supported by the increased number of nonfatal suicidal behaviors in students who were discordant, female, or gay or lesbian, according to investigators. “The minority stress theory suggests that stigma experienced by sexual minorities may cause chronic, cumulative stress that may negatively impact both mental and physical health,” Dr. Francis and associates explained. “Minority stress has been associated with increased depression, overall poor physical health, and increased risk of chronic disease diagnosis.”
To help prevent these suicidal tendencies, Dr. Annor and colleagues suggested using a multipronged public health approach, including using CDC suicide prevention materials, creating safe spaces for kids to understand their developing sexual identities, and further studies to examine risk among discordant teens and nonfatal suicidal behaviors.
The findings of this study are limited by the use of only high school students, which excludes what may be a significant part of the population. Certain aspects of the survey, including no specific definition of sexual contact, as well as the self-reported nature of the information, might have affected findings. Finally, some of those involved in the study may not have been fully aware of their sexual preference at this age and may have experimented with those of the opposite sex as their reported sexual preference, and this may not have been associated with distress, the researchers said.
Dr. Annor and associates reported no relevant financial disclosures.
ezimmerman@frontlinemedcom.com
SOURCE: Annor F et al. Am J Prev Med. 2018. doi: 10.1016/j.amepre.2018.01.013
FROM THE AMERICAN JOURNAL OF PREVENTIVE MEDICINE
Key clinical point:
Major finding: Teens with conflicting answers about sexual preference were 70% more likely to report suicidal ideation than their concordant counterparts.
Study details: Retrospective study of 6,790 high school students surveyed in the 2015 national Youth Risk Behavior Survey.
Disclosures: Dr. Annor and associates reported no relevant financial disclosures.
Source: Annor F et al. Am J Prev Med. 2018. doi: 10.1016/j.amepre.2018.01.013.
Pediatric Dermatology Consult - February 2018
The patient was diagnosed with pityriasis rosea (PR) on the basis of the clinical findings; a biopsy was not performed. The patient’s pruritus was treated with oral hydroxyzine and topical 1% triamcinolone ointment. She experienced itch relief with these treatments. On follow-up at 3 months, the patient’s lesions had mostly resolved with some postinflammatory hyperpigmentation.
In some patients, flu-like symptoms precede the onset of skin lesions; this has led to speculation regarding a viral etiology for PR. This prodrome, which is present in as many as half of all cases,can include mild headache, low-grade fever, joint aches, or malaise.2 Pityriasis rosea is thought to occur secondary to a systemic activation of human herpesviruses (HHV) 6 and/or HHV-7. Three cases of PR have been reported in the setting of H1N1 influenza virus infection.3 In one small study, HHV-8 was detected by polymerase chain reaction in approximately 20% of biopsy samples of lesional skin in patients with PR.4 However, most research on a viral etiology for pityriasis rosea has focused on HHV-6 and to a lesser extent HHV-7. DNA from both viruses has been isolated from PR lesions, but at varying detection rates.5,6 Furthermore, HHV-7 DNA has been isolated in as many as 14% of normal individuals without pityriasis rosea, suggesting that the presence of this virus on the skin is fairly common.7
Pityriasis rosea occurs in males and females of all ethnicities, with a slight female predominance. It is rare in young children and older adults. Most cases occur in adolescents and in adults in their twenties and early thirties. Cases occur most frequently in fall and spring.8
The herald patch of pityriasis rosea is typically solitary, but cases with multiple herald patches have been described. The herald patch can range in size from 1-10 cm and usually contains the best example of trailing scale – scale seen on the inside edge of the annular lesion. The satellite lesions of pityriasis rosea are typically papules or plaques with a collarette of scale. These lesions usually are oriented along the Langer cleavage lines, giving them a “Christmas tree” configuration when they appear on the posterior trunk.
Mimics
The herald patch of pityriasis rosea can resemble tinea corporis, and if there is any doubt as to the diagnosis, potassium hydroxide examination (also known as a KOH test) and/or fungal culture should be done to rule out a fungal etiology. However, certain features of this case, particularly the subsequent development of satellite lesions, are more consistent with pityriasis rosea.
Secondary syphilis should be considered in patients who are sexually active. The lesions of secondary syphilis are not typically pruritic, and involvement of the palms and soles is common (whereas such involvement is rare in pityriasis rosea).
Like pityriasis rosea, pityriasis lichenoides et varioliformis acuta (PLEVA) is characterized by papular lesions that resolve spontaneously; the lesions of PLEVA usually evolve to vesicular, necrotic, and purpuric papules that take longer to resolve than PR lesions. The lesions of PLEVA are more erythematous, pustular, and crusting than the lesions of pityriasis rosea.
Guttate psoriasis, which occurs following streptococcal pharyngitis in over 50% of patients, does not present with a herald lesion or distribution along Langer’s lines.10 If guttate psoriasis is suspected, rapid streptococcal testing of the throat or perianal area may be considered.
Nummular eczema presents as papules that enlarge to form erythematous, lichenified plaques that measure 1-2 cm in diameter. A relatively sudden eruption, such as this patient’s, would be unusual for nummular eczema. Also, nummular eczema typically occurs on xerotic skin, more often on the extremities than the trunk.
Diagnostic tests, treatment
Most patients do not require specific therapy for pityriasis rosea. Patients should be reassured that PR is typically a self-limited disease without long-term sequelae. Pregnant patients who develop pityriasis rosea in the first trimester may be at higher risk for spontaneous abortion,although data on the subject are sorely lacking.11 Oral antihistamines are useful in reducing pruritus associated with PR, and some patients experience relief by applying a low-potency topical corticosteroid.
In more severe cases, or in cases in which the patient is greatly distressed by the lesions, both broadband and narrowband UVB phototherapy effectively improve severity of lesions and reduces symptoms.12 These observations suggest that moderate sun exposure can help to reduce severity of PR lesions and hasten their resolution, but no studies assessing the effect of sun exposure on pityriasis rosea symptoms have been performed.
Furthermore, the possible role of the HHV-6 in PR has led some investigators to explore the utility of acyclovir in managing pityriasis rosea.13 One group recently found that 400 mg of acyclovir three times per day for 7 days decreased the number of lesions and pruritus associated with pityriasis rosea, compared those seen in controls, at 1-month follow-up.13
Timely recognition of the diagnosis, consideration of mimics, and ample reassurance are appropriate when approaching this disease.
Mr. Kusari is with the division of pediatric and adolescent dermatology at Rady Children’s Hospital, San Diego, and the departments of dermatology and pediatrics, University of California, San Diego. Dr. Matiz is a pediatric dermatologist at Southern California Permanente Medical Group, San Diego. They have no relevant financial disclosures. Email them at pdnews@frontlinemedcom.com.
References
1. Dermatology. 2015;231(1):9-14.
2. World J Clin Cases. 2017 Jun 16;5(6):203-11.
3. Pediatr Dermatol. 2011 May-Jun;28(3):341-2.
4. J Eur Acad Dermatol Venereol. 2006 Jul;20(6):667-71.
5. Dermatology. 1997;195(4):374-8.
6. J Invest Dermatol. 2005 Jun;124(6):1234-40.
7. Arch Dermatol. 1999 Sep;135(9):1070-2.
8. J Am Acad Dermatol. 1982 Jul;7(1):80-9.
9. Iran J Pediatr. 2010 Jun;20(2):237-41.
10. J Pediatr. 1988 Dec;113(6):1037-9.
11. J Am Acad Dermatol. 2008 May;58(5 Suppl 1):S78-83.
12. J Am Acad Dermatol. 1995 Dec;33(6):996-9.
13. Indian Dermatol Online J. 2015 May-Jun;6(3):181-4.
The patient was diagnosed with pityriasis rosea (PR) on the basis of the clinical findings; a biopsy was not performed. The patient’s pruritus was treated with oral hydroxyzine and topical 1% triamcinolone ointment. She experienced itch relief with these treatments. On follow-up at 3 months, the patient’s lesions had mostly resolved with some postinflammatory hyperpigmentation.
In some patients, flu-like symptoms precede the onset of skin lesions; this has led to speculation regarding a viral etiology for PR. This prodrome, which is present in as many as half of all cases,can include mild headache, low-grade fever, joint aches, or malaise.2 Pityriasis rosea is thought to occur secondary to a systemic activation of human herpesviruses (HHV) 6 and/or HHV-7. Three cases of PR have been reported in the setting of H1N1 influenza virus infection.3 In one small study, HHV-8 was detected by polymerase chain reaction in approximately 20% of biopsy samples of lesional skin in patients with PR.4 However, most research on a viral etiology for pityriasis rosea has focused on HHV-6 and to a lesser extent HHV-7. DNA from both viruses has been isolated from PR lesions, but at varying detection rates.5,6 Furthermore, HHV-7 DNA has been isolated in as many as 14% of normal individuals without pityriasis rosea, suggesting that the presence of this virus on the skin is fairly common.7
Pityriasis rosea occurs in males and females of all ethnicities, with a slight female predominance. It is rare in young children and older adults. Most cases occur in adolescents and in adults in their twenties and early thirties. Cases occur most frequently in fall and spring.8
The herald patch of pityriasis rosea is typically solitary, but cases with multiple herald patches have been described. The herald patch can range in size from 1-10 cm and usually contains the best example of trailing scale – scale seen on the inside edge of the annular lesion. The satellite lesions of pityriasis rosea are typically papules or plaques with a collarette of scale. These lesions usually are oriented along the Langer cleavage lines, giving them a “Christmas tree” configuration when they appear on the posterior trunk.
Mimics
The herald patch of pityriasis rosea can resemble tinea corporis, and if there is any doubt as to the diagnosis, potassium hydroxide examination (also known as a KOH test) and/or fungal culture should be done to rule out a fungal etiology. However, certain features of this case, particularly the subsequent development of satellite lesions, are more consistent with pityriasis rosea.
Secondary syphilis should be considered in patients who are sexually active. The lesions of secondary syphilis are not typically pruritic, and involvement of the palms and soles is common (whereas such involvement is rare in pityriasis rosea).
Like pityriasis rosea, pityriasis lichenoides et varioliformis acuta (PLEVA) is characterized by papular lesions that resolve spontaneously; the lesions of PLEVA usually evolve to vesicular, necrotic, and purpuric papules that take longer to resolve than PR lesions. The lesions of PLEVA are more erythematous, pustular, and crusting than the lesions of pityriasis rosea.
Guttate psoriasis, which occurs following streptococcal pharyngitis in over 50% of patients, does not present with a herald lesion or distribution along Langer’s lines.10 If guttate psoriasis is suspected, rapid streptococcal testing of the throat or perianal area may be considered.
Nummular eczema presents as papules that enlarge to form erythematous, lichenified plaques that measure 1-2 cm in diameter. A relatively sudden eruption, such as this patient’s, would be unusual for nummular eczema. Also, nummular eczema typically occurs on xerotic skin, more often on the extremities than the trunk.
Diagnostic tests, treatment
Most patients do not require specific therapy for pityriasis rosea. Patients should be reassured that PR is typically a self-limited disease without long-term sequelae. Pregnant patients who develop pityriasis rosea in the first trimester may be at higher risk for spontaneous abortion,although data on the subject are sorely lacking.11 Oral antihistamines are useful in reducing pruritus associated with PR, and some patients experience relief by applying a low-potency topical corticosteroid.
In more severe cases, or in cases in which the patient is greatly distressed by the lesions, both broadband and narrowband UVB phototherapy effectively improve severity of lesions and reduces symptoms.12 These observations suggest that moderate sun exposure can help to reduce severity of PR lesions and hasten their resolution, but no studies assessing the effect of sun exposure on pityriasis rosea symptoms have been performed.
Furthermore, the possible role of the HHV-6 in PR has led some investigators to explore the utility of acyclovir in managing pityriasis rosea.13 One group recently found that 400 mg of acyclovir three times per day for 7 days decreased the number of lesions and pruritus associated with pityriasis rosea, compared those seen in controls, at 1-month follow-up.13
Timely recognition of the diagnosis, consideration of mimics, and ample reassurance are appropriate when approaching this disease.
Mr. Kusari is with the division of pediatric and adolescent dermatology at Rady Children’s Hospital, San Diego, and the departments of dermatology and pediatrics, University of California, San Diego. Dr. Matiz is a pediatric dermatologist at Southern California Permanente Medical Group, San Diego. They have no relevant financial disclosures. Email them at pdnews@frontlinemedcom.com.
References
1. Dermatology. 2015;231(1):9-14.
2. World J Clin Cases. 2017 Jun 16;5(6):203-11.
3. Pediatr Dermatol. 2011 May-Jun;28(3):341-2.
4. J Eur Acad Dermatol Venereol. 2006 Jul;20(6):667-71.
5. Dermatology. 1997;195(4):374-8.
6. J Invest Dermatol. 2005 Jun;124(6):1234-40.
7. Arch Dermatol. 1999 Sep;135(9):1070-2.
8. J Am Acad Dermatol. 1982 Jul;7(1):80-9.
9. Iran J Pediatr. 2010 Jun;20(2):237-41.
10. J Pediatr. 1988 Dec;113(6):1037-9.
11. J Am Acad Dermatol. 2008 May;58(5 Suppl 1):S78-83.
12. J Am Acad Dermatol. 1995 Dec;33(6):996-9.
13. Indian Dermatol Online J. 2015 May-Jun;6(3):181-4.
The patient was diagnosed with pityriasis rosea (PR) on the basis of the clinical findings; a biopsy was not performed. The patient’s pruritus was treated with oral hydroxyzine and topical 1% triamcinolone ointment. She experienced itch relief with these treatments. On follow-up at 3 months, the patient’s lesions had mostly resolved with some postinflammatory hyperpigmentation.
In some patients, flu-like symptoms precede the onset of skin lesions; this has led to speculation regarding a viral etiology for PR. This prodrome, which is present in as many as half of all cases,can include mild headache, low-grade fever, joint aches, or malaise.2 Pityriasis rosea is thought to occur secondary to a systemic activation of human herpesviruses (HHV) 6 and/or HHV-7. Three cases of PR have been reported in the setting of H1N1 influenza virus infection.3 In one small study, HHV-8 was detected by polymerase chain reaction in approximately 20% of biopsy samples of lesional skin in patients with PR.4 However, most research on a viral etiology for pityriasis rosea has focused on HHV-6 and to a lesser extent HHV-7. DNA from both viruses has been isolated from PR lesions, but at varying detection rates.5,6 Furthermore, HHV-7 DNA has been isolated in as many as 14% of normal individuals without pityriasis rosea, suggesting that the presence of this virus on the skin is fairly common.7
Pityriasis rosea occurs in males and females of all ethnicities, with a slight female predominance. It is rare in young children and older adults. Most cases occur in adolescents and in adults in their twenties and early thirties. Cases occur most frequently in fall and spring.8
The herald patch of pityriasis rosea is typically solitary, but cases with multiple herald patches have been described. The herald patch can range in size from 1-10 cm and usually contains the best example of trailing scale – scale seen on the inside edge of the annular lesion. The satellite lesions of pityriasis rosea are typically papules or plaques with a collarette of scale. These lesions usually are oriented along the Langer cleavage lines, giving them a “Christmas tree” configuration when they appear on the posterior trunk.
Mimics
The herald patch of pityriasis rosea can resemble tinea corporis, and if there is any doubt as to the diagnosis, potassium hydroxide examination (also known as a KOH test) and/or fungal culture should be done to rule out a fungal etiology. However, certain features of this case, particularly the subsequent development of satellite lesions, are more consistent with pityriasis rosea.
Secondary syphilis should be considered in patients who are sexually active. The lesions of secondary syphilis are not typically pruritic, and involvement of the palms and soles is common (whereas such involvement is rare in pityriasis rosea).
Like pityriasis rosea, pityriasis lichenoides et varioliformis acuta (PLEVA) is characterized by papular lesions that resolve spontaneously; the lesions of PLEVA usually evolve to vesicular, necrotic, and purpuric papules that take longer to resolve than PR lesions. The lesions of PLEVA are more erythematous, pustular, and crusting than the lesions of pityriasis rosea.
Guttate psoriasis, which occurs following streptococcal pharyngitis in over 50% of patients, does not present with a herald lesion or distribution along Langer’s lines.10 If guttate psoriasis is suspected, rapid streptococcal testing of the throat or perianal area may be considered.
Nummular eczema presents as papules that enlarge to form erythematous, lichenified plaques that measure 1-2 cm in diameter. A relatively sudden eruption, such as this patient’s, would be unusual for nummular eczema. Also, nummular eczema typically occurs on xerotic skin, more often on the extremities than the trunk.
Diagnostic tests, treatment
Most patients do not require specific therapy for pityriasis rosea. Patients should be reassured that PR is typically a self-limited disease without long-term sequelae. Pregnant patients who develop pityriasis rosea in the first trimester may be at higher risk for spontaneous abortion,although data on the subject are sorely lacking.11 Oral antihistamines are useful in reducing pruritus associated with PR, and some patients experience relief by applying a low-potency topical corticosteroid.
In more severe cases, or in cases in which the patient is greatly distressed by the lesions, both broadband and narrowband UVB phototherapy effectively improve severity of lesions and reduces symptoms.12 These observations suggest that moderate sun exposure can help to reduce severity of PR lesions and hasten their resolution, but no studies assessing the effect of sun exposure on pityriasis rosea symptoms have been performed.
Furthermore, the possible role of the HHV-6 in PR has led some investigators to explore the utility of acyclovir in managing pityriasis rosea.13 One group recently found that 400 mg of acyclovir three times per day for 7 days decreased the number of lesions and pruritus associated with pityriasis rosea, compared those seen in controls, at 1-month follow-up.13
Timely recognition of the diagnosis, consideration of mimics, and ample reassurance are appropriate when approaching this disease.
Mr. Kusari is with the division of pediatric and adolescent dermatology at Rady Children’s Hospital, San Diego, and the departments of dermatology and pediatrics, University of California, San Diego. Dr. Matiz is a pediatric dermatologist at Southern California Permanente Medical Group, San Diego. They have no relevant financial disclosures. Email them at pdnews@frontlinemedcom.com.
References
1. Dermatology. 2015;231(1):9-14.
2. World J Clin Cases. 2017 Jun 16;5(6):203-11.
3. Pediatr Dermatol. 2011 May-Jun;28(3):341-2.
4. J Eur Acad Dermatol Venereol. 2006 Jul;20(6):667-71.
5. Dermatology. 1997;195(4):374-8.
6. J Invest Dermatol. 2005 Jun;124(6):1234-40.
7. Arch Dermatol. 1999 Sep;135(9):1070-2.
8. J Am Acad Dermatol. 1982 Jul;7(1):80-9.
9. Iran J Pediatr. 2010 Jun;20(2):237-41.
10. J Pediatr. 1988 Dec;113(6):1037-9.
11. J Am Acad Dermatol. 2008 May;58(5 Suppl 1):S78-83.
12. J Am Acad Dermatol. 1995 Dec;33(6):996-9.
13. Indian Dermatol Online J. 2015 May-Jun;6(3):181-4.
A 6-year-old female presents to the pediatric dermatology office with a 2-day history of a slightly itchy skin lesion on her back. Her birthday was a week prior, and her mother gave her a new kitten, and since then she has been playing with the kitten daily. She has tried some over-the-counter antifungal cream since the lesion first appeared, but there hasn’t been much improvement. The night prior to presenting to the office, the mother noticed more lesions developing on the child’s torso, and because of this, she became worried.
On physical exam, the patient is well appearing, and vital signs are normal. She has multiple scaly, pink, oval plaques and papules on her torso. There are no oral lesions, and her palms and soles are spared.
Newborn oral rotavirus vaccine held effective
A new oral rotavirus vaccine administered within the first few days of life appears effective against severe rotavirus gastroenteritis in newborns, a study has found.
Julie E. Bines, MD, from the RV3 Rotavirus Vaccine Program at the Murdoch Children’s Research Institute in Melbourne, and her coauthors reported the results of a double-blind, placebo-controlled phase 2b trial in 1,513 healthy newborns in Indonesia. Participants were randomized to three doses of oral human neonatal rotavirus vaccine either on a neonatal schedule (0-5 days, 8-10 weeks, and 14-16 weeks of age) or an infant schedule (8-10 weeks, 14-16 weeks, and 18-20 weeks of age), or the equivalent schedules of placebo.
That efficacy was 77% in those who received the doses on the infant schedule.
Overall, severe rotavirus gastroenteritis was reported in 5.6% of the placebo group, compared with 2.1% of the combined vaccine group. The time from randomization to first episode of gastroenteritis was significantly longer among participants who received the vaccine, compared with those who received placebo.
“The use of a neonatal dose was investigated in the early phase of development of the rotavirus vaccine but was not pursued because of concerns regarding inadequate immune responses and safety,” wrote Dr. Bines and her associates
They noted that the results of this trial compared favorably with the efficacy of licensed vaccines in similar low-income countries that experienced a high burden of rotavirus disease.
The rates of severe adverse events were similar across all the trial groups. There were no episodes of intussusception seen within the 21-day risk period after immunization, either in the vaccine or placebo groups. However, there was one episode of intussusception in a child on the infant schedule group, which occurred 114 days after the third dose of the vaccine.
“Because intussusception is rare in newborns, the administration of a rotavirus vaccine at the time of birth may offer a safety advantage,” Dr. Bines and her associates said.
The study was supported by the Bill and Melinda Gates Foundation, the National Health and Medical Research Council, PT Bio Farma, and the Victorian government’s Operational Infrastructure Support Program. Authors declared fees, grants, and institutional support from the study sponsors, and three authors also declared a stake in the patent of the RV3-BB vaccine, which is licensed to PT Bio Farma.
SOURCE: Bines JE et al. N Engl J Med. 2018;378:719-30.
A new oral rotavirus vaccine administered within the first few days of life appears effective against severe rotavirus gastroenteritis in newborns, a study has found.
Julie E. Bines, MD, from the RV3 Rotavirus Vaccine Program at the Murdoch Children’s Research Institute in Melbourne, and her coauthors reported the results of a double-blind, placebo-controlled phase 2b trial in 1,513 healthy newborns in Indonesia. Participants were randomized to three doses of oral human neonatal rotavirus vaccine either on a neonatal schedule (0-5 days, 8-10 weeks, and 14-16 weeks of age) or an infant schedule (8-10 weeks, 14-16 weeks, and 18-20 weeks of age), or the equivalent schedules of placebo.
That efficacy was 77% in those who received the doses on the infant schedule.
Overall, severe rotavirus gastroenteritis was reported in 5.6% of the placebo group, compared with 2.1% of the combined vaccine group. The time from randomization to first episode of gastroenteritis was significantly longer among participants who received the vaccine, compared with those who received placebo.
“The use of a neonatal dose was investigated in the early phase of development of the rotavirus vaccine but was not pursued because of concerns regarding inadequate immune responses and safety,” wrote Dr. Bines and her associates
They noted that the results of this trial compared favorably with the efficacy of licensed vaccines in similar low-income countries that experienced a high burden of rotavirus disease.
The rates of severe adverse events were similar across all the trial groups. There were no episodes of intussusception seen within the 21-day risk period after immunization, either in the vaccine or placebo groups. However, there was one episode of intussusception in a child on the infant schedule group, which occurred 114 days after the third dose of the vaccine.
“Because intussusception is rare in newborns, the administration of a rotavirus vaccine at the time of birth may offer a safety advantage,” Dr. Bines and her associates said.
The study was supported by the Bill and Melinda Gates Foundation, the National Health and Medical Research Council, PT Bio Farma, and the Victorian government’s Operational Infrastructure Support Program. Authors declared fees, grants, and institutional support from the study sponsors, and three authors also declared a stake in the patent of the RV3-BB vaccine, which is licensed to PT Bio Farma.
SOURCE: Bines JE et al. N Engl J Med. 2018;378:719-30.
A new oral rotavirus vaccine administered within the first few days of life appears effective against severe rotavirus gastroenteritis in newborns, a study has found.
Julie E. Bines, MD, from the RV3 Rotavirus Vaccine Program at the Murdoch Children’s Research Institute in Melbourne, and her coauthors reported the results of a double-blind, placebo-controlled phase 2b trial in 1,513 healthy newborns in Indonesia. Participants were randomized to three doses of oral human neonatal rotavirus vaccine either on a neonatal schedule (0-5 days, 8-10 weeks, and 14-16 weeks of age) or an infant schedule (8-10 weeks, 14-16 weeks, and 18-20 weeks of age), or the equivalent schedules of placebo.
That efficacy was 77% in those who received the doses on the infant schedule.
Overall, severe rotavirus gastroenteritis was reported in 5.6% of the placebo group, compared with 2.1% of the combined vaccine group. The time from randomization to first episode of gastroenteritis was significantly longer among participants who received the vaccine, compared with those who received placebo.
“The use of a neonatal dose was investigated in the early phase of development of the rotavirus vaccine but was not pursued because of concerns regarding inadequate immune responses and safety,” wrote Dr. Bines and her associates
They noted that the results of this trial compared favorably with the efficacy of licensed vaccines in similar low-income countries that experienced a high burden of rotavirus disease.
The rates of severe adverse events were similar across all the trial groups. There were no episodes of intussusception seen within the 21-day risk period after immunization, either in the vaccine or placebo groups. However, there was one episode of intussusception in a child on the infant schedule group, which occurred 114 days after the third dose of the vaccine.
“Because intussusception is rare in newborns, the administration of a rotavirus vaccine at the time of birth may offer a safety advantage,” Dr. Bines and her associates said.
The study was supported by the Bill and Melinda Gates Foundation, the National Health and Medical Research Council, PT Bio Farma, and the Victorian government’s Operational Infrastructure Support Program. Authors declared fees, grants, and institutional support from the study sponsors, and three authors also declared a stake in the patent of the RV3-BB vaccine, which is licensed to PT Bio Farma.
SOURCE: Bines JE et al. N Engl J Med. 2018;378:719-30.
FROM THE NEW ENGLAND JOURNAL OF MEDICINE
Key clinical point: A new oral rotavirus vaccine given to newborns was associated with significant reductions in the incidence of severe rotavirus gastroenteritis.
Major finding: A new oral rotavirus vaccine given within the first 5 days of life showed 94% efficacy at 12 months of age.
Data source: A randomized double-blind, placebo-controlled phase 2b trial in 1,513 healthy newborns.
Disclosures: The study was supported by the Bill and Melinda Gates Foundation, the National Health and Medical Research Council, PT Bio Farma, and the Victorian government’s Operational Infrastructure Support Program. Authors declared fees, grants and institutional support from the study sponsors, and three authors also declared a stake in the patent of the RV3-BB vaccine, which is licensed to PT Bio Farma.
Source: Bines JE et al. N Engl J Med. 2018;378:719-30.
Learning from the 2017 Oscar fiasco
It was a “never event.” At the very end of the 2017 Academy Awards presentation, the winner for Best Picture was announced. It was wrong. Two and a half minutes later it was corrected. The true winner was “Moonlight,” not “La La Land.” But by then much damage had been done.
I watched it happen live on TV and reviewed it again on YouTube. Several news agencies investigated and reported on what happened. I don’t have any inside information beyond that, but my engineering perspective can illuminate how to reduce mistakes.
The first lesson is how quickly people seek to assign blame after something goes wrong. I saw various online news agencies say Warren Beatty had announced the wrong winner. While he opened the envelope, it was Faye Dunaway who actually made the announcement of “La La Land.” Furthermore, Warren and Faye were merely reading the card. Warren had been given the wrong envelope, as high resolution photographs prove. The envelope was a duplicate for the prize announced just before them for the Best Actress award. The card said Emma Stone and in a smaller font “La La Land,” the film in which she starred. Warren hesitated because of how this was written on the card. Faye thought he was trying to pause as a shtick to increase suspense so she glanced at the card and blurted out “La La Land.”
Experts in quality improvement have learned that the best way to reduce errors is to resist this tendency to assign blame. A better approach is to assume, absent evidence to the contrary, that everyone is acting responsibly and sincerely to help the patient. Hear both sides of the story before jumping to any conclusions. Find systemic factors that contributed to a human error. Then focus on ameliorating systemic weaknesses.
One contributing factor for the error at the Oscars was that there were two copies of the set of award envelopes, with one set available on each side of the stage. This way the presenters can enter from either side of the stage. They are handed an envelope by one of the two auditors from PricewaterhouseCoopers, who are the only ones who know the contents.
A key component of safety is having check backs. The envelopes have the name of the award on the outside. One might hope the presenter would double check that they are being given the correct envelope by the auditor. But backstage is a very nervous and hectic place for the presenters. Actors are not professionals dedicated to safety.
Medical care is different. Before giving a transfusion, one nurse reads the number on the bag of blood to another nurse, who confirms that it matches a paper form. That simple act can prevent mistakes. Perhaps the auditor handing the envelope to the Oscar presenter should ask the presenter, who knows which award s/he is scheduled to announce, to read out loud the award title on the front of the envelope.
Clearly, Warren Beatty was confused by the contents of the envelope. He was expecting a card to have the name of a film, not the name of an actress with the film’s name in small print below it. He didn’t know what action to take and hesitated. Faye Dunaway plunged forward and misinterpreted the card. A key component of quality is making it safe for anyone, if they are not confident in what is happening, to stop the proceeding, ask questions, and challenge plans. For example, there are time-outs prior to surgery. A second component is presenting information in a form less likely to be misinterpreted. Medicine has a problem with many sound-alike and look-alike drug names, so sometimes these words are spelled with particular letters capitalized, to distinguish them. I wish EHRs would present lab results in large, bold font.
Another contributing factor here was that Faye misinterpreted Warren’s behaviors as a joke. Major airlines utilize the “sterile cockpit.” During the few minutes that they are running through the preflight checklist, the pilot and copilot do not discuss last night’s football game, crack jokes, or engage in any other extraneous conversations. They avoid interruptions and distractions, focusing solely on the task. Sign outs in medicine need to adopt this habit.
There is a concern that one of the auditors tweeted a picture of Emma Stone backstage holding her Oscar at the same time the fiasco was happening on stage. In the modern world, cell phones and selfies are a key source of distraction, errors, and car accidents.
Per the Army, “Prior planning prevents poor performance.” A couple days before the Oscar fiasco, the auditors were interviewed and they revealed that they didn’t have an action plan to deal with the situation of a mistaken announcement. They figured it was extremely unlikely and that the circumstances would determine the best response.
Experience has shown that in the hours leading up to a pediatric code, there may be several opportunities to recognize the risk and intervene so that blame cannot be assigned to a single person or action. Mock codes prepare people to think on their feet. And it is important to have a clearly designated person in charge of a code. Leadership matters.
In the Oscar fiasco, the damage was quickly limited by the gracious words of a “La La Land” producer He assessed the situation, announced the mistake, beckoned the “Moonlight” cast and crew to the stage, graciously complimented them, showed the correct award envelope and card to the camera, and offered the statue to the correct producer. Then he hastened his team off the stage. These actions of responsibility, truthfulness, transparency, and grace staunched the bleeding, minimized the damage, and as best as possible, remediated the error. Movie producers are experts at dealing with crises and catastrophes. Medical staff, when revealing errors to patients, can learn from this role model.
Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. Email him at pdnews@frontlinemedcom.com.
It was a “never event.” At the very end of the 2017 Academy Awards presentation, the winner for Best Picture was announced. It was wrong. Two and a half minutes later it was corrected. The true winner was “Moonlight,” not “La La Land.” But by then much damage had been done.
I watched it happen live on TV and reviewed it again on YouTube. Several news agencies investigated and reported on what happened. I don’t have any inside information beyond that, but my engineering perspective can illuminate how to reduce mistakes.
The first lesson is how quickly people seek to assign blame after something goes wrong. I saw various online news agencies say Warren Beatty had announced the wrong winner. While he opened the envelope, it was Faye Dunaway who actually made the announcement of “La La Land.” Furthermore, Warren and Faye were merely reading the card. Warren had been given the wrong envelope, as high resolution photographs prove. The envelope was a duplicate for the prize announced just before them for the Best Actress award. The card said Emma Stone and in a smaller font “La La Land,” the film in which she starred. Warren hesitated because of how this was written on the card. Faye thought he was trying to pause as a shtick to increase suspense so she glanced at the card and blurted out “La La Land.”
Experts in quality improvement have learned that the best way to reduce errors is to resist this tendency to assign blame. A better approach is to assume, absent evidence to the contrary, that everyone is acting responsibly and sincerely to help the patient. Hear both sides of the story before jumping to any conclusions. Find systemic factors that contributed to a human error. Then focus on ameliorating systemic weaknesses.
One contributing factor for the error at the Oscars was that there were two copies of the set of award envelopes, with one set available on each side of the stage. This way the presenters can enter from either side of the stage. They are handed an envelope by one of the two auditors from PricewaterhouseCoopers, who are the only ones who know the contents.
A key component of safety is having check backs. The envelopes have the name of the award on the outside. One might hope the presenter would double check that they are being given the correct envelope by the auditor. But backstage is a very nervous and hectic place for the presenters. Actors are not professionals dedicated to safety.
Medical care is different. Before giving a transfusion, one nurse reads the number on the bag of blood to another nurse, who confirms that it matches a paper form. That simple act can prevent mistakes. Perhaps the auditor handing the envelope to the Oscar presenter should ask the presenter, who knows which award s/he is scheduled to announce, to read out loud the award title on the front of the envelope.
Clearly, Warren Beatty was confused by the contents of the envelope. He was expecting a card to have the name of a film, not the name of an actress with the film’s name in small print below it. He didn’t know what action to take and hesitated. Faye Dunaway plunged forward and misinterpreted the card. A key component of quality is making it safe for anyone, if they are not confident in what is happening, to stop the proceeding, ask questions, and challenge plans. For example, there are time-outs prior to surgery. A second component is presenting information in a form less likely to be misinterpreted. Medicine has a problem with many sound-alike and look-alike drug names, so sometimes these words are spelled with particular letters capitalized, to distinguish them. I wish EHRs would present lab results in large, bold font.
Another contributing factor here was that Faye misinterpreted Warren’s behaviors as a joke. Major airlines utilize the “sterile cockpit.” During the few minutes that they are running through the preflight checklist, the pilot and copilot do not discuss last night’s football game, crack jokes, or engage in any other extraneous conversations. They avoid interruptions and distractions, focusing solely on the task. Sign outs in medicine need to adopt this habit.
There is a concern that one of the auditors tweeted a picture of Emma Stone backstage holding her Oscar at the same time the fiasco was happening on stage. In the modern world, cell phones and selfies are a key source of distraction, errors, and car accidents.
Per the Army, “Prior planning prevents poor performance.” A couple days before the Oscar fiasco, the auditors were interviewed and they revealed that they didn’t have an action plan to deal with the situation of a mistaken announcement. They figured it was extremely unlikely and that the circumstances would determine the best response.
Experience has shown that in the hours leading up to a pediatric code, there may be several opportunities to recognize the risk and intervene so that blame cannot be assigned to a single person or action. Mock codes prepare people to think on their feet. And it is important to have a clearly designated person in charge of a code. Leadership matters.
In the Oscar fiasco, the damage was quickly limited by the gracious words of a “La La Land” producer He assessed the situation, announced the mistake, beckoned the “Moonlight” cast and crew to the stage, graciously complimented them, showed the correct award envelope and card to the camera, and offered the statue to the correct producer. Then he hastened his team off the stage. These actions of responsibility, truthfulness, transparency, and grace staunched the bleeding, minimized the damage, and as best as possible, remediated the error. Movie producers are experts at dealing with crises and catastrophes. Medical staff, when revealing errors to patients, can learn from this role model.
Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. Email him at pdnews@frontlinemedcom.com.
It was a “never event.” At the very end of the 2017 Academy Awards presentation, the winner for Best Picture was announced. It was wrong. Two and a half minutes later it was corrected. The true winner was “Moonlight,” not “La La Land.” But by then much damage had been done.
I watched it happen live on TV and reviewed it again on YouTube. Several news agencies investigated and reported on what happened. I don’t have any inside information beyond that, but my engineering perspective can illuminate how to reduce mistakes.
The first lesson is how quickly people seek to assign blame after something goes wrong. I saw various online news agencies say Warren Beatty had announced the wrong winner. While he opened the envelope, it was Faye Dunaway who actually made the announcement of “La La Land.” Furthermore, Warren and Faye were merely reading the card. Warren had been given the wrong envelope, as high resolution photographs prove. The envelope was a duplicate for the prize announced just before them for the Best Actress award. The card said Emma Stone and in a smaller font “La La Land,” the film in which she starred. Warren hesitated because of how this was written on the card. Faye thought he was trying to pause as a shtick to increase suspense so she glanced at the card and blurted out “La La Land.”
Experts in quality improvement have learned that the best way to reduce errors is to resist this tendency to assign blame. A better approach is to assume, absent evidence to the contrary, that everyone is acting responsibly and sincerely to help the patient. Hear both sides of the story before jumping to any conclusions. Find systemic factors that contributed to a human error. Then focus on ameliorating systemic weaknesses.
One contributing factor for the error at the Oscars was that there were two copies of the set of award envelopes, with one set available on each side of the stage. This way the presenters can enter from either side of the stage. They are handed an envelope by one of the two auditors from PricewaterhouseCoopers, who are the only ones who know the contents.
A key component of safety is having check backs. The envelopes have the name of the award on the outside. One might hope the presenter would double check that they are being given the correct envelope by the auditor. But backstage is a very nervous and hectic place for the presenters. Actors are not professionals dedicated to safety.
Medical care is different. Before giving a transfusion, one nurse reads the number on the bag of blood to another nurse, who confirms that it matches a paper form. That simple act can prevent mistakes. Perhaps the auditor handing the envelope to the Oscar presenter should ask the presenter, who knows which award s/he is scheduled to announce, to read out loud the award title on the front of the envelope.
Clearly, Warren Beatty was confused by the contents of the envelope. He was expecting a card to have the name of a film, not the name of an actress with the film’s name in small print below it. He didn’t know what action to take and hesitated. Faye Dunaway plunged forward and misinterpreted the card. A key component of quality is making it safe for anyone, if they are not confident in what is happening, to stop the proceeding, ask questions, and challenge plans. For example, there are time-outs prior to surgery. A second component is presenting information in a form less likely to be misinterpreted. Medicine has a problem with many sound-alike and look-alike drug names, so sometimes these words are spelled with particular letters capitalized, to distinguish them. I wish EHRs would present lab results in large, bold font.
Another contributing factor here was that Faye misinterpreted Warren’s behaviors as a joke. Major airlines utilize the “sterile cockpit.” During the few minutes that they are running through the preflight checklist, the pilot and copilot do not discuss last night’s football game, crack jokes, or engage in any other extraneous conversations. They avoid interruptions and distractions, focusing solely on the task. Sign outs in medicine need to adopt this habit.
There is a concern that one of the auditors tweeted a picture of Emma Stone backstage holding her Oscar at the same time the fiasco was happening on stage. In the modern world, cell phones and selfies are a key source of distraction, errors, and car accidents.
Per the Army, “Prior planning prevents poor performance.” A couple days before the Oscar fiasco, the auditors were interviewed and they revealed that they didn’t have an action plan to deal with the situation of a mistaken announcement. They figured it was extremely unlikely and that the circumstances would determine the best response.
Experience has shown that in the hours leading up to a pediatric code, there may be several opportunities to recognize the risk and intervene so that blame cannot be assigned to a single person or action. Mock codes prepare people to think on their feet. And it is important to have a clearly designated person in charge of a code. Leadership matters.
In the Oscar fiasco, the damage was quickly limited by the gracious words of a “La La Land” producer He assessed the situation, announced the mistake, beckoned the “Moonlight” cast and crew to the stage, graciously complimented them, showed the correct award envelope and card to the camera, and offered the statue to the correct producer. Then he hastened his team off the stage. These actions of responsibility, truthfulness, transparency, and grace staunched the bleeding, minimized the damage, and as best as possible, remediated the error. Movie producers are experts at dealing with crises and catastrophes. Medical staff, when revealing errors to patients, can learn from this role model.
Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. Email him at pdnews@frontlinemedcom.com.
RF-positive polyarticular JIA looks like adult RA
New evidence suggests the rheumatoid factor–positive polyarticular subtype of juvenile idiopathic arthritis bears a close genetic resemblance to adult rheumatoid arthritis, lending support to the growing suspicion that in arthritis, biological underpinnings are more important than age of onset when it comes to characterizing and, potentially, choosing treatments.
Previous work had shown that rheumatoid factor (RF)–negative patients have genetic risks similar to those of adults with RF-negative disease. “If the RF-negative patients in adult and childhood are similar, then maybe the RF-positive patients are similar in their genetic background as well. That’s what this study was testing,” study coauthor Anne M. Stevens, MD, PhD, division chief of rheumatology at the University of Washington, Seattle, said in an interview. The study was published online Feb. 9 in Arthritis & Rheumatology.
There are seven recognized categories of juvenile idiopathic arthritis (JIA), and all are believed to have genetic risk factors. Previously, the researchers used the Immunochip custom microarray to map 186 autoimmune disease-associated loci from 11 autoimmune phenotypes, including adult rheumatoid arthritis (RA). In the current work, the researchers analyzed 340 RF-positive polyarticular JIA cases (292 females) and 14,412 controls (8,002 females) from the United States, United Kingdom, Germany, Canada, and Norway. RF-positive polyarticular disease accounts for about 5% of JIA cases, and its symptoms and presentations resemble adult RA.
The researchers found associations in the human leukocyte antigen (HLA) region. The most significant was found at rs3129769, near HLA-DRB1 (P = 5.51 x 10-31). This single nucleotide polymorphism (SNP) was in strong linkage disequilibrium (LD, r2 = 0.88) with the rs660895 HLA-DRB1 SNP that has been reported in adult RA (P = 2.14 x 10-29).
The researchers examined links between RF-positive polyarticular JIA and the 27 SNPs that had been identified in the previous study of oligoarticular/RF-negative polyarticular JIA. Just 6 of those 27 SNPs were significantly associated with RF-positive polyarticular JIA (P less than .05). On the other hand, of 44 SNPs most strongly associated with RA, 19 were associated with RF-positive polyarticular JIA (P less than .05).
That suggests that RF-positive polyarticular JIA cases are different from other JIA cases. “They’re more like adult patients than they’re like child patients,” said Dr. Stevens.
The researchers also compared the weighted genetic risk scores (wGRS) produced from the top RA loci to wGRS produced from the top oligoarticular/RF-negative polyarticular JIA loci. The wGRS from the top RA loci was a better predictor of RF-positive polyarticular JIA cases (area under the curve [AUC] = 0.71 versus AUC = 0.58; P = 8.26 x 10-33).
The wGRS from RA had similar success in predicting RF-positive polyarticular JIA and early-onset RA cases (AUC = 0.75; P = .25), but it fared worse in predicting late-onset RA (at 70 years or older, AUC = 0.62), compared with the wGRS from RF-positive polyarticular JIA (P = 1.65 x 10-5).
Those results suggest that RF-positive polyarticular JIA more closely resembles younger RA cases than older RA cases.
“If you consider early-onset RA patients, less than 29 years old when they develop RA, they look like JIA patients. But older RA patients, who are over 70 when they develop RA, they look like they totally have a different genetic background,” Dr. Stevens said.
The study could have clinical implications. The lead author, Anne Hinks, PhD, is a research fellow at the University of Manchester (England) and has led the charge to characterize JIA. The wGRS score she developed has the potential to help physicians diagnose classify and treat JIA patients. Currently, they must rely on the International League of Associations for Rheumatology criteria, which can take months to work through and may lead to misclassification diagnoses.
And in any case, the emerging genetic research suggests that the underlying genetics of JIA may be a better way to classify patients. “There’s a lot of overlap and risk of misclassifying patients with the current system. This weighted genetic risk score that Dr. Hinks developed could be used to classify patients with one DNA sample. This is the kind of clinical test we need,” Dr. Stevens said.
The study received funding from a range of government and private sources. Dr. Stevens has a patent licensed to Quest Diagnostics, is conducting research collaborations with Seattle Genetics and Kineta, and has received fellowship support from Pfizer.
SOURCE: Hinks A et al. Arthritis Rheumatol. 2018 Feb 9. doi: 10.1002/art.40443
New evidence suggests the rheumatoid factor–positive polyarticular subtype of juvenile idiopathic arthritis bears a close genetic resemblance to adult rheumatoid arthritis, lending support to the growing suspicion that in arthritis, biological underpinnings are more important than age of onset when it comes to characterizing and, potentially, choosing treatments.
Previous work had shown that rheumatoid factor (RF)–negative patients have genetic risks similar to those of adults with RF-negative disease. “If the RF-negative patients in adult and childhood are similar, then maybe the RF-positive patients are similar in their genetic background as well. That’s what this study was testing,” study coauthor Anne M. Stevens, MD, PhD, division chief of rheumatology at the University of Washington, Seattle, said in an interview. The study was published online Feb. 9 in Arthritis & Rheumatology.
There are seven recognized categories of juvenile idiopathic arthritis (JIA), and all are believed to have genetic risk factors. Previously, the researchers used the Immunochip custom microarray to map 186 autoimmune disease-associated loci from 11 autoimmune phenotypes, including adult rheumatoid arthritis (RA). In the current work, the researchers analyzed 340 RF-positive polyarticular JIA cases (292 females) and 14,412 controls (8,002 females) from the United States, United Kingdom, Germany, Canada, and Norway. RF-positive polyarticular disease accounts for about 5% of JIA cases, and its symptoms and presentations resemble adult RA.
The researchers found associations in the human leukocyte antigen (HLA) region. The most significant was found at rs3129769, near HLA-DRB1 (P = 5.51 x 10-31). This single nucleotide polymorphism (SNP) was in strong linkage disequilibrium (LD, r2 = 0.88) with the rs660895 HLA-DRB1 SNP that has been reported in adult RA (P = 2.14 x 10-29).
The researchers examined links between RF-positive polyarticular JIA and the 27 SNPs that had been identified in the previous study of oligoarticular/RF-negative polyarticular JIA. Just 6 of those 27 SNPs were significantly associated with RF-positive polyarticular JIA (P less than .05). On the other hand, of 44 SNPs most strongly associated with RA, 19 were associated with RF-positive polyarticular JIA (P less than .05).
That suggests that RF-positive polyarticular JIA cases are different from other JIA cases. “They’re more like adult patients than they’re like child patients,” said Dr. Stevens.
The researchers also compared the weighted genetic risk scores (wGRS) produced from the top RA loci to wGRS produced from the top oligoarticular/RF-negative polyarticular JIA loci. The wGRS from the top RA loci was a better predictor of RF-positive polyarticular JIA cases (area under the curve [AUC] = 0.71 versus AUC = 0.58; P = 8.26 x 10-33).
The wGRS from RA had similar success in predicting RF-positive polyarticular JIA and early-onset RA cases (AUC = 0.75; P = .25), but it fared worse in predicting late-onset RA (at 70 years or older, AUC = 0.62), compared with the wGRS from RF-positive polyarticular JIA (P = 1.65 x 10-5).
Those results suggest that RF-positive polyarticular JIA more closely resembles younger RA cases than older RA cases.
“If you consider early-onset RA patients, less than 29 years old when they develop RA, they look like JIA patients. But older RA patients, who are over 70 when they develop RA, they look like they totally have a different genetic background,” Dr. Stevens said.
The study could have clinical implications. The lead author, Anne Hinks, PhD, is a research fellow at the University of Manchester (England) and has led the charge to characterize JIA. The wGRS score she developed has the potential to help physicians diagnose classify and treat JIA patients. Currently, they must rely on the International League of Associations for Rheumatology criteria, which can take months to work through and may lead to misclassification diagnoses.
And in any case, the emerging genetic research suggests that the underlying genetics of JIA may be a better way to classify patients. “There’s a lot of overlap and risk of misclassifying patients with the current system. This weighted genetic risk score that Dr. Hinks developed could be used to classify patients with one DNA sample. This is the kind of clinical test we need,” Dr. Stevens said.
The study received funding from a range of government and private sources. Dr. Stevens has a patent licensed to Quest Diagnostics, is conducting research collaborations with Seattle Genetics and Kineta, and has received fellowship support from Pfizer.
SOURCE: Hinks A et al. Arthritis Rheumatol. 2018 Feb 9. doi: 10.1002/art.40443
New evidence suggests the rheumatoid factor–positive polyarticular subtype of juvenile idiopathic arthritis bears a close genetic resemblance to adult rheumatoid arthritis, lending support to the growing suspicion that in arthritis, biological underpinnings are more important than age of onset when it comes to characterizing and, potentially, choosing treatments.
Previous work had shown that rheumatoid factor (RF)–negative patients have genetic risks similar to those of adults with RF-negative disease. “If the RF-negative patients in adult and childhood are similar, then maybe the RF-positive patients are similar in their genetic background as well. That’s what this study was testing,” study coauthor Anne M. Stevens, MD, PhD, division chief of rheumatology at the University of Washington, Seattle, said in an interview. The study was published online Feb. 9 in Arthritis & Rheumatology.
There are seven recognized categories of juvenile idiopathic arthritis (JIA), and all are believed to have genetic risk factors. Previously, the researchers used the Immunochip custom microarray to map 186 autoimmune disease-associated loci from 11 autoimmune phenotypes, including adult rheumatoid arthritis (RA). In the current work, the researchers analyzed 340 RF-positive polyarticular JIA cases (292 females) and 14,412 controls (8,002 females) from the United States, United Kingdom, Germany, Canada, and Norway. RF-positive polyarticular disease accounts for about 5% of JIA cases, and its symptoms and presentations resemble adult RA.
The researchers found associations in the human leukocyte antigen (HLA) region. The most significant was found at rs3129769, near HLA-DRB1 (P = 5.51 x 10-31). This single nucleotide polymorphism (SNP) was in strong linkage disequilibrium (LD, r2 = 0.88) with the rs660895 HLA-DRB1 SNP that has been reported in adult RA (P = 2.14 x 10-29).
The researchers examined links between RF-positive polyarticular JIA and the 27 SNPs that had been identified in the previous study of oligoarticular/RF-negative polyarticular JIA. Just 6 of those 27 SNPs were significantly associated with RF-positive polyarticular JIA (P less than .05). On the other hand, of 44 SNPs most strongly associated with RA, 19 were associated with RF-positive polyarticular JIA (P less than .05).
That suggests that RF-positive polyarticular JIA cases are different from other JIA cases. “They’re more like adult patients than they’re like child patients,” said Dr. Stevens.
The researchers also compared the weighted genetic risk scores (wGRS) produced from the top RA loci to wGRS produced from the top oligoarticular/RF-negative polyarticular JIA loci. The wGRS from the top RA loci was a better predictor of RF-positive polyarticular JIA cases (area under the curve [AUC] = 0.71 versus AUC = 0.58; P = 8.26 x 10-33).
The wGRS from RA had similar success in predicting RF-positive polyarticular JIA and early-onset RA cases (AUC = 0.75; P = .25), but it fared worse in predicting late-onset RA (at 70 years or older, AUC = 0.62), compared with the wGRS from RF-positive polyarticular JIA (P = 1.65 x 10-5).
Those results suggest that RF-positive polyarticular JIA more closely resembles younger RA cases than older RA cases.
“If you consider early-onset RA patients, less than 29 years old when they develop RA, they look like JIA patients. But older RA patients, who are over 70 when they develop RA, they look like they totally have a different genetic background,” Dr. Stevens said.
The study could have clinical implications. The lead author, Anne Hinks, PhD, is a research fellow at the University of Manchester (England) and has led the charge to characterize JIA. The wGRS score she developed has the potential to help physicians diagnose classify and treat JIA patients. Currently, they must rely on the International League of Associations for Rheumatology criteria, which can take months to work through and may lead to misclassification diagnoses.
And in any case, the emerging genetic research suggests that the underlying genetics of JIA may be a better way to classify patients. “There’s a lot of overlap and risk of misclassifying patients with the current system. This weighted genetic risk score that Dr. Hinks developed could be used to classify patients with one DNA sample. This is the kind of clinical test we need,” Dr. Stevens said.
The study received funding from a range of government and private sources. Dr. Stevens has a patent licensed to Quest Diagnostics, is conducting research collaborations with Seattle Genetics and Kineta, and has received fellowship support from Pfizer.
SOURCE: Hinks A et al. Arthritis Rheumatol. 2018 Feb 9. doi: 10.1002/art.40443
FROM ARTHRITIS & RHEUMATOLOGY
Key clinical point: Genetics underlying arthritis may be more important than age of onset.
Major finding: The weighted genetic risk scores produced from the top RA loci was a better predictor of RF-positive polyarticular JIA than that generated from the top oligoarticular/RF-negative polyarticular JIA loci.
Data source: Case-control analysis of 340 cases and 14,412 controls.
Disclosures: The study received funding from a range of government and private sources. Dr. Stevens has a patent licensed to Quest Diagnostics, is conducting research collaborations with Seattle Genetics and Kineta, and has received fellowship support from Pfizer.
Source: Hinks A et al. Arthritis Rheumatol. 2018 Feb 9. doi: 10.1002/art.40443.
AYA cancer patients lost to follow-up
ORLANDO—Many adolescent and young adult (AYA) cancer survivors don’t continue with follow-up care, according to a new study.
Researchers analyzed nearly 2400 AYAs diagnosed with cancer between 2000 and 2015 and found that 37% of these patients had no follow-up visits since 2015.
The proportion of patients with follow-up visits in 2016 did not vary according to cancer type or insurance status, but it did vary according to patients’ time since last cancer treatment.
These findings were presented at the 2018 Cancer Survivorship Symposium (abstract 29).
“Many adolescents and young adults are unaware of what their long-term risks are after they have finished their cancer treatment,” said study investigator Lynda M. Beaupin, MD, of the Roswell Park Cancer Institute in Buffalo, New York.
“Doctors and other healthcare providers need to be more diligent in letting these patients know about future potential side effects and health risks that could occur based on certain aspects of their cancer treatment.”
In a previous study, Dr Beaupin and her colleagues conducted a focus group discussion with 27 AYAs, ages 18 to 39, to query them about the major barriers that prevented them from seeking follow-up care.
Among the factors mentioned were poor communication with their oncologists, ongoing problems in adjusting to life as a cancer survivor, and loss of health insurance.
As a follow-up to that focus group session, the investigators looked at a larger group of AYAs who were treated at Roswell Park Comprehensive Cancer Center.
The team analyzed data from the cancer center’s tumor registry, which included information on a patient’s current age, age at cancer diagnosis, gender, date of diagnosis, date of most recent doctor visit, and type of cancer.
The investigators also looked at patient-provided information on follow-up doctor appointments and insurance status for 2 cohorts of AYA cancer survivors. Patients in cohort A were diagnosed with cancer between 2010 and 2014, and patients in cohort B were diagnosed between 2005 and 2009.
The most common types of cancer were leukemia/lymphoma, melanoma, germ cell tumors, and thyroid and breast cancers.
Findings
There were 2367 patients, ages 18 to 39, who were diagnosed with cancer between 2000 and 2015.
Thirty-seven percent of these patients did not have a follow-up visit since 2015.
There was no difference in follow-up contact according to cancer type or insurance status. However, length of time since patients’ final cancer treatment was a factor in not scheduling a follow-up appointment.
Regardless of insurance status, 33% of cohort A (diagnosed 2010-2014) and 48% of cohort B (diagnosed 2005-2009) did not have a follow-up visit in 2016.
Among insured patients, 33% of those in cohort A and 47% of those in cohort B did not have a visit in 2016. Among uninsured patients, the percentages were 39% and 46%, respectively.
Next steps
The investigators hope to conduct future studies looking at other factors that may affect AYAs’ willingness to seek follow-up care, such as employment status, distance to a cancer center, whether they are getting tested or treated at a facility other than a cancer center, and how AYAs perceive their current quality of life.
“These patients have the potential to live a normal lifespan, and we need to educate them to become their own advocates so they may receive follow-up care on a regular basis,” Dr Beaupin said.
“We hope they continue to receive that follow-up at an established cancer center that has the facilities to assess cardiac health and provide rehabilitation if needed. There are now established survivorship programs nationwide that can provide follow-up care for those who have completed treatment.”
This study was supported by the National Cancer Institute.
ORLANDO—Many adolescent and young adult (AYA) cancer survivors don’t continue with follow-up care, according to a new study.
Researchers analyzed nearly 2400 AYAs diagnosed with cancer between 2000 and 2015 and found that 37% of these patients had no follow-up visits since 2015.
The proportion of patients with follow-up visits in 2016 did not vary according to cancer type or insurance status, but it did vary according to patients’ time since last cancer treatment.
These findings were presented at the 2018 Cancer Survivorship Symposium (abstract 29).
“Many adolescents and young adults are unaware of what their long-term risks are after they have finished their cancer treatment,” said study investigator Lynda M. Beaupin, MD, of the Roswell Park Cancer Institute in Buffalo, New York.
“Doctors and other healthcare providers need to be more diligent in letting these patients know about future potential side effects and health risks that could occur based on certain aspects of their cancer treatment.”
In a previous study, Dr Beaupin and her colleagues conducted a focus group discussion with 27 AYAs, ages 18 to 39, to query them about the major barriers that prevented them from seeking follow-up care.
Among the factors mentioned were poor communication with their oncologists, ongoing problems in adjusting to life as a cancer survivor, and loss of health insurance.
As a follow-up to that focus group session, the investigators looked at a larger group of AYAs who were treated at Roswell Park Comprehensive Cancer Center.
The team analyzed data from the cancer center’s tumor registry, which included information on a patient’s current age, age at cancer diagnosis, gender, date of diagnosis, date of most recent doctor visit, and type of cancer.
The investigators also looked at patient-provided information on follow-up doctor appointments and insurance status for 2 cohorts of AYA cancer survivors. Patients in cohort A were diagnosed with cancer between 2010 and 2014, and patients in cohort B were diagnosed between 2005 and 2009.
The most common types of cancer were leukemia/lymphoma, melanoma, germ cell tumors, and thyroid and breast cancers.
Findings
There were 2367 patients, ages 18 to 39, who were diagnosed with cancer between 2000 and 2015.
Thirty-seven percent of these patients did not have a follow-up visit since 2015.
There was no difference in follow-up contact according to cancer type or insurance status. However, length of time since patients’ final cancer treatment was a factor in not scheduling a follow-up appointment.
Regardless of insurance status, 33% of cohort A (diagnosed 2010-2014) and 48% of cohort B (diagnosed 2005-2009) did not have a follow-up visit in 2016.
Among insured patients, 33% of those in cohort A and 47% of those in cohort B did not have a visit in 2016. Among uninsured patients, the percentages were 39% and 46%, respectively.
Next steps
The investigators hope to conduct future studies looking at other factors that may affect AYAs’ willingness to seek follow-up care, such as employment status, distance to a cancer center, whether they are getting tested or treated at a facility other than a cancer center, and how AYAs perceive their current quality of life.
“These patients have the potential to live a normal lifespan, and we need to educate them to become their own advocates so they may receive follow-up care on a regular basis,” Dr Beaupin said.
“We hope they continue to receive that follow-up at an established cancer center that has the facilities to assess cardiac health and provide rehabilitation if needed. There are now established survivorship programs nationwide that can provide follow-up care for those who have completed treatment.”
This study was supported by the National Cancer Institute.
ORLANDO—Many adolescent and young adult (AYA) cancer survivors don’t continue with follow-up care, according to a new study.
Researchers analyzed nearly 2400 AYAs diagnosed with cancer between 2000 and 2015 and found that 37% of these patients had no follow-up visits since 2015.
The proportion of patients with follow-up visits in 2016 did not vary according to cancer type or insurance status, but it did vary according to patients’ time since last cancer treatment.
These findings were presented at the 2018 Cancer Survivorship Symposium (abstract 29).
“Many adolescents and young adults are unaware of what their long-term risks are after they have finished their cancer treatment,” said study investigator Lynda M. Beaupin, MD, of the Roswell Park Cancer Institute in Buffalo, New York.
“Doctors and other healthcare providers need to be more diligent in letting these patients know about future potential side effects and health risks that could occur based on certain aspects of their cancer treatment.”
In a previous study, Dr Beaupin and her colleagues conducted a focus group discussion with 27 AYAs, ages 18 to 39, to query them about the major barriers that prevented them from seeking follow-up care.
Among the factors mentioned were poor communication with their oncologists, ongoing problems in adjusting to life as a cancer survivor, and loss of health insurance.
As a follow-up to that focus group session, the investigators looked at a larger group of AYAs who were treated at Roswell Park Comprehensive Cancer Center.
The team analyzed data from the cancer center’s tumor registry, which included information on a patient’s current age, age at cancer diagnosis, gender, date of diagnosis, date of most recent doctor visit, and type of cancer.
The investigators also looked at patient-provided information on follow-up doctor appointments and insurance status for 2 cohorts of AYA cancer survivors. Patients in cohort A were diagnosed with cancer between 2010 and 2014, and patients in cohort B were diagnosed between 2005 and 2009.
The most common types of cancer were leukemia/lymphoma, melanoma, germ cell tumors, and thyroid and breast cancers.
Findings
There were 2367 patients, ages 18 to 39, who were diagnosed with cancer between 2000 and 2015.
Thirty-seven percent of these patients did not have a follow-up visit since 2015.
There was no difference in follow-up contact according to cancer type or insurance status. However, length of time since patients’ final cancer treatment was a factor in not scheduling a follow-up appointment.
Regardless of insurance status, 33% of cohort A (diagnosed 2010-2014) and 48% of cohort B (diagnosed 2005-2009) did not have a follow-up visit in 2016.
Among insured patients, 33% of those in cohort A and 47% of those in cohort B did not have a visit in 2016. Among uninsured patients, the percentages were 39% and 46%, respectively.
Next steps
The investigators hope to conduct future studies looking at other factors that may affect AYAs’ willingness to seek follow-up care, such as employment status, distance to a cancer center, whether they are getting tested or treated at a facility other than a cancer center, and how AYAs perceive their current quality of life.
“These patients have the potential to live a normal lifespan, and we need to educate them to become their own advocates so they may receive follow-up care on a regular basis,” Dr Beaupin said.
“We hope they continue to receive that follow-up at an established cancer center that has the facilities to assess cardiac health and provide rehabilitation if needed. There are now established survivorship programs nationwide that can provide follow-up care for those who have completed treatment.”
This study was supported by the National Cancer Institute.
Experts review the year in rheumatology ... and what lies ahead
MAUI, HAWAII – Arthur Kavanaugh, MD, program director for the Rheumatology Winter Clinical Symposium, likes to close out the meeting each year in high style by assembling selected conference faculty to offer their personal picks for the top developments in the field during the past year and make predictions about the year to come.
Here’s how they called it:
The top events in rheumatology during the last year
The rise of oral small molecules: The Janus kinase (JAK) inhibitors and other oral small molecules that have begun reaching the marketplace, with many more in development, will bring a paradigm shift in the treatment not only of rheumatic diseases, but in inflammatory bowel disease and skin diseases as well, predicted Alvin F. Wells, MD, PhD, a rheumatologist at Duke University in Durham, N.C., who is also director of the Rheumatology and Immunotherapy Center in Franklin, Wisc.
“The challenge is whether Medicare will cover the pills the way they cover the infusions and the other things we do,” according to Dr. Wells.
A bevy of new drugs for psoriatic arthritis and psoriasis: “I think the most important advance in the past year was the approval of a profusion of drugs for psoriatic arthritis and psoriasis. It’s really opened up the landscape for us in terms of treatment options. The downside is it’s going to take us a while to sort through which drugs fit where,” noted Eric J. Ruderman, MD, professor of medicine and associate chief of clinical affairs in the division of rheumatology at Northwestern University in Chicago.
“The drug I was most impressed with was tofacitinib [Xeljanz, an oral JAK inhibitor], not just by its effectiveness but by its potential to change the game, and particularly the data in tumor necrosis factor inhibitor inadequate responders. That was pretty solid data. It really opens the way to oral small molecules for joint diseases,” he added.
Interleukin-18 binding protein for monogenic inflammasome diseases: The biggest recent breakthrough in pediatric rheumatology was the Food and Drug Administration’s April 2017 designation of Breakthrough Therapy status for the recombinant human IL-18 binding protein known as tadekinig alfa for monogenic IL-18-associated autoinflammatory conditions, as well as the biologic’s Orphan Drug Designation for treatment of hemophagocytic lymphohistiocytosis, according to Anne M. Stevens, MD, PhD, professor of pediatrics at the University of Washington, Seattle, and chief of pediatric rheumatology at Seattle Children’s Hospital.
Novel treatment concept emerges in severe SLE: The study that knocked the socks off of Martin J. Bergman, MD, in 2017 was the Dutch SymBiose study, presented at both the European League Against Rheumatism and American College of Rheumatology annual meetings. It included just 14 patients with severe refractory SLE – including 10 with lupus nephritis – and tested a treatment strategy of rituximab (Rituxan) followed a few weeks later by a course of belimumab (Benlysta).
“The results were very dramatic, to say the least,” said Dr. Bergman of Drexel University in Philadelphia. Indeed, this one-two therapeutic punch resulted in sharply reduced levels of pathogenic autoantibodies and immune complex-mediated neutrophil extracellular traps while also knocking down very high baseline Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) scores to near zero, even while enabling patients to discontinue systemic corticosteroids and mycophenolate mofetil (CellCept). Several much larger clinical trials of this regimen and other similar ones are ongoing in an effort to duplicate the results.
Dr. Kavanaugh said the SymBiose study was one of his own top picks for study of the year as well.
Mainstream use of dupilumab (Dupixent) for moderate to severe atopic dermatitis: “This is a total game changer. It’s really changed a lot of people’s lives,” commented George M. Martin, MD, a dermatologist in private practice on Maui.
“Interestingly, historically drugs that started out in your realm later made their way to dermatology, but now we’re seeing the IL-23 inhibitors starting with us and then making their way into rheumatology and gastroenterology. The IL-23 inhibitors are very powerful drugs; when we’re seeing half of our psoriasis patients achieve PASI 100 responses, it’s very exciting. And these are durable responses,” he noted.
The opioid crisis: What’s the most important recent event in rheumatology?
“That’s easy: The biggest thing in all of medicine is the opioid crisis. Whether you recognize it or not, it’s gigantic. It’s $500 billion of the U.S. economy, every year. Forty percent of rheumatoid arthritis patients and 30% with ankylosing spondylitis are on opioids, and what goes along with that is a lot of ugly stuff,” said John J. Cush, MD, professor of medicine and rheumatology at Baylor University in Dallas.
Moreover, the FDA is now so leery of opioids that the agency has set the bar unrealistically high for approval of newer agents offering reduced abuse potential.
“I’ve been involved with or watched at least six FDA advisory panels looking at new, lower abuse-potential opioids in the last couple years. Only one agent got through,” according to Dr. Cush.
Dr. Troum commented, “I really think this whole opioid epidemic started with the campaign to make pain the fifth vital sign back in the 1990s. Some of the pharmaceutical companies took that concept and really ran with it.”
Rapamycin for inclusion body myositis: Dr. Kavanaugh’s pick for study of the year was what he described as “a brilliant presentation” of a French multicenter, placebo-controlled clinical trial of rapamycin for patients with inclusion body myositis at the 2017 ACR annual meeting.
“The French group considers IBM [inclusion body myositis] to be essentially Alzheimer’s disease of the muscle, marked by amyloid deposition. They chose to study rapamycin, which not only has immunosuppressive properties because it binds to mTOR [the mammalian target of rapamycin], but it also has the ability to inhibit amyloid protein deposition,” he explained.
The investigators reported improved 6-minute-walk distance and pulmonary function in the rapamycin group, whereas placebo-treated controls rapidly deteriorated.
“This is an approved drug for other indications, and we scratch our heads with IBM. It’s super nice to have something like that,” Dr. Kavanaugh observed.
A look at what’s in store
More tele-rheumatology: “I think the biggest thing is going to be more tele-rheumatology, more tele-ultrasound. Kaiser Permanente said 49% of their visits last year were virtual visits; that number is just going to grow,” predicted Dr. Wells.
Especially in medically underserved areas of the country, including large rural expanses, demand for remote tele-rheumatologic consults with high-quality imaging is going to increase, he added.
Here come cannabinoids for pain control: Dr. Troum predicted that in the depths of the national opioid epidemic, in a climate that discourages legitimate prescribing of traditional pain medications, rheumatologists can anticipate growing patient demand for cannabidiol and other cannabinoids for pain relief.
“I have patients coming in their 60s, 70s, and 80s – these are not young people – who are whispering to me, ‘Can I use this for my chronic pain?’ I think there’s going to be a big push for ways other than opioids to treat our patients’ pain,” according to Dr. Troum.
Tipping point nears for JAK inhibitors: In 2018, it will become clear just how seriously the Food and Drug Administration views the signal of possible increased venous thromboembolic risk associated with the oral JAK inhibitors for rheumatoid arthritis. The agency is expected to rule on Eli Lilly and Incyte’s resubmitted application for marketing approval for the JAK inhibitor baricitinib, which was tripped up earlier based in part upon VTE concerns.
“I think the big story in 2018 will be how the JAK story shakes out – whether this VTE thing has legs,” Dr. Ruderman predicted. “A sea change could be coming in our field, and it’s not coming next year or the year after, but 10 years from now: Are we going to move past the era of methotrexate and use generic small molecules instead? We’re going to find out within the next year whether that’s going to happen.”
Phase 3 results coming on tocilizumab for systemic sclerosis: “I think we’re going to see some really exciting systemic sclerosis data coming out this year,” Dr. Stevens said. Based upon the positive phase 2 results presented for tocilizumab (Actemra) last year, she’s optimistic that the ongoing phase 3 randomized trial will demonstrate a significant advantage over placebo in lung function. Also, ongoing separate clinical trials are evaluating an antifibrotic drug and rapamycin for systemic sclerosis.
Dr. Bergman, too, has high hopes for these studies: “I think we may finally be getting to a place where we can see effective drugs in systemic sclerosis.”
Amazon, Berkshire Hathaway, and JPMorgan Chase form a nonprofit to improve employee health care: In a recent press conference, the three CEOs weren’t specific about their plans, but Dr. Martin predicted the companies are likely to self-insure, bypassing Cigna and the other major health insurance companies and then contracting with physicians. He forecast that “probably within the next 5 years, what they do is going to affect everybody in this room.”
Rheumatologists will need to master a new mindset: Many rheumatologists have gotten comfortable with an all-tumor necrosis factor inhibitor treatment menu for their patients with moderate or severe rheumatoid arthritis. That’s got to change, according to Dr. Cush.
“We now have two IL-6 inhibitors, two IL-17 inhibitors, and we’ll soon have two JAK inhibitors. That’s going to be a direct threat to the not right- or left-brain, but the TNF-brain rheumatologist who now writes prescriptions for three TNF inhibitors in a row before questioning the efficacy. The idea is you will now be using drugs with other mechanisms of action first-line, or at the very least, second-line, and that’s going to be a paradigm shift for a lot of people,” he explained.
None of the speakers reported having financial conflicts regarding their comments.
MAUI, HAWAII – Arthur Kavanaugh, MD, program director for the Rheumatology Winter Clinical Symposium, likes to close out the meeting each year in high style by assembling selected conference faculty to offer their personal picks for the top developments in the field during the past year and make predictions about the year to come.
Here’s how they called it:
The top events in rheumatology during the last year
The rise of oral small molecules: The Janus kinase (JAK) inhibitors and other oral small molecules that have begun reaching the marketplace, with many more in development, will bring a paradigm shift in the treatment not only of rheumatic diseases, but in inflammatory bowel disease and skin diseases as well, predicted Alvin F. Wells, MD, PhD, a rheumatologist at Duke University in Durham, N.C., who is also director of the Rheumatology and Immunotherapy Center in Franklin, Wisc.
“The challenge is whether Medicare will cover the pills the way they cover the infusions and the other things we do,” according to Dr. Wells.
A bevy of new drugs for psoriatic arthritis and psoriasis: “I think the most important advance in the past year was the approval of a profusion of drugs for psoriatic arthritis and psoriasis. It’s really opened up the landscape for us in terms of treatment options. The downside is it’s going to take us a while to sort through which drugs fit where,” noted Eric J. Ruderman, MD, professor of medicine and associate chief of clinical affairs in the division of rheumatology at Northwestern University in Chicago.
“The drug I was most impressed with was tofacitinib [Xeljanz, an oral JAK inhibitor], not just by its effectiveness but by its potential to change the game, and particularly the data in tumor necrosis factor inhibitor inadequate responders. That was pretty solid data. It really opens the way to oral small molecules for joint diseases,” he added.
Interleukin-18 binding protein for monogenic inflammasome diseases: The biggest recent breakthrough in pediatric rheumatology was the Food and Drug Administration’s April 2017 designation of Breakthrough Therapy status for the recombinant human IL-18 binding protein known as tadekinig alfa for monogenic IL-18-associated autoinflammatory conditions, as well as the biologic’s Orphan Drug Designation for treatment of hemophagocytic lymphohistiocytosis, according to Anne M. Stevens, MD, PhD, professor of pediatrics at the University of Washington, Seattle, and chief of pediatric rheumatology at Seattle Children’s Hospital.
Novel treatment concept emerges in severe SLE: The study that knocked the socks off of Martin J. Bergman, MD, in 2017 was the Dutch SymBiose study, presented at both the European League Against Rheumatism and American College of Rheumatology annual meetings. It included just 14 patients with severe refractory SLE – including 10 with lupus nephritis – and tested a treatment strategy of rituximab (Rituxan) followed a few weeks later by a course of belimumab (Benlysta).
“The results were very dramatic, to say the least,” said Dr. Bergman of Drexel University in Philadelphia. Indeed, this one-two therapeutic punch resulted in sharply reduced levels of pathogenic autoantibodies and immune complex-mediated neutrophil extracellular traps while also knocking down very high baseline Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) scores to near zero, even while enabling patients to discontinue systemic corticosteroids and mycophenolate mofetil (CellCept). Several much larger clinical trials of this regimen and other similar ones are ongoing in an effort to duplicate the results.
Dr. Kavanaugh said the SymBiose study was one of his own top picks for study of the year as well.
Mainstream use of dupilumab (Dupixent) for moderate to severe atopic dermatitis: “This is a total game changer. It’s really changed a lot of people’s lives,” commented George M. Martin, MD, a dermatologist in private practice on Maui.
“Interestingly, historically drugs that started out in your realm later made their way to dermatology, but now we’re seeing the IL-23 inhibitors starting with us and then making their way into rheumatology and gastroenterology. The IL-23 inhibitors are very powerful drugs; when we’re seeing half of our psoriasis patients achieve PASI 100 responses, it’s very exciting. And these are durable responses,” he noted.
The opioid crisis: What’s the most important recent event in rheumatology?
“That’s easy: The biggest thing in all of medicine is the opioid crisis. Whether you recognize it or not, it’s gigantic. It’s $500 billion of the U.S. economy, every year. Forty percent of rheumatoid arthritis patients and 30% with ankylosing spondylitis are on opioids, and what goes along with that is a lot of ugly stuff,” said John J. Cush, MD, professor of medicine and rheumatology at Baylor University in Dallas.
Moreover, the FDA is now so leery of opioids that the agency has set the bar unrealistically high for approval of newer agents offering reduced abuse potential.
“I’ve been involved with or watched at least six FDA advisory panels looking at new, lower abuse-potential opioids in the last couple years. Only one agent got through,” according to Dr. Cush.
Dr. Troum commented, “I really think this whole opioid epidemic started with the campaign to make pain the fifth vital sign back in the 1990s. Some of the pharmaceutical companies took that concept and really ran with it.”
Rapamycin for inclusion body myositis: Dr. Kavanaugh’s pick for study of the year was what he described as “a brilliant presentation” of a French multicenter, placebo-controlled clinical trial of rapamycin for patients with inclusion body myositis at the 2017 ACR annual meeting.
“The French group considers IBM [inclusion body myositis] to be essentially Alzheimer’s disease of the muscle, marked by amyloid deposition. They chose to study rapamycin, which not only has immunosuppressive properties because it binds to mTOR [the mammalian target of rapamycin], but it also has the ability to inhibit amyloid protein deposition,” he explained.
The investigators reported improved 6-minute-walk distance and pulmonary function in the rapamycin group, whereas placebo-treated controls rapidly deteriorated.
“This is an approved drug for other indications, and we scratch our heads with IBM. It’s super nice to have something like that,” Dr. Kavanaugh observed.
A look at what’s in store
More tele-rheumatology: “I think the biggest thing is going to be more tele-rheumatology, more tele-ultrasound. Kaiser Permanente said 49% of their visits last year were virtual visits; that number is just going to grow,” predicted Dr. Wells.
Especially in medically underserved areas of the country, including large rural expanses, demand for remote tele-rheumatologic consults with high-quality imaging is going to increase, he added.
Here come cannabinoids for pain control: Dr. Troum predicted that in the depths of the national opioid epidemic, in a climate that discourages legitimate prescribing of traditional pain medications, rheumatologists can anticipate growing patient demand for cannabidiol and other cannabinoids for pain relief.
“I have patients coming in their 60s, 70s, and 80s – these are not young people – who are whispering to me, ‘Can I use this for my chronic pain?’ I think there’s going to be a big push for ways other than opioids to treat our patients’ pain,” according to Dr. Troum.
Tipping point nears for JAK inhibitors: In 2018, it will become clear just how seriously the Food and Drug Administration views the signal of possible increased venous thromboembolic risk associated with the oral JAK inhibitors for rheumatoid arthritis. The agency is expected to rule on Eli Lilly and Incyte’s resubmitted application for marketing approval for the JAK inhibitor baricitinib, which was tripped up earlier based in part upon VTE concerns.
“I think the big story in 2018 will be how the JAK story shakes out – whether this VTE thing has legs,” Dr. Ruderman predicted. “A sea change could be coming in our field, and it’s not coming next year or the year after, but 10 years from now: Are we going to move past the era of methotrexate and use generic small molecules instead? We’re going to find out within the next year whether that’s going to happen.”
Phase 3 results coming on tocilizumab for systemic sclerosis: “I think we’re going to see some really exciting systemic sclerosis data coming out this year,” Dr. Stevens said. Based upon the positive phase 2 results presented for tocilizumab (Actemra) last year, she’s optimistic that the ongoing phase 3 randomized trial will demonstrate a significant advantage over placebo in lung function. Also, ongoing separate clinical trials are evaluating an antifibrotic drug and rapamycin for systemic sclerosis.
Dr. Bergman, too, has high hopes for these studies: “I think we may finally be getting to a place where we can see effective drugs in systemic sclerosis.”
Amazon, Berkshire Hathaway, and JPMorgan Chase form a nonprofit to improve employee health care: In a recent press conference, the three CEOs weren’t specific about their plans, but Dr. Martin predicted the companies are likely to self-insure, bypassing Cigna and the other major health insurance companies and then contracting with physicians. He forecast that “probably within the next 5 years, what they do is going to affect everybody in this room.”
Rheumatologists will need to master a new mindset: Many rheumatologists have gotten comfortable with an all-tumor necrosis factor inhibitor treatment menu for their patients with moderate or severe rheumatoid arthritis. That’s got to change, according to Dr. Cush.
“We now have two IL-6 inhibitors, two IL-17 inhibitors, and we’ll soon have two JAK inhibitors. That’s going to be a direct threat to the not right- or left-brain, but the TNF-brain rheumatologist who now writes prescriptions for three TNF inhibitors in a row before questioning the efficacy. The idea is you will now be using drugs with other mechanisms of action first-line, or at the very least, second-line, and that’s going to be a paradigm shift for a lot of people,” he explained.
None of the speakers reported having financial conflicts regarding their comments.
MAUI, HAWAII – Arthur Kavanaugh, MD, program director for the Rheumatology Winter Clinical Symposium, likes to close out the meeting each year in high style by assembling selected conference faculty to offer their personal picks for the top developments in the field during the past year and make predictions about the year to come.
Here’s how they called it:
The top events in rheumatology during the last year
The rise of oral small molecules: The Janus kinase (JAK) inhibitors and other oral small molecules that have begun reaching the marketplace, with many more in development, will bring a paradigm shift in the treatment not only of rheumatic diseases, but in inflammatory bowel disease and skin diseases as well, predicted Alvin F. Wells, MD, PhD, a rheumatologist at Duke University in Durham, N.C., who is also director of the Rheumatology and Immunotherapy Center in Franklin, Wisc.
“The challenge is whether Medicare will cover the pills the way they cover the infusions and the other things we do,” according to Dr. Wells.
A bevy of new drugs for psoriatic arthritis and psoriasis: “I think the most important advance in the past year was the approval of a profusion of drugs for psoriatic arthritis and psoriasis. It’s really opened up the landscape for us in terms of treatment options. The downside is it’s going to take us a while to sort through which drugs fit where,” noted Eric J. Ruderman, MD, professor of medicine and associate chief of clinical affairs in the division of rheumatology at Northwestern University in Chicago.
“The drug I was most impressed with was tofacitinib [Xeljanz, an oral JAK inhibitor], not just by its effectiveness but by its potential to change the game, and particularly the data in tumor necrosis factor inhibitor inadequate responders. That was pretty solid data. It really opens the way to oral small molecules for joint diseases,” he added.
Interleukin-18 binding protein for monogenic inflammasome diseases: The biggest recent breakthrough in pediatric rheumatology was the Food and Drug Administration’s April 2017 designation of Breakthrough Therapy status for the recombinant human IL-18 binding protein known as tadekinig alfa for monogenic IL-18-associated autoinflammatory conditions, as well as the biologic’s Orphan Drug Designation for treatment of hemophagocytic lymphohistiocytosis, according to Anne M. Stevens, MD, PhD, professor of pediatrics at the University of Washington, Seattle, and chief of pediatric rheumatology at Seattle Children’s Hospital.
Novel treatment concept emerges in severe SLE: The study that knocked the socks off of Martin J. Bergman, MD, in 2017 was the Dutch SymBiose study, presented at both the European League Against Rheumatism and American College of Rheumatology annual meetings. It included just 14 patients with severe refractory SLE – including 10 with lupus nephritis – and tested a treatment strategy of rituximab (Rituxan) followed a few weeks later by a course of belimumab (Benlysta).
“The results were very dramatic, to say the least,” said Dr. Bergman of Drexel University in Philadelphia. Indeed, this one-two therapeutic punch resulted in sharply reduced levels of pathogenic autoantibodies and immune complex-mediated neutrophil extracellular traps while also knocking down very high baseline Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) scores to near zero, even while enabling patients to discontinue systemic corticosteroids and mycophenolate mofetil (CellCept). Several much larger clinical trials of this regimen and other similar ones are ongoing in an effort to duplicate the results.
Dr. Kavanaugh said the SymBiose study was one of his own top picks for study of the year as well.
Mainstream use of dupilumab (Dupixent) for moderate to severe atopic dermatitis: “This is a total game changer. It’s really changed a lot of people’s lives,” commented George M. Martin, MD, a dermatologist in private practice on Maui.
“Interestingly, historically drugs that started out in your realm later made their way to dermatology, but now we’re seeing the IL-23 inhibitors starting with us and then making their way into rheumatology and gastroenterology. The IL-23 inhibitors are very powerful drugs; when we’re seeing half of our psoriasis patients achieve PASI 100 responses, it’s very exciting. And these are durable responses,” he noted.
The opioid crisis: What’s the most important recent event in rheumatology?
“That’s easy: The biggest thing in all of medicine is the opioid crisis. Whether you recognize it or not, it’s gigantic. It’s $500 billion of the U.S. economy, every year. Forty percent of rheumatoid arthritis patients and 30% with ankylosing spondylitis are on opioids, and what goes along with that is a lot of ugly stuff,” said John J. Cush, MD, professor of medicine and rheumatology at Baylor University in Dallas.
Moreover, the FDA is now so leery of opioids that the agency has set the bar unrealistically high for approval of newer agents offering reduced abuse potential.
“I’ve been involved with or watched at least six FDA advisory panels looking at new, lower abuse-potential opioids in the last couple years. Only one agent got through,” according to Dr. Cush.
Dr. Troum commented, “I really think this whole opioid epidemic started with the campaign to make pain the fifth vital sign back in the 1990s. Some of the pharmaceutical companies took that concept and really ran with it.”
Rapamycin for inclusion body myositis: Dr. Kavanaugh’s pick for study of the year was what he described as “a brilliant presentation” of a French multicenter, placebo-controlled clinical trial of rapamycin for patients with inclusion body myositis at the 2017 ACR annual meeting.
“The French group considers IBM [inclusion body myositis] to be essentially Alzheimer’s disease of the muscle, marked by amyloid deposition. They chose to study rapamycin, which not only has immunosuppressive properties because it binds to mTOR [the mammalian target of rapamycin], but it also has the ability to inhibit amyloid protein deposition,” he explained.
The investigators reported improved 6-minute-walk distance and pulmonary function in the rapamycin group, whereas placebo-treated controls rapidly deteriorated.
“This is an approved drug for other indications, and we scratch our heads with IBM. It’s super nice to have something like that,” Dr. Kavanaugh observed.
A look at what’s in store
More tele-rheumatology: “I think the biggest thing is going to be more tele-rheumatology, more tele-ultrasound. Kaiser Permanente said 49% of their visits last year were virtual visits; that number is just going to grow,” predicted Dr. Wells.
Especially in medically underserved areas of the country, including large rural expanses, demand for remote tele-rheumatologic consults with high-quality imaging is going to increase, he added.
Here come cannabinoids for pain control: Dr. Troum predicted that in the depths of the national opioid epidemic, in a climate that discourages legitimate prescribing of traditional pain medications, rheumatologists can anticipate growing patient demand for cannabidiol and other cannabinoids for pain relief.
“I have patients coming in their 60s, 70s, and 80s – these are not young people – who are whispering to me, ‘Can I use this for my chronic pain?’ I think there’s going to be a big push for ways other than opioids to treat our patients’ pain,” according to Dr. Troum.
Tipping point nears for JAK inhibitors: In 2018, it will become clear just how seriously the Food and Drug Administration views the signal of possible increased venous thromboembolic risk associated with the oral JAK inhibitors for rheumatoid arthritis. The agency is expected to rule on Eli Lilly and Incyte’s resubmitted application for marketing approval for the JAK inhibitor baricitinib, which was tripped up earlier based in part upon VTE concerns.
“I think the big story in 2018 will be how the JAK story shakes out – whether this VTE thing has legs,” Dr. Ruderman predicted. “A sea change could be coming in our field, and it’s not coming next year or the year after, but 10 years from now: Are we going to move past the era of methotrexate and use generic small molecules instead? We’re going to find out within the next year whether that’s going to happen.”
Phase 3 results coming on tocilizumab for systemic sclerosis: “I think we’re going to see some really exciting systemic sclerosis data coming out this year,” Dr. Stevens said. Based upon the positive phase 2 results presented for tocilizumab (Actemra) last year, she’s optimistic that the ongoing phase 3 randomized trial will demonstrate a significant advantage over placebo in lung function. Also, ongoing separate clinical trials are evaluating an antifibrotic drug and rapamycin for systemic sclerosis.
Dr. Bergman, too, has high hopes for these studies: “I think we may finally be getting to a place where we can see effective drugs in systemic sclerosis.”
Amazon, Berkshire Hathaway, and JPMorgan Chase form a nonprofit to improve employee health care: In a recent press conference, the three CEOs weren’t specific about their plans, but Dr. Martin predicted the companies are likely to self-insure, bypassing Cigna and the other major health insurance companies and then contracting with physicians. He forecast that “probably within the next 5 years, what they do is going to affect everybody in this room.”
Rheumatologists will need to master a new mindset: Many rheumatologists have gotten comfortable with an all-tumor necrosis factor inhibitor treatment menu for their patients with moderate or severe rheumatoid arthritis. That’s got to change, according to Dr. Cush.
“We now have two IL-6 inhibitors, two IL-17 inhibitors, and we’ll soon have two JAK inhibitors. That’s going to be a direct threat to the not right- or left-brain, but the TNF-brain rheumatologist who now writes prescriptions for three TNF inhibitors in a row before questioning the efficacy. The idea is you will now be using drugs with other mechanisms of action first-line, or at the very least, second-line, and that’s going to be a paradigm shift for a lot of people,” he explained.
None of the speakers reported having financial conflicts regarding their comments.
EXPERT ANALYSIS FROM RWCS 2018
VIDEO: Vulvar disorders in preadolescent patients
SAN DIEGO – Over the past few years, pediatric dermatologist Kalyani Marathe, MD, has been seeing young patients with vulvar diseases in a multidisciplinary vulvar dermatology clinic at Children’s National Health System, in Washington, DC.
When Dr. Marathe started, it was her first experience treating such patients and there still are not much data in this population. She and Veronica Gomez-Lobo, MD, a pediatric and adolescent gynecologist at Children’s, “have now been doing the clinic every month for the last three and a half years,” and counsel and treat patients together. With longitudinal follow-up, “we’re learning so much about these conditions in children,” most of whom are about ages 3-11 years.
In a video interview at the annual meeting of the American Academy of Dermatology, Dr. Marathe discussed some of what she and Dr. Gomez-Lobo have learned over the past 3 years, with algorithms for treatment for the most common conditions they encounter in the clinic: non-specific vulvovaginitis, lichen sclerosus, and vitiligo.
Dr. Marathe had no relevant disclosures. She is a Dermatology News editorial board advisor.
emechcatie@frontlinemedcom.com
SOURCE: Marathe, K. et al, Session U018
SAN DIEGO – Over the past few years, pediatric dermatologist Kalyani Marathe, MD, has been seeing young patients with vulvar diseases in a multidisciplinary vulvar dermatology clinic at Children’s National Health System, in Washington, DC.
When Dr. Marathe started, it was her first experience treating such patients and there still are not much data in this population. She and Veronica Gomez-Lobo, MD, a pediatric and adolescent gynecologist at Children’s, “have now been doing the clinic every month for the last three and a half years,” and counsel and treat patients together. With longitudinal follow-up, “we’re learning so much about these conditions in children,” most of whom are about ages 3-11 years.
In a video interview at the annual meeting of the American Academy of Dermatology, Dr. Marathe discussed some of what she and Dr. Gomez-Lobo have learned over the past 3 years, with algorithms for treatment for the most common conditions they encounter in the clinic: non-specific vulvovaginitis, lichen sclerosus, and vitiligo.
Dr. Marathe had no relevant disclosures. She is a Dermatology News editorial board advisor.
emechcatie@frontlinemedcom.com
SOURCE: Marathe, K. et al, Session U018
SAN DIEGO – Over the past few years, pediatric dermatologist Kalyani Marathe, MD, has been seeing young patients with vulvar diseases in a multidisciplinary vulvar dermatology clinic at Children’s National Health System, in Washington, DC.
When Dr. Marathe started, it was her first experience treating such patients and there still are not much data in this population. She and Veronica Gomez-Lobo, MD, a pediatric and adolescent gynecologist at Children’s, “have now been doing the clinic every month for the last three and a half years,” and counsel and treat patients together. With longitudinal follow-up, “we’re learning so much about these conditions in children,” most of whom are about ages 3-11 years.
In a video interview at the annual meeting of the American Academy of Dermatology, Dr. Marathe discussed some of what she and Dr. Gomez-Lobo have learned over the past 3 years, with algorithms for treatment for the most common conditions they encounter in the clinic: non-specific vulvovaginitis, lichen sclerosus, and vitiligo.
Dr. Marathe had no relevant disclosures. She is a Dermatology News editorial board advisor.
emechcatie@frontlinemedcom.com
SOURCE: Marathe, K. et al, Session U018
REPORTING FROM AAD 18
