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SSI risk after cesarean is nearly double for Medicaid patients
SAN DIEGO – Medicaid patients were nearly twice as likely to develop surgical site infections after cesarean delivery than privately insured women, according to investigators from the Centers for Disease Control and Prevention.
The association remained even after researchers accounted for several demographic and clinical variables, Dr. Sarah Yi said in an interview at an annual scientific meeting on infectious diseases.
“If we can identify a population that is at higher risk for health care–associated infections, then maybe we can intervene at some level,” said Dr. Yi of the division of healthcare quality promotion at the CDC. “If we can elucidate the mechanism better, it will give us other clues about where we can prevent infections.”
More than 1.2 million cesareans were performed in the United States in 2012, and low transverse C-sections ranked fifth among all procedures performed during hospital stays, Dr. Yi noted. Post-cesarean surgical site infections (SSIs) remain a major cause of expense and morbidity, but not many studies have evaluated the relationship between insurance type and the risk of SSIs or other health care–associated infections, she added.
To explore the issue, Dr. Yi and her associates analyzed national health care safety data for 2,769 women who had a cesarean delivery in New York in 2010 or 2011 and had either Medicaid or private insurance at the time of their delivery. The Medicaid group included 1,763 women, while the privately insured group included 1,006 women. Medicaid patients were younger, more likely to be Hispanic, black, or homeless, and were more often treated at government and teaching facilities than privately insured patients were.
After researchers accounted for age, race, ethnicity, body mass index, facility type, American Society of Anesthesiologists score, emergency and labor status, use of anesthesia, duration of surgery, and wound classification, Medicaid patients still had nearly double the risk of an SSI after cesarean as did their counterparts with private insurance (risk ratio, 1.8; 95% confidence interval, 1.2-2.8; P = .02).
While homelessness could potentially increase the risk of SSI by limiting opportunities for self-care, social support, and clinical follow-up, Medicaid remained a significant predictor of SSI even after excluding homeless women from the analysis, Dr. Yi said.
But Medicaid might represent one, or several, factors that the model did not account for, such as socioeconomic status or prenatal care, said Dr. Yi.
Prenatal care, in particular, might have been lower among Medicaid patients for women who did not obtain coverage until after arriving at the hospital for delivery, she said. Inadequate prenatal care has been linked to complications after delivery, and the proportion of eligible women who are enrolled in Medicaid has been found to vary at different times during pregnancy, she added (MMWR Surveill Summ. 2015 Jun 19;64[4]:1-19).
The CDC investigators plan to continue the research by trying to validate the association in other populations, in other years, and in other states, Dr. Yi said.
IDWeek marks the combined annual meetings of the Infectious Diseases Society of America, the Society for Healthcare Epidemiology of America, the HIV Medicine Association, and the Pediatric Infectious Diseases Society.
The researchers reported having no financial disclosures.
SAN DIEGO – Medicaid patients were nearly twice as likely to develop surgical site infections after cesarean delivery than privately insured women, according to investigators from the Centers for Disease Control and Prevention.
The association remained even after researchers accounted for several demographic and clinical variables, Dr. Sarah Yi said in an interview at an annual scientific meeting on infectious diseases.
“If we can identify a population that is at higher risk for health care–associated infections, then maybe we can intervene at some level,” said Dr. Yi of the division of healthcare quality promotion at the CDC. “If we can elucidate the mechanism better, it will give us other clues about where we can prevent infections.”
More than 1.2 million cesareans were performed in the United States in 2012, and low transverse C-sections ranked fifth among all procedures performed during hospital stays, Dr. Yi noted. Post-cesarean surgical site infections (SSIs) remain a major cause of expense and morbidity, but not many studies have evaluated the relationship between insurance type and the risk of SSIs or other health care–associated infections, she added.
To explore the issue, Dr. Yi and her associates analyzed national health care safety data for 2,769 women who had a cesarean delivery in New York in 2010 or 2011 and had either Medicaid or private insurance at the time of their delivery. The Medicaid group included 1,763 women, while the privately insured group included 1,006 women. Medicaid patients were younger, more likely to be Hispanic, black, or homeless, and were more often treated at government and teaching facilities than privately insured patients were.
After researchers accounted for age, race, ethnicity, body mass index, facility type, American Society of Anesthesiologists score, emergency and labor status, use of anesthesia, duration of surgery, and wound classification, Medicaid patients still had nearly double the risk of an SSI after cesarean as did their counterparts with private insurance (risk ratio, 1.8; 95% confidence interval, 1.2-2.8; P = .02).
While homelessness could potentially increase the risk of SSI by limiting opportunities for self-care, social support, and clinical follow-up, Medicaid remained a significant predictor of SSI even after excluding homeless women from the analysis, Dr. Yi said.
But Medicaid might represent one, or several, factors that the model did not account for, such as socioeconomic status or prenatal care, said Dr. Yi.
Prenatal care, in particular, might have been lower among Medicaid patients for women who did not obtain coverage until after arriving at the hospital for delivery, she said. Inadequate prenatal care has been linked to complications after delivery, and the proportion of eligible women who are enrolled in Medicaid has been found to vary at different times during pregnancy, she added (MMWR Surveill Summ. 2015 Jun 19;64[4]:1-19).
The CDC investigators plan to continue the research by trying to validate the association in other populations, in other years, and in other states, Dr. Yi said.
IDWeek marks the combined annual meetings of the Infectious Diseases Society of America, the Society for Healthcare Epidemiology of America, the HIV Medicine Association, and the Pediatric Infectious Diseases Society.
The researchers reported having no financial disclosures.
SAN DIEGO – Medicaid patients were nearly twice as likely to develop surgical site infections after cesarean delivery than privately insured women, according to investigators from the Centers for Disease Control and Prevention.
The association remained even after researchers accounted for several demographic and clinical variables, Dr. Sarah Yi said in an interview at an annual scientific meeting on infectious diseases.
“If we can identify a population that is at higher risk for health care–associated infections, then maybe we can intervene at some level,” said Dr. Yi of the division of healthcare quality promotion at the CDC. “If we can elucidate the mechanism better, it will give us other clues about where we can prevent infections.”
More than 1.2 million cesareans were performed in the United States in 2012, and low transverse C-sections ranked fifth among all procedures performed during hospital stays, Dr. Yi noted. Post-cesarean surgical site infections (SSIs) remain a major cause of expense and morbidity, but not many studies have evaluated the relationship between insurance type and the risk of SSIs or other health care–associated infections, she added.
To explore the issue, Dr. Yi and her associates analyzed national health care safety data for 2,769 women who had a cesarean delivery in New York in 2010 or 2011 and had either Medicaid or private insurance at the time of their delivery. The Medicaid group included 1,763 women, while the privately insured group included 1,006 women. Medicaid patients were younger, more likely to be Hispanic, black, or homeless, and were more often treated at government and teaching facilities than privately insured patients were.
After researchers accounted for age, race, ethnicity, body mass index, facility type, American Society of Anesthesiologists score, emergency and labor status, use of anesthesia, duration of surgery, and wound classification, Medicaid patients still had nearly double the risk of an SSI after cesarean as did their counterparts with private insurance (risk ratio, 1.8; 95% confidence interval, 1.2-2.8; P = .02).
While homelessness could potentially increase the risk of SSI by limiting opportunities for self-care, social support, and clinical follow-up, Medicaid remained a significant predictor of SSI even after excluding homeless women from the analysis, Dr. Yi said.
But Medicaid might represent one, or several, factors that the model did not account for, such as socioeconomic status or prenatal care, said Dr. Yi.
Prenatal care, in particular, might have been lower among Medicaid patients for women who did not obtain coverage until after arriving at the hospital for delivery, she said. Inadequate prenatal care has been linked to complications after delivery, and the proportion of eligible women who are enrolled in Medicaid has been found to vary at different times during pregnancy, she added (MMWR Surveill Summ. 2015 Jun 19;64[4]:1-19).
The CDC investigators plan to continue the research by trying to validate the association in other populations, in other years, and in other states, Dr. Yi said.
IDWeek marks the combined annual meetings of the Infectious Diseases Society of America, the Society for Healthcare Epidemiology of America, the HIV Medicine Association, and the Pediatric Infectious Diseases Society.
The researchers reported having no financial disclosures.
AT IDWEEK 2015
Key clinical point: Medicaid patients had about a twofold higher risk of surgical site infections after cesarean delivery than did privately insured women.
Major finding: The association between Medicaid coverage and surgical site infections after cesarean delivery remained significant after researchers controlled for several potential confounders (risk ratio, 1.8; P = .02).
Data source: Analysis of national health care safety data for 2,769 women who had a cesarean in New York in 2010 or 2011.
Disclosures: The investigators reported having no financial disclosures.
Widespread rotavirus vaccination caused plunge in pediatric hospitalizations
SAN DIEGO – Rhode Island’s universal vaccine policy led to widespread vaccination against rotavirus, steep drops in pediatric hospitalizations for gastroenteritis, and major shifts in circulating rotavirus genotypes, investigators reported at an annual scientific meeting on infectious diseases.
“Vaccination with both RV5 (RotaTeq) and RV1 (Rotarix) decreased rotavirus disease in Rhode Island,” said Dr. Sabina Holland, who led the single-center, prospective study at Hasbro Children’s Hospital, Brown University, Providence, R.I. “Variations in genotype distribution and the emergence of uncommon strains occurred only after introduction of RV1,” she and her associates reported.
Rotavirus, the leading cause of severe diarrhea worldwide, was implicated in 453,000 deaths in 2008 alone, Dr. Holland noted. The Rhode Island health department gives pediatric vaccines to health care providers free of charge, and as a result, rotavirus vaccine coverage in the state is about 89%, she said.
To understand the effects of this high vaccination rate, Dr. Holland and her associates conducted active surveillance for hospitalizations of children younger than 10 years old with gastroenteritis between 2002 and 2012. Between 2012 and 2015, they performed passive laboratory surveillance by testing stool samples for rotavirus with a commercially available enzyme immunoassay. They also used reverse transcription polymerase chain reaction (RT-PCR) to genotype rotavirus RNA. Finally, they examined vaccination records of cases from the state immunization registry for the years 2009-2015, Dr. Holland said at the combined annual meetings of the Infectious Diseases Society of America, the Society for Healthcare Epidemiology of America, the HIV Medicine Association, and the Pediatric Infectious Diseases Society.
The hospital admitted between 79 and 159 children every year with rotavirus disease between 2002 and 2006, and there was no overall upward or downward trend during this period, said Dr. Holland. Hospitalizations for rotavirus then dropped by about 50% 1 year after RV5 was introduced, she said. Hospitalizations kept dropping every subsequent year until 2014, when the hospital admitted only one child with rotavirus disease.
But, in 2015, the hospital admitted six children for rotavirus disease, including three who had not received RV1 or RV5, Dr. Holland said. “We need to continue surveillance to see if the increase in hospitalizations in 2015 will continue, and if it is related to genotype variation secondary to vaccine-induced immune pressure, or due to natural variation,” she added.
Genotype 1 rotavirus, which is most common globally, predominated until after Rhode Island implemented RV5, the study found. Genotype 2 prevailed in 2010, when the state switched to RV1. Since then, nontypeable strains have predominated, and the research team is continuing to sequence them.
The National Science Foundation partially supported the research with a grant to the University of Rhode Island Genomics and Sequencing Center in Kingston. The Center for International Health Research also helped with analyses. Dr. Holland reported no relevant financial disclosures. Senior author Dr. Penelope Dennehy reported receiving relevant research funding from Merck, the maker of RotaTeq.
SAN DIEGO – Rhode Island’s universal vaccine policy led to widespread vaccination against rotavirus, steep drops in pediatric hospitalizations for gastroenteritis, and major shifts in circulating rotavirus genotypes, investigators reported at an annual scientific meeting on infectious diseases.
“Vaccination with both RV5 (RotaTeq) and RV1 (Rotarix) decreased rotavirus disease in Rhode Island,” said Dr. Sabina Holland, who led the single-center, prospective study at Hasbro Children’s Hospital, Brown University, Providence, R.I. “Variations in genotype distribution and the emergence of uncommon strains occurred only after introduction of RV1,” she and her associates reported.
Rotavirus, the leading cause of severe diarrhea worldwide, was implicated in 453,000 deaths in 2008 alone, Dr. Holland noted. The Rhode Island health department gives pediatric vaccines to health care providers free of charge, and as a result, rotavirus vaccine coverage in the state is about 89%, she said.
To understand the effects of this high vaccination rate, Dr. Holland and her associates conducted active surveillance for hospitalizations of children younger than 10 years old with gastroenteritis between 2002 and 2012. Between 2012 and 2015, they performed passive laboratory surveillance by testing stool samples for rotavirus with a commercially available enzyme immunoassay. They also used reverse transcription polymerase chain reaction (RT-PCR) to genotype rotavirus RNA. Finally, they examined vaccination records of cases from the state immunization registry for the years 2009-2015, Dr. Holland said at the combined annual meetings of the Infectious Diseases Society of America, the Society for Healthcare Epidemiology of America, the HIV Medicine Association, and the Pediatric Infectious Diseases Society.
The hospital admitted between 79 and 159 children every year with rotavirus disease between 2002 and 2006, and there was no overall upward or downward trend during this period, said Dr. Holland. Hospitalizations for rotavirus then dropped by about 50% 1 year after RV5 was introduced, she said. Hospitalizations kept dropping every subsequent year until 2014, when the hospital admitted only one child with rotavirus disease.
But, in 2015, the hospital admitted six children for rotavirus disease, including three who had not received RV1 or RV5, Dr. Holland said. “We need to continue surveillance to see if the increase in hospitalizations in 2015 will continue, and if it is related to genotype variation secondary to vaccine-induced immune pressure, or due to natural variation,” she added.
Genotype 1 rotavirus, which is most common globally, predominated until after Rhode Island implemented RV5, the study found. Genotype 2 prevailed in 2010, when the state switched to RV1. Since then, nontypeable strains have predominated, and the research team is continuing to sequence them.
The National Science Foundation partially supported the research with a grant to the University of Rhode Island Genomics and Sequencing Center in Kingston. The Center for International Health Research also helped with analyses. Dr. Holland reported no relevant financial disclosures. Senior author Dr. Penelope Dennehy reported receiving relevant research funding from Merck, the maker of RotaTeq.
SAN DIEGO – Rhode Island’s universal vaccine policy led to widespread vaccination against rotavirus, steep drops in pediatric hospitalizations for gastroenteritis, and major shifts in circulating rotavirus genotypes, investigators reported at an annual scientific meeting on infectious diseases.
“Vaccination with both RV5 (RotaTeq) and RV1 (Rotarix) decreased rotavirus disease in Rhode Island,” said Dr. Sabina Holland, who led the single-center, prospective study at Hasbro Children’s Hospital, Brown University, Providence, R.I. “Variations in genotype distribution and the emergence of uncommon strains occurred only after introduction of RV1,” she and her associates reported.
Rotavirus, the leading cause of severe diarrhea worldwide, was implicated in 453,000 deaths in 2008 alone, Dr. Holland noted. The Rhode Island health department gives pediatric vaccines to health care providers free of charge, and as a result, rotavirus vaccine coverage in the state is about 89%, she said.
To understand the effects of this high vaccination rate, Dr. Holland and her associates conducted active surveillance for hospitalizations of children younger than 10 years old with gastroenteritis between 2002 and 2012. Between 2012 and 2015, they performed passive laboratory surveillance by testing stool samples for rotavirus with a commercially available enzyme immunoassay. They also used reverse transcription polymerase chain reaction (RT-PCR) to genotype rotavirus RNA. Finally, they examined vaccination records of cases from the state immunization registry for the years 2009-2015, Dr. Holland said at the combined annual meetings of the Infectious Diseases Society of America, the Society for Healthcare Epidemiology of America, the HIV Medicine Association, and the Pediatric Infectious Diseases Society.
The hospital admitted between 79 and 159 children every year with rotavirus disease between 2002 and 2006, and there was no overall upward or downward trend during this period, said Dr. Holland. Hospitalizations for rotavirus then dropped by about 50% 1 year after RV5 was introduced, she said. Hospitalizations kept dropping every subsequent year until 2014, when the hospital admitted only one child with rotavirus disease.
But, in 2015, the hospital admitted six children for rotavirus disease, including three who had not received RV1 or RV5, Dr. Holland said. “We need to continue surveillance to see if the increase in hospitalizations in 2015 will continue, and if it is related to genotype variation secondary to vaccine-induced immune pressure, or due to natural variation,” she added.
Genotype 1 rotavirus, which is most common globally, predominated until after Rhode Island implemented RV5, the study found. Genotype 2 prevailed in 2010, when the state switched to RV1. Since then, nontypeable strains have predominated, and the research team is continuing to sequence them.
The National Science Foundation partially supported the research with a grant to the University of Rhode Island Genomics and Sequencing Center in Kingston. The Center for International Health Research also helped with analyses. Dr. Holland reported no relevant financial disclosures. Senior author Dr. Penelope Dennehy reported receiving relevant research funding from Merck, the maker of RotaTeq.
AT IDWEEK 2015
Key clinical point: Widespread rotavirus vaccination led to a steep drop in pediatric hospitalizations for rotavirus disease.
Major finding: Hospitalizations for rotavirus disease fell by about 50% at one hospital a year after Rhode Island introduced universal rotavirus vaccination.
Data source: Single-center hospital-based and laboratory surveillance for pediatric rotavirus disease between 2002 and 2015.
Disclosures: The National Science Foundation helped support the work of the University of Rhode Island Genomics and Sequencing Center. The Center for International Health Research also helped with analyses. Dr. Holland reported no financial disclosures. Senior author Dr. Penelope Dennehy reported receiving an investigator-initiated grant from Merck, the maker of RotaTeq.
Hospitals report inadequate duodenoscope reprocessing practices
SAN DIEGO – Less than a third of hospitals reprocessed duodenoscopes adequately to prevent potential transmission of carbapenem-resistant Enterobacteriaceae (CRE) and other pathogens, investigators reported at an annual scientific meeting on infectious diseases.
Moreover, only a third of facilities had conducted active surveillance for multidrug-resistant infections related to use of their duodenoscopes in the past year, reported Susan Beekmann of the Emerging Infections Network of the Infectious Diseases Society of America. “These findings suggest that endemic bacterial transmission associated with duodenoscopy may occur and may go unrecognized,” said Ms. Beekmann, program coordinator for EIN at the University of Iowa Carver College of Medicine in Iowa City.
Duodenoscopes, which are used in endoscopic retrograde cholangiopancreatography (ERCP), became a hot topic earlier this year after causing outbreaks of fatal CRE infections in Los Angeles County. The Food and Drug Administration has acknowledged that the “complex design of the devices makes it difficult to remove contaminants compared to other types of endoscopes,” and both the CDC and the FDA have recommended specific reprocessing and surveillance steps to reduce the chances that the scopes transmit serious infections.
To understand how hospitals were actually reprocessing and culturing the scopes at the time CDC released its guidance, Ms. Beekmann and her colleagues electronically surveyed 740 hospital epidemiologists through IDSA-EIN. They received responses from 378 physicians (52%), of which half said their facilities used duodenoscopes, Ms. Beekmann reported at the combined annual meetings of the Infectious Diseases Society of America, the Society for Healthcare Epidemiology of America, the HIV Medicine Association, and the Pediatric Infectious Diseases Society.
Only 55 (29%) of these respondents said their facilities reprocessed duodenoscopes to an extent that the IDSA researchers defined as adequate – that is, manual reprocessing with high-level disinfection, either alone or in combination with other options, Ms. Beekmann said. Furthermore, only a third of facilities had cultured their duodenoscopes or done any other surveillance for bacterial transmission after duodenoscopy in the past year, even though most said they reviewed their reprocessing policies and procedures more often than once a year.
Respondents also described widely varying methodologies for sampling and culturing, Ms. Beekmann said. “Although we did not ask about them, ten respondents mentioned ATP bioluminescence assays,” she added. Based on the findings, better reprocessing technologies and consistent, real-time strategies to monitor the effectiveness of scope reprocessing are “urgent patient safety needs,” she and her colleagues concluded.
Ms. Beekmann and her associates reported no relevant financial disclosures.
SAN DIEGO – Less than a third of hospitals reprocessed duodenoscopes adequately to prevent potential transmission of carbapenem-resistant Enterobacteriaceae (CRE) and other pathogens, investigators reported at an annual scientific meeting on infectious diseases.
Moreover, only a third of facilities had conducted active surveillance for multidrug-resistant infections related to use of their duodenoscopes in the past year, reported Susan Beekmann of the Emerging Infections Network of the Infectious Diseases Society of America. “These findings suggest that endemic bacterial transmission associated with duodenoscopy may occur and may go unrecognized,” said Ms. Beekmann, program coordinator for EIN at the University of Iowa Carver College of Medicine in Iowa City.
Duodenoscopes, which are used in endoscopic retrograde cholangiopancreatography (ERCP), became a hot topic earlier this year after causing outbreaks of fatal CRE infections in Los Angeles County. The Food and Drug Administration has acknowledged that the “complex design of the devices makes it difficult to remove contaminants compared to other types of endoscopes,” and both the CDC and the FDA have recommended specific reprocessing and surveillance steps to reduce the chances that the scopes transmit serious infections.
To understand how hospitals were actually reprocessing and culturing the scopes at the time CDC released its guidance, Ms. Beekmann and her colleagues electronically surveyed 740 hospital epidemiologists through IDSA-EIN. They received responses from 378 physicians (52%), of which half said their facilities used duodenoscopes, Ms. Beekmann reported at the combined annual meetings of the Infectious Diseases Society of America, the Society for Healthcare Epidemiology of America, the HIV Medicine Association, and the Pediatric Infectious Diseases Society.
Only 55 (29%) of these respondents said their facilities reprocessed duodenoscopes to an extent that the IDSA researchers defined as adequate – that is, manual reprocessing with high-level disinfection, either alone or in combination with other options, Ms. Beekmann said. Furthermore, only a third of facilities had cultured their duodenoscopes or done any other surveillance for bacterial transmission after duodenoscopy in the past year, even though most said they reviewed their reprocessing policies and procedures more often than once a year.
Respondents also described widely varying methodologies for sampling and culturing, Ms. Beekmann said. “Although we did not ask about them, ten respondents mentioned ATP bioluminescence assays,” she added. Based on the findings, better reprocessing technologies and consistent, real-time strategies to monitor the effectiveness of scope reprocessing are “urgent patient safety needs,” she and her colleagues concluded.
Ms. Beekmann and her associates reported no relevant financial disclosures.
SAN DIEGO – Less than a third of hospitals reprocessed duodenoscopes adequately to prevent potential transmission of carbapenem-resistant Enterobacteriaceae (CRE) and other pathogens, investigators reported at an annual scientific meeting on infectious diseases.
Moreover, only a third of facilities had conducted active surveillance for multidrug-resistant infections related to use of their duodenoscopes in the past year, reported Susan Beekmann of the Emerging Infections Network of the Infectious Diseases Society of America. “These findings suggest that endemic bacterial transmission associated with duodenoscopy may occur and may go unrecognized,” said Ms. Beekmann, program coordinator for EIN at the University of Iowa Carver College of Medicine in Iowa City.
Duodenoscopes, which are used in endoscopic retrograde cholangiopancreatography (ERCP), became a hot topic earlier this year after causing outbreaks of fatal CRE infections in Los Angeles County. The Food and Drug Administration has acknowledged that the “complex design of the devices makes it difficult to remove contaminants compared to other types of endoscopes,” and both the CDC and the FDA have recommended specific reprocessing and surveillance steps to reduce the chances that the scopes transmit serious infections.
To understand how hospitals were actually reprocessing and culturing the scopes at the time CDC released its guidance, Ms. Beekmann and her colleagues electronically surveyed 740 hospital epidemiologists through IDSA-EIN. They received responses from 378 physicians (52%), of which half said their facilities used duodenoscopes, Ms. Beekmann reported at the combined annual meetings of the Infectious Diseases Society of America, the Society for Healthcare Epidemiology of America, the HIV Medicine Association, and the Pediatric Infectious Diseases Society.
Only 55 (29%) of these respondents said their facilities reprocessed duodenoscopes to an extent that the IDSA researchers defined as adequate – that is, manual reprocessing with high-level disinfection, either alone or in combination with other options, Ms. Beekmann said. Furthermore, only a third of facilities had cultured their duodenoscopes or done any other surveillance for bacterial transmission after duodenoscopy in the past year, even though most said they reviewed their reprocessing policies and procedures more often than once a year.
Respondents also described widely varying methodologies for sampling and culturing, Ms. Beekmann said. “Although we did not ask about them, ten respondents mentioned ATP bioluminescence assays,” she added. Based on the findings, better reprocessing technologies and consistent, real-time strategies to monitor the effectiveness of scope reprocessing are “urgent patient safety needs,” she and her colleagues concluded.
Ms. Beekmann and her associates reported no relevant financial disclosures.
AT IDWEEK 2015
Key clinical point: Most hospitals did not reprocess duodenoscopes in a way that the Infectious Diseases Society of America considers adequate.
Major finding: Only 29% of facilities followed the minimum adequate practices.
Data source: A cross-sectional electronic survey of 378 physician members of the Emerging Infections Network of the Infectious Diseases Society of America.
Disclosures: Susan Beekmann reported no relevant financial disclosures.
Study reveals patterns of concurrent MRI lesions in knee OA
Groupings of coexisting MRI lesions of the tibiofemoral and patellofemoral joints were linked to the risk of subsequent radiographic osteoarthritis, investigators reported. Their analysis of data from the prospective, observational MOST study was published online Sept. 28 in Arthritis and Rheumatism.
“The magnitude of lesions such as cartilage damage and coexisting meniscal damage appear to be the main distinction between the subgroups,” said Dr. Jingbo Niu of Boston University and her associates. Several studies have linked individual MRI lesions with incident knee OA, but patterns of coexisting lesions more accurately reflect real-world injuries, such as anterior cruciate ligament tears, which tend to affect more than one knee structure, the investigators noted.
Because directly comparing lesions in a multivariate model does not account for chronology, the investigators used latent class analysis to identify subgroups of coexisting MRI lesions of the tibiofemoral and patellofemoral joints, such as cartilage damage, meniscal tear, meniscal extrusion, synovitis, and effusion. Then they modeled associations between these subgroups and incident OA of the knee (Arthritis Rheum. 2015 Sep 28. doi: 10.1002/art.3943).
Among 885 knees from the MOST study, 203 developed radiographic tibiofemoral OA and 64 developed patellofemoral OA after up to 84 months of follow-up, the researchers reported. Latent class analysis identified four groups of MRI lesions for each knee joint, which exhibited sequentially increasing baseline severity for all MRI features except meniscal damage, the investigators added.
For the patellofemoral joint, the odds of incident knee OA rose sequentially with increasing MRI severity, ranging from 1.0 for minimal lesions to 13.7 for severe lesions (95% confidence interval, 5.0-37.0), according to the study. In contrast, the odds of incident knee radiographic OA (ROA) of the tibiofemoral joint were highest for the “mild” and “severe” groups, which had the most meniscal damage and the most extensive history of knee injury and surgery. Odds ratios for these two groups were 5.6 (95% CI, 3.4-9.4) and 5.0 (95% CI, 2.8-9.0), respectively, said the researchers. “Meniscal damage might play a prominent role in the development of incident ROA in the tibiofemoral joint but not the patellofemoral joint,” they added.
Patients in the MOST study had a high risk of knee OA at baseline, which could limit the generalizability of the findings, Dr. Niu and her associates noted.
The National Institute on Aging and National Institute of Arthritis and Musculoskeletal and Skin Disease, both a part of the National Institutes of Health, supported the study. The investigators did not report conflicts of interest.
It was not until recently that the osteoarthritis community directed a shift toward new ways of halting joint damage rather than the palliative approach of analgesics followed by joint replacement. However, the sequential failures of novel disease-modifying therapies attempting to target diverse pathogenic mechanisms have highlighted the need to target early disease and to better identify and target distinct disease phenotypes. In this light of recent efforts to uncover the various mechanisms leading to joint deterioration, Niu et al. have used a novel approach to detect distinct clusters of multiple joint abnormalities on MRI at the preradiographic stage. They also examined the association between each cluster and the risk of radiographic OA during follow-up.
Probably the most important [conclusion from this study] is that it is possible to identify distinct phenotypes of joint damage as early as at the preradiographic phase. Consequently, it is intuitive that alternative pathways caused by various risk factors exist and play diverse roles in the process of joint destruction. Phenotyping patients in regards to their genetic profile, serologic, and MRI markers, demographic features, metabolic status, etc., is promising and probably the best solution to achieve improvements in the way we are treating OA patients.
The use of these results to assess prognosis seems premature in clinical research and inappropriate in the clinical setting. Nevertheless, the latent class analysis is an attractive approach in the field of OA and can aid in unraveling the pathogenesis of this enigmatic disease.
Dr. Leticia A. Deveza and Dr. David J. Hunter are with the department of rheumatology at the University of Sydney. They declared no conflicts of interest. These comments are from their accompanying editorial (Arthritis Rheum. 2015 Sep 28 doi: 10.1002/art.39439).
It was not until recently that the osteoarthritis community directed a shift toward new ways of halting joint damage rather than the palliative approach of analgesics followed by joint replacement. However, the sequential failures of novel disease-modifying therapies attempting to target diverse pathogenic mechanisms have highlighted the need to target early disease and to better identify and target distinct disease phenotypes. In this light of recent efforts to uncover the various mechanisms leading to joint deterioration, Niu et al. have used a novel approach to detect distinct clusters of multiple joint abnormalities on MRI at the preradiographic stage. They also examined the association between each cluster and the risk of radiographic OA during follow-up.
Probably the most important [conclusion from this study] is that it is possible to identify distinct phenotypes of joint damage as early as at the preradiographic phase. Consequently, it is intuitive that alternative pathways caused by various risk factors exist and play diverse roles in the process of joint destruction. Phenotyping patients in regards to their genetic profile, serologic, and MRI markers, demographic features, metabolic status, etc., is promising and probably the best solution to achieve improvements in the way we are treating OA patients.
The use of these results to assess prognosis seems premature in clinical research and inappropriate in the clinical setting. Nevertheless, the latent class analysis is an attractive approach in the field of OA and can aid in unraveling the pathogenesis of this enigmatic disease.
Dr. Leticia A. Deveza and Dr. David J. Hunter are with the department of rheumatology at the University of Sydney. They declared no conflicts of interest. These comments are from their accompanying editorial (Arthritis Rheum. 2015 Sep 28 doi: 10.1002/art.39439).
It was not until recently that the osteoarthritis community directed a shift toward new ways of halting joint damage rather than the palliative approach of analgesics followed by joint replacement. However, the sequential failures of novel disease-modifying therapies attempting to target diverse pathogenic mechanisms have highlighted the need to target early disease and to better identify and target distinct disease phenotypes. In this light of recent efforts to uncover the various mechanisms leading to joint deterioration, Niu et al. have used a novel approach to detect distinct clusters of multiple joint abnormalities on MRI at the preradiographic stage. They also examined the association between each cluster and the risk of radiographic OA during follow-up.
Probably the most important [conclusion from this study] is that it is possible to identify distinct phenotypes of joint damage as early as at the preradiographic phase. Consequently, it is intuitive that alternative pathways caused by various risk factors exist and play diverse roles in the process of joint destruction. Phenotyping patients in regards to their genetic profile, serologic, and MRI markers, demographic features, metabolic status, etc., is promising and probably the best solution to achieve improvements in the way we are treating OA patients.
The use of these results to assess prognosis seems premature in clinical research and inappropriate in the clinical setting. Nevertheless, the latent class analysis is an attractive approach in the field of OA and can aid in unraveling the pathogenesis of this enigmatic disease.
Dr. Leticia A. Deveza and Dr. David J. Hunter are with the department of rheumatology at the University of Sydney. They declared no conflicts of interest. These comments are from their accompanying editorial (Arthritis Rheum. 2015 Sep 28 doi: 10.1002/art.39439).
Groupings of coexisting MRI lesions of the tibiofemoral and patellofemoral joints were linked to the risk of subsequent radiographic osteoarthritis, investigators reported. Their analysis of data from the prospective, observational MOST study was published online Sept. 28 in Arthritis and Rheumatism.
“The magnitude of lesions such as cartilage damage and coexisting meniscal damage appear to be the main distinction between the subgroups,” said Dr. Jingbo Niu of Boston University and her associates. Several studies have linked individual MRI lesions with incident knee OA, but patterns of coexisting lesions more accurately reflect real-world injuries, such as anterior cruciate ligament tears, which tend to affect more than one knee structure, the investigators noted.
Because directly comparing lesions in a multivariate model does not account for chronology, the investigators used latent class analysis to identify subgroups of coexisting MRI lesions of the tibiofemoral and patellofemoral joints, such as cartilage damage, meniscal tear, meniscal extrusion, synovitis, and effusion. Then they modeled associations between these subgroups and incident OA of the knee (Arthritis Rheum. 2015 Sep 28. doi: 10.1002/art.3943).
Among 885 knees from the MOST study, 203 developed radiographic tibiofemoral OA and 64 developed patellofemoral OA after up to 84 months of follow-up, the researchers reported. Latent class analysis identified four groups of MRI lesions for each knee joint, which exhibited sequentially increasing baseline severity for all MRI features except meniscal damage, the investigators added.
For the patellofemoral joint, the odds of incident knee OA rose sequentially with increasing MRI severity, ranging from 1.0 for minimal lesions to 13.7 for severe lesions (95% confidence interval, 5.0-37.0), according to the study. In contrast, the odds of incident knee radiographic OA (ROA) of the tibiofemoral joint were highest for the “mild” and “severe” groups, which had the most meniscal damage and the most extensive history of knee injury and surgery. Odds ratios for these two groups were 5.6 (95% CI, 3.4-9.4) and 5.0 (95% CI, 2.8-9.0), respectively, said the researchers. “Meniscal damage might play a prominent role in the development of incident ROA in the tibiofemoral joint but not the patellofemoral joint,” they added.
Patients in the MOST study had a high risk of knee OA at baseline, which could limit the generalizability of the findings, Dr. Niu and her associates noted.
The National Institute on Aging and National Institute of Arthritis and Musculoskeletal and Skin Disease, both a part of the National Institutes of Health, supported the study. The investigators did not report conflicts of interest.
Groupings of coexisting MRI lesions of the tibiofemoral and patellofemoral joints were linked to the risk of subsequent radiographic osteoarthritis, investigators reported. Their analysis of data from the prospective, observational MOST study was published online Sept. 28 in Arthritis and Rheumatism.
“The magnitude of lesions such as cartilage damage and coexisting meniscal damage appear to be the main distinction between the subgroups,” said Dr. Jingbo Niu of Boston University and her associates. Several studies have linked individual MRI lesions with incident knee OA, but patterns of coexisting lesions more accurately reflect real-world injuries, such as anterior cruciate ligament tears, which tend to affect more than one knee structure, the investigators noted.
Because directly comparing lesions in a multivariate model does not account for chronology, the investigators used latent class analysis to identify subgroups of coexisting MRI lesions of the tibiofemoral and patellofemoral joints, such as cartilage damage, meniscal tear, meniscal extrusion, synovitis, and effusion. Then they modeled associations between these subgroups and incident OA of the knee (Arthritis Rheum. 2015 Sep 28. doi: 10.1002/art.3943).
Among 885 knees from the MOST study, 203 developed radiographic tibiofemoral OA and 64 developed patellofemoral OA after up to 84 months of follow-up, the researchers reported. Latent class analysis identified four groups of MRI lesions for each knee joint, which exhibited sequentially increasing baseline severity for all MRI features except meniscal damage, the investigators added.
For the patellofemoral joint, the odds of incident knee OA rose sequentially with increasing MRI severity, ranging from 1.0 for minimal lesions to 13.7 for severe lesions (95% confidence interval, 5.0-37.0), according to the study. In contrast, the odds of incident knee radiographic OA (ROA) of the tibiofemoral joint were highest for the “mild” and “severe” groups, which had the most meniscal damage and the most extensive history of knee injury and surgery. Odds ratios for these two groups were 5.6 (95% CI, 3.4-9.4) and 5.0 (95% CI, 2.8-9.0), respectively, said the researchers. “Meniscal damage might play a prominent role in the development of incident ROA in the tibiofemoral joint but not the patellofemoral joint,” they added.
Patients in the MOST study had a high risk of knee OA at baseline, which could limit the generalizability of the findings, Dr. Niu and her associates noted.
The National Institute on Aging and National Institute of Arthritis and Musculoskeletal and Skin Disease, both a part of the National Institutes of Health, supported the study. The investigators did not report conflicts of interest.
FROM ARTHRITIS & RHEUMATISM
Key clinical point: Phenotypes of MRI lesions of the tibiofemoral and patellofemoral joints were differentially associated with risk of incident radiographic osteoarthritis.
Major finding: An MRI of the tibiofemoral and patellofemoral joints revealed minimal, mild, moderate, and severe lesions, with corresponding changes in the odds of incident OA.
Data source: Analysis of cohort data for 885 knees from the multicenter, prospective, observational MOST study.
Disclosures: The National Institute on Aging and National Institute of Arthritis and Musculoskeletal and Skin Disease, both a part of the National Institutes of Health, supported the study. The investigators did not report conflicts of interest.
Inflammatory features linked to erosive development in hand OA
Among adults with hand osteoarthritis, ultrasonographic evidence of persistent joint-level inflammation increased the odds of subsequent erosions by as much as 11 times, said authors of a 2-year prospective study.
“These observations implicate a role for inflammation in the pathogenesis of erosive osteoarthritis and might render new therapeutic options that can halt erosive development,” said Dr. Marion C. Kortekaas and her associates at Leiden (the Netherlands) University Medical Center. The findings appeared online in Arthritis & Rheumatology.
The pathogenesis of erosive hand OA remains poorly understood, despite its high clinical burden, the researchers noted. To assess potential risk factors for erosive development, they used standard ultrasonographic methods to examine the interphalangeal joints of 56 consecutive patients who presented to a rheumatology outpatient clinic with hand OA based on American College of Rheumatology criteria. They also scored radiographs for osteophytes or joint-space narrowing with the OARSI method and used the Verbruggen-Veys method to identify and exclude joints that were already eroded (E phase) or remodeled (R phase) at baseline (Arthritis Rheum. 2015 Sep 28. doi: 10.1002/art.39438). At baseline, 18 patients had ultrasonographic evidence of erosions in a total of 51 interphalangeal joints, the investigators said. At the 2.3-year follow-up, a total of 38 interphalangeal joints from 26 patients showed erosive development.
After accounting for age, gender, body mass index, and baseline cartilage and bone abnormalities, all ultrasonographic features of inflammation that were at least grade 1 at baseline and follow-up predicted erosive development. Persistent power Doppler signal was the strongest risk factor, yielding an odds ratio of 11.4 in the adjusted model (95% confidence interval, 2.7-49.1). Other significant risk factors included moderate to severe baseline synovial thickening (OR, 8.8; 95% CI, 2.4-32.3) and power Doppler signal (OR, 7.1; 95% CI, 1.9-26.9).
“The present study confirms that inflammatory US features found at baseline are associated with erosive development on the joint level in hand OA,” the investigators wrote. “These associations are already found after 2 years of follow-up, which is important for future prospective trials.”
The researchers reported having no funding sources or conflicts of interest.
Among adults with hand osteoarthritis, ultrasonographic evidence of persistent joint-level inflammation increased the odds of subsequent erosions by as much as 11 times, said authors of a 2-year prospective study.
“These observations implicate a role for inflammation in the pathogenesis of erosive osteoarthritis and might render new therapeutic options that can halt erosive development,” said Dr. Marion C. Kortekaas and her associates at Leiden (the Netherlands) University Medical Center. The findings appeared online in Arthritis & Rheumatology.
The pathogenesis of erosive hand OA remains poorly understood, despite its high clinical burden, the researchers noted. To assess potential risk factors for erosive development, they used standard ultrasonographic methods to examine the interphalangeal joints of 56 consecutive patients who presented to a rheumatology outpatient clinic with hand OA based on American College of Rheumatology criteria. They also scored radiographs for osteophytes or joint-space narrowing with the OARSI method and used the Verbruggen-Veys method to identify and exclude joints that were already eroded (E phase) or remodeled (R phase) at baseline (Arthritis Rheum. 2015 Sep 28. doi: 10.1002/art.39438). At baseline, 18 patients had ultrasonographic evidence of erosions in a total of 51 interphalangeal joints, the investigators said. At the 2.3-year follow-up, a total of 38 interphalangeal joints from 26 patients showed erosive development.
After accounting for age, gender, body mass index, and baseline cartilage and bone abnormalities, all ultrasonographic features of inflammation that were at least grade 1 at baseline and follow-up predicted erosive development. Persistent power Doppler signal was the strongest risk factor, yielding an odds ratio of 11.4 in the adjusted model (95% confidence interval, 2.7-49.1). Other significant risk factors included moderate to severe baseline synovial thickening (OR, 8.8; 95% CI, 2.4-32.3) and power Doppler signal (OR, 7.1; 95% CI, 1.9-26.9).
“The present study confirms that inflammatory US features found at baseline are associated with erosive development on the joint level in hand OA,” the investigators wrote. “These associations are already found after 2 years of follow-up, which is important for future prospective trials.”
The researchers reported having no funding sources or conflicts of interest.
Among adults with hand osteoarthritis, ultrasonographic evidence of persistent joint-level inflammation increased the odds of subsequent erosions by as much as 11 times, said authors of a 2-year prospective study.
“These observations implicate a role for inflammation in the pathogenesis of erosive osteoarthritis and might render new therapeutic options that can halt erosive development,” said Dr. Marion C. Kortekaas and her associates at Leiden (the Netherlands) University Medical Center. The findings appeared online in Arthritis & Rheumatology.
The pathogenesis of erosive hand OA remains poorly understood, despite its high clinical burden, the researchers noted. To assess potential risk factors for erosive development, they used standard ultrasonographic methods to examine the interphalangeal joints of 56 consecutive patients who presented to a rheumatology outpatient clinic with hand OA based on American College of Rheumatology criteria. They also scored radiographs for osteophytes or joint-space narrowing with the OARSI method and used the Verbruggen-Veys method to identify and exclude joints that were already eroded (E phase) or remodeled (R phase) at baseline (Arthritis Rheum. 2015 Sep 28. doi: 10.1002/art.39438). At baseline, 18 patients had ultrasonographic evidence of erosions in a total of 51 interphalangeal joints, the investigators said. At the 2.3-year follow-up, a total of 38 interphalangeal joints from 26 patients showed erosive development.
After accounting for age, gender, body mass index, and baseline cartilage and bone abnormalities, all ultrasonographic features of inflammation that were at least grade 1 at baseline and follow-up predicted erosive development. Persistent power Doppler signal was the strongest risk factor, yielding an odds ratio of 11.4 in the adjusted model (95% confidence interval, 2.7-49.1). Other significant risk factors included moderate to severe baseline synovial thickening (OR, 8.8; 95% CI, 2.4-32.3) and power Doppler signal (OR, 7.1; 95% CI, 1.9-26.9).
“The present study confirms that inflammatory US features found at baseline are associated with erosive development on the joint level in hand OA,” the investigators wrote. “These associations are already found after 2 years of follow-up, which is important for future prospective trials.”
The researchers reported having no funding sources or conflicts of interest.
FROM ARTHRITIS & RHEUMATOLOGY
Key clinical point: Ultrasonographic evidence of inflammation significantly predicted the development of erosions in hand osteoarthritis.
Major finding: All inflammatory ultrasonographic features that were at least grade 1 at baseline and follow-up significantly predicted erosive development.
Data source: Single-center, prospective, ultrasonographic and radiographic study of 56 patients who met ACR criteria for hand OA.
Disclosures: The investigators reported having no funding sources or conflicts of interest.
Hepatitis C drove steep rises in cirrhosis, HCC, and related deaths
Cirrhosis nearly doubled among Veterans Affairs patients between 2001 and 2013, while cirrhosis-related mortality rose by about 50% and deaths from hepatocellular carcinoma almost tripled, investigators reported in the November issue of Gastroenterology.
Hepatitis C virus infection was “the overwhelming driver of these trends, with smaller contributions from alcoholic liver disease, nonalcoholic fatty liver disease, and other liver diseases,” said Dr. Lauren Beste of the University of Washington, Seattle, and her associates. Based on their data, the prevalence of cirrhosis in the United States will peak in 2021, they said. “In contrast, the incidence of HCC continues to increase, confirming worrisome predictions of rapid growth put forward by work (Gastroenterology. 2010;138[2]:513-21) conducted” in the early 2000s.
New HCV infections have dropped sharply in the United States since about 1990, but cases of HCV-related cirrhosis and HCC continue to rise as chronically infected patients age and their liver disease progresses. Although the burden of cirrhosis and HCC due to HCV infection is expected to peak in about the year 2020, the population-level effects of nonalcoholic fatty liver disease, alcoholic liver disease, and hepatitis B virus infection remained unclear, the investigators said. Therefore, they retrospectively studied underlying etiologies among a national cohort of almost 130,000 Veterans Affairs patients with cirrhosis and more than 21,000 patients with HCC between 2001 and 2013 (Gastroenterology 2015. doi: 10.1053/j.gastro.2015.07.056).
In 2013, the VA cared for more than 5.7 million patients, including about 1% with cirrhosis and 0.13% with HCC. Between 2001 and 2013, the prevalence of cirrhosis almost doubled, rising from 664 to 1,058 cases for every 100,000 patients. Deaths among cirrhotic patients also increased by about half, rising from 83 to 126 for every 100,000 patient-years. These liver-related deaths were mainly caused by HCC, whose incidence rose about 2.5 times from 17 to 45 per 100,000 patient-years, Dr. Beste and her associates reported.
Notably, deaths due to liver cancer rose threefold – from 13 to 37 per 100,000 patient-years between 2001 and 2013, “driven overwhelmingly by HCV with much smaller contributions from NAFLD and alcoholic liver disease,” said the researchers. By 2013, almost half of cirrhosis cases and related deaths occurred among HCV-infected patients, as did 67% of HCC cases and related deaths, they noted.
About 60% of patients with cirrhosis and HCV infection also had a longstanding history of alcohol use, the researchers noted. Addressing both factors, as well as diabetes, obesity, and other drivers of nonalcoholic fatty liver disease, could help ease the national burden of liver disease and liver-related mortality among U.S. veterans and other groups, they added. “The increasing burden of cirrhosis and HCC highlights the need for greater efforts to address their causes at a population level,” Dr. Beste and her associates wrote. “Health care systems will need to accommodate rising numbers of patients with cirrhosis and HCC.”
The Department of Veterans Affairs and the Veterans Health Administration funded the study. The investigators declared no competing interests.
Despite recent advances in hepatitis C virus treatment, many infected patients have preexisting liver fibrosis that puts them at risk for cirrhosis and hepatocellular carcinoma. Meanwhile, risk factors for nonalcoholic fatty liver disease (NAFLD) are increasingly prevalent. In this study, the investigators sought to understand the contribution of liver disease etiology to trends in adverse liver outcomes (the prevalence, incidence, and mortality of cirrhosis and HCC). They identified all VA health care users from 2001 to 2013 with diagnoses of cirrhosis (n = 129,998) or HCC (n = 21,326) and their liver disease etiology, and compared outcomes by calendar year.
 |
Dr. Barry Schlansky |
Over the study period, marked increases in cirrhosis prevalence (59%), cirrhosis mortality (52%), HCC incidence (164%), and HCC mortality (185%) were observed in this national VA cohort. The increasing prevalence of cirrhosis was mainly driven by increasing contributions from HCV or NAFLD liver disease, but rises in mortality from cirrhosis and both incidence and mortality from HCC were almost entirely due to HCV. Based on these trends, the researchers forecasted that the prevalence of cirrhosis will plateau and begin to decline in 2021 (2020 in the HCV subgroup), but rates of HCC will continue to surge.
Although these results differ from two recent analyses of the national cancer surveillance registry (SEER) that found decelerations in HCC incidence and mortality in recent years, the current study included methodologic features (stratification by liver disease etiology and absence of age standardization) that likely facilitated more accurate estimates of HCC incidence and mortality. The generalizability of VA data to the general population is always debated (the former is nearly exclusively men with a higher prevalence of HCV infection and other liver disease risk factors, all of whom have access to medical care), yet the researchers rightly note that the time trends in cirrhosis and HCC outcomes (rather than absolute numbers) are still applicable to the non-VA population, particularly men. This study highlights the dramatic rise in cirrhosis and HCC, and associated deaths from these conditions, over the last decade. In addition to aggressive treatment of the underlying cause of liver disease, meaningful reductions in the burden of advanced liver disease will require a renewed focus on measures to improve adherence with maintenance care for cirrhotic patients, especially liver cancer screening.
Dr. Barry Schlansky is assistant professor, division of gastroenterology and hepatology, department of medicine, Oregon Health and Science University, Portland. He has no conflicts of interest.
Despite recent advances in hepatitis C virus treatment, many infected patients have preexisting liver fibrosis that puts them at risk for cirrhosis and hepatocellular carcinoma. Meanwhile, risk factors for nonalcoholic fatty liver disease (NAFLD) are increasingly prevalent. In this study, the investigators sought to understand the contribution of liver disease etiology to trends in adverse liver outcomes (the prevalence, incidence, and mortality of cirrhosis and HCC). They identified all VA health care users from 2001 to 2013 with diagnoses of cirrhosis (n = 129,998) or HCC (n = 21,326) and their liver disease etiology, and compared outcomes by calendar year.
|
Dr. Barry Schlansky |
Over the study period, marked increases in cirrhosis prevalence (59%), cirrhosis mortality (52%), HCC incidence (164%), and HCC mortality (185%) were observed in this national VA cohort. The increasing prevalence of cirrhosis was mainly driven by increasing contributions from HCV or NAFLD liver disease, but rises in mortality from cirrhosis and both incidence and mortality from HCC were almost entirely due to HCV. Based on these trends, the researchers forecasted that the prevalence of cirrhosis will plateau and begin to decline in 2021 (2020 in the HCV subgroup), but rates of HCC will continue to surge.
Although these results differ from two recent analyses of the national cancer surveillance registry (SEER) that found decelerations in HCC incidence and mortality in recent years, the current study included methodologic features (stratification by liver disease etiology and absence of age standardization) that likely facilitated more accurate estimates of HCC incidence and mortality. The generalizability of VA data to the general population is always debated (the former is nearly exclusively men with a higher prevalence of HCV infection and other liver disease risk factors, all of whom have access to medical care), yet the researchers rightly note that the time trends in cirrhosis and HCC outcomes (rather than absolute numbers) are still applicable to the non-VA population, particularly men. This study highlights the dramatic rise in cirrhosis and HCC, and associated deaths from these conditions, over the last decade. In addition to aggressive treatment of the underlying cause of liver disease, meaningful reductions in the burden of advanced liver disease will require a renewed focus on measures to improve adherence with maintenance care for cirrhotic patients, especially liver cancer screening.
Dr. Barry Schlansky is assistant professor, division of gastroenterology and hepatology, department of medicine, Oregon Health and Science University, Portland. He has no conflicts of interest.
Despite recent advances in hepatitis C virus treatment, many infected patients have preexisting liver fibrosis that puts them at risk for cirrhosis and hepatocellular carcinoma. Meanwhile, risk factors for nonalcoholic fatty liver disease (NAFLD) are increasingly prevalent. In this study, the investigators sought to understand the contribution of liver disease etiology to trends in adverse liver outcomes (the prevalence, incidence, and mortality of cirrhosis and HCC). They identified all VA health care users from 2001 to 2013 with diagnoses of cirrhosis (n = 129,998) or HCC (n = 21,326) and their liver disease etiology, and compared outcomes by calendar year.
|
Dr. Barry Schlansky |
Over the study period, marked increases in cirrhosis prevalence (59%), cirrhosis mortality (52%), HCC incidence (164%), and HCC mortality (185%) were observed in this national VA cohort. The increasing prevalence of cirrhosis was mainly driven by increasing contributions from HCV or NAFLD liver disease, but rises in mortality from cirrhosis and both incidence and mortality from HCC were almost entirely due to HCV. Based on these trends, the researchers forecasted that the prevalence of cirrhosis will plateau and begin to decline in 2021 (2020 in the HCV subgroup), but rates of HCC will continue to surge.
Although these results differ from two recent analyses of the national cancer surveillance registry (SEER) that found decelerations in HCC incidence and mortality in recent years, the current study included methodologic features (stratification by liver disease etiology and absence of age standardization) that likely facilitated more accurate estimates of HCC incidence and mortality. The generalizability of VA data to the general population is always debated (the former is nearly exclusively men with a higher prevalence of HCV infection and other liver disease risk factors, all of whom have access to medical care), yet the researchers rightly note that the time trends in cirrhosis and HCC outcomes (rather than absolute numbers) are still applicable to the non-VA population, particularly men. This study highlights the dramatic rise in cirrhosis and HCC, and associated deaths from these conditions, over the last decade. In addition to aggressive treatment of the underlying cause of liver disease, meaningful reductions in the burden of advanced liver disease will require a renewed focus on measures to improve adherence with maintenance care for cirrhotic patients, especially liver cancer screening.
Dr. Barry Schlansky is assistant professor, division of gastroenterology and hepatology, department of medicine, Oregon Health and Science University, Portland. He has no conflicts of interest.
Cirrhosis nearly doubled among Veterans Affairs patients between 2001 and 2013, while cirrhosis-related mortality rose by about 50% and deaths from hepatocellular carcinoma almost tripled, investigators reported in the November issue of Gastroenterology.
Hepatitis C virus infection was “the overwhelming driver of these trends, with smaller contributions from alcoholic liver disease, nonalcoholic fatty liver disease, and other liver diseases,” said Dr. Lauren Beste of the University of Washington, Seattle, and her associates. Based on their data, the prevalence of cirrhosis in the United States will peak in 2021, they said. “In contrast, the incidence of HCC continues to increase, confirming worrisome predictions of rapid growth put forward by work (Gastroenterology. 2010;138[2]:513-21) conducted” in the early 2000s.
New HCV infections have dropped sharply in the United States since about 1990, but cases of HCV-related cirrhosis and HCC continue to rise as chronically infected patients age and their liver disease progresses. Although the burden of cirrhosis and HCC due to HCV infection is expected to peak in about the year 2020, the population-level effects of nonalcoholic fatty liver disease, alcoholic liver disease, and hepatitis B virus infection remained unclear, the investigators said. Therefore, they retrospectively studied underlying etiologies among a national cohort of almost 130,000 Veterans Affairs patients with cirrhosis and more than 21,000 patients with HCC between 2001 and 2013 (Gastroenterology 2015. doi: 10.1053/j.gastro.2015.07.056).
In 2013, the VA cared for more than 5.7 million patients, including about 1% with cirrhosis and 0.13% with HCC. Between 2001 and 2013, the prevalence of cirrhosis almost doubled, rising from 664 to 1,058 cases for every 100,000 patients. Deaths among cirrhotic patients also increased by about half, rising from 83 to 126 for every 100,000 patient-years. These liver-related deaths were mainly caused by HCC, whose incidence rose about 2.5 times from 17 to 45 per 100,000 patient-years, Dr. Beste and her associates reported.
Notably, deaths due to liver cancer rose threefold – from 13 to 37 per 100,000 patient-years between 2001 and 2013, “driven overwhelmingly by HCV with much smaller contributions from NAFLD and alcoholic liver disease,” said the researchers. By 2013, almost half of cirrhosis cases and related deaths occurred among HCV-infected patients, as did 67% of HCC cases and related deaths, they noted.
About 60% of patients with cirrhosis and HCV infection also had a longstanding history of alcohol use, the researchers noted. Addressing both factors, as well as diabetes, obesity, and other drivers of nonalcoholic fatty liver disease, could help ease the national burden of liver disease and liver-related mortality among U.S. veterans and other groups, they added. “The increasing burden of cirrhosis and HCC highlights the need for greater efforts to address their causes at a population level,” Dr. Beste and her associates wrote. “Health care systems will need to accommodate rising numbers of patients with cirrhosis and HCC.”
The Department of Veterans Affairs and the Veterans Health Administration funded the study. The investigators declared no competing interests.
Cirrhosis nearly doubled among Veterans Affairs patients between 2001 and 2013, while cirrhosis-related mortality rose by about 50% and deaths from hepatocellular carcinoma almost tripled, investigators reported in the November issue of Gastroenterology.
Hepatitis C virus infection was “the overwhelming driver of these trends, with smaller contributions from alcoholic liver disease, nonalcoholic fatty liver disease, and other liver diseases,” said Dr. Lauren Beste of the University of Washington, Seattle, and her associates. Based on their data, the prevalence of cirrhosis in the United States will peak in 2021, they said. “In contrast, the incidence of HCC continues to increase, confirming worrisome predictions of rapid growth put forward by work (Gastroenterology. 2010;138[2]:513-21) conducted” in the early 2000s.
New HCV infections have dropped sharply in the United States since about 1990, but cases of HCV-related cirrhosis and HCC continue to rise as chronically infected patients age and their liver disease progresses. Although the burden of cirrhosis and HCC due to HCV infection is expected to peak in about the year 2020, the population-level effects of nonalcoholic fatty liver disease, alcoholic liver disease, and hepatitis B virus infection remained unclear, the investigators said. Therefore, they retrospectively studied underlying etiologies among a national cohort of almost 130,000 Veterans Affairs patients with cirrhosis and more than 21,000 patients with HCC between 2001 and 2013 (Gastroenterology 2015. doi: 10.1053/j.gastro.2015.07.056).
In 2013, the VA cared for more than 5.7 million patients, including about 1% with cirrhosis and 0.13% with HCC. Between 2001 and 2013, the prevalence of cirrhosis almost doubled, rising from 664 to 1,058 cases for every 100,000 patients. Deaths among cirrhotic patients also increased by about half, rising from 83 to 126 for every 100,000 patient-years. These liver-related deaths were mainly caused by HCC, whose incidence rose about 2.5 times from 17 to 45 per 100,000 patient-years, Dr. Beste and her associates reported.
Notably, deaths due to liver cancer rose threefold – from 13 to 37 per 100,000 patient-years between 2001 and 2013, “driven overwhelmingly by HCV with much smaller contributions from NAFLD and alcoholic liver disease,” said the researchers. By 2013, almost half of cirrhosis cases and related deaths occurred among HCV-infected patients, as did 67% of HCC cases and related deaths, they noted.
About 60% of patients with cirrhosis and HCV infection also had a longstanding history of alcohol use, the researchers noted. Addressing both factors, as well as diabetes, obesity, and other drivers of nonalcoholic fatty liver disease, could help ease the national burden of liver disease and liver-related mortality among U.S. veterans and other groups, they added. “The increasing burden of cirrhosis and HCC highlights the need for greater efforts to address their causes at a population level,” Dr. Beste and her associates wrote. “Health care systems will need to accommodate rising numbers of patients with cirrhosis and HCC.”
The Department of Veterans Affairs and the Veterans Health Administration funded the study. The investigators declared no competing interests.
FROM GASTROENTEROLOGY
Key clinical point: Cirrhosis, hepatocellular carcinoma, and liver-related mortality rose substantially among Veterans Affairs patients over the past 12 years, mainly driven by HCV infection.
Major finding: The prevalence of cirrhosis nearly doubled between 2001 and 2013, while cirrhosis-related deaths rose by about 50% and the incidence of hepatocellular carcinoma almost tripled.
Data source: A retrospective cohort study of 129,998 Veterans Affairs patients with cirrhosis and 21,326 VA patients with HCC between 2001 and 2013.
Disclosures: The Department of Veterans Affairs and the Veterans Health Administration funded the study. The investigators declared no competing interests.
CRE infections linked to catheters, hospitalization
About 3 in every 100,000 individuals developed a carbapenem-resistant Enterobacteriaceae infection in 2012-2013, most of whom had previously been hospitalized or had an indwelling device, researchers reported Oct. 5 in JAMA.
The relatively low incidence of these serious infections compared with other resistant organisms “highlights that CRE are emerging and suggests that control interventions implemented now could have a substantial effect,” wrote Dr. Alice Guh of the Centers for Disease Control and Prevention in Atlanta, and her associates. But the high rates of recent hospitalizations and discharges to nursing homes underscore the need for local control efforts, the researchers added.
Carbapenem-resistant Enterobacteriaceae have become a global public health problem since emerging in 2001. In 2012, the Emerging Infections Program of the CDC began active CRE surveillance in metropolitan areas of Colorado, Georgia, Maryland, Minnesota, New Mexico, New York, and Oregon. The researchers studied reported cases of carbapenem-nonsusceptible (excluding ertapenem) and extended-spectrum cephalosporin-resistant Escherichia coli, Enterobacter aerogenes, Enterobacter cloacae complex, Klebsiella pneumoniae, and Klebsiella oxytoca infections cultured from urine or sterile sites (JAMA. 2015 Oct 5, doi:10.1001/jama.2015.12480.).
In all, 599 CRE infections occurred in 481 individuals, including 87% in urine and 11% in sterile sites, the investigators reported. Patients averaged 66 years of age and 59% were female. Overall CRE incidence was 2.93 cases per 100,000 population – substantially lower than rates of methicillin-resistant Staphylococcus aureus (about 25 per 100,000 population), invasive candidiasis (13-26 per 100,000 population), and Clostridium difficile (147 per 100,000 population).
Most of the CRE infections were among individuals who has been hospitalized in the past year (75%), who had an indwelling device (73%), or who had been discharged to a long-term care setting (56%). The indwelling devices with the highest rates of infection were urinary catheters, central venous catheters, and gastrostomy or jejunostomy tubes.
The case-fatality rate was 9% overall, but exceeded 27% when CRE was isolated from sterile sites, according to the study.
The standardized incidence ratio was significantly higher than predicted for sites in Georgia, Maryland, and New York, but significantly lower than expected for sites in Colorado, New Mexico, and Oregon. Such heterogeneity “further highlights the need to understand the local epidemiology to tailor prevention efforts in individual regions of the United States,” the researchers wrote.
And only 48% of CRE strains produced a carbapenemase, which carries antimicrobial resistance genes on mobile plasmids that can move between organisms, allowing for a potentially wider and more rapid spread. This suggests “the potential need for a tiered response to these organisms as well as the need for more rapid and readily available laboratory tests to differentiate these strains,” the researchers added.
The study was funded by the CDC Emerging Infections Program and the National Center for Emerging and Zoonotic Infectious Diseases. The researchers reported having no financial disclosures.
Carbapenem-resistant Enterobacteriaceae (CRE) may be the most concerning contemporary antibiotic resistance threat. Enterobacteriaceae comprise a large group of bacteria, including Escherichia coli and Klebsiella pneumoniae, and are common causes of healthcare–associated and community-acquired infections. Carbapenems, such as imipenem, meropenem, ertapenem, and doripenem are among the broadest-spectrum and most potent beta-lactam antibiotics.
The study by Guh et al represents an important step forward for CRE control in the United States. Expansion of surveillance to more geographic regions, including rural settings and metropolitan areas known to have high prevalence of CRE, would provide a more complete picture of the U.S. burden. Molecular characterization of isolates would also inform prevention efforts.
Whether the resources needed for this work will be made available is unclear. The 2014 presidential executive order on combating antibiotic resistance contained actions to strengthen national surveillance efforts for resistant bacteria, including the establishment of regional public health laboratories with advanced molecular diagnostic capabilities. These actions were not approved for funding in fiscal year 2015; however, an appropriation to support the initiative currently awaits congressional approval of the fiscal year 2016 federal budget. In the meantime, physicians, infection control practitioners, and public health workers will continue to rely on the Multi-site Gram-negative Surveillance Initiative and other surveillance networks to measure the extent of CRE and estimate the effects of prevention efforts.
Dr. Mary K. Hayden is at Rush University Medical Center, Chicago. She reported having received grants from the Centers for Disease Control and Prevention, which funded this study. These comments were adapted from her accompanying editorial (JAMA 2015 Oct. 5, doi: 10.1001/jama.2015.11629.).
Carbapenem-resistant Enterobacteriaceae (CRE) may be the most concerning contemporary antibiotic resistance threat. Enterobacteriaceae comprise a large group of bacteria, including Escherichia coli and Klebsiella pneumoniae, and are common causes of healthcare–associated and community-acquired infections. Carbapenems, such as imipenem, meropenem, ertapenem, and doripenem are among the broadest-spectrum and most potent beta-lactam antibiotics.
The study by Guh et al represents an important step forward for CRE control in the United States. Expansion of surveillance to more geographic regions, including rural settings and metropolitan areas known to have high prevalence of CRE, would provide a more complete picture of the U.S. burden. Molecular characterization of isolates would also inform prevention efforts.
Whether the resources needed for this work will be made available is unclear. The 2014 presidential executive order on combating antibiotic resistance contained actions to strengthen national surveillance efforts for resistant bacteria, including the establishment of regional public health laboratories with advanced molecular diagnostic capabilities. These actions were not approved for funding in fiscal year 2015; however, an appropriation to support the initiative currently awaits congressional approval of the fiscal year 2016 federal budget. In the meantime, physicians, infection control practitioners, and public health workers will continue to rely on the Multi-site Gram-negative Surveillance Initiative and other surveillance networks to measure the extent of CRE and estimate the effects of prevention efforts.
Dr. Mary K. Hayden is at Rush University Medical Center, Chicago. She reported having received grants from the Centers for Disease Control and Prevention, which funded this study. These comments were adapted from her accompanying editorial (JAMA 2015 Oct. 5, doi: 10.1001/jama.2015.11629.).
Carbapenem-resistant Enterobacteriaceae (CRE) may be the most concerning contemporary antibiotic resistance threat. Enterobacteriaceae comprise a large group of bacteria, including Escherichia coli and Klebsiella pneumoniae, and are common causes of healthcare–associated and community-acquired infections. Carbapenems, such as imipenem, meropenem, ertapenem, and doripenem are among the broadest-spectrum and most potent beta-lactam antibiotics.
The study by Guh et al represents an important step forward for CRE control in the United States. Expansion of surveillance to more geographic regions, including rural settings and metropolitan areas known to have high prevalence of CRE, would provide a more complete picture of the U.S. burden. Molecular characterization of isolates would also inform prevention efforts.
Whether the resources needed for this work will be made available is unclear. The 2014 presidential executive order on combating antibiotic resistance contained actions to strengthen national surveillance efforts for resistant bacteria, including the establishment of regional public health laboratories with advanced molecular diagnostic capabilities. These actions were not approved for funding in fiscal year 2015; however, an appropriation to support the initiative currently awaits congressional approval of the fiscal year 2016 federal budget. In the meantime, physicians, infection control practitioners, and public health workers will continue to rely on the Multi-site Gram-negative Surveillance Initiative and other surveillance networks to measure the extent of CRE and estimate the effects of prevention efforts.
Dr. Mary K. Hayden is at Rush University Medical Center, Chicago. She reported having received grants from the Centers for Disease Control and Prevention, which funded this study. These comments were adapted from her accompanying editorial (JAMA 2015 Oct. 5, doi: 10.1001/jama.2015.11629.).
About 3 in every 100,000 individuals developed a carbapenem-resistant Enterobacteriaceae infection in 2012-2013, most of whom had previously been hospitalized or had an indwelling device, researchers reported Oct. 5 in JAMA.
The relatively low incidence of these serious infections compared with other resistant organisms “highlights that CRE are emerging and suggests that control interventions implemented now could have a substantial effect,” wrote Dr. Alice Guh of the Centers for Disease Control and Prevention in Atlanta, and her associates. But the high rates of recent hospitalizations and discharges to nursing homes underscore the need for local control efforts, the researchers added.
Carbapenem-resistant Enterobacteriaceae have become a global public health problem since emerging in 2001. In 2012, the Emerging Infections Program of the CDC began active CRE surveillance in metropolitan areas of Colorado, Georgia, Maryland, Minnesota, New Mexico, New York, and Oregon. The researchers studied reported cases of carbapenem-nonsusceptible (excluding ertapenem) and extended-spectrum cephalosporin-resistant Escherichia coli, Enterobacter aerogenes, Enterobacter cloacae complex, Klebsiella pneumoniae, and Klebsiella oxytoca infections cultured from urine or sterile sites (JAMA. 2015 Oct 5, doi:10.1001/jama.2015.12480.).
In all, 599 CRE infections occurred in 481 individuals, including 87% in urine and 11% in sterile sites, the investigators reported. Patients averaged 66 years of age and 59% were female. Overall CRE incidence was 2.93 cases per 100,000 population – substantially lower than rates of methicillin-resistant Staphylococcus aureus (about 25 per 100,000 population), invasive candidiasis (13-26 per 100,000 population), and Clostridium difficile (147 per 100,000 population).
Most of the CRE infections were among individuals who has been hospitalized in the past year (75%), who had an indwelling device (73%), or who had been discharged to a long-term care setting (56%). The indwelling devices with the highest rates of infection were urinary catheters, central venous catheters, and gastrostomy or jejunostomy tubes.
The case-fatality rate was 9% overall, but exceeded 27% when CRE was isolated from sterile sites, according to the study.
The standardized incidence ratio was significantly higher than predicted for sites in Georgia, Maryland, and New York, but significantly lower than expected for sites in Colorado, New Mexico, and Oregon. Such heterogeneity “further highlights the need to understand the local epidemiology to tailor prevention efforts in individual regions of the United States,” the researchers wrote.
And only 48% of CRE strains produced a carbapenemase, which carries antimicrobial resistance genes on mobile plasmids that can move between organisms, allowing for a potentially wider and more rapid spread. This suggests “the potential need for a tiered response to these organisms as well as the need for more rapid and readily available laboratory tests to differentiate these strains,” the researchers added.
The study was funded by the CDC Emerging Infections Program and the National Center for Emerging and Zoonotic Infectious Diseases. The researchers reported having no financial disclosures.
About 3 in every 100,000 individuals developed a carbapenem-resistant Enterobacteriaceae infection in 2012-2013, most of whom had previously been hospitalized or had an indwelling device, researchers reported Oct. 5 in JAMA.
The relatively low incidence of these serious infections compared with other resistant organisms “highlights that CRE are emerging and suggests that control interventions implemented now could have a substantial effect,” wrote Dr. Alice Guh of the Centers for Disease Control and Prevention in Atlanta, and her associates. But the high rates of recent hospitalizations and discharges to nursing homes underscore the need for local control efforts, the researchers added.
Carbapenem-resistant Enterobacteriaceae have become a global public health problem since emerging in 2001. In 2012, the Emerging Infections Program of the CDC began active CRE surveillance in metropolitan areas of Colorado, Georgia, Maryland, Minnesota, New Mexico, New York, and Oregon. The researchers studied reported cases of carbapenem-nonsusceptible (excluding ertapenem) and extended-spectrum cephalosporin-resistant Escherichia coli, Enterobacter aerogenes, Enterobacter cloacae complex, Klebsiella pneumoniae, and Klebsiella oxytoca infections cultured from urine or sterile sites (JAMA. 2015 Oct 5, doi:10.1001/jama.2015.12480.).
In all, 599 CRE infections occurred in 481 individuals, including 87% in urine and 11% in sterile sites, the investigators reported. Patients averaged 66 years of age and 59% were female. Overall CRE incidence was 2.93 cases per 100,000 population – substantially lower than rates of methicillin-resistant Staphylococcus aureus (about 25 per 100,000 population), invasive candidiasis (13-26 per 100,000 population), and Clostridium difficile (147 per 100,000 population).
Most of the CRE infections were among individuals who has been hospitalized in the past year (75%), who had an indwelling device (73%), or who had been discharged to a long-term care setting (56%). The indwelling devices with the highest rates of infection were urinary catheters, central venous catheters, and gastrostomy or jejunostomy tubes.
The case-fatality rate was 9% overall, but exceeded 27% when CRE was isolated from sterile sites, according to the study.
The standardized incidence ratio was significantly higher than predicted for sites in Georgia, Maryland, and New York, but significantly lower than expected for sites in Colorado, New Mexico, and Oregon. Such heterogeneity “further highlights the need to understand the local epidemiology to tailor prevention efforts in individual regions of the United States,” the researchers wrote.
And only 48% of CRE strains produced a carbapenemase, which carries antimicrobial resistance genes on mobile plasmids that can move between organisms, allowing for a potentially wider and more rapid spread. This suggests “the potential need for a tiered response to these organisms as well as the need for more rapid and readily available laboratory tests to differentiate these strains,” the researchers added.
The study was funded by the CDC Emerging Infections Program and the National Center for Emerging and Zoonotic Infectious Diseases. The researchers reported having no financial disclosures.
FROM JAMA
Key clinical point: Carbapenem-resistant Enterobacteriaceae infections developed in about 3 in every 100,000 individuals, most often in association with recent hospitalization or indwelling devices.
Major finding: The incidence of CRE was 2.93 per 100,000 population, 75% of patients had been hospitalized in the past year, and 73% had an indwelling device.
Data source: Analysis of active surveillance data for 2012-2013 from metropolitan areas in seven states reported through the CDC Emerging Infections Program.
Disclosures: The study was funded by the CDC Emerging Infections Program and the National Center for Emerging and Zoonotic Infectious Diseases. The investigators reported having no financial disclosures.
Flu shot linked to lower risk of hospitalization for influenza pneumonia
Patients hospitalized with laboratory-confirmed, influenza-associated pneumonia had a 57% lower odds of having received the influenza vaccine than controls whose pneumonia was due to other causes, investigators reported Oct. 5 in JAMA.
The findings could be used in future studies to estimate the number of hospitalizations prevented by influenza vaccination, according to Dr. Carlos Grijalva of Vanderbilt University, Nashville, Tenn., and his associates.
Seasonal influenza causes about 226,000 hospitalizations and 3,000 to 49,000 deaths every year in the United States. Observational studies show that influenza vaccination helps prevent hospitalizations for acute respiratory illness, but whether it also cuts the odds of hospitalization for community-acquired pneumonia is unknown, the investigators wrote.
To explore this question, they conducted an observational, multicenter study of 2,767 patients who had been hospitalized with community-acquired pneumonia over 3 consecutive influenza seasons at four sites in the United States. Patients were at least 6 months old, were not severely immunosuppressed, and had not been recently hospitalized or resided in a long-term care facility (JAMA. 2015 Oct 5, doi:10.1001/jama.2015.12160.).
In all, 162 (6%) patients had laboratory-confirmed influenza, including 17% who had received the influenza vaccine, the researchers wrote. In contrast, 29% of controls had received the vaccine, for an adjusted odds ratio of 0.43 (95% confidence interval, 0.28 to 0.68) after controlling for demographic characteristics, comorbidities, influenza season, study site, and time of disease onset. The estimated vaccine effectiveness was 57%.
The test-positive case, test-negative control design is widely used to study vaccine effectiveness and is better than comparing hospitalized cases with population controls, because it “implicitly” accounts for the risk of hospitalization, the researchers wrote. But “despite enrollment over 3 consecutive seasons, a relatively small number of influenza-associated pneumonia cases met eligibility criteria, resulting in limited precision for some subgroup analyses,” they added. “Thus, the association between influenza vaccines and pneumonia among older adults remains controversial, and additional studies in this group are needed.”
Dr. Grijalva reported having served as a consultant to Pfizer. Several coauthors reported having received grant and other support from the National Institutes of Health, the Agency for Healthcare Research and Quality, Medscape, MedImmune, Roche, Abbvie, and a number of pharmaceutical companies.
Patients hospitalized with laboratory-confirmed, influenza-associated pneumonia had a 57% lower odds of having received the influenza vaccine than controls whose pneumonia was due to other causes, investigators reported Oct. 5 in JAMA.
The findings could be used in future studies to estimate the number of hospitalizations prevented by influenza vaccination, according to Dr. Carlos Grijalva of Vanderbilt University, Nashville, Tenn., and his associates.
Seasonal influenza causes about 226,000 hospitalizations and 3,000 to 49,000 deaths every year in the United States. Observational studies show that influenza vaccination helps prevent hospitalizations for acute respiratory illness, but whether it also cuts the odds of hospitalization for community-acquired pneumonia is unknown, the investigators wrote.
To explore this question, they conducted an observational, multicenter study of 2,767 patients who had been hospitalized with community-acquired pneumonia over 3 consecutive influenza seasons at four sites in the United States. Patients were at least 6 months old, were not severely immunosuppressed, and had not been recently hospitalized or resided in a long-term care facility (JAMA. 2015 Oct 5, doi:10.1001/jama.2015.12160.).
In all, 162 (6%) patients had laboratory-confirmed influenza, including 17% who had received the influenza vaccine, the researchers wrote. In contrast, 29% of controls had received the vaccine, for an adjusted odds ratio of 0.43 (95% confidence interval, 0.28 to 0.68) after controlling for demographic characteristics, comorbidities, influenza season, study site, and time of disease onset. The estimated vaccine effectiveness was 57%.
The test-positive case, test-negative control design is widely used to study vaccine effectiveness and is better than comparing hospitalized cases with population controls, because it “implicitly” accounts for the risk of hospitalization, the researchers wrote. But “despite enrollment over 3 consecutive seasons, a relatively small number of influenza-associated pneumonia cases met eligibility criteria, resulting in limited precision for some subgroup analyses,” they added. “Thus, the association between influenza vaccines and pneumonia among older adults remains controversial, and additional studies in this group are needed.”
Dr. Grijalva reported having served as a consultant to Pfizer. Several coauthors reported having received grant and other support from the National Institutes of Health, the Agency for Healthcare Research and Quality, Medscape, MedImmune, Roche, Abbvie, and a number of pharmaceutical companies.
Patients hospitalized with laboratory-confirmed, influenza-associated pneumonia had a 57% lower odds of having received the influenza vaccine than controls whose pneumonia was due to other causes, investigators reported Oct. 5 in JAMA.
The findings could be used in future studies to estimate the number of hospitalizations prevented by influenza vaccination, according to Dr. Carlos Grijalva of Vanderbilt University, Nashville, Tenn., and his associates.
Seasonal influenza causes about 226,000 hospitalizations and 3,000 to 49,000 deaths every year in the United States. Observational studies show that influenza vaccination helps prevent hospitalizations for acute respiratory illness, but whether it also cuts the odds of hospitalization for community-acquired pneumonia is unknown, the investigators wrote.
To explore this question, they conducted an observational, multicenter study of 2,767 patients who had been hospitalized with community-acquired pneumonia over 3 consecutive influenza seasons at four sites in the United States. Patients were at least 6 months old, were not severely immunosuppressed, and had not been recently hospitalized or resided in a long-term care facility (JAMA. 2015 Oct 5, doi:10.1001/jama.2015.12160.).
In all, 162 (6%) patients had laboratory-confirmed influenza, including 17% who had received the influenza vaccine, the researchers wrote. In contrast, 29% of controls had received the vaccine, for an adjusted odds ratio of 0.43 (95% confidence interval, 0.28 to 0.68) after controlling for demographic characteristics, comorbidities, influenza season, study site, and time of disease onset. The estimated vaccine effectiveness was 57%.
The test-positive case, test-negative control design is widely used to study vaccine effectiveness and is better than comparing hospitalized cases with population controls, because it “implicitly” accounts for the risk of hospitalization, the researchers wrote. But “despite enrollment over 3 consecutive seasons, a relatively small number of influenza-associated pneumonia cases met eligibility criteria, resulting in limited precision for some subgroup analyses,” they added. “Thus, the association between influenza vaccines and pneumonia among older adults remains controversial, and additional studies in this group are needed.”
Dr. Grijalva reported having served as a consultant to Pfizer. Several coauthors reported having received grant and other support from the National Institutes of Health, the Agency for Healthcare Research and Quality, Medscape, MedImmune, Roche, Abbvie, and a number of pharmaceutical companies.
FROM JAMA
Key clinical point: Hospitalized patients with laboratory-confirmed, influenza-associated pneumonia were less likely to have been vaccinated against influenza than hospitalized controls with non-influenza pneumonia.
Major finding: Influenza-associated pneumonia patients had a 57% lower odds of having been vaccinated against influenza than controls (adjusted odds ratio, 0.43).
Data source: An observational, multicenter study of 2,767 hospitalizations for community-acquired pneumonia at four sites in the United States.
Disclosures: The Centers for Disease Control and Prevention funded the study. Dr. Grijalva reported having served as a consultant to Pfizer. Several coauthors reported having received grant and other support from the National Institutes of Health, the Agency for Healthcare Research and Quality, Medscape, MedImmune, Roche, Abbvie, and a number of pharmaceutical companies.
Narrow-band colonoscopy faster, as sensitive as white light in ulcerative colitis
Among patients with ulcerative colitis (UC), narrow-band imaging colonoscopy with targeted and segmental biopsy specimens was faster, needed fewer specimens, and was as sensitive for detecting intraepithelial neoplasias as white light colonoscopy with targeted and stepwise sampling, researchers reported.
“Our study shows the high yield of stepwise random biopsy specimens in long-standing colitis,” Dr. Ludger Leifeld of the department of internal medicine at Evangelisches Krankenhaus Kalk in Cologne, Germany, and his associates wrote in the October issue of Clinical Gastroenterology and Hepatology. “The highest sensitivity should be reached by combining the white light and narrow-band imaging techniques by switching between the modes.”
Ulcerative colitis increases colorectal cancer risk, and detecting lesions early can be lifesaving. But the best technique for colonoscopy in UC remains controversial, the investigators noted. Therefore, they prospectively studied 159 adults with left-sided UC diagnosed at least 15 years earlier who were in clinical remission and had not undergone partial colectomy. Each patient underwent both narrow-band imaging and white light colonoscopy separated by 3 weeks to 3 months. In addition to targeted sampling, white-light colonoscopists took four predefined biopsy specimens every 10 cm, as well as two biopsy specimens in each of the five segments of the colon. Narrow-band imaging procedures only involved taking targeted and segmental biopsy specimens (Clin Gastro Hepatol. doi: 10.1016/j.cgh.2015.04.172).
Overall, colonoscopy detected dysplastic lesions in more than 22% of patients, the researchers reported. The narrow-band method identified similar numbers of intraepithelial cancers as white light, but required an average of only 11.9 specimens per patient – less than one-third as many as white light (38.6; P less than .001), the investigators said. Furthermore, withdrawal times averaged only 13 minutes for narrow-band imaging, compared with 23 minutes for white light colonoscopy (P less than .001). The two techniques had similar miss rates, according to the researchers.
Notably, 37% of intraepithelial neoplasias that were detected by white light colonoscopy came from stepwise random biopsy specimens, said the investigators. “The idea to take random biopsy specimens is ignored by many endoscopists, which limits the sensitivity of those colonoscopies,” they emphasized. “The sensitivity of stepwise random biopsy specimens could be increased further by adding 10 more segmental random biopsy specimens, which uncovered an additional 13% of lesions,” they added. Fourteen of these 15 lesions were non–adenomalike, showing the importance of random biopsy specimens, especially for detecting nonadenoma lesions, they said.
“When the white light technique is used, stepwise biopsy specimens are indispensable,” the investigators concluded. For narrow-band imaging technology, “combining targeted biopsy specimens … with 10 segmental biopsy specimens is an equipotent alternative to targeted biopsy specimens using white light in addition to four biopsy specimens every 10 cm. However, [the narrow-band] approach significantly saves time and numbers of biopsy specimens, which should have positive effects on feasibility, costs, and endoscopist compliance.”
The study was funded by Deutsche Morbus Crohn/Colitis Ulcerosa Vereinigung, the Working Group for Endoscopic Research of the DGVS, and the Kurscheid Foundation, and Olympus Medical. The authors reported having no conflicts of interest.
Among patients with ulcerative colitis (UC), narrow-band imaging colonoscopy with targeted and segmental biopsy specimens was faster, needed fewer specimens, and was as sensitive for detecting intraepithelial neoplasias as white light colonoscopy with targeted and stepwise sampling, researchers reported.
“Our study shows the high yield of stepwise random biopsy specimens in long-standing colitis,” Dr. Ludger Leifeld of the department of internal medicine at Evangelisches Krankenhaus Kalk in Cologne, Germany, and his associates wrote in the October issue of Clinical Gastroenterology and Hepatology. “The highest sensitivity should be reached by combining the white light and narrow-band imaging techniques by switching between the modes.”
Ulcerative colitis increases colorectal cancer risk, and detecting lesions early can be lifesaving. But the best technique for colonoscopy in UC remains controversial, the investigators noted. Therefore, they prospectively studied 159 adults with left-sided UC diagnosed at least 15 years earlier who were in clinical remission and had not undergone partial colectomy. Each patient underwent both narrow-band imaging and white light colonoscopy separated by 3 weeks to 3 months. In addition to targeted sampling, white-light colonoscopists took four predefined biopsy specimens every 10 cm, as well as two biopsy specimens in each of the five segments of the colon. Narrow-band imaging procedures only involved taking targeted and segmental biopsy specimens (Clin Gastro Hepatol. doi: 10.1016/j.cgh.2015.04.172).
Overall, colonoscopy detected dysplastic lesions in more than 22% of patients, the researchers reported. The narrow-band method identified similar numbers of intraepithelial cancers as white light, but required an average of only 11.9 specimens per patient – less than one-third as many as white light (38.6; P less than .001), the investigators said. Furthermore, withdrawal times averaged only 13 minutes for narrow-band imaging, compared with 23 minutes for white light colonoscopy (P less than .001). The two techniques had similar miss rates, according to the researchers.
Notably, 37% of intraepithelial neoplasias that were detected by white light colonoscopy came from stepwise random biopsy specimens, said the investigators. “The idea to take random biopsy specimens is ignored by many endoscopists, which limits the sensitivity of those colonoscopies,” they emphasized. “The sensitivity of stepwise random biopsy specimens could be increased further by adding 10 more segmental random biopsy specimens, which uncovered an additional 13% of lesions,” they added. Fourteen of these 15 lesions were non–adenomalike, showing the importance of random biopsy specimens, especially for detecting nonadenoma lesions, they said.
“When the white light technique is used, stepwise biopsy specimens are indispensable,” the investigators concluded. For narrow-band imaging technology, “combining targeted biopsy specimens … with 10 segmental biopsy specimens is an equipotent alternative to targeted biopsy specimens using white light in addition to four biopsy specimens every 10 cm. However, [the narrow-band] approach significantly saves time and numbers of biopsy specimens, which should have positive effects on feasibility, costs, and endoscopist compliance.”
The study was funded by Deutsche Morbus Crohn/Colitis Ulcerosa Vereinigung, the Working Group for Endoscopic Research of the DGVS, and the Kurscheid Foundation, and Olympus Medical. The authors reported having no conflicts of interest.
Among patients with ulcerative colitis (UC), narrow-band imaging colonoscopy with targeted and segmental biopsy specimens was faster, needed fewer specimens, and was as sensitive for detecting intraepithelial neoplasias as white light colonoscopy with targeted and stepwise sampling, researchers reported.
“Our study shows the high yield of stepwise random biopsy specimens in long-standing colitis,” Dr. Ludger Leifeld of the department of internal medicine at Evangelisches Krankenhaus Kalk in Cologne, Germany, and his associates wrote in the October issue of Clinical Gastroenterology and Hepatology. “The highest sensitivity should be reached by combining the white light and narrow-band imaging techniques by switching between the modes.”
Ulcerative colitis increases colorectal cancer risk, and detecting lesions early can be lifesaving. But the best technique for colonoscopy in UC remains controversial, the investigators noted. Therefore, they prospectively studied 159 adults with left-sided UC diagnosed at least 15 years earlier who were in clinical remission and had not undergone partial colectomy. Each patient underwent both narrow-band imaging and white light colonoscopy separated by 3 weeks to 3 months. In addition to targeted sampling, white-light colonoscopists took four predefined biopsy specimens every 10 cm, as well as two biopsy specimens in each of the five segments of the colon. Narrow-band imaging procedures only involved taking targeted and segmental biopsy specimens (Clin Gastro Hepatol. doi: 10.1016/j.cgh.2015.04.172).
Overall, colonoscopy detected dysplastic lesions in more than 22% of patients, the researchers reported. The narrow-band method identified similar numbers of intraepithelial cancers as white light, but required an average of only 11.9 specimens per patient – less than one-third as many as white light (38.6; P less than .001), the investigators said. Furthermore, withdrawal times averaged only 13 minutes for narrow-band imaging, compared with 23 minutes for white light colonoscopy (P less than .001). The two techniques had similar miss rates, according to the researchers.
Notably, 37% of intraepithelial neoplasias that were detected by white light colonoscopy came from stepwise random biopsy specimens, said the investigators. “The idea to take random biopsy specimens is ignored by many endoscopists, which limits the sensitivity of those colonoscopies,” they emphasized. “The sensitivity of stepwise random biopsy specimens could be increased further by adding 10 more segmental random biopsy specimens, which uncovered an additional 13% of lesions,” they added. Fourteen of these 15 lesions were non–adenomalike, showing the importance of random biopsy specimens, especially for detecting nonadenoma lesions, they said.
“When the white light technique is used, stepwise biopsy specimens are indispensable,” the investigators concluded. For narrow-band imaging technology, “combining targeted biopsy specimens … with 10 segmental biopsy specimens is an equipotent alternative to targeted biopsy specimens using white light in addition to four biopsy specimens every 10 cm. However, [the narrow-band] approach significantly saves time and numbers of biopsy specimens, which should have positive effects on feasibility, costs, and endoscopist compliance.”
The study was funded by Deutsche Morbus Crohn/Colitis Ulcerosa Vereinigung, the Working Group for Endoscopic Research of the DGVS, and the Kurscheid Foundation, and Olympus Medical. The authors reported having no conflicts of interest.
FROM CLINICAL GASTROENTEROLOGY AND HEPATOLOGY
Key clinical point: The narrow-band method identified similar numbers of intraepithelial cancers in ulcerative colitis patients as white light, but required less than one-third as many samples as white light and was faster.
Major finding: In patients with ulcerative colitis, narrow-band imaging colonoscopy with targeted and segmental biopsy specimens was faster, needed fewer specimens, and was as sensitive for detecting intraepithelial neoplasias as white light colonoscopy with targeted and stepwise sampling.
Data source: Prospective multicenter study of 159 patients with long-standing ulcerative colitis.
Disclosures: The study was funded by Deutsche Morbus Crohn/Colitis Ulcerosa Vereinigung, the Working Group for Endoscopic Research of the DGVS, and the Kurscheid Foundation, and Olympus Medical. The authors reported having no conflicts of interest.
Fukuoka, Sendai guidelines identified advanced pancreatic neoplasias
Both the Sendai and Fukuoka guidelines correctly identified all patients whose cystic pancreatic lesions were advanced neoplasias, but the “high-risk” criteria for both guidelines missed some high-grade dysplasias, researchers reported in the October issue of Clinical Gastroenterology and Hepatology.
“The updated Fukuoka guidelines are not superior to the Sendai guidelines in identifying neoplasias,” said Dr. Pavlos Kaimakliotis and his associates at the University of Pennsylvania in Philadelphia. The single-center retrospective study showed that both guidelines can help triage patients with suspected pancreatic mucinous cystic neoplasms, but “have low specificity and positive predictive value, underscoring the pressing need to develop more accurate predictors of malignancy,” the researchers said. “On the basis of our data, we recommend that the Fukuoka guidelines be used only as a framework for the work-up of a patient with a suspected pancreatic mucinous cystic neoplasm, and that management be adapted in the context of the individual patient.”
Developed in 2006, the Sendai consensus guidelines (Pancreatology 2006;6:17-32) reliably detected patients with malignant mucinous lesions of the pancreas, but poor specificity led to many needless resections, noted the investigators. The revised Fukuoka guidelines (Pancreatology 2012;12:183-97), improved specificity by classifying cysts measuring more than 3 cm as worrisome, rather than high risk. Notably, cyst size did not predict advanced neoplasia in the study, even though several consensus guidelines recommend resection when cysts exceed 3 cm, the investigators said. “Other studies have demonstrated similar results, with rates of advanced neoplasia of 25%-34% in cysts less than 3 cm in size,” they added (Clin Gastro Hepatol. 2015 Mar 15. doi: 10.1016/j.cgh.2015.03.01).
The study included 194 patients with suspected pancreatic mucinous cystic neoplasias assessed by cross-sectional imaging prior to surgical resection between 2000 and 2008. Surgical pathology revealed advanced neoplasias among 18.5% of patients. Overall median cyst size was 33 mm, said the investigators. All patients with invasive cancers met the high-risk criteria in both guidelines, but three patients in the Sendai low-risk group and two patients in the Fukuoka low-risk group had high-grade dysplasias, they said. The Sendai consensus guidelines identified patients with advanced neoplasia with about 92% sensitivity, 21% specificity, 21% positive predictive value, and 92% negative predictive value, while the Fukuoka had about 55% sensitivity, 73% specificity, 32% positive predictive value, and 88% negative predictive value. However, the guidelines did not statistically differ in their ability to predict neoplasia, the researchers said.
“In the course of reviewing our data, we have become increasingly conservative in the management of patients with pancreatic cysts,” the researchers commented. “This approach has been underscored by the low number of cases of advanced neoplasia, even among those who would be considered high risk on the basis of the updated guidelines, in surgically resected patients. With the elimination of cyst size as a high-risk predictor of malignancy for mucinous cysts, cognizance that smaller cysts can also harbor malignancy should come.”
The researchers reported no funding sources and declared no conflicts of interest.
This study by Kaimakliotis et al. highlights the limitations in the current diagnostic and management algorithm for mucinous cystic lesion of the pancreas. Although both the Sendai and Fukuoka guidelines accurately detected patients with advanced neoplasia with a sensitivity higher than 90%, the specificity of both guidelines in detecting advanced neoplasia did not exceed 22%. The updated Fukuoka guidelines were not superior to the Sendai guidelines in detecting advanced neoplasia.
 |
| Dr. Mohamed O. Othman |
The worrisome group in the Fukuoka guidelines was introduced to decrease the unnecessary resection of benign pancreatic cystic lesions and surveillance with endoscopic ultrasound (EUS) imaging is recommended for this group. If a definite mural nodule, dilated pancreatic duct, or positive cytology is found on follow-up EUS, then the patient should be triaged for surgery. Lumping the low-risk lesions and the worrisome lesions of the Fukuoka guidelines into one group resulted in increasing the specificity of detecting advanced neoplasia to 73% at the expense of sensitivity, which dropped to 55.6%, which may result in missing many cases of advanced neoplasia.
Prospective evaluation of the performance of the updated Fukuoka guidelines with particular attention to the worrisome group is needed. Ultimately, molecular markers that can predict the risk of progression to malignancy will be validated and will most likely replace the current experts’ opinion and consensus guidelines.
Dr. Mohamed O. Othman is director of advanced endoscopy, assistant professor of medicine, gastroenterology section, Baylor College of Medicine, Houston. He has no relevant conflicts of interest.
This study by Kaimakliotis et al. highlights the limitations in the current diagnostic and management algorithm for mucinous cystic lesion of the pancreas. Although both the Sendai and Fukuoka guidelines accurately detected patients with advanced neoplasia with a sensitivity higher than 90%, the specificity of both guidelines in detecting advanced neoplasia did not exceed 22%. The updated Fukuoka guidelines were not superior to the Sendai guidelines in detecting advanced neoplasia.
|
| Dr. Mohamed O. Othman |
The worrisome group in the Fukuoka guidelines was introduced to decrease the unnecessary resection of benign pancreatic cystic lesions and surveillance with endoscopic ultrasound (EUS) imaging is recommended for this group. If a definite mural nodule, dilated pancreatic duct, or positive cytology is found on follow-up EUS, then the patient should be triaged for surgery. Lumping the low-risk lesions and the worrisome lesions of the Fukuoka guidelines into one group resulted in increasing the specificity of detecting advanced neoplasia to 73% at the expense of sensitivity, which dropped to 55.6%, which may result in missing many cases of advanced neoplasia.
Prospective evaluation of the performance of the updated Fukuoka guidelines with particular attention to the worrisome group is needed. Ultimately, molecular markers that can predict the risk of progression to malignancy will be validated and will most likely replace the current experts’ opinion and consensus guidelines.
Dr. Mohamed O. Othman is director of advanced endoscopy, assistant professor of medicine, gastroenterology section, Baylor College of Medicine, Houston. He has no relevant conflicts of interest.
This study by Kaimakliotis et al. highlights the limitations in the current diagnostic and management algorithm for mucinous cystic lesion of the pancreas. Although both the Sendai and Fukuoka guidelines accurately detected patients with advanced neoplasia with a sensitivity higher than 90%, the specificity of both guidelines in detecting advanced neoplasia did not exceed 22%. The updated Fukuoka guidelines were not superior to the Sendai guidelines in detecting advanced neoplasia.
|
| Dr. Mohamed O. Othman |
The worrisome group in the Fukuoka guidelines was introduced to decrease the unnecessary resection of benign pancreatic cystic lesions and surveillance with endoscopic ultrasound (EUS) imaging is recommended for this group. If a definite mural nodule, dilated pancreatic duct, or positive cytology is found on follow-up EUS, then the patient should be triaged for surgery. Lumping the low-risk lesions and the worrisome lesions of the Fukuoka guidelines into one group resulted in increasing the specificity of detecting advanced neoplasia to 73% at the expense of sensitivity, which dropped to 55.6%, which may result in missing many cases of advanced neoplasia.
Prospective evaluation of the performance of the updated Fukuoka guidelines with particular attention to the worrisome group is needed. Ultimately, molecular markers that can predict the risk of progression to malignancy will be validated and will most likely replace the current experts’ opinion and consensus guidelines.
Dr. Mohamed O. Othman is director of advanced endoscopy, assistant professor of medicine, gastroenterology section, Baylor College of Medicine, Houston. He has no relevant conflicts of interest.
Both the Sendai and Fukuoka guidelines correctly identified all patients whose cystic pancreatic lesions were advanced neoplasias, but the “high-risk” criteria for both guidelines missed some high-grade dysplasias, researchers reported in the October issue of Clinical Gastroenterology and Hepatology.
“The updated Fukuoka guidelines are not superior to the Sendai guidelines in identifying neoplasias,” said Dr. Pavlos Kaimakliotis and his associates at the University of Pennsylvania in Philadelphia. The single-center retrospective study showed that both guidelines can help triage patients with suspected pancreatic mucinous cystic neoplasms, but “have low specificity and positive predictive value, underscoring the pressing need to develop more accurate predictors of malignancy,” the researchers said. “On the basis of our data, we recommend that the Fukuoka guidelines be used only as a framework for the work-up of a patient with a suspected pancreatic mucinous cystic neoplasm, and that management be adapted in the context of the individual patient.”
Developed in 2006, the Sendai consensus guidelines (Pancreatology 2006;6:17-32) reliably detected patients with malignant mucinous lesions of the pancreas, but poor specificity led to many needless resections, noted the investigators. The revised Fukuoka guidelines (Pancreatology 2012;12:183-97), improved specificity by classifying cysts measuring more than 3 cm as worrisome, rather than high risk. Notably, cyst size did not predict advanced neoplasia in the study, even though several consensus guidelines recommend resection when cysts exceed 3 cm, the investigators said. “Other studies have demonstrated similar results, with rates of advanced neoplasia of 25%-34% in cysts less than 3 cm in size,” they added (Clin Gastro Hepatol. 2015 Mar 15. doi: 10.1016/j.cgh.2015.03.01).
The study included 194 patients with suspected pancreatic mucinous cystic neoplasias assessed by cross-sectional imaging prior to surgical resection between 2000 and 2008. Surgical pathology revealed advanced neoplasias among 18.5% of patients. Overall median cyst size was 33 mm, said the investigators. All patients with invasive cancers met the high-risk criteria in both guidelines, but three patients in the Sendai low-risk group and two patients in the Fukuoka low-risk group had high-grade dysplasias, they said. The Sendai consensus guidelines identified patients with advanced neoplasia with about 92% sensitivity, 21% specificity, 21% positive predictive value, and 92% negative predictive value, while the Fukuoka had about 55% sensitivity, 73% specificity, 32% positive predictive value, and 88% negative predictive value. However, the guidelines did not statistically differ in their ability to predict neoplasia, the researchers said.
“In the course of reviewing our data, we have become increasingly conservative in the management of patients with pancreatic cysts,” the researchers commented. “This approach has been underscored by the low number of cases of advanced neoplasia, even among those who would be considered high risk on the basis of the updated guidelines, in surgically resected patients. With the elimination of cyst size as a high-risk predictor of malignancy for mucinous cysts, cognizance that smaller cysts can also harbor malignancy should come.”
The researchers reported no funding sources and declared no conflicts of interest.
Both the Sendai and Fukuoka guidelines correctly identified all patients whose cystic pancreatic lesions were advanced neoplasias, but the “high-risk” criteria for both guidelines missed some high-grade dysplasias, researchers reported in the October issue of Clinical Gastroenterology and Hepatology.
“The updated Fukuoka guidelines are not superior to the Sendai guidelines in identifying neoplasias,” said Dr. Pavlos Kaimakliotis and his associates at the University of Pennsylvania in Philadelphia. The single-center retrospective study showed that both guidelines can help triage patients with suspected pancreatic mucinous cystic neoplasms, but “have low specificity and positive predictive value, underscoring the pressing need to develop more accurate predictors of malignancy,” the researchers said. “On the basis of our data, we recommend that the Fukuoka guidelines be used only as a framework for the work-up of a patient with a suspected pancreatic mucinous cystic neoplasm, and that management be adapted in the context of the individual patient.”
Developed in 2006, the Sendai consensus guidelines (Pancreatology 2006;6:17-32) reliably detected patients with malignant mucinous lesions of the pancreas, but poor specificity led to many needless resections, noted the investigators. The revised Fukuoka guidelines (Pancreatology 2012;12:183-97), improved specificity by classifying cysts measuring more than 3 cm as worrisome, rather than high risk. Notably, cyst size did not predict advanced neoplasia in the study, even though several consensus guidelines recommend resection when cysts exceed 3 cm, the investigators said. “Other studies have demonstrated similar results, with rates of advanced neoplasia of 25%-34% in cysts less than 3 cm in size,” they added (Clin Gastro Hepatol. 2015 Mar 15. doi: 10.1016/j.cgh.2015.03.01).
The study included 194 patients with suspected pancreatic mucinous cystic neoplasias assessed by cross-sectional imaging prior to surgical resection between 2000 and 2008. Surgical pathology revealed advanced neoplasias among 18.5% of patients. Overall median cyst size was 33 mm, said the investigators. All patients with invasive cancers met the high-risk criteria in both guidelines, but three patients in the Sendai low-risk group and two patients in the Fukuoka low-risk group had high-grade dysplasias, they said. The Sendai consensus guidelines identified patients with advanced neoplasia with about 92% sensitivity, 21% specificity, 21% positive predictive value, and 92% negative predictive value, while the Fukuoka had about 55% sensitivity, 73% specificity, 32% positive predictive value, and 88% negative predictive value. However, the guidelines did not statistically differ in their ability to predict neoplasia, the researchers said.
“In the course of reviewing our data, we have become increasingly conservative in the management of patients with pancreatic cysts,” the researchers commented. “This approach has been underscored by the low number of cases of advanced neoplasia, even among those who would be considered high risk on the basis of the updated guidelines, in surgically resected patients. With the elimination of cyst size as a high-risk predictor of malignancy for mucinous cysts, cognizance that smaller cysts can also harbor malignancy should come.”
The researchers reported no funding sources and declared no conflicts of interest.
FROM CLINICAL GASTROENTEROLOGY AND HEPATOLOGY
Key clinical point: The Sendai and Fukuoka guidelines were equivalent when detecting advanced neoplasias among patients with pancreatic cystic lesions.
Major finding: All patients found to have invasive cancers met the high-risk criteria for both guidelines. Both guidelines missed some high-grade dysplasias.
Data source: Retrospective study of 194 patients with cystic lesions of the pancreas.
Disclosures: The researchers reported no funding sources and declared no conflicts of interest.
