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1 in 10 youths, 1 in 4 adults in U.S. use tobacco products
More than one in four U.S. adults are current users of at least one type of tobacco product, and nearly 1 in 10 youths report using tobacco in the previous month, according to a report published in the Jan. 26 edition of the New England Journal of Medicine.
Analysis of data from 45,971 adults and youths aged 12 years and older in Wave 1 of the national longitudinal Population Assessment of Tobacco and Health (PATH) study showed 28% of adults were current users of tobacco products, and 20% were daily users. Cigarettes were the most commonly used tobacco product: 18% of adults said they were current users of cigarettes and 16% were daily users. Cigars and e-cigarettes were the next most common tobacco products, with 8% of adults currently using cigars, and 6% currently using e-cigarettes. (N Eng J Med. 2016, Jan 26. doi: 10.1056/NEJMsa1607538).
“Among adults, tobacco use was generally higher among younger adults, men, members of racial minorities, members of sexual minorities, those with lower educational attainment and lower household income, and those living in the South or Midwest than among their counterparts,” wrote Karin A. Kasza of the department of health behavior at the Roswell Park Cancer Institute, Buffalo, N.Y., and coauthors. “Among youths, the prevalences of ever use and use in the previous 30 days were higher among older youths, male youths, and members of sexual minorities than among their counterparts.”
Many also reported using combinations of tobacco products in the previous 30 days, with 23% of adults and 15% of youths using cigarettes and e-cigarettes concurrently.
The authors noted that the estimates of tobacco use among youths obtained from this household-based survey were lower than those seen in previous school-based surveys, and suggested the survey method may have influenced young people’s responses.
“Surveys administered in a school-based environment may overestimate tobacco-use behaviors because of peer influences, whereas youths may underreport tobacco-use behaviors in a home-based survey out of fear that their parents will overhear answers or learn about them from the interviewer,” Ms. Kasza and her associates wrote.
The study was supported by the National Institute on Drug Abuse, National Institutes of Health, and the Food and Drug Administration and U.S. Department of Health and Human Services under a contract to Westat. One author declared grant support from a pharmaceutical company and having acted as an expert witness against the tobacco industry. Another declared advisory board positions and grant support from private industry, and a third declared stock in private industry. No other conflicts of interest were declared.
More than one in four U.S. adults are current users of at least one type of tobacco product, and nearly 1 in 10 youths report using tobacco in the previous month, according to a report published in the Jan. 26 edition of the New England Journal of Medicine.
Analysis of data from 45,971 adults and youths aged 12 years and older in Wave 1 of the national longitudinal Population Assessment of Tobacco and Health (PATH) study showed 28% of adults were current users of tobacco products, and 20% were daily users. Cigarettes were the most commonly used tobacco product: 18% of adults said they were current users of cigarettes and 16% were daily users. Cigars and e-cigarettes were the next most common tobacco products, with 8% of adults currently using cigars, and 6% currently using e-cigarettes. (N Eng J Med. 2016, Jan 26. doi: 10.1056/NEJMsa1607538).
“Among adults, tobacco use was generally higher among younger adults, men, members of racial minorities, members of sexual minorities, those with lower educational attainment and lower household income, and those living in the South or Midwest than among their counterparts,” wrote Karin A. Kasza of the department of health behavior at the Roswell Park Cancer Institute, Buffalo, N.Y., and coauthors. “Among youths, the prevalences of ever use and use in the previous 30 days were higher among older youths, male youths, and members of sexual minorities than among their counterparts.”
Many also reported using combinations of tobacco products in the previous 30 days, with 23% of adults and 15% of youths using cigarettes and e-cigarettes concurrently.
The authors noted that the estimates of tobacco use among youths obtained from this household-based survey were lower than those seen in previous school-based surveys, and suggested the survey method may have influenced young people’s responses.
“Surveys administered in a school-based environment may overestimate tobacco-use behaviors because of peer influences, whereas youths may underreport tobacco-use behaviors in a home-based survey out of fear that their parents will overhear answers or learn about them from the interviewer,” Ms. Kasza and her associates wrote.
The study was supported by the National Institute on Drug Abuse, National Institutes of Health, and the Food and Drug Administration and U.S. Department of Health and Human Services under a contract to Westat. One author declared grant support from a pharmaceutical company and having acted as an expert witness against the tobacco industry. Another declared advisory board positions and grant support from private industry, and a third declared stock in private industry. No other conflicts of interest were declared.
More than one in four U.S. adults are current users of at least one type of tobacco product, and nearly 1 in 10 youths report using tobacco in the previous month, according to a report published in the Jan. 26 edition of the New England Journal of Medicine.
Analysis of data from 45,971 adults and youths aged 12 years and older in Wave 1 of the national longitudinal Population Assessment of Tobacco and Health (PATH) study showed 28% of adults were current users of tobacco products, and 20% were daily users. Cigarettes were the most commonly used tobacco product: 18% of adults said they were current users of cigarettes and 16% were daily users. Cigars and e-cigarettes were the next most common tobacco products, with 8% of adults currently using cigars, and 6% currently using e-cigarettes. (N Eng J Med. 2016, Jan 26. doi: 10.1056/NEJMsa1607538).
“Among adults, tobacco use was generally higher among younger adults, men, members of racial minorities, members of sexual minorities, those with lower educational attainment and lower household income, and those living in the South or Midwest than among their counterparts,” wrote Karin A. Kasza of the department of health behavior at the Roswell Park Cancer Institute, Buffalo, N.Y., and coauthors. “Among youths, the prevalences of ever use and use in the previous 30 days were higher among older youths, male youths, and members of sexual minorities than among their counterparts.”
Many also reported using combinations of tobacco products in the previous 30 days, with 23% of adults and 15% of youths using cigarettes and e-cigarettes concurrently.
The authors noted that the estimates of tobacco use among youths obtained from this household-based survey were lower than those seen in previous school-based surveys, and suggested the survey method may have influenced young people’s responses.
“Surveys administered in a school-based environment may overestimate tobacco-use behaviors because of peer influences, whereas youths may underreport tobacco-use behaviors in a home-based survey out of fear that their parents will overhear answers or learn about them from the interviewer,” Ms. Kasza and her associates wrote.
The study was supported by the National Institute on Drug Abuse, National Institutes of Health, and the Food and Drug Administration and U.S. Department of Health and Human Services under a contract to Westat. One author declared grant support from a pharmaceutical company and having acted as an expert witness against the tobacco industry. Another declared advisory board positions and grant support from private industry, and a third declared stock in private industry. No other conflicts of interest were declared.
FROM THE NEW ENGLAND JOURNAL OF MEDICINE
Key clinical point: More than one in four U.S. adults are current users of at least one type of tobacco product, and nearly 1 in 10 youths report using tobacco in the previous month.
Major finding: The PATH study found 28% of adults are current users of tobacco products, and 20% are daily users.
Data source: Wave 1 of the national longitudinal Population Assessment of Tobacco and Health (PATH) study.
Disclosures: The study was supported by the National Institute on Drug Abuse, National Institutes of Health, and the Food and Drug Administration and U.S. Department of Health and Human Services. One author declared grant support from a pharmaceutical company and having acted as an expert witness against the tobacco industry. Another declared advisory board positions and grant support from private industry, and a third declared stock in private industry. No other conflicts of interest were declared.
Vascular anomalies often misdiagnosed amidst confusion
CHICAGO – Thanks to convoluted terminology, not to mention confusion in the literature, physicians have been known to frequently misdiagnose vascular malformations as hemangiomas, but an evolving understanding of their differences may lead to more precise diagnoses, according to a report at a symposium on vascular surgery sponsored by Northwestern University.
“Historically there has been a great deal of confusion in the literature when it comes to the nomenclature used to describe vascular anomalies,” said Naiem Nassiri, MD, of Robert Wood Johnson Medical School, New Brunswick, N.J. He pointed out that the term hemangioma “or derivatives thereof” – cavernous hemangioma, cavernous angioma, lymphangioma and cystic hygroma – are “absolute misnomers and continue to be misused and applied almost haphazardly to any anomalous vascular lesion.”
He cited reports that 71% of vascular anomalies have been improperly called hemangiomas, 69% have initially been diagnosed incorrectly, and 21% received the wrong treatment (Pediatr Dermatol. 2008;25[1]:7-12; Plast Reconstr Surg. 2011:127[1]:347-51). “Erroneous terminology has prognostic as well as diagnostic and therapeutic implications, and these can actually be quite devastating for the patient, not only clinically and physically but psychologically as well,” Dr. Nassiri said.
Using the International Society for the Study of Vascular Anomalies classification for hemangiomas and vascular malformations can help physicians make the differential diagnosis, Dr. Nassiri said. Hemangiomas are neoplastic lesions of infancy, though not always congenital, with a finite growth phase, whereas vascular malformations (VMs) are nonneoplastic, congenital lesions that can appear at any age and do not regress spontaneously, he said.
Infantile hemangiomas typically appear as the classic strawberry birthmark in children, whereas VMs tend to appear later in life. “They require some environmental trigger, such as trauma, activity, or changes in the hormonal milieu to manifest onset,” he said of VMs.
Simply put, VMs fall into three broad categories: slow-flow malformations, which include lymphatic and venous malformations; high-flow arteriovenous malformations (AVMs) and fistulas; and congenital mixed syndromes, which can include combinations thereof.
Dr. Nassiri noted that contrast-enhanced MRI is the standard imaging modality for diagnosis of VMs, and can differentiate between slow-flow and high-flow lesions. However, vascular specialists must be vigilant in ordering imaging for slow-flow lesions. “Orders can be changed to MR venography, and I’ve had patients who’ve gone decades with multiple MR venograms and no one can figure out what’s going on as no identifiable lesion is readily detected,” he said. “MR venograms are fantastic for detecting truncular blood flow where there typically are no anomalies in the vast majority of patients with isolated venous malformations, but on contrast-enhanced MRI these convoluted cluster of anomalous veins light up like Christmas trees.”
Lymphatic malformations affect the head and neck more so than the extremities, trunk or viscera, and are prone to infection and bleeding. “You can think of these as fluid-filled balloons, and the goal of treatment is fairly simple: You want to puncture the balloon and drain the fluid inside so as to obtain maximum wall collapse,” Dr. Nassiri said. Infusion of a sclerosant causes an inflammatory reaction leading to fibrosis, which then prevents balloon re-expansion. Surgical excision is best used as a secondary adjunct.
Venous malformations, comprising about 80% of all VMs, typically present as soft, spongy blue or purple compressible masses with associated pain that worsens with exertion, Dr. Nassiri said. “The most dangerous thing that is often overlooked, even by some of the physicians that treat these on a regular basis, is localized intravascular coagulopathy, which if left untreated can progress to fulminant disseminated intravascular coagulopathy,” he said. This tends to occur more in the more widespread varieties of venous malformations.
A common misnomer associated with venous malformations in adults is “liver hemangioma,” owing to the confusing nomenclature, Dr. Nassiri said. “When interrogated angiographically,” he said, “what is often labeled as a hepatic hemangioma is in fact a venous malformation. Natural history of the two entities is completely different.”
Dr. Nassiri described congenital high-flow AVMs as “convoluted networks of blood vessels with poorly differentiated endothelial cells that have neither a venous nor an arterial designation; this entity, otherwise known as a nidus, sits between the feeding arteries and the draining veins.” Treatment aims to eliminate the flow within that nidus.
Super-selective microcatheterization is the best option for nidus access and embolization using liquid embolic agents, preferably those that polymerize when infused. “This is probably the most potent angiogenic entity I’ve ever seen,” Dr. Nassiri said of the nidus.
“It’s like a low-pressure sump and it will recruit collaterals vigorously, so you have to eliminate that nidus.” A variety of different embolic agents, some off label, may be used for high flow AVMs.
For congenital mixed syndromes, the same diagnostic and therapeutic concepts hold true depending on the type of VM involved. Dr. Nassiri advised a multidisciplinary approach, and noted that early trials have investigated the use of sirolimus in severe, life-threatening cases (Br J Clin Pharmacol. 2016;82[5]:1171-9. doi: 10.1111/bcp.13022).
Dr. Nassiri disclosed serving on the speakers bureaus for Boston Scientific, Penumbra, and Merritt Medical, and is a consultant to Merritt Medical.
CHICAGO – Thanks to convoluted terminology, not to mention confusion in the literature, physicians have been known to frequently misdiagnose vascular malformations as hemangiomas, but an evolving understanding of their differences may lead to more precise diagnoses, according to a report at a symposium on vascular surgery sponsored by Northwestern University.
“Historically there has been a great deal of confusion in the literature when it comes to the nomenclature used to describe vascular anomalies,” said Naiem Nassiri, MD, of Robert Wood Johnson Medical School, New Brunswick, N.J. He pointed out that the term hemangioma “or derivatives thereof” – cavernous hemangioma, cavernous angioma, lymphangioma and cystic hygroma – are “absolute misnomers and continue to be misused and applied almost haphazardly to any anomalous vascular lesion.”
He cited reports that 71% of vascular anomalies have been improperly called hemangiomas, 69% have initially been diagnosed incorrectly, and 21% received the wrong treatment (Pediatr Dermatol. 2008;25[1]:7-12; Plast Reconstr Surg. 2011:127[1]:347-51). “Erroneous terminology has prognostic as well as diagnostic and therapeutic implications, and these can actually be quite devastating for the patient, not only clinically and physically but psychologically as well,” Dr. Nassiri said.
Using the International Society for the Study of Vascular Anomalies classification for hemangiomas and vascular malformations can help physicians make the differential diagnosis, Dr. Nassiri said. Hemangiomas are neoplastic lesions of infancy, though not always congenital, with a finite growth phase, whereas vascular malformations (VMs) are nonneoplastic, congenital lesions that can appear at any age and do not regress spontaneously, he said.
Infantile hemangiomas typically appear as the classic strawberry birthmark in children, whereas VMs tend to appear later in life. “They require some environmental trigger, such as trauma, activity, or changes in the hormonal milieu to manifest onset,” he said of VMs.
Simply put, VMs fall into three broad categories: slow-flow malformations, which include lymphatic and venous malformations; high-flow arteriovenous malformations (AVMs) and fistulas; and congenital mixed syndromes, which can include combinations thereof.
Dr. Nassiri noted that contrast-enhanced MRI is the standard imaging modality for diagnosis of VMs, and can differentiate between slow-flow and high-flow lesions. However, vascular specialists must be vigilant in ordering imaging for slow-flow lesions. “Orders can be changed to MR venography, and I’ve had patients who’ve gone decades with multiple MR venograms and no one can figure out what’s going on as no identifiable lesion is readily detected,” he said. “MR venograms are fantastic for detecting truncular blood flow where there typically are no anomalies in the vast majority of patients with isolated venous malformations, but on contrast-enhanced MRI these convoluted cluster of anomalous veins light up like Christmas trees.”
Lymphatic malformations affect the head and neck more so than the extremities, trunk or viscera, and are prone to infection and bleeding. “You can think of these as fluid-filled balloons, and the goal of treatment is fairly simple: You want to puncture the balloon and drain the fluid inside so as to obtain maximum wall collapse,” Dr. Nassiri said. Infusion of a sclerosant causes an inflammatory reaction leading to fibrosis, which then prevents balloon re-expansion. Surgical excision is best used as a secondary adjunct.
Venous malformations, comprising about 80% of all VMs, typically present as soft, spongy blue or purple compressible masses with associated pain that worsens with exertion, Dr. Nassiri said. “The most dangerous thing that is often overlooked, even by some of the physicians that treat these on a regular basis, is localized intravascular coagulopathy, which if left untreated can progress to fulminant disseminated intravascular coagulopathy,” he said. This tends to occur more in the more widespread varieties of venous malformations.
A common misnomer associated with venous malformations in adults is “liver hemangioma,” owing to the confusing nomenclature, Dr. Nassiri said. “When interrogated angiographically,” he said, “what is often labeled as a hepatic hemangioma is in fact a venous malformation. Natural history of the two entities is completely different.”
Dr. Nassiri described congenital high-flow AVMs as “convoluted networks of blood vessels with poorly differentiated endothelial cells that have neither a venous nor an arterial designation; this entity, otherwise known as a nidus, sits between the feeding arteries and the draining veins.” Treatment aims to eliminate the flow within that nidus.
Super-selective microcatheterization is the best option for nidus access and embolization using liquid embolic agents, preferably those that polymerize when infused. “This is probably the most potent angiogenic entity I’ve ever seen,” Dr. Nassiri said of the nidus.
“It’s like a low-pressure sump and it will recruit collaterals vigorously, so you have to eliminate that nidus.” A variety of different embolic agents, some off label, may be used for high flow AVMs.
For congenital mixed syndromes, the same diagnostic and therapeutic concepts hold true depending on the type of VM involved. Dr. Nassiri advised a multidisciplinary approach, and noted that early trials have investigated the use of sirolimus in severe, life-threatening cases (Br J Clin Pharmacol. 2016;82[5]:1171-9. doi: 10.1111/bcp.13022).
Dr. Nassiri disclosed serving on the speakers bureaus for Boston Scientific, Penumbra, and Merritt Medical, and is a consultant to Merritt Medical.
CHICAGO – Thanks to convoluted terminology, not to mention confusion in the literature, physicians have been known to frequently misdiagnose vascular malformations as hemangiomas, but an evolving understanding of their differences may lead to more precise diagnoses, according to a report at a symposium on vascular surgery sponsored by Northwestern University.
“Historically there has been a great deal of confusion in the literature when it comes to the nomenclature used to describe vascular anomalies,” said Naiem Nassiri, MD, of Robert Wood Johnson Medical School, New Brunswick, N.J. He pointed out that the term hemangioma “or derivatives thereof” – cavernous hemangioma, cavernous angioma, lymphangioma and cystic hygroma – are “absolute misnomers and continue to be misused and applied almost haphazardly to any anomalous vascular lesion.”
He cited reports that 71% of vascular anomalies have been improperly called hemangiomas, 69% have initially been diagnosed incorrectly, and 21% received the wrong treatment (Pediatr Dermatol. 2008;25[1]:7-12; Plast Reconstr Surg. 2011:127[1]:347-51). “Erroneous terminology has prognostic as well as diagnostic and therapeutic implications, and these can actually be quite devastating for the patient, not only clinically and physically but psychologically as well,” Dr. Nassiri said.
Using the International Society for the Study of Vascular Anomalies classification for hemangiomas and vascular malformations can help physicians make the differential diagnosis, Dr. Nassiri said. Hemangiomas are neoplastic lesions of infancy, though not always congenital, with a finite growth phase, whereas vascular malformations (VMs) are nonneoplastic, congenital lesions that can appear at any age and do not regress spontaneously, he said.
Infantile hemangiomas typically appear as the classic strawberry birthmark in children, whereas VMs tend to appear later in life. “They require some environmental trigger, such as trauma, activity, or changes in the hormonal milieu to manifest onset,” he said of VMs.
Simply put, VMs fall into three broad categories: slow-flow malformations, which include lymphatic and venous malformations; high-flow arteriovenous malformations (AVMs) and fistulas; and congenital mixed syndromes, which can include combinations thereof.
Dr. Nassiri noted that contrast-enhanced MRI is the standard imaging modality for diagnosis of VMs, and can differentiate between slow-flow and high-flow lesions. However, vascular specialists must be vigilant in ordering imaging for slow-flow lesions. “Orders can be changed to MR venography, and I’ve had patients who’ve gone decades with multiple MR venograms and no one can figure out what’s going on as no identifiable lesion is readily detected,” he said. “MR venograms are fantastic for detecting truncular blood flow where there typically are no anomalies in the vast majority of patients with isolated venous malformations, but on contrast-enhanced MRI these convoluted cluster of anomalous veins light up like Christmas trees.”
Lymphatic malformations affect the head and neck more so than the extremities, trunk or viscera, and are prone to infection and bleeding. “You can think of these as fluid-filled balloons, and the goal of treatment is fairly simple: You want to puncture the balloon and drain the fluid inside so as to obtain maximum wall collapse,” Dr. Nassiri said. Infusion of a sclerosant causes an inflammatory reaction leading to fibrosis, which then prevents balloon re-expansion. Surgical excision is best used as a secondary adjunct.
Venous malformations, comprising about 80% of all VMs, typically present as soft, spongy blue or purple compressible masses with associated pain that worsens with exertion, Dr. Nassiri said. “The most dangerous thing that is often overlooked, even by some of the physicians that treat these on a regular basis, is localized intravascular coagulopathy, which if left untreated can progress to fulminant disseminated intravascular coagulopathy,” he said. This tends to occur more in the more widespread varieties of venous malformations.
A common misnomer associated with venous malformations in adults is “liver hemangioma,” owing to the confusing nomenclature, Dr. Nassiri said. “When interrogated angiographically,” he said, “what is often labeled as a hepatic hemangioma is in fact a venous malformation. Natural history of the two entities is completely different.”
Dr. Nassiri described congenital high-flow AVMs as “convoluted networks of blood vessels with poorly differentiated endothelial cells that have neither a venous nor an arterial designation; this entity, otherwise known as a nidus, sits between the feeding arteries and the draining veins.” Treatment aims to eliminate the flow within that nidus.
Super-selective microcatheterization is the best option for nidus access and embolization using liquid embolic agents, preferably those that polymerize when infused. “This is probably the most potent angiogenic entity I’ve ever seen,” Dr. Nassiri said of the nidus.
“It’s like a low-pressure sump and it will recruit collaterals vigorously, so you have to eliminate that nidus.” A variety of different embolic agents, some off label, may be used for high flow AVMs.
For congenital mixed syndromes, the same diagnostic and therapeutic concepts hold true depending on the type of VM involved. Dr. Nassiri advised a multidisciplinary approach, and noted that early trials have investigated the use of sirolimus in severe, life-threatening cases (Br J Clin Pharmacol. 2016;82[5]:1171-9. doi: 10.1111/bcp.13022).
Dr. Nassiri disclosed serving on the speakers bureaus for Boston Scientific, Penumbra, and Merritt Medical, and is a consultant to Merritt Medical.
AT THE NORTHWESTERN VASCULAR SYMPOSIUM
Key clinical point:
Major finding: Use of imaging and a clearer understanding of the lack of neoplastic activity are key to more precisely diagnosing vascular malformations.
Data source: Review of literature and center experience.
Disclosure: Dr. Nassiri disclosed serving on the speakers bureaus for Boston Scientific, Penumbra, and Merritt Medical, and is a consultant to Merritt Medical.
Childhood obesity tied to maternal obesity, cesarean birth
NEW ORLEANS – Maternal obesity and cesarean delivery were each independently associated with increased rates of overweight or obesity during childhood in a prospective study of 1,441 mothers and their children.
In addition, these risks for childhood obesity appeared to interact in an additive way, so that women who were both obese and delivered by C-section had a nearly threefold increased rate of having a child who was overweight or obese at about 5 years of age, compared with children born to normal-weight women who delivered vaginally, Noel T. Mueller, PhD, said at the American Heart Association Scientific Sessions.
This finding of a link between maternal overweight and obesity and childhood obesity in the next generation supports results from previously reported studies. The new results “also add to the growing evidence for an association between C-section and obesity [in offspring], as well as C-section and immune-related disorders such as asthma and allergies” in offspring, Dr. Mueller said in an interview.
He hypothesized that delivery mode may contribute to a child’s obesity risk by producing an abnormal gastrointestinal microbiome. For example, vaginal delivery seems to associate with a higher prevalence of Bacteroides species in a child’s gut, bacteria that aid in the digestion of breast milk, Dr. Mueller said.
His study used data collected in the Boston Birth Cohort from 1,441 mothers and their children from full-term, singleton pregnancies born to women with a body mass index of at least 18.5 kg/m2 during 1998-2014. The child’s weight was measured at a median age of 4.8 years, with an interquartile range of 3-6 years. Children were deemed overweight if they were at or above the 85th percentile for weight, according to standards from the Centers for Disease Control and Prevention.
Just under half the women were normal weight, slightly more than a quarter were overweight, and a quarter were obese. The incidence of 5-year-old children who were overweight or obese was 70% higher in children of overweight mothers and 80% higher in those with obese mothers, compared with children with normal-weight mothers in an analysis that adjusted for maternal age at delivery, race or ethnicity, and education. Both were statistically significant differences, Dr. Mueller reported.
Two-thirds of the women had vaginal deliveries and a third had C-sections. Overweight or obesity occurred in 40% more of the children delivered by C-section, compared with children born vaginally, a statistically significant difference in an analysis that controlled for the same three covariates as well as prepregnancy body mass index, pregnancy weight gain, and other variables.
When Dr. Mueller and his associates ran a combined analysis they found that the highest risk for childhood overweight or obesity was in children born to obese mothers by C-section, and it was a 2.8-fold higher rate than that in the children born to normal-weight mothers by vaginal delivery, a statistically significant difference.
Dr. Mueller had no disclosures.
mzoler@frontlinemedcom.com
On Twitter @mitchelzoler
NEW ORLEANS – Maternal obesity and cesarean delivery were each independently associated with increased rates of overweight or obesity during childhood in a prospective study of 1,441 mothers and their children.
In addition, these risks for childhood obesity appeared to interact in an additive way, so that women who were both obese and delivered by C-section had a nearly threefold increased rate of having a child who was overweight or obese at about 5 years of age, compared with children born to normal-weight women who delivered vaginally, Noel T. Mueller, PhD, said at the American Heart Association Scientific Sessions.
This finding of a link between maternal overweight and obesity and childhood obesity in the next generation supports results from previously reported studies. The new results “also add to the growing evidence for an association between C-section and obesity [in offspring], as well as C-section and immune-related disorders such as asthma and allergies” in offspring, Dr. Mueller said in an interview.
He hypothesized that delivery mode may contribute to a child’s obesity risk by producing an abnormal gastrointestinal microbiome. For example, vaginal delivery seems to associate with a higher prevalence of Bacteroides species in a child’s gut, bacteria that aid in the digestion of breast milk, Dr. Mueller said.
His study used data collected in the Boston Birth Cohort from 1,441 mothers and their children from full-term, singleton pregnancies born to women with a body mass index of at least 18.5 kg/m2 during 1998-2014. The child’s weight was measured at a median age of 4.8 years, with an interquartile range of 3-6 years. Children were deemed overweight if they were at or above the 85th percentile for weight, according to standards from the Centers for Disease Control and Prevention.
Just under half the women were normal weight, slightly more than a quarter were overweight, and a quarter were obese. The incidence of 5-year-old children who were overweight or obese was 70% higher in children of overweight mothers and 80% higher in those with obese mothers, compared with children with normal-weight mothers in an analysis that adjusted for maternal age at delivery, race or ethnicity, and education. Both were statistically significant differences, Dr. Mueller reported.
Two-thirds of the women had vaginal deliveries and a third had C-sections. Overweight or obesity occurred in 40% more of the children delivered by C-section, compared with children born vaginally, a statistically significant difference in an analysis that controlled for the same three covariates as well as prepregnancy body mass index, pregnancy weight gain, and other variables.
When Dr. Mueller and his associates ran a combined analysis they found that the highest risk for childhood overweight or obesity was in children born to obese mothers by C-section, and it was a 2.8-fold higher rate than that in the children born to normal-weight mothers by vaginal delivery, a statistically significant difference.
Dr. Mueller had no disclosures.
mzoler@frontlinemedcom.com
On Twitter @mitchelzoler
NEW ORLEANS – Maternal obesity and cesarean delivery were each independently associated with increased rates of overweight or obesity during childhood in a prospective study of 1,441 mothers and their children.
In addition, these risks for childhood obesity appeared to interact in an additive way, so that women who were both obese and delivered by C-section had a nearly threefold increased rate of having a child who was overweight or obese at about 5 years of age, compared with children born to normal-weight women who delivered vaginally, Noel T. Mueller, PhD, said at the American Heart Association Scientific Sessions.
This finding of a link between maternal overweight and obesity and childhood obesity in the next generation supports results from previously reported studies. The new results “also add to the growing evidence for an association between C-section and obesity [in offspring], as well as C-section and immune-related disorders such as asthma and allergies” in offspring, Dr. Mueller said in an interview.
He hypothesized that delivery mode may contribute to a child’s obesity risk by producing an abnormal gastrointestinal microbiome. For example, vaginal delivery seems to associate with a higher prevalence of Bacteroides species in a child’s gut, bacteria that aid in the digestion of breast milk, Dr. Mueller said.
His study used data collected in the Boston Birth Cohort from 1,441 mothers and their children from full-term, singleton pregnancies born to women with a body mass index of at least 18.5 kg/m2 during 1998-2014. The child’s weight was measured at a median age of 4.8 years, with an interquartile range of 3-6 years. Children were deemed overweight if they were at or above the 85th percentile for weight, according to standards from the Centers for Disease Control and Prevention.
Just under half the women were normal weight, slightly more than a quarter were overweight, and a quarter were obese. The incidence of 5-year-old children who were overweight or obese was 70% higher in children of overweight mothers and 80% higher in those with obese mothers, compared with children with normal-weight mothers in an analysis that adjusted for maternal age at delivery, race or ethnicity, and education. Both were statistically significant differences, Dr. Mueller reported.
Two-thirds of the women had vaginal deliveries and a third had C-sections. Overweight or obesity occurred in 40% more of the children delivered by C-section, compared with children born vaginally, a statistically significant difference in an analysis that controlled for the same three covariates as well as prepregnancy body mass index, pregnancy weight gain, and other variables.
When Dr. Mueller and his associates ran a combined analysis they found that the highest risk for childhood overweight or obesity was in children born to obese mothers by C-section, and it was a 2.8-fold higher rate than that in the children born to normal-weight mothers by vaginal delivery, a statistically significant difference.
Dr. Mueller had no disclosures.
mzoler@frontlinemedcom.com
On Twitter @mitchelzoler
AT THE AHA SCIENTIFIC SESSIONS
Key clinical point:
Major finding: Children from obese mothers who had cesarean sections had a 2.8-fold higher obesity rate, compared with children from normal-weight mothers who had vaginal deliveries.
Data source: The Boston Birth Cohort, with prospective data from 1,441 pregnant women and their children.
Disclosures: Dr. Mueller had no disclosures.
Observe, assess, intervene
On most days when I walk into the exam room for a well-child visit, I find an anxious mom or a fretful father sitting next to a fearless child. I quickly shove aside my unrealistic expectation of finding both parents together holding the child. During the progression of my day, I see a diversity of parents playing their parts in caring for their children. It is sometimes a single mom, strong and robust, surrounded by a firm aura of principles and rules; she is concealing all signs of weakness, to make sure her child doesn’t cross any line that she has so cautiously made. Sometimes it is a single mom who is nervous and scared with a galaxy of fear in her eyes, desperately seeking for reassurance of her parenting. Fathers also come playing many roles, from someone struggling with tears as his child gets immunizations, to someone who has parenting in his bag, and skillfully plays eeny meeny miny moe with the little ones in the waiting room.
They all have one thing in common: the immense love for their children and the pressure of being a single or separated parent. It is indeed a reality that I see in most of the clinic rooms – that 60%-70% of children are not living with both mom and dad in the same house. Please note that these are raw data based entirely on my observation. While I watch each parent struggling as mentioned above, my mind often wanders to how each young child copes with such a situation.
What is our role as pediatricians as we walk into the exam room, as we encounter these different family dynamics? To simplify it for myself, I divide it into three categories: Observe, assess, and intervene. Most of the time as physicians, our gut feelings and instincts guide us to where help is needed. It is important to anticipate the changes a family might go through as we meet a first-time single mom or a family who has recently been separated. As we anticipate and observe, it also is important to ask specific questions of parents who may not feel comfortable volunteering this information:
• “Are you and your child undergoing any sort of stress?”
• “How do you think your child is coping with the separation?”
• “Do you identify any flaws in how things are going now?”
Of course, we need to ask questions about stress and family dynamics of all parents. We also should maintain a high level of sensitivity as we approach such questions. It is important to identify any changes in a child’s emotional and social development as we see them on every visit. And when we deem the need, to intervene and identify resources for the family. We also can help parents with ideas for communication with the child; anger management; helping parents and children understand changes; and encouraging open discussion when possible, instead of bottling up unsaid feelings and emotions. This is especially true for single-parent families, but two-parent families undergo stresses as well, for which pediatricians should keep an eye out.
While it is extremely important for us on every well-child visit to ensure that a child’s physical health is up to par, it is equally important not to ignore their emotional and social well-being as we walk in the room so we can help them flourish into the best version of themselves.
Dr. Fatima is a first-year pediatric resident at Albert Einstein Medical Center, Philadelphia. Email her at pdnews@frontlinemedcom.com.
On most days when I walk into the exam room for a well-child visit, I find an anxious mom or a fretful father sitting next to a fearless child. I quickly shove aside my unrealistic expectation of finding both parents together holding the child. During the progression of my day, I see a diversity of parents playing their parts in caring for their children. It is sometimes a single mom, strong and robust, surrounded by a firm aura of principles and rules; she is concealing all signs of weakness, to make sure her child doesn’t cross any line that she has so cautiously made. Sometimes it is a single mom who is nervous and scared with a galaxy of fear in her eyes, desperately seeking for reassurance of her parenting. Fathers also come playing many roles, from someone struggling with tears as his child gets immunizations, to someone who has parenting in his bag, and skillfully plays eeny meeny miny moe with the little ones in the waiting room.
They all have one thing in common: the immense love for their children and the pressure of being a single or separated parent. It is indeed a reality that I see in most of the clinic rooms – that 60%-70% of children are not living with both mom and dad in the same house. Please note that these are raw data based entirely on my observation. While I watch each parent struggling as mentioned above, my mind often wanders to how each young child copes with such a situation.
What is our role as pediatricians as we walk into the exam room, as we encounter these different family dynamics? To simplify it for myself, I divide it into three categories: Observe, assess, and intervene. Most of the time as physicians, our gut feelings and instincts guide us to where help is needed. It is important to anticipate the changes a family might go through as we meet a first-time single mom or a family who has recently been separated. As we anticipate and observe, it also is important to ask specific questions of parents who may not feel comfortable volunteering this information:
• “Are you and your child undergoing any sort of stress?”
• “How do you think your child is coping with the separation?”
• “Do you identify any flaws in how things are going now?”
Of course, we need to ask questions about stress and family dynamics of all parents. We also should maintain a high level of sensitivity as we approach such questions. It is important to identify any changes in a child’s emotional and social development as we see them on every visit. And when we deem the need, to intervene and identify resources for the family. We also can help parents with ideas for communication with the child; anger management; helping parents and children understand changes; and encouraging open discussion when possible, instead of bottling up unsaid feelings and emotions. This is especially true for single-parent families, but two-parent families undergo stresses as well, for which pediatricians should keep an eye out.
While it is extremely important for us on every well-child visit to ensure that a child’s physical health is up to par, it is equally important not to ignore their emotional and social well-being as we walk in the room so we can help them flourish into the best version of themselves.
Dr. Fatima is a first-year pediatric resident at Albert Einstein Medical Center, Philadelphia. Email her at pdnews@frontlinemedcom.com.
On most days when I walk into the exam room for a well-child visit, I find an anxious mom or a fretful father sitting next to a fearless child. I quickly shove aside my unrealistic expectation of finding both parents together holding the child. During the progression of my day, I see a diversity of parents playing their parts in caring for their children. It is sometimes a single mom, strong and robust, surrounded by a firm aura of principles and rules; she is concealing all signs of weakness, to make sure her child doesn’t cross any line that she has so cautiously made. Sometimes it is a single mom who is nervous and scared with a galaxy of fear in her eyes, desperately seeking for reassurance of her parenting. Fathers also come playing many roles, from someone struggling with tears as his child gets immunizations, to someone who has parenting in his bag, and skillfully plays eeny meeny miny moe with the little ones in the waiting room.
They all have one thing in common: the immense love for their children and the pressure of being a single or separated parent. It is indeed a reality that I see in most of the clinic rooms – that 60%-70% of children are not living with both mom and dad in the same house. Please note that these are raw data based entirely on my observation. While I watch each parent struggling as mentioned above, my mind often wanders to how each young child copes with such a situation.
What is our role as pediatricians as we walk into the exam room, as we encounter these different family dynamics? To simplify it for myself, I divide it into three categories: Observe, assess, and intervene. Most of the time as physicians, our gut feelings and instincts guide us to where help is needed. It is important to anticipate the changes a family might go through as we meet a first-time single mom or a family who has recently been separated. As we anticipate and observe, it also is important to ask specific questions of parents who may not feel comfortable volunteering this information:
• “Are you and your child undergoing any sort of stress?”
• “How do you think your child is coping with the separation?”
• “Do you identify any flaws in how things are going now?”
Of course, we need to ask questions about stress and family dynamics of all parents. We also should maintain a high level of sensitivity as we approach such questions. It is important to identify any changes in a child’s emotional and social development as we see them on every visit. And when we deem the need, to intervene and identify resources for the family. We also can help parents with ideas for communication with the child; anger management; helping parents and children understand changes; and encouraging open discussion when possible, instead of bottling up unsaid feelings and emotions. This is especially true for single-parent families, but two-parent families undergo stresses as well, for which pediatricians should keep an eye out.
While it is extremely important for us on every well-child visit to ensure that a child’s physical health is up to par, it is equally important not to ignore their emotional and social well-being as we walk in the room so we can help them flourish into the best version of themselves.
Dr. Fatima is a first-year pediatric resident at Albert Einstein Medical Center, Philadelphia. Email her at pdnews@frontlinemedcom.com.
Don’t delay pneumococcal conjugate vaccine for preterm infants
There should be no hesitation in administering the routine vaccination schedule for 13-valent pneumococcal conjugate vaccine (PCV13) on account of gestational age or birth weight in preterm infants, researchers concluded.
In a phase IV study, researchers compared 100 term with 100 preterm infants; both groups were vaccinated on the routine schedule at ages 2, 3, 4, and 12 months. After the 12-month (toddler) dose of the PCV13, the infants were evaluated for serum antibody persistence at 12 and 24 months. “To date, no studies have examined the long-term persistence of immune responses to PCV13 in formerly preterm infants,” noted Federico Martinón-Torres, MD, PhD, of Hospital Clínico Universitario de Santiago de Compostela, Spain, and his coauthors. 
In the study, at six sites in Spain and five sites in Poland between October 2010 and January 2014, both groups were checked for geometric mean concentrations of serotype-specific anticapsular immunoglobulin G binding antibodies and for opsonophagocytic activity. All 200 subjects were white and were generally healthy; the preterm infants were grouped by gestational age at birth of less than 29 weeks (n = 25), 29 weeks to less than 32 weeks (n = 50), or 32 weeks to less than 37 weeks (n = 25). Twelve subjects dropped out of the study by the first year’s evaluation, and another eight of the term subjects and seven of preterm subjects dropped out by the second year’s evaluation (Ped Infect Dis J. 2017. doi: 10.1097/INF.0000000000001428).
At both follow-up time points, no discernible patterns were observed in IgG GMCs for any serotype or in opsonophagocytic activity geometric mean titers across preterm subgroups based on gestational age.
“The vaccination phase of the study demonstrated that preterm infants are able to generate an immune response to PCV13 that is likely to protect against invasive pneumococcal disease. However, IgG GMCs were lower in preterm than term infants for nearly half of the serotypes at all time points. Antipneumococcal IgG levels in preterm infants were generally lower than in term infants, but fewer differences in opsonophagocytic activity were seen between the groups,” Dr. Martinón-Torres and his associates reported.
Pfizer funded the study. Dr. Martinón-Torres reported receiving research grants and/or honoraria as a consultant/adviser and/or speaker and for conducting vaccine trials for GlaxoSmithKline, MedImmune, Merck, Novartis, Pfizer/Wyeth, Sanofi Pasteur, and the Carlos III Health Institute. Several coauthors disclosed ties with pharmaceutical companies; four are stock-holding employees of Pfizer and another is an employee of a company contracted by Pfizer.
There should be no hesitation in administering the routine vaccination schedule for 13-valent pneumococcal conjugate vaccine (PCV13) on account of gestational age or birth weight in preterm infants, researchers concluded.
In a phase IV study, researchers compared 100 term with 100 preterm infants; both groups were vaccinated on the routine schedule at ages 2, 3, 4, and 12 months. After the 12-month (toddler) dose of the PCV13, the infants were evaluated for serum antibody persistence at 12 and 24 months. “To date, no studies have examined the long-term persistence of immune responses to PCV13 in formerly preterm infants,” noted Federico Martinón-Torres, MD, PhD, of Hospital Clínico Universitario de Santiago de Compostela, Spain, and his coauthors.
In the study, at six sites in Spain and five sites in Poland between October 2010 and January 2014, both groups were checked for geometric mean concentrations of serotype-specific anticapsular immunoglobulin G binding antibodies and for opsonophagocytic activity. All 200 subjects were white and were generally healthy; the preterm infants were grouped by gestational age at birth of less than 29 weeks (n = 25), 29 weeks to less than 32 weeks (n = 50), or 32 weeks to less than 37 weeks (n = 25). Twelve subjects dropped out of the study by the first year’s evaluation, and another eight of the term subjects and seven of preterm subjects dropped out by the second year’s evaluation (Ped Infect Dis J. 2017. doi: 10.1097/INF.0000000000001428).
At both follow-up time points, no discernible patterns were observed in IgG GMCs for any serotype or in opsonophagocytic activity geometric mean titers across preterm subgroups based on gestational age.
“The vaccination phase of the study demonstrated that preterm infants are able to generate an immune response to PCV13 that is likely to protect against invasive pneumococcal disease. However, IgG GMCs were lower in preterm than term infants for nearly half of the serotypes at all time points. Antipneumococcal IgG levels in preterm infants were generally lower than in term infants, but fewer differences in opsonophagocytic activity were seen between the groups,” Dr. Martinón-Torres and his associates reported.
Pfizer funded the study. Dr. Martinón-Torres reported receiving research grants and/or honoraria as a consultant/adviser and/or speaker and for conducting vaccine trials for GlaxoSmithKline, MedImmune, Merck, Novartis, Pfizer/Wyeth, Sanofi Pasteur, and the Carlos III Health Institute. Several coauthors disclosed ties with pharmaceutical companies; four are stock-holding employees of Pfizer and another is an employee of a company contracted by Pfizer.
There should be no hesitation in administering the routine vaccination schedule for 13-valent pneumococcal conjugate vaccine (PCV13) on account of gestational age or birth weight in preterm infants, researchers concluded.
In a phase IV study, researchers compared 100 term with 100 preterm infants; both groups were vaccinated on the routine schedule at ages 2, 3, 4, and 12 months. After the 12-month (toddler) dose of the PCV13, the infants were evaluated for serum antibody persistence at 12 and 24 months. “To date, no studies have examined the long-term persistence of immune responses to PCV13 in formerly preterm infants,” noted Federico Martinón-Torres, MD, PhD, of Hospital Clínico Universitario de Santiago de Compostela, Spain, and his coauthors.
In the study, at six sites in Spain and five sites in Poland between October 2010 and January 2014, both groups were checked for geometric mean concentrations of serotype-specific anticapsular immunoglobulin G binding antibodies and for opsonophagocytic activity. All 200 subjects were white and were generally healthy; the preterm infants were grouped by gestational age at birth of less than 29 weeks (n = 25), 29 weeks to less than 32 weeks (n = 50), or 32 weeks to less than 37 weeks (n = 25). Twelve subjects dropped out of the study by the first year’s evaluation, and another eight of the term subjects and seven of preterm subjects dropped out by the second year’s evaluation (Ped Infect Dis J. 2017. doi: 10.1097/INF.0000000000001428).
At both follow-up time points, no discernible patterns were observed in IgG GMCs for any serotype or in opsonophagocytic activity geometric mean titers across preterm subgroups based on gestational age.
“The vaccination phase of the study demonstrated that preterm infants are able to generate an immune response to PCV13 that is likely to protect against invasive pneumococcal disease. However, IgG GMCs were lower in preterm than term infants for nearly half of the serotypes at all time points. Antipneumococcal IgG levels in preterm infants were generally lower than in term infants, but fewer differences in opsonophagocytic activity were seen between the groups,” Dr. Martinón-Torres and his associates reported.
Pfizer funded the study. Dr. Martinón-Torres reported receiving research grants and/or honoraria as a consultant/adviser and/or speaker and for conducting vaccine trials for GlaxoSmithKline, MedImmune, Merck, Novartis, Pfizer/Wyeth, Sanofi Pasteur, and the Carlos III Health Institute. Several coauthors disclosed ties with pharmaceutical companies; four are stock-holding employees of Pfizer and another is an employee of a company contracted by Pfizer.
Key clinical point:
Major finding: IgG GMCs were lower in preterm than term infants for nearly half of the serotypes at all time points. Antipneumococcal IgG levels in preterm infants were generally lower than in term infants, but fewer differences in opsonophagocytic activity were seen between the groups.
Data source: In a phase IV study, 100 term and 100 preterm infants were evaluated for serum antibody persistence at 12 and 24 months.
Disclosures: Pfizer funded the study. Dr. Martinón-Torres reported receiving research grants and/or honoraria as a consultant/adviser and/or speaker and for conducting vaccine trials for GlaxoSmithKline, MedImmune, Merck, Novartis, Pfizer/Wyeth, Sanofi Pasteur, and the Carlos III Health Institute. Several coauthors disclosed ties with pharmaceutical companies; four are stock-holding employees of Pfizer and another is an employee of a company contracted by Pfizer.
Hypothermia confers no benefits in children with cardiac arrest
Comatose children who survived cardiac arrest in the hospital do not benefit more from treatment with therapeutic hypothermia than from keeping their body temperatures normal, according to results from a randomized trial conducted in 37 hospitals in three countries.
The findings were presented in Honolulu at the Critical Care Congress, sponsored by the Society for Critical Care Medicine, and published online Jan. 24 in the New England Journal of Medicine (2017 Jan 24. doi: 10.1056/NEJMoa1610493). They add to a growing consensus from adult studies that the use of induced hypothermia to prevent fevers and neurologic injury after cardiac arrest does not confer additional survival or functional benefit over normothermia. Less was known about children, particularly those whose cardiac arrest occurred in a hospital setting.
Frank W. Moler, MD, of the University of Michigan, Ann Arbor, led the study, which randomized 329 comatose children, from newborns to age 18 years, to either 120 hours of normothermia (target temperature, 36.8° C) or 48 hours of hypothermia (33°) followed by normal temperature maintenance to 120 days following an in-hospital cardiac arrest.
Fever prevention in both groups was achieved through active intervention, with hypothermia-treated patients also having been pharmacologically paralyzed and sedated. The investigators used the Vineland Adaptive Behavioral Scales to measure neurobehavioral function, with a score of 70 or higher deemed indicative of good function.
The study’s primary outcome was survival at 12 months after cardiac arrest and a favorable neurobehavioral outcome. In the 257 children with scores of 70 or higher before cardiac arrest, no significant differences were seen between the two different groups, with 36% of the hypothermia-treated patients (48/133) and 39% of normothermia-treated patients (48/124) surviving with a favorable neurobehavioral outcome (relative risk, 0.92; 95% confidence interval, 0.67-1.27; P = .63). In 317 children who could be evaluated for changes in neurobehavioral function, the changes from baseline between groups did not reach statistical significance (P = .70), and 1-year survival also did not differ significantly (49% for hypothermia-treated vs. 46% for normothermia; RR, 1.07; 95% CI, 0.85-1.34, P = .56). Adverse events did not differ significantly between groups.
The trial was stopped early for futility, leaving fewer than the hoped-for number of patients available for analysis, and wider confidence intervals. However, the investigators said their hypothesized 15 percentage point benefit for hypothermia treatment could be ruled out. Dr. Moler and his colleagues wrote in their analysis that unanswered questions remain regarding the role of body temperature interventions in this population, noting that different duration of treatment, different temperatures, and combination of temperature management with neuroprotective agents are worth considering for future studies. Dr. Moler and his colleagues’ study was funded by the National Heart, Lung, and Blood Institute. Four of its 49 coauthors disclosed commercial conflicts of interest.
Comatose children who survived cardiac arrest in the hospital do not benefit more from treatment with therapeutic hypothermia than from keeping their body temperatures normal, according to results from a randomized trial conducted in 37 hospitals in three countries.
The findings were presented in Honolulu at the Critical Care Congress, sponsored by the Society for Critical Care Medicine, and published online Jan. 24 in the New England Journal of Medicine (2017 Jan 24. doi: 10.1056/NEJMoa1610493). They add to a growing consensus from adult studies that the use of induced hypothermia to prevent fevers and neurologic injury after cardiac arrest does not confer additional survival or functional benefit over normothermia. Less was known about children, particularly those whose cardiac arrest occurred in a hospital setting.
Frank W. Moler, MD, of the University of Michigan, Ann Arbor, led the study, which randomized 329 comatose children, from newborns to age 18 years, to either 120 hours of normothermia (target temperature, 36.8° C) or 48 hours of hypothermia (33°) followed by normal temperature maintenance to 120 days following an in-hospital cardiac arrest.
Fever prevention in both groups was achieved through active intervention, with hypothermia-treated patients also having been pharmacologically paralyzed and sedated. The investigators used the Vineland Adaptive Behavioral Scales to measure neurobehavioral function, with a score of 70 or higher deemed indicative of good function.
The study’s primary outcome was survival at 12 months after cardiac arrest and a favorable neurobehavioral outcome. In the 257 children with scores of 70 or higher before cardiac arrest, no significant differences were seen between the two different groups, with 36% of the hypothermia-treated patients (48/133) and 39% of normothermia-treated patients (48/124) surviving with a favorable neurobehavioral outcome (relative risk, 0.92; 95% confidence interval, 0.67-1.27; P = .63). In 317 children who could be evaluated for changes in neurobehavioral function, the changes from baseline between groups did not reach statistical significance (P = .70), and 1-year survival also did not differ significantly (49% for hypothermia-treated vs. 46% for normothermia; RR, 1.07; 95% CI, 0.85-1.34, P = .56). Adverse events did not differ significantly between groups.
The trial was stopped early for futility, leaving fewer than the hoped-for number of patients available for analysis, and wider confidence intervals. However, the investigators said their hypothesized 15 percentage point benefit for hypothermia treatment could be ruled out. Dr. Moler and his colleagues wrote in their analysis that unanswered questions remain regarding the role of body temperature interventions in this population, noting that different duration of treatment, different temperatures, and combination of temperature management with neuroprotective agents are worth considering for future studies. Dr. Moler and his colleagues’ study was funded by the National Heart, Lung, and Blood Institute. Four of its 49 coauthors disclosed commercial conflicts of interest.
Comatose children who survived cardiac arrest in the hospital do not benefit more from treatment with therapeutic hypothermia than from keeping their body temperatures normal, according to results from a randomized trial conducted in 37 hospitals in three countries.
The findings were presented in Honolulu at the Critical Care Congress, sponsored by the Society for Critical Care Medicine, and published online Jan. 24 in the New England Journal of Medicine (2017 Jan 24. doi: 10.1056/NEJMoa1610493). They add to a growing consensus from adult studies that the use of induced hypothermia to prevent fevers and neurologic injury after cardiac arrest does not confer additional survival or functional benefit over normothermia. Less was known about children, particularly those whose cardiac arrest occurred in a hospital setting.
Frank W. Moler, MD, of the University of Michigan, Ann Arbor, led the study, which randomized 329 comatose children, from newborns to age 18 years, to either 120 hours of normothermia (target temperature, 36.8° C) or 48 hours of hypothermia (33°) followed by normal temperature maintenance to 120 days following an in-hospital cardiac arrest.
Fever prevention in both groups was achieved through active intervention, with hypothermia-treated patients also having been pharmacologically paralyzed and sedated. The investigators used the Vineland Adaptive Behavioral Scales to measure neurobehavioral function, with a score of 70 or higher deemed indicative of good function.
The study’s primary outcome was survival at 12 months after cardiac arrest and a favorable neurobehavioral outcome. In the 257 children with scores of 70 or higher before cardiac arrest, no significant differences were seen between the two different groups, with 36% of the hypothermia-treated patients (48/133) and 39% of normothermia-treated patients (48/124) surviving with a favorable neurobehavioral outcome (relative risk, 0.92; 95% confidence interval, 0.67-1.27; P = .63). In 317 children who could be evaluated for changes in neurobehavioral function, the changes from baseline between groups did not reach statistical significance (P = .70), and 1-year survival also did not differ significantly (49% for hypothermia-treated vs. 46% for normothermia; RR, 1.07; 95% CI, 0.85-1.34, P = .56). Adverse events did not differ significantly between groups.
The trial was stopped early for futility, leaving fewer than the hoped-for number of patients available for analysis, and wider confidence intervals. However, the investigators said their hypothesized 15 percentage point benefit for hypothermia treatment could be ruled out. Dr. Moler and his colleagues wrote in their analysis that unanswered questions remain regarding the role of body temperature interventions in this population, noting that different duration of treatment, different temperatures, and combination of temperature management with neuroprotective agents are worth considering for future studies. Dr. Moler and his colleagues’ study was funded by the National Heart, Lung, and Blood Institute. Four of its 49 coauthors disclosed commercial conflicts of interest.
FROM THE CRITICAL CARE CONGRESS
Key clinical point: Treating comatose children with hypothermia following cardiac arrest did not produce better neurobehavioral or survival outcomes at 1 year, compared with children whose body temperatures were held to normal.
Major finding: 36% of hypothermia-treated patients and 39% of normothermia-treated patients survived with a favorable neurobehavioral outcome (RR, 0.92; 95% CI, 0.67-1.27; P = .63).
Data source: A multisite, international trial randomizing 329 infants and children comatose after cardiac arrest while in hospital to hypothermia or normothermia.
Disclosures: The National Heart, Lung, and Blood Institute sponsored the study. Several investigators disclosed National Institutes of Health or university funding while four disclosed commercial conflicts.
Expert reviews options for refractory pediatric warts
For refractory warts, there are some “last resort” treatments every dermatologist should have on hand, according to pediatric dermatologist Fred E. Ghali, MD.
“It’s good to know about these, although it’s also good to know that sometimes you just have to wait out the warts and let them clear up on their own,” said Dr. Ghali, of the departments of dermatology at University of Texas, Dallas, and Baylor College of Medicine, Houston. Because very few treatment options are approved for warts, Dr. Ghali shared some of his preferred off-label approaches at the meeting provided by Global Academy for Medical Education.
By the time patients make it to his clinic, Dr. Ghali noted that many patients have failed home remedies such as salicylic acid or duct tape. In some cases, however, warts may not respond well to the standard in-office options such as cryotherapy. For refractory cases, he said that one of the following approaches can be considered:
Sectional cryotherapy
For larger, solitary warts, especially ring warts, freezing them in sections can be a good option, according to Dr. Ghali. This can be done best using a cotton-tip applicator rather than the traditional spray gun. In his experience, this minimizes the risk of ring wart formation, which may occur from aggressive cryotherapy focused primarily on the central portion of the wart, sometimes creating a resultant blister much larger than the original wart, with the formation of a ring wart.
Topical immunotherapy
When it comes to refractory cases in younger children, or in cases with multiple warts on the hands and feet, topical immunotherapy is often a preferred treatment. In these cases, Dr. Ghali recommended squaric acid. “The general principle with topical immunotherapy is that you would induce contact allergy with the treatment by applying it to one place on the skin, usually the arm, in the office setting,” he said. If using squaric acid, he recommended starting with 2% to sensitize in the office; then for home use, prescribing a lower concentration of the treatment – usually 0.6% – painted directly onto the lesions to provoke an immune response. This should be done three times a week at first, and then adding one application each week until the warts are being treated daily.
“If there is no response in 2 months, then increase the strength used at home,” Dr. Ghali said.
With this treatment, there is the potential for contact dermatitis, which is usually localized, but can be widespread beyond the areas of application, he cautioned. When this occurs, he recommended decreasing or discontinuing the applications and considering a topical steroid or oral steroid depending upon the severity of the reaction. “I mainly use squaric acid for the hands and feet, and almost always avoid it on the face, neck, and groin,” Dr. Ghali said.
In his practice, he finds this treatment is effective about three-quarters of the time, and seems to work particularly well with plantar warts, clearing them up in 2-4 months. The advantages of this approach are that it is not painful, is relatively easy for patients to comply with, and can be combined with other treatments if desired.
Intralesional immunotherapy
When squaric acid or cryotherapy fails, Candida antigen injection is a commonly used technique used to train the immune system to attack the warts, inducing a delayed hypersensitivity reaction. “Injectable immunotherapy is ideal in cases of a solitary [wart] or a limited number of warts,” Dr. Ghali said in an interview. “For most patients, I typically inject 0.1-0.2 cc of Candida antigen per wart. In the case of larger, ring-type warts, especially on the knees and elbows, we may need to use larger volumes, up to 0.2 cc-0.6cc,” he added.
“It’s important to remind patients that temporary, localized swelling may occur after injections; thus, care should be taken when injecting near periungual locations,” Dr. Ghali continued, noting that “it’s probably best practice to avoid subungual injections.”
Immunotherapy has relatively few side effects, and may be effective in about three-quarters of cases, according to Dr. Ghali, although he cautioned that younger children may be anxious about receiving injections and may resist treatment.
Electrodessication and curettage
For challenging warts, such as stubborn palmar or plantar warts, Dr. Ghali suggested using local anesthesia plus electrodessication and curettage.
“Sometimes with these refractory warts, we resort to off-label therapies compounded for home use,” he added. Such therapies may include salicylic acid with 5-fluorouracil, or topical cidofovir 2%-3%. These compounds can be costly depending upon the patient’s insurance coverage.
Dr. Ghali concluded by presenting his top three rules to consider when treating warts, regardless of treatment: There is no cure for warts, no therapy is uniformly effective, and the chosen therapy should take into account the family’s costs, according to their insurance coverage.
Since the landscape of insurance coverage has changed over recent years, the code most often used to treat warts in the office, often applies to the patient’s or family’s deductible. “It’s important to discuss this with the family beforehand, especially since treatment for warts may require several visits,” he said.
Dr. Ghali disclosed several financial relationships with the pharmaceutical industry including Astellas, Galderma, and Valeant, among others.
Global Academy and this news organization are owned by the same parent company.
For refractory warts, there are some “last resort” treatments every dermatologist should have on hand, according to pediatric dermatologist Fred E. Ghali, MD.
“It’s good to know about these, although it’s also good to know that sometimes you just have to wait out the warts and let them clear up on their own,” said Dr. Ghali, of the departments of dermatology at University of Texas, Dallas, and Baylor College of Medicine, Houston. Because very few treatment options are approved for warts, Dr. Ghali shared some of his preferred off-label approaches at the meeting provided by Global Academy for Medical Education.
By the time patients make it to his clinic, Dr. Ghali noted that many patients have failed home remedies such as salicylic acid or duct tape. In some cases, however, warts may not respond well to the standard in-office options such as cryotherapy. For refractory cases, he said that one of the following approaches can be considered:
Sectional cryotherapy
For larger, solitary warts, especially ring warts, freezing them in sections can be a good option, according to Dr. Ghali. This can be done best using a cotton-tip applicator rather than the traditional spray gun. In his experience, this minimizes the risk of ring wart formation, which may occur from aggressive cryotherapy focused primarily on the central portion of the wart, sometimes creating a resultant blister much larger than the original wart, with the formation of a ring wart.
Topical immunotherapy
When it comes to refractory cases in younger children, or in cases with multiple warts on the hands and feet, topical immunotherapy is often a preferred treatment. In these cases, Dr. Ghali recommended squaric acid. “The general principle with topical immunotherapy is that you would induce contact allergy with the treatment by applying it to one place on the skin, usually the arm, in the office setting,” he said. If using squaric acid, he recommended starting with 2% to sensitize in the office; then for home use, prescribing a lower concentration of the treatment – usually 0.6% – painted directly onto the lesions to provoke an immune response. This should be done three times a week at first, and then adding one application each week until the warts are being treated daily.
“If there is no response in 2 months, then increase the strength used at home,” Dr. Ghali said.
With this treatment, there is the potential for contact dermatitis, which is usually localized, but can be widespread beyond the areas of application, he cautioned. When this occurs, he recommended decreasing or discontinuing the applications and considering a topical steroid or oral steroid depending upon the severity of the reaction. “I mainly use squaric acid for the hands and feet, and almost always avoid it on the face, neck, and groin,” Dr. Ghali said.
In his practice, he finds this treatment is effective about three-quarters of the time, and seems to work particularly well with plantar warts, clearing them up in 2-4 months. The advantages of this approach are that it is not painful, is relatively easy for patients to comply with, and can be combined with other treatments if desired.
Intralesional immunotherapy
When squaric acid or cryotherapy fails, Candida antigen injection is a commonly used technique used to train the immune system to attack the warts, inducing a delayed hypersensitivity reaction. “Injectable immunotherapy is ideal in cases of a solitary [wart] or a limited number of warts,” Dr. Ghali said in an interview. “For most patients, I typically inject 0.1-0.2 cc of Candida antigen per wart. In the case of larger, ring-type warts, especially on the knees and elbows, we may need to use larger volumes, up to 0.2 cc-0.6cc,” he added.
“It’s important to remind patients that temporary, localized swelling may occur after injections; thus, care should be taken when injecting near periungual locations,” Dr. Ghali continued, noting that “it’s probably best practice to avoid subungual injections.”
Immunotherapy has relatively few side effects, and may be effective in about three-quarters of cases, according to Dr. Ghali, although he cautioned that younger children may be anxious about receiving injections and may resist treatment.
Electrodessication and curettage
For challenging warts, such as stubborn palmar or plantar warts, Dr. Ghali suggested using local anesthesia plus electrodessication and curettage.
“Sometimes with these refractory warts, we resort to off-label therapies compounded for home use,” he added. Such therapies may include salicylic acid with 5-fluorouracil, or topical cidofovir 2%-3%. These compounds can be costly depending upon the patient’s insurance coverage.
Dr. Ghali concluded by presenting his top three rules to consider when treating warts, regardless of treatment: There is no cure for warts, no therapy is uniformly effective, and the chosen therapy should take into account the family’s costs, according to their insurance coverage.
Since the landscape of insurance coverage has changed over recent years, the code most often used to treat warts in the office, often applies to the patient’s or family’s deductible. “It’s important to discuss this with the family beforehand, especially since treatment for warts may require several visits,” he said.
Dr. Ghali disclosed several financial relationships with the pharmaceutical industry including Astellas, Galderma, and Valeant, among others.
Global Academy and this news organization are owned by the same parent company.
For refractory warts, there are some “last resort” treatments every dermatologist should have on hand, according to pediatric dermatologist Fred E. Ghali, MD.
“It’s good to know about these, although it’s also good to know that sometimes you just have to wait out the warts and let them clear up on their own,” said Dr. Ghali, of the departments of dermatology at University of Texas, Dallas, and Baylor College of Medicine, Houston. Because very few treatment options are approved for warts, Dr. Ghali shared some of his preferred off-label approaches at the meeting provided by Global Academy for Medical Education.
By the time patients make it to his clinic, Dr. Ghali noted that many patients have failed home remedies such as salicylic acid or duct tape. In some cases, however, warts may not respond well to the standard in-office options such as cryotherapy. For refractory cases, he said that one of the following approaches can be considered:
Sectional cryotherapy
For larger, solitary warts, especially ring warts, freezing them in sections can be a good option, according to Dr. Ghali. This can be done best using a cotton-tip applicator rather than the traditional spray gun. In his experience, this minimizes the risk of ring wart formation, which may occur from aggressive cryotherapy focused primarily on the central portion of the wart, sometimes creating a resultant blister much larger than the original wart, with the formation of a ring wart.
Topical immunotherapy
When it comes to refractory cases in younger children, or in cases with multiple warts on the hands and feet, topical immunotherapy is often a preferred treatment. In these cases, Dr. Ghali recommended squaric acid. “The general principle with topical immunotherapy is that you would induce contact allergy with the treatment by applying it to one place on the skin, usually the arm, in the office setting,” he said. If using squaric acid, he recommended starting with 2% to sensitize in the office; then for home use, prescribing a lower concentration of the treatment – usually 0.6% – painted directly onto the lesions to provoke an immune response. This should be done three times a week at first, and then adding one application each week until the warts are being treated daily.
“If there is no response in 2 months, then increase the strength used at home,” Dr. Ghali said.
With this treatment, there is the potential for contact dermatitis, which is usually localized, but can be widespread beyond the areas of application, he cautioned. When this occurs, he recommended decreasing or discontinuing the applications and considering a topical steroid or oral steroid depending upon the severity of the reaction. “I mainly use squaric acid for the hands and feet, and almost always avoid it on the face, neck, and groin,” Dr. Ghali said.
In his practice, he finds this treatment is effective about three-quarters of the time, and seems to work particularly well with plantar warts, clearing them up in 2-4 months. The advantages of this approach are that it is not painful, is relatively easy for patients to comply with, and can be combined with other treatments if desired.
Intralesional immunotherapy
When squaric acid or cryotherapy fails, Candida antigen injection is a commonly used technique used to train the immune system to attack the warts, inducing a delayed hypersensitivity reaction. “Injectable immunotherapy is ideal in cases of a solitary [wart] or a limited number of warts,” Dr. Ghali said in an interview. “For most patients, I typically inject 0.1-0.2 cc of Candida antigen per wart. In the case of larger, ring-type warts, especially on the knees and elbows, we may need to use larger volumes, up to 0.2 cc-0.6cc,” he added.
“It’s important to remind patients that temporary, localized swelling may occur after injections; thus, care should be taken when injecting near periungual locations,” Dr. Ghali continued, noting that “it’s probably best practice to avoid subungual injections.”
Immunotherapy has relatively few side effects, and may be effective in about three-quarters of cases, according to Dr. Ghali, although he cautioned that younger children may be anxious about receiving injections and may resist treatment.
Electrodessication and curettage
For challenging warts, such as stubborn palmar or plantar warts, Dr. Ghali suggested using local anesthesia plus electrodessication and curettage.
“Sometimes with these refractory warts, we resort to off-label therapies compounded for home use,” he added. Such therapies may include salicylic acid with 5-fluorouracil, or topical cidofovir 2%-3%. These compounds can be costly depending upon the patient’s insurance coverage.
Dr. Ghali concluded by presenting his top three rules to consider when treating warts, regardless of treatment: There is no cure for warts, no therapy is uniformly effective, and the chosen therapy should take into account the family’s costs, according to their insurance coverage.
Since the landscape of insurance coverage has changed over recent years, the code most often used to treat warts in the office, often applies to the patient’s or family’s deductible. “It’s important to discuss this with the family beforehand, especially since treatment for warts may require several visits,” he said.
Dr. Ghali disclosed several financial relationships with the pharmaceutical industry including Astellas, Galderma, and Valeant, among others.
Global Academy and this news organization are owned by the same parent company.
EXPERT ANALYSIS FROM THE CARIBBEAN DERMATOLOGY SYMPOSIUM
Topical crisaborole new option for AD
There’s a new addition to the armamentarium for atopic dermatitis: a topical phosphodiesterase 4 (PDE-4) inhibitor.
“It’s a real boon to patients, now that we have crisaborole as a first-line treatment for mild to moderate atopic dermatitis,” Joseph F. Fowler Jr., MD, of the University of Louisville (Ky.), said in an interview. “In the trials leading up to its approval, crisaborole was impressive in that it was well tolerated, and the results held up across all age groups over time.” Dr. Fowler spoke at the meeting provided by Global Academy for Medical Education.
Topical ointment crisaborole 2% (Eucrisa) was approved by the Food and Drug Administration in December 2016 for mild to moderate atopic dermatitis in patients aged 2 years and older. Approval was based on two placebo-controlled trials with more than 1,500 participants between the ages of 2 and 79 years with mild to moderate atopic dermatitis.
“That it’s not a steroid is important since there are so few options for this pesky condition. We have topical steroids, but a lot of patients get nervous about the overuse of those, just as they do about the box warning for cancer risk on topical calcineurin inhibitors,” Dr. Fowler said. The most common treatment-related adverse event recorded during the trials were burning and stinging at the site of application.
“While topical corticosteroids are certainly effective, I am concerned about the risk of atrophy, especially in children and on sensitive areas such as the face and intertriginous areas. This new treatment does not have that potential adverse effect,” he said.
Global Academy and this news organization are owned by the same parent company.
Dr. Fowler disclosed that he has financial relationships with Anacor Pharmaceuticals – the manufacturer of crisaborole – and Pfizer, among other companies.
There’s a new addition to the armamentarium for atopic dermatitis: a topical phosphodiesterase 4 (PDE-4) inhibitor.
“It’s a real boon to patients, now that we have crisaborole as a first-line treatment for mild to moderate atopic dermatitis,” Joseph F. Fowler Jr., MD, of the University of Louisville (Ky.), said in an interview. “In the trials leading up to its approval, crisaborole was impressive in that it was well tolerated, and the results held up across all age groups over time.” Dr. Fowler spoke at the meeting provided by Global Academy for Medical Education.
Topical ointment crisaborole 2% (Eucrisa) was approved by the Food and Drug Administration in December 2016 for mild to moderate atopic dermatitis in patients aged 2 years and older. Approval was based on two placebo-controlled trials with more than 1,500 participants between the ages of 2 and 79 years with mild to moderate atopic dermatitis.
“That it’s not a steroid is important since there are so few options for this pesky condition. We have topical steroids, but a lot of patients get nervous about the overuse of those, just as they do about the box warning for cancer risk on topical calcineurin inhibitors,” Dr. Fowler said. The most common treatment-related adverse event recorded during the trials were burning and stinging at the site of application.
“While topical corticosteroids are certainly effective, I am concerned about the risk of atrophy, especially in children and on sensitive areas such as the face and intertriginous areas. This new treatment does not have that potential adverse effect,” he said.
Global Academy and this news organization are owned by the same parent company.
Dr. Fowler disclosed that he has financial relationships with Anacor Pharmaceuticals – the manufacturer of crisaborole – and Pfizer, among other companies.
There’s a new addition to the armamentarium for atopic dermatitis: a topical phosphodiesterase 4 (PDE-4) inhibitor.
“It’s a real boon to patients, now that we have crisaborole as a first-line treatment for mild to moderate atopic dermatitis,” Joseph F. Fowler Jr., MD, of the University of Louisville (Ky.), said in an interview. “In the trials leading up to its approval, crisaborole was impressive in that it was well tolerated, and the results held up across all age groups over time.” Dr. Fowler spoke at the meeting provided by Global Academy for Medical Education.
Topical ointment crisaborole 2% (Eucrisa) was approved by the Food and Drug Administration in December 2016 for mild to moderate atopic dermatitis in patients aged 2 years and older. Approval was based on two placebo-controlled trials with more than 1,500 participants between the ages of 2 and 79 years with mild to moderate atopic dermatitis.
“That it’s not a steroid is important since there are so few options for this pesky condition. We have topical steroids, but a lot of patients get nervous about the overuse of those, just as they do about the box warning for cancer risk on topical calcineurin inhibitors,” Dr. Fowler said. The most common treatment-related adverse event recorded during the trials were burning and stinging at the site of application.
“While topical corticosteroids are certainly effective, I am concerned about the risk of atrophy, especially in children and on sensitive areas such as the face and intertriginous areas. This new treatment does not have that potential adverse effect,” he said.
Global Academy and this news organization are owned by the same parent company.
Dr. Fowler disclosed that he has financial relationships with Anacor Pharmaceuticals – the manufacturer of crisaborole – and Pfizer, among other companies.
FROM THE CARIBBEAN DERMATOLOGY SYMPOSIUM
New recommendations for pediatric AMKL
Image courtesy of St. Jude
Children’s Research Hospital
and Tina Motroni
Research has revealed genetic alterations that may prove useful for predicting treatment outcomes in pediatric patients with acute megakaryoblastic leukemia (AMKL) who do not have Down syndrome.
The study suggests that 3
genetic alterations can be used to identify high-risk patients who may benefit
from allogeneic stem cell transplant, and 1 alteration may identify
low-risk patients who require less chemotherapy than their peers.
Researchers said these findings, published in Nature Genetics, support revised diagnostic screening and treatment recommendations for pediatric AMKL.
“Because long-term survival for pediatric AMKL patients without Down syndrome is poor, just 14% to 34%, the standard recommendation by many pediatric oncologists has been to treat all patients with allogeneic stem cell transplantation during their first remission,” said study author Tanja Gruber, MD, PhD, of St. Jude Children’s Research Hospital in Memphis, Tennessee.
“In this study, we identified several genetic alterations that are important predictors of treatment success. All newly identified pediatric AMKL patients without Down syndrome should be screened for these prognostic indicators at diagnosis. The results will help identify which patients need allogeneic stem cell transplants during their first remission and which do not.”
This study involved next-generation sequencing of the whole exome or RNA of 99 AMKL patients without Down syndrome (75 pediatric and 24 adult patients). Along with the sequencing data, researchers analyzed patients’ gene expression and long-term survival.
Results
The results showed that non-Down syndrome pediatric AMKL can be divided into 7 subgroups based on the underlying genetic alteration, pattern of gene expression, and treatment outcome.
The subgroups include the newly identified HOX subgroup. About 15% of the pediatric patients in this study were in the HOX subgroup, which is characterized by several different HOX fusion genes.
The researchers also identified cooperating mutations that help fuel AMKL in different subgroups. The cooperating mutations include changes in the RB1 gene and recurring mutations in the RAS and JAK pathways.
In addition, the study showed that 3 genetic alterations—CBFA2T3-GLIS2, KMT2A rearrangements, and NUP98-KDM5A—are associated with reduced survival in pediatric AMKL subtypes.
The researchers said patients with these alterations may benefit from allogeneic stem cell transplants, so non-Down syndrome pediatric AMKL patients should be screened for these alterations at diagnosis.
The team also recommended testing AMKL patients for mutations in the GATA1 gene. GATA1 mutations are a hallmark of AMKL in children with Down syndrome, who almost always survive the leukemia. In this study, AMKL patients with GATA1 mutations and no fusion gene had the same favorable outcomes.
“The results raise the possibility that pediatric AMKL patients without Down syndrome who have mutations in GATA1 may benefit from the same reduced chemotherapy used to treat the leukemia in patients with Down syndrome,” Dr Gruber said.
These revised diagnostic screening and treatment recommendations are being implemented at St. Jude.
This study also showed that adults with AMKL lacked recurrent fusion genes. The most common mutations found in the adult patients were in TP53 (21%), cohesin genes (17%), splicing factor genes (17%), ASXL genes (17%), and DNMT3A (13%). About 4% had GATA1 mutations. 
Image courtesy of St. Jude
Children’s Research Hospital
and Tina Motroni
Research has revealed genetic alterations that may prove useful for predicting treatment outcomes in pediatric patients with acute megakaryoblastic leukemia (AMKL) who do not have Down syndrome.
The study suggests that 3
genetic alterations can be used to identify high-risk patients who may benefit
from allogeneic stem cell transplant, and 1 alteration may identify
low-risk patients who require less chemotherapy than their peers.
Researchers said these findings, published in Nature Genetics, support revised diagnostic screening and treatment recommendations for pediatric AMKL.
“Because long-term survival for pediatric AMKL patients without Down syndrome is poor, just 14% to 34%, the standard recommendation by many pediatric oncologists has been to treat all patients with allogeneic stem cell transplantation during their first remission,” said study author Tanja Gruber, MD, PhD, of St. Jude Children’s Research Hospital in Memphis, Tennessee.
“In this study, we identified several genetic alterations that are important predictors of treatment success. All newly identified pediatric AMKL patients without Down syndrome should be screened for these prognostic indicators at diagnosis. The results will help identify which patients need allogeneic stem cell transplants during their first remission and which do not.”
This study involved next-generation sequencing of the whole exome or RNA of 99 AMKL patients without Down syndrome (75 pediatric and 24 adult patients). Along with the sequencing data, researchers analyzed patients’ gene expression and long-term survival.
Results
The results showed that non-Down syndrome pediatric AMKL can be divided into 7 subgroups based on the underlying genetic alteration, pattern of gene expression, and treatment outcome.
The subgroups include the newly identified HOX subgroup. About 15% of the pediatric patients in this study were in the HOX subgroup, which is characterized by several different HOX fusion genes.
The researchers also identified cooperating mutations that help fuel AMKL in different subgroups. The cooperating mutations include changes in the RB1 gene and recurring mutations in the RAS and JAK pathways.
In addition, the study showed that 3 genetic alterations—CBFA2T3-GLIS2, KMT2A rearrangements, and NUP98-KDM5A—are associated with reduced survival in pediatric AMKL subtypes.
The researchers said patients with these alterations may benefit from allogeneic stem cell transplants, so non-Down syndrome pediatric AMKL patients should be screened for these alterations at diagnosis.
The team also recommended testing AMKL patients for mutations in the GATA1 gene. GATA1 mutations are a hallmark of AMKL in children with Down syndrome, who almost always survive the leukemia. In this study, AMKL patients with GATA1 mutations and no fusion gene had the same favorable outcomes.
“The results raise the possibility that pediatric AMKL patients without Down syndrome who have mutations in GATA1 may benefit from the same reduced chemotherapy used to treat the leukemia in patients with Down syndrome,” Dr Gruber said.
These revised diagnostic screening and treatment recommendations are being implemented at St. Jude.
This study also showed that adults with AMKL lacked recurrent fusion genes. The most common mutations found in the adult patients were in TP53 (21%), cohesin genes (17%), splicing factor genes (17%), ASXL genes (17%), and DNMT3A (13%). About 4% had GATA1 mutations.
Image courtesy of St. Jude
Children’s Research Hospital
and Tina Motroni
Research has revealed genetic alterations that may prove useful for predicting treatment outcomes in pediatric patients with acute megakaryoblastic leukemia (AMKL) who do not have Down syndrome.
The study suggests that 3
genetic alterations can be used to identify high-risk patients who may benefit
from allogeneic stem cell transplant, and 1 alteration may identify
low-risk patients who require less chemotherapy than their peers.
Researchers said these findings, published in Nature Genetics, support revised diagnostic screening and treatment recommendations for pediatric AMKL.
“Because long-term survival for pediatric AMKL patients without Down syndrome is poor, just 14% to 34%, the standard recommendation by many pediatric oncologists has been to treat all patients with allogeneic stem cell transplantation during their first remission,” said study author Tanja Gruber, MD, PhD, of St. Jude Children’s Research Hospital in Memphis, Tennessee.
“In this study, we identified several genetic alterations that are important predictors of treatment success. All newly identified pediatric AMKL patients without Down syndrome should be screened for these prognostic indicators at diagnosis. The results will help identify which patients need allogeneic stem cell transplants during their first remission and which do not.”
This study involved next-generation sequencing of the whole exome or RNA of 99 AMKL patients without Down syndrome (75 pediatric and 24 adult patients). Along with the sequencing data, researchers analyzed patients’ gene expression and long-term survival.
Results
The results showed that non-Down syndrome pediatric AMKL can be divided into 7 subgroups based on the underlying genetic alteration, pattern of gene expression, and treatment outcome.
The subgroups include the newly identified HOX subgroup. About 15% of the pediatric patients in this study were in the HOX subgroup, which is characterized by several different HOX fusion genes.
The researchers also identified cooperating mutations that help fuel AMKL in different subgroups. The cooperating mutations include changes in the RB1 gene and recurring mutations in the RAS and JAK pathways.
In addition, the study showed that 3 genetic alterations—CBFA2T3-GLIS2, KMT2A rearrangements, and NUP98-KDM5A—are associated with reduced survival in pediatric AMKL subtypes.
The researchers said patients with these alterations may benefit from allogeneic stem cell transplants, so non-Down syndrome pediatric AMKL patients should be screened for these alterations at diagnosis.
The team also recommended testing AMKL patients for mutations in the GATA1 gene. GATA1 mutations are a hallmark of AMKL in children with Down syndrome, who almost always survive the leukemia. In this study, AMKL patients with GATA1 mutations and no fusion gene had the same favorable outcomes.
“The results raise the possibility that pediatric AMKL patients without Down syndrome who have mutations in GATA1 may benefit from the same reduced chemotherapy used to treat the leukemia in patients with Down syndrome,” Dr Gruber said.
These revised diagnostic screening and treatment recommendations are being implemented at St. Jude.
This study also showed that adults with AMKL lacked recurrent fusion genes. The most common mutations found in the adult patients were in TP53 (21%), cohesin genes (17%), splicing factor genes (17%), ASXL genes (17%), and DNMT3A (13%). About 4% had GATA1 mutations.
AAP: Teen access to abortion care is a right
.
“Genuine concern for the best interests of minors argues strongly against mandatory parental consent and notification laws,” the statement authors wrote in the updated policy statement, “The Adolescent’s Right to Confidential Care When Considering Abortion,” published online in Pediatrics.
The AAP Committee on Adolescence, which wrote the policy statement, encourages adolescents to voluntarily involve their parents – or other adults they trust – in decisions surrounding an unintended pregnancy, stating that teens who do will “likely benefit from adult experience, wisdom, emotional support, and financial support.” However, the policy statement also stresses that legally emphasizing parental involvement over a teen’s autonomy can result in barriers to care when timely access is most crucial, especially if a teen is reluctant to tell her parents of the situation (Pediatrics. 2017. doi: 10.1542/peds.2016-3861).
Currently, 37 states require some level of parental involvement in an adolescent’s decision to pursue an abortion. Most of these states will allow a minor to terminate a pregnancy without parental consent in the case of a medical emergency; about half waive the parental involvement requirement when there is evidence of incest, abuse, or neglect. All states with parental involvement laws also have a so-called judicial bypass, allowing a minor to obtain an abortion with a court’s approval; however, because the process can take as long as several weeks, access to medical treatment can be delayed, upping the risk of complications from later-term abortions. Data cited in the statement indicate that following the enactment of parental involvement laws in three states, second-trimester abortion rates increased by as much as 21% (N Engl J Med. 2006;354[10]:1031-8; Fam Plann Perspect. 1995;27[3]:120-2; Women Health. 1995;22[3]:47-58.
Even when a judicial bypass is obtained, a study of 12,000 such petitions obtained in Minnesota and Massachusetts showed that only 21 of them were denied, and half of those were overturned, meaning the outcome was the same, but the potential risks of delaying care were higher (J Adolesc Health. 1991;12[2]:143-7). The AAP statement suggests physicians learn their state requirements for judicial bypass, if any.
The updated statement also refutes the notion that parental involvement laws improve communication within families and lead to better health outcomes for teens facing an unintended pregnancy. Instead, the statement says that on average, minors who discuss pregnancy termination with their parents do so at the same rate as in states with and without such laws, and that a teen is more likely to involve her parents than not, a likelihood that increases the younger a teen is. When she doesn’t choose to discuss it with parents, fear of some sort of danger such as an escalation in any ongoing family tensions, coercion into a decision, or abuse of some kind is often why (Contraception. 2010 Oct;82[4]:310-3; Fam Plann Perspect. 1992 Jul-Aug;24[4]:148-54, 173).
“In a perfect world of butterflies and unicorns, parents and kids have a perfect relationship, but we know that’s not always true. There can be significant discord in families, and parental notification could result in harm to the adolescent, or risk to the family’s tapestry with significant consequences for the family and the adolescent,” Dr. Breuner said.
Dr. Beers argued that while she believed most parents would rather be the one their teen turns to for advice in such a situation, it’s not possible to legislate trust within families, each of which has its own history and unique family culture and style of communication. “This is the type of conversation that doesn’t begin with the acute event. This is the kind of conversation that should begin [at] a very early age between a parent and a child,” she said.
The physician’s role, according to Dr. Beers, is to ensure parents and their children have “a shared understanding of the facts to [rely on] when they talk about what is important to their family and what their family values are.”
The updated statement, originally issued in 1993, roughly coincides with the release of a new Guttmacher Institute report indicating that abortion rates in the United States are at their lowest since passage of Roe v. Wade in 1973. The report credits lower unintended pregnancy rates and better access to contraception, not restrictive abortion legislation, for the drop. The AAP’s updated statement also comes within days of the inauguration of President Donald Trump, whose run-up to election featured rhetoric challenging the status quo of federal abortion laws.
Dr. Breuner said the timing was a coincidence, and that plans to reissue the statement began over 3 years ago as she and her colleagues drew up plans to recommit their membership to protecting the reproductive rights of their patients. “With all of the regulations, restrictions, and decreased access to [abortion] care that are occurring, the academy wanted members to know just how much more difficult it is to obtain an abortion,” she said, noting that access and confidentiality are not the same. “If you can’t get an abortion, what difference does confidentiality make?”
Last year, the Supreme Court reversed a law that would have greatly limited access to abortion in Texas by closing all but nine clinics statewide, burdening them with care for tens of thousands of women annually. Also in 2016, citing a Constitutional violation of a woman’s right to privacy, a federal judge blocked an Indiana law signed by then governor and now vice president Mike Pence, that restricted the reasons a woman could cite to seek an abortion.
Dr. Breuner views this as an erosion of the rights of all women to comprehensive reproductive care, including those of adolescents. “You can’t ‘Google Map’ how to figure this out anymore. The roads are closed and all the ways people say you can get there don’t really lead you there,” she said, noting that the AAP’s statement is in line with several other professional medical societies, including the American College of Obstetricians and Gynecologists and the American Medical Association.
Regardless of timing, the statement should be viewed not through a political – or even partisan – lens, but as a reaffirmation of “core values,” according to Dr. Beers. “We do live in divided times. I think it’s important to circle back to our core values as pediatricians. That’s the agenda – making sure adolescents are healthy, safe, and supported.”
.
“Genuine concern for the best interests of minors argues strongly against mandatory parental consent and notification laws,” the statement authors wrote in the updated policy statement, “The Adolescent’s Right to Confidential Care When Considering Abortion,” published online in Pediatrics.
The AAP Committee on Adolescence, which wrote the policy statement, encourages adolescents to voluntarily involve their parents – or other adults they trust – in decisions surrounding an unintended pregnancy, stating that teens who do will “likely benefit from adult experience, wisdom, emotional support, and financial support.” However, the policy statement also stresses that legally emphasizing parental involvement over a teen’s autonomy can result in barriers to care when timely access is most crucial, especially if a teen is reluctant to tell her parents of the situation (Pediatrics. 2017. doi: 10.1542/peds.2016-3861).
Currently, 37 states require some level of parental involvement in an adolescent’s decision to pursue an abortion. Most of these states will allow a minor to terminate a pregnancy without parental consent in the case of a medical emergency; about half waive the parental involvement requirement when there is evidence of incest, abuse, or neglect. All states with parental involvement laws also have a so-called judicial bypass, allowing a minor to obtain an abortion with a court’s approval; however, because the process can take as long as several weeks, access to medical treatment can be delayed, upping the risk of complications from later-term abortions. Data cited in the statement indicate that following the enactment of parental involvement laws in three states, second-trimester abortion rates increased by as much as 21% (N Engl J Med. 2006;354[10]:1031-8; Fam Plann Perspect. 1995;27[3]:120-2; Women Health. 1995;22[3]:47-58.
Even when a judicial bypass is obtained, a study of 12,000 such petitions obtained in Minnesota and Massachusetts showed that only 21 of them were denied, and half of those were overturned, meaning the outcome was the same, but the potential risks of delaying care were higher (J Adolesc Health. 1991;12[2]:143-7). The AAP statement suggests physicians learn their state requirements for judicial bypass, if any.
The updated statement also refutes the notion that parental involvement laws improve communication within families and lead to better health outcomes for teens facing an unintended pregnancy. Instead, the statement says that on average, minors who discuss pregnancy termination with their parents do so at the same rate as in states with and without such laws, and that a teen is more likely to involve her parents than not, a likelihood that increases the younger a teen is. When she doesn’t choose to discuss it with parents, fear of some sort of danger such as an escalation in any ongoing family tensions, coercion into a decision, or abuse of some kind is often why (Contraception. 2010 Oct;82[4]:310-3; Fam Plann Perspect. 1992 Jul-Aug;24[4]:148-54, 173).
“In a perfect world of butterflies and unicorns, parents and kids have a perfect relationship, but we know that’s not always true. There can be significant discord in families, and parental notification could result in harm to the adolescent, or risk to the family’s tapestry with significant consequences for the family and the adolescent,” Dr. Breuner said.
Dr. Beers argued that while she believed most parents would rather be the one their teen turns to for advice in such a situation, it’s not possible to legislate trust within families, each of which has its own history and unique family culture and style of communication. “This is the type of conversation that doesn’t begin with the acute event. This is the kind of conversation that should begin [at] a very early age between a parent and a child,” she said.
The physician’s role, according to Dr. Beers, is to ensure parents and their children have “a shared understanding of the facts to [rely on] when they talk about what is important to their family and what their family values are.”
The updated statement, originally issued in 1993, roughly coincides with the release of a new Guttmacher Institute report indicating that abortion rates in the United States are at their lowest since passage of Roe v. Wade in 1973. The report credits lower unintended pregnancy rates and better access to contraception, not restrictive abortion legislation, for the drop. The AAP’s updated statement also comes within days of the inauguration of President Donald Trump, whose run-up to election featured rhetoric challenging the status quo of federal abortion laws.
Dr. Breuner said the timing was a coincidence, and that plans to reissue the statement began over 3 years ago as she and her colleagues drew up plans to recommit their membership to protecting the reproductive rights of their patients. “With all of the regulations, restrictions, and decreased access to [abortion] care that are occurring, the academy wanted members to know just how much more difficult it is to obtain an abortion,” she said, noting that access and confidentiality are not the same. “If you can’t get an abortion, what difference does confidentiality make?”
Last year, the Supreme Court reversed a law that would have greatly limited access to abortion in Texas by closing all but nine clinics statewide, burdening them with care for tens of thousands of women annually. Also in 2016, citing a Constitutional violation of a woman’s right to privacy, a federal judge blocked an Indiana law signed by then governor and now vice president Mike Pence, that restricted the reasons a woman could cite to seek an abortion.
Dr. Breuner views this as an erosion of the rights of all women to comprehensive reproductive care, including those of adolescents. “You can’t ‘Google Map’ how to figure this out anymore. The roads are closed and all the ways people say you can get there don’t really lead you there,” she said, noting that the AAP’s statement is in line with several other professional medical societies, including the American College of Obstetricians and Gynecologists and the American Medical Association.
Regardless of timing, the statement should be viewed not through a political – or even partisan – lens, but as a reaffirmation of “core values,” according to Dr. Beers. “We do live in divided times. I think it’s important to circle back to our core values as pediatricians. That’s the agenda – making sure adolescents are healthy, safe, and supported.”
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“Genuine concern for the best interests of minors argues strongly against mandatory parental consent and notification laws,” the statement authors wrote in the updated policy statement, “The Adolescent’s Right to Confidential Care When Considering Abortion,” published online in Pediatrics.
The AAP Committee on Adolescence, which wrote the policy statement, encourages adolescents to voluntarily involve their parents – or other adults they trust – in decisions surrounding an unintended pregnancy, stating that teens who do will “likely benefit from adult experience, wisdom, emotional support, and financial support.” However, the policy statement also stresses that legally emphasizing parental involvement over a teen’s autonomy can result in barriers to care when timely access is most crucial, especially if a teen is reluctant to tell her parents of the situation (Pediatrics. 2017. doi: 10.1542/peds.2016-3861).
Currently, 37 states require some level of parental involvement in an adolescent’s decision to pursue an abortion. Most of these states will allow a minor to terminate a pregnancy without parental consent in the case of a medical emergency; about half waive the parental involvement requirement when there is evidence of incest, abuse, or neglect. All states with parental involvement laws also have a so-called judicial bypass, allowing a minor to obtain an abortion with a court’s approval; however, because the process can take as long as several weeks, access to medical treatment can be delayed, upping the risk of complications from later-term abortions. Data cited in the statement indicate that following the enactment of parental involvement laws in three states, second-trimester abortion rates increased by as much as 21% (N Engl J Med. 2006;354[10]:1031-8; Fam Plann Perspect. 1995;27[3]:120-2; Women Health. 1995;22[3]:47-58.
Even when a judicial bypass is obtained, a study of 12,000 such petitions obtained in Minnesota and Massachusetts showed that only 21 of them were denied, and half of those were overturned, meaning the outcome was the same, but the potential risks of delaying care were higher (J Adolesc Health. 1991;12[2]:143-7). The AAP statement suggests physicians learn their state requirements for judicial bypass, if any.
The updated statement also refutes the notion that parental involvement laws improve communication within families and lead to better health outcomes for teens facing an unintended pregnancy. Instead, the statement says that on average, minors who discuss pregnancy termination with their parents do so at the same rate as in states with and without such laws, and that a teen is more likely to involve her parents than not, a likelihood that increases the younger a teen is. When she doesn’t choose to discuss it with parents, fear of some sort of danger such as an escalation in any ongoing family tensions, coercion into a decision, or abuse of some kind is often why (Contraception. 2010 Oct;82[4]:310-3; Fam Plann Perspect. 1992 Jul-Aug;24[4]:148-54, 173).
“In a perfect world of butterflies and unicorns, parents and kids have a perfect relationship, but we know that’s not always true. There can be significant discord in families, and parental notification could result in harm to the adolescent, or risk to the family’s tapestry with significant consequences for the family and the adolescent,” Dr. Breuner said.
Dr. Beers argued that while she believed most parents would rather be the one their teen turns to for advice in such a situation, it’s not possible to legislate trust within families, each of which has its own history and unique family culture and style of communication. “This is the type of conversation that doesn’t begin with the acute event. This is the kind of conversation that should begin [at] a very early age between a parent and a child,” she said.
The physician’s role, according to Dr. Beers, is to ensure parents and their children have “a shared understanding of the facts to [rely on] when they talk about what is important to their family and what their family values are.”
The updated statement, originally issued in 1993, roughly coincides with the release of a new Guttmacher Institute report indicating that abortion rates in the United States are at their lowest since passage of Roe v. Wade in 1973. The report credits lower unintended pregnancy rates and better access to contraception, not restrictive abortion legislation, for the drop. The AAP’s updated statement also comes within days of the inauguration of President Donald Trump, whose run-up to election featured rhetoric challenging the status quo of federal abortion laws.
Dr. Breuner said the timing was a coincidence, and that plans to reissue the statement began over 3 years ago as she and her colleagues drew up plans to recommit their membership to protecting the reproductive rights of their patients. “With all of the regulations, restrictions, and decreased access to [abortion] care that are occurring, the academy wanted members to know just how much more difficult it is to obtain an abortion,” she said, noting that access and confidentiality are not the same. “If you can’t get an abortion, what difference does confidentiality make?”
Last year, the Supreme Court reversed a law that would have greatly limited access to abortion in Texas by closing all but nine clinics statewide, burdening them with care for tens of thousands of women annually. Also in 2016, citing a Constitutional violation of a woman’s right to privacy, a federal judge blocked an Indiana law signed by then governor and now vice president Mike Pence, that restricted the reasons a woman could cite to seek an abortion.
Dr. Breuner views this as an erosion of the rights of all women to comprehensive reproductive care, including those of adolescents. “You can’t ‘Google Map’ how to figure this out anymore. The roads are closed and all the ways people say you can get there don’t really lead you there,” she said, noting that the AAP’s statement is in line with several other professional medical societies, including the American College of Obstetricians and Gynecologists and the American Medical Association.
Regardless of timing, the statement should be viewed not through a political – or even partisan – lens, but as a reaffirmation of “core values,” according to Dr. Beers. “We do live in divided times. I think it’s important to circle back to our core values as pediatricians. That’s the agenda – making sure adolescents are healthy, safe, and supported.”