Doug Brunk

AUSTIN – Not long ago, Rajani Katta, MD, received a text message from a friend who expressed concern about a rash that developed in the underarm of her teenage daughter.

The culprit turned out to be the lavender essential oil contained in an “all natural” deodorant that her daughter had recently switched to – a storyline that Dr. Katta encounters with increasing frequency in her role as clinical professor of dermatology at the University of Texas Health Science Center at Houston.

“Some people may think that you can’t get an allergic reaction to natural products, but we are seeing many allergic reactions to essential oils,” Dr. Katta said at the annual meeting of the Society for Pediatric Dermatology. “When you talk about a natural allergy, it is more likely to occur if your skin barrier is compromised, so I think that’s why we’re seeing it, especially in young girls in the underarm area. If you shave the underarm, you impair that skin barrier and you’re more likely to develop a reaction to something you’re using over it.”

Her list of recommended deodorants includes Almay Roll-On Antiperspirant & Deodorant, Crystal Body Deodorant Stick, Crystal Roll-On Body Deodorant, Vanicream Deodorant for Sensitive Skin (aluminum-free), Vanicream Antiperspirant/Deodorant, and CertainDri Clinical Strength Roll-On. They are fragrance-free and lack propylene glycol, which is a common allergen.

Increasingly, essential oils are being added to lip balms and toothpastes, said Dr. Katta, who is also author of the 2018 book “Glow: The Dermatologist’s Guide to a Whole Foods Younger Skin Diet.” She recalled one patient who presented with chronic chapped lips. “It doesn’t matter how many lip glosses I try; it just keeps getting worse,” the patient told her. The likely culprit turned out to be ingredients contained in flavored lip balm from EOS. Reports of blistering and cracking of the lips from use of the products prompted a class action lawsuit and a notice to consumers from the Food and Drug Administration.

Another patient presented with cracked lips after switching to an “all natural” toothpaste that was labeled “gluten free.”

“It looked great,” Dr. Katta recalled. “Unfortunately it was not flavoring free. She reacted to multiple essential oils, including tea tree oil, contained in the toothpaste. This is being added to a number of toothpastes, and I think we’re going to see more of these types of reactions.”

Other toothpastes contain balsam of Peru, “which is consistently one of the top allergens in patch test clinics,” she said. “One of the components of balsam of Peru is a cinnamon compound, which can be an issue.”

Dr. Katta advises her patients to use Vaseline petroleum jelly as a lip balm and recommends Tom’s of Maine Silly Strawberry Flavor (this flavor only) toothpaste for children.

A few years ago, a teenager presented to Dr. Katta with intense bullae on the dorsum of the foot after wearing shoes without socks. “She was wearing white canvas Keds, which looked very innocuous,” she said. Patch testing revealed that the teen reacted to four different rubber accelerators. “When we contacted the company, they [acknowledged] using rubber cement to make the canvas Keds,” Dr. Katta said. “Rubber cement is an adhesive and it does contain rubber accelerators. Later, I saw two cases of children who had walked around all day at the amusement park wearing their Sperry Topsiders without any socks. We couldn’t get any information from that manufacturer, but I suspect that they also use a rubber-based glue to make those shoes.” She characterized shoes as “a real setup for a foot allergy because you have friction, sweat that’s pulling allergen out of an object, and sweat is carrying it over, especially to the dorsum of the foot.”


Dr. Katta has also noticed an uptick in the number of young patients who develop allergic reactions to dyes used to make workout clothing. “If you ever see rashes that do not involve the axillary vault but do have peraxillary accentuation, think textile allergy,” she said. “We’re seeing a lot of reactions to disperse blue clothing dyes. When you think about textile allergy from the dyes, it tends to be the blue and black clothing. It’s more likely in the setting of synthetic fabrics because they leach out dyes more easily, and it’s more likely in the setting of sweat because sweat helps pull allergen out. I’m seeing it a lot from sports uniforms and tight black leggings and tight sports bras that people are wearing. I’m also seeing some from bathing suits and swim shirts.”

Exposure to products containing the preservative methylisothiazolinone (MI) is also on the rise. It ranks as the second most frequent allergen for which the North American Contact Dermatitis Group is seeing positive results on patch testing, with rates of 13.4%. MI can be found in many skin care products and “probably about half of school glues, fabric glues, and craft glues,” Dr. Katta said. “Stick versus liquid doesn’t make a difference.” Children and teens often use craft glues, laundry detergents, and other products to create “slime” as a way to learn about viscosity, polymers, and chemical reactions. “Sometimes these children have sensitive skin, or they’re using it with prolonged contact, so they may be sensitizing themselves to the MI,” she said.

She concluded her remarks by noting that an increasing number of young patients are developing reactions to wearable medical devices such as insulin pumps and glucose monitors. “With this, the first thing to think about is frictional irritant dermatitis,” she said. “You can put Scanpor medical paper tape on people’s back for 48 hours straight to patch test them. Some people are incredibly reactive to the friction of just that tape. You also have to think about trapped allergen. One of my patients reacted to colophony, fragrance mix, and propylene glycol, all of which were contained in his skin care products. Some people are getting advice from other patients to use Mastisol liquid adhesive to help their glucose monitors stick better. Mastisol has a high rate of cross-reactivity with balsam of Peru, so it’s a fragrance allergen. That’s the first thing you want to ask patients about: what products they’re using.”

One of her patients thought she was reacting to adhesive tape on her skin, but in fact she was reacting to two different acrylates: ethylene glycol dimethacrylate (EGDMA) and hydroxyethyl methacrylate (HEMA). “I know about these allergens because I see reactions from butterfly needles in dialysis patients,” Dr. Katta explained. “What happens is, these acrylates are glues or plastics used somewhere else on the device, and they can migrate through barriers.”

In one published case, a 9-year-old boy developed a reaction to ethyl cyanoacrylate contained in a glucose sensor adhesive (Dermatitis. 2017; 28[4]:289-91). It never touched the boy’s skin directly but was presumed to migrate through that tape. “The bottom line is that acrylates may induce contact dermatitis even through perceived barriers,” she said. “Their use anywhere in medical devices may prove problematic.”

Dr. Katta reported that she is a member of the advisory board for Vichy Laboratories.
 

[email protected]

AUSTIN – Not long ago, Rajani Katta, MD, received a text message from a friend who expressed concern about a rash that developed in the underarm of her teenage daughter.

The culprit turned out to be the lavender essential oil contained in an “all natural” deodorant that her daughter had recently switched to – a storyline that Dr. Katta encounters with increasing frequency in her role as clinical professor of dermatology at the University of Texas Health Science Center at Houston.

“Some people may think that you can’t get an allergic reaction to natural products, but we are seeing many allergic reactions to essential oils,” Dr. Katta said at the annual meeting of the Society for Pediatric Dermatology. “When you talk about a natural allergy, it is more likely to occur if your skin barrier is compromised, so I think that’s why we’re seeing it, especially in young girls in the underarm area. If you shave the underarm, you impair that skin barrier and you’re more likely to develop a reaction to something you’re using over it.”

Her list of recommended deodorants includes Almay Roll-On Antiperspirant & Deodorant, Crystal Body Deodorant Stick, Crystal Roll-On Body Deodorant, Vanicream Deodorant for Sensitive Skin (aluminum-free), Vanicream Antiperspirant/Deodorant, and CertainDri Clinical Strength Roll-On. They are fragrance-free and lack propylene glycol, which is a common allergen.

Increasingly, essential oils are being added to lip balms and toothpastes, said Dr. Katta, who is also author of the 2018 book “Glow: The Dermatologist’s Guide to a Whole Foods Younger Skin Diet.” She recalled one patient who presented with chronic chapped lips. “It doesn’t matter how many lip glosses I try; it just keeps getting worse,” the patient told her. The likely culprit turned out to be ingredients contained in flavored lip balm from EOS. Reports of blistering and cracking of the lips from use of the products prompted a class action lawsuit and a notice to consumers from the Food and Drug Administration.

Another patient presented with cracked lips after switching to an “all natural” toothpaste that was labeled “gluten free.”

“It looked great,” Dr. Katta recalled. “Unfortunately it was not flavoring free. She reacted to multiple essential oils, including tea tree oil, contained in the toothpaste. This is being added to a number of toothpastes, and I think we’re going to see more of these types of reactions.”

Other toothpastes contain balsam of Peru, “which is consistently one of the top allergens in patch test clinics,” she said. “One of the components of balsam of Peru is a cinnamon compound, which can be an issue.”

Dr. Katta advises her patients to use Vaseline petroleum jelly as a lip balm and recommends Tom’s of Maine Silly Strawberry Flavor (this flavor only) toothpaste for children.

A few years ago, a teenager presented to Dr. Katta with intense bullae on the dorsum of the foot after wearing shoes without socks. “She was wearing white canvas Keds, which looked very innocuous,” she said. Patch testing revealed that the teen reacted to four different rubber accelerators. “When we contacted the company, they [acknowledged] using rubber cement to make the canvas Keds,” Dr. Katta said. “Rubber cement is an adhesive and it does contain rubber accelerators. Later, I saw two cases of children who had walked around all day at the amusement park wearing their Sperry Topsiders without any socks. We couldn’t get any information from that manufacturer, but I suspect that they also use a rubber-based glue to make those shoes.” She characterized shoes as “a real setup for a foot allergy because you have friction, sweat that’s pulling allergen out of an object, and sweat is carrying it over, especially to the dorsum of the foot.”


Dr. Katta has also noticed an uptick in the number of young patients who develop allergic reactions to dyes used to make workout clothing. “If you ever see rashes that do not involve the axillary vault but do have peraxillary accentuation, think textile allergy,” she said. “We’re seeing a lot of reactions to disperse blue clothing dyes. When you think about textile allergy from the dyes, it tends to be the blue and black clothing. It’s more likely in the setting of synthetic fabrics because they leach out dyes more easily, and it’s more likely in the setting of sweat because sweat helps pull allergen out. I’m seeing it a lot from sports uniforms and tight black leggings and tight sports bras that people are wearing. I’m also seeing some from bathing suits and swim shirts.”

Exposure to products containing the preservative methylisothiazolinone (MI) is also on the rise. It ranks as the second most frequent allergen for which the North American Contact Dermatitis Group is seeing positive results on patch testing, with rates of 13.4%. MI can be found in many skin care products and “probably about half of school glues, fabric glues, and craft glues,” Dr. Katta said. “Stick versus liquid doesn’t make a difference.” Children and teens often use craft glues, laundry detergents, and other products to create “slime” as a way to learn about viscosity, polymers, and chemical reactions. “Sometimes these children have sensitive skin, or they’re using it with prolonged contact, so they may be sensitizing themselves to the MI,” she said.

She concluded her remarks by noting that an increasing number of young patients are developing reactions to wearable medical devices such as insulin pumps and glucose monitors. “With this, the first thing to think about is frictional irritant dermatitis,” she said. “You can put Scanpor medical paper tape on people’s back for 48 hours straight to patch test them. Some people are incredibly reactive to the friction of just that tape. You also have to think about trapped allergen. One of my patients reacted to colophony, fragrance mix, and propylene glycol, all of which were contained in his skin care products. Some people are getting advice from other patients to use Mastisol liquid adhesive to help their glucose monitors stick better. Mastisol has a high rate of cross-reactivity with balsam of Peru, so it’s a fragrance allergen. That’s the first thing you want to ask patients about: what products they’re using.”

One of her patients thought she was reacting to adhesive tape on her skin, but in fact she was reacting to two different acrylates: ethylene glycol dimethacrylate (EGDMA) and hydroxyethyl methacrylate (HEMA). “I know about these allergens because I see reactions from butterfly needles in dialysis patients,” Dr. Katta explained. “What happens is, these acrylates are glues or plastics used somewhere else on the device, and they can migrate through barriers.”

In one published case, a 9-year-old boy developed a reaction to ethyl cyanoacrylate contained in a glucose sensor adhesive (Dermatitis. 2017; 28[4]:289-91). It never touched the boy’s skin directly but was presumed to migrate through that tape. “The bottom line is that acrylates may induce contact dermatitis even through perceived barriers,” she said. “Their use anywhere in medical devices may prove problematic.”

Dr. Katta reported that she is a member of the advisory board for Vichy Laboratories.
 

[email protected]

AUSTIN – Not long ago, Rajani Katta, MD, received a text message from a friend who expressed concern about a rash that developed in the underarm of her teenage daughter.

The culprit turned out to be the lavender essential oil contained in an “all natural” deodorant that her daughter had recently switched to – a storyline that Dr. Katta encounters with increasing frequency in her role as clinical professor of dermatology at the University of Texas Health Science Center at Houston.

“Some people may think that you can’t get an allergic reaction to natural products, but we are seeing many allergic reactions to essential oils,” Dr. Katta said at the annual meeting of the Society for Pediatric Dermatology. “When you talk about a natural allergy, it is more likely to occur if your skin barrier is compromised, so I think that’s why we’re seeing it, especially in young girls in the underarm area. If you shave the underarm, you impair that skin barrier and you’re more likely to develop a reaction to something you’re using over it.”

Her list of recommended deodorants includes Almay Roll-On Antiperspirant & Deodorant, Crystal Body Deodorant Stick, Crystal Roll-On Body Deodorant, Vanicream Deodorant for Sensitive Skin (aluminum-free), Vanicream Antiperspirant/Deodorant, and CertainDri Clinical Strength Roll-On. They are fragrance-free and lack propylene glycol, which is a common allergen.

Increasingly, essential oils are being added to lip balms and toothpastes, said Dr. Katta, who is also author of the 2018 book “Glow: The Dermatologist’s Guide to a Whole Foods Younger Skin Diet.” She recalled one patient who presented with chronic chapped lips. “It doesn’t matter how many lip glosses I try; it just keeps getting worse,” the patient told her. The likely culprit turned out to be ingredients contained in flavored lip balm from EOS. Reports of blistering and cracking of the lips from use of the products prompted a class action lawsuit and a notice to consumers from the Food and Drug Administration.

Another patient presented with cracked lips after switching to an “all natural” toothpaste that was labeled “gluten free.”

“It looked great,” Dr. Katta recalled. “Unfortunately it was not flavoring free. She reacted to multiple essential oils, including tea tree oil, contained in the toothpaste. This is being added to a number of toothpastes, and I think we’re going to see more of these types of reactions.”

Other toothpastes contain balsam of Peru, “which is consistently one of the top allergens in patch test clinics,” she said. “One of the components of balsam of Peru is a cinnamon compound, which can be an issue.”

Dr. Katta advises her patients to use Vaseline petroleum jelly as a lip balm and recommends Tom’s of Maine Silly Strawberry Flavor (this flavor only) toothpaste for children.

A few years ago, a teenager presented to Dr. Katta with intense bullae on the dorsum of the foot after wearing shoes without socks. “She was wearing white canvas Keds, which looked very innocuous,” she said. Patch testing revealed that the teen reacted to four different rubber accelerators. “When we contacted the company, they [acknowledged] using rubber cement to make the canvas Keds,” Dr. Katta said. “Rubber cement is an adhesive and it does contain rubber accelerators. Later, I saw two cases of children who had walked around all day at the amusement park wearing their Sperry Topsiders without any socks. We couldn’t get any information from that manufacturer, but I suspect that they also use a rubber-based glue to make those shoes.” She characterized shoes as “a real setup for a foot allergy because you have friction, sweat that’s pulling allergen out of an object, and sweat is carrying it over, especially to the dorsum of the foot.”


Dr. Katta has also noticed an uptick in the number of young patients who develop allergic reactions to dyes used to make workout clothing. “If you ever see rashes that do not involve the axillary vault but do have peraxillary accentuation, think textile allergy,” she said. “We’re seeing a lot of reactions to disperse blue clothing dyes. When you think about textile allergy from the dyes, it tends to be the blue and black clothing. It’s more likely in the setting of synthetic fabrics because they leach out dyes more easily, and it’s more likely in the setting of sweat because sweat helps pull allergen out. I’m seeing it a lot from sports uniforms and tight black leggings and tight sports bras that people are wearing. I’m also seeing some from bathing suits and swim shirts.”

Exposure to products containing the preservative methylisothiazolinone (MI) is also on the rise. It ranks as the second most frequent allergen for which the North American Contact Dermatitis Group is seeing positive results on patch testing, with rates of 13.4%. MI can be found in many skin care products and “probably about half of school glues, fabric glues, and craft glues,” Dr. Katta said. “Stick versus liquid doesn’t make a difference.” Children and teens often use craft glues, laundry detergents, and other products to create “slime” as a way to learn about viscosity, polymers, and chemical reactions. “Sometimes these children have sensitive skin, or they’re using it with prolonged contact, so they may be sensitizing themselves to the MI,” she said.

She concluded her remarks by noting that an increasing number of young patients are developing reactions to wearable medical devices such as insulin pumps and glucose monitors. “With this, the first thing to think about is frictional irritant dermatitis,” she said. “You can put Scanpor medical paper tape on people’s back for 48 hours straight to patch test them. Some people are incredibly reactive to the friction of just that tape. You also have to think about trapped allergen. One of my patients reacted to colophony, fragrance mix, and propylene glycol, all of which were contained in his skin care products. Some people are getting advice from other patients to use Mastisol liquid adhesive to help their glucose monitors stick better. Mastisol has a high rate of cross-reactivity with balsam of Peru, so it’s a fragrance allergen. That’s the first thing you want to ask patients about: what products they’re using.”

One of her patients thought she was reacting to adhesive tape on her skin, but in fact she was reacting to two different acrylates: ethylene glycol dimethacrylate (EGDMA) and hydroxyethyl methacrylate (HEMA). “I know about these allergens because I see reactions from butterfly needles in dialysis patients,” Dr. Katta explained. “What happens is, these acrylates are glues or plastics used somewhere else on the device, and they can migrate through barriers.”

In one published case, a 9-year-old boy developed a reaction to ethyl cyanoacrylate contained in a glucose sensor adhesive (Dermatitis. 2017; 28[4]:289-91). It never touched the boy’s skin directly but was presumed to migrate through that tape. “The bottom line is that acrylates may induce contact dermatitis even through perceived barriers,” she said. “Their use anywhere in medical devices may prove problematic.”

Dr. Katta reported that she is a member of the advisory board for Vichy Laboratories.
 

[email protected]

AUSTIN – The incidence of pediatric invasive melanoma has decreased since 2002, but males are more likely to die from the disease, compared with females. The risk of death is also significantly increased in black patients, other nonwhite patients, and in cases where surgery was not performed.

Doug Brunk/MDedge News

Those are key findings from a study that set out to investigate the incidence of pediatric melanoma over the last 2 decades and factors influencing survival. At the annual meeting of the Society for Pediatric Dermatology, one of the study authors, Spandana Maddukuri, said that pediatric melanoma is the most common skin cancer in the pediatric population, accounting for 1-3% of all pediatric malignancies and 1%-4% of all cases of melanoma (Pediatr Surg. 2013;48[11]:2207-13).

“Nonmodifiable risk factors are similar to those in adult melanoma and include fair skin, light hair and eye color, increased number of congenital nevi, and family history of melanoma,” said Ms. Maddukuri, a third-year student at New Jersey Medical School, Newark. “Environmental risk factors are similar to those in adult melanoma and include exposure to UV radiation. About 60% of children do not meet standard ABCDE [asymmetrical, border, color, diameter, evolving] diagnosis criteria, which often leads to delayed diagnosis.”

Some of the characteristics that are more commonly found in pediatric lesions include amelanosis, bleeding, uniform color, and variable diameter (J Am Acad Dermatol. 2013; 68[6]:913-25).

Ms. Maddukuri and colleagues queried the National Cancer Institute Surveillance, Epidemiology, and End Results (SEER) database for cases of malignant melanoma that were diagnosed in individuals aged younger than 20 years between 2002 and 2015. After excluding all cases of adult melanoma and all cases of in situ melanoma, they included 1,620 patients in the final analysis and divided them into five age groups: less than 1 year, 1-4 years, 5-9 years, 10-14 years, and 15-19 years. They calculated the overall incidence rate per 100,000 population of pediatric melanoma based on data from the 2000 U.S. Census. Age-, sex-, and race-specific incidence rates were also calculated. Kaplan-Meier and Cox regression analyses to investigate disease-specific survival and risk factors.

With each successive age group, the investigators observed that incidence rate was significantly higher than that of the previous age group (P less than .005). “However, the most striking increase in incidence occurs between the age group of 10-14 and 15-19,” she said. “Sex also influenced incidence rates. Males had an incidence rate of 0.396 per 100,000 population while females had an incidence rate of 0.579 per 100,000 population.”


Race also influenced incidence rates. White patients had the highest incidence rate of 0.605 per 100,000 population, while blacks had the lowest incident rate at 0.042 per 100,000 population. American Indian and Alaska Native patients had incidence rates of 0.046 per 100,000 population, while Asians and Pacific Islanders had an incidence rate of 0.127 per 100,000 population.

The researchers found that increased survival was associated with white race, female sex, treatment with surgical intervention, and age older than 5 years. No differences in survival were observed regarding the primary anatomic location or extent of disease. The hazard ratio of death from invasive melanoma was significantly increased in males (HR, 2.34), black patients (HR, 3.96), other nonwhite patients (HR, 3.64), and in cases where surgery was not performed (HR, 6.04).

“It is surprising that, although incidence is significantly higher in white patients and females, compared to black patients and males, respectively, the risk of dying from melanoma is much higher in black patients and males,” Ms. Maddukuri said in an interview at the meeting. “Overall, the dermatologic community is on the right track in screening and diagnosing pediatric melanoma, as seen by the decreased incidence over the last 2 decades. However, increased awareness regarding pediatric melanoma is still encouraged. I believe we were able to identify certain populations that need more attention in terms of screening, diagnosis, and treatment, which are patients less than 5 years old, black and other nonwhite patients, and males.”

She acknowledged certain shortcomings of the study, including a limited clinical history of the patient population because of the nature of the database. She also said that further studies are required to investigate the contributing factors to decreasing incidence and to evaluate the relationship of the favorable prognostic factors to increased survival. The researchers are currently working on correlating incidence rates with UV exposure and geographical location.

They reported having no financial disclosures.

[email protected]

AUSTIN – The incidence of pediatric invasive melanoma has decreased since 2002, but males are more likely to die from the disease, compared with females. The risk of death is also significantly increased in black patients, other nonwhite patients, and in cases where surgery was not performed.

Doug Brunk/MDedge News

Those are key findings from a study that set out to investigate the incidence of pediatric melanoma over the last 2 decades and factors influencing survival. At the annual meeting of the Society for Pediatric Dermatology, one of the study authors, Spandana Maddukuri, said that pediatric melanoma is the most common skin cancer in the pediatric population, accounting for 1-3% of all pediatric malignancies and 1%-4% of all cases of melanoma (Pediatr Surg. 2013;48[11]:2207-13).

“Nonmodifiable risk factors are similar to those in adult melanoma and include fair skin, light hair and eye color, increased number of congenital nevi, and family history of melanoma,” said Ms. Maddukuri, a third-year student at New Jersey Medical School, Newark. “Environmental risk factors are similar to those in adult melanoma and include exposure to UV radiation. About 60% of children do not meet standard ABCDE [asymmetrical, border, color, diameter, evolving] diagnosis criteria, which often leads to delayed diagnosis.”

Some of the characteristics that are more commonly found in pediatric lesions include amelanosis, bleeding, uniform color, and variable diameter (J Am Acad Dermatol. 2013; 68[6]:913-25).

Ms. Maddukuri and colleagues queried the National Cancer Institute Surveillance, Epidemiology, and End Results (SEER) database for cases of malignant melanoma that were diagnosed in individuals aged younger than 20 years between 2002 and 2015. After excluding all cases of adult melanoma and all cases of in situ melanoma, they included 1,620 patients in the final analysis and divided them into five age groups: less than 1 year, 1-4 years, 5-9 years, 10-14 years, and 15-19 years. They calculated the overall incidence rate per 100,000 population of pediatric melanoma based on data from the 2000 U.S. Census. Age-, sex-, and race-specific incidence rates were also calculated. Kaplan-Meier and Cox regression analyses to investigate disease-specific survival and risk factors.

With each successive age group, the investigators observed that incidence rate was significantly higher than that of the previous age group (P less than .005). “However, the most striking increase in incidence occurs between the age group of 10-14 and 15-19,” she said. “Sex also influenced incidence rates. Males had an incidence rate of 0.396 per 100,000 population while females had an incidence rate of 0.579 per 100,000 population.”


Race also influenced incidence rates. White patients had the highest incidence rate of 0.605 per 100,000 population, while blacks had the lowest incident rate at 0.042 per 100,000 population. American Indian and Alaska Native patients had incidence rates of 0.046 per 100,000 population, while Asians and Pacific Islanders had an incidence rate of 0.127 per 100,000 population.

The researchers found that increased survival was associated with white race, female sex, treatment with surgical intervention, and age older than 5 years. No differences in survival were observed regarding the primary anatomic location or extent of disease. The hazard ratio of death from invasive melanoma was significantly increased in males (HR, 2.34), black patients (HR, 3.96), other nonwhite patients (HR, 3.64), and in cases where surgery was not performed (HR, 6.04).

“It is surprising that, although incidence is significantly higher in white patients and females, compared to black patients and males, respectively, the risk of dying from melanoma is much higher in black patients and males,” Ms. Maddukuri said in an interview at the meeting. “Overall, the dermatologic community is on the right track in screening and diagnosing pediatric melanoma, as seen by the decreased incidence over the last 2 decades. However, increased awareness regarding pediatric melanoma is still encouraged. I believe we were able to identify certain populations that need more attention in terms of screening, diagnosis, and treatment, which are patients less than 5 years old, black and other nonwhite patients, and males.”

She acknowledged certain shortcomings of the study, including a limited clinical history of the patient population because of the nature of the database. She also said that further studies are required to investigate the contributing factors to decreasing incidence and to evaluate the relationship of the favorable prognostic factors to increased survival. The researchers are currently working on correlating incidence rates with UV exposure and geographical location.

They reported having no financial disclosures.

[email protected]

AUSTIN – The incidence of pediatric invasive melanoma has decreased since 2002, but males are more likely to die from the disease, compared with females. The risk of death is also significantly increased in black patients, other nonwhite patients, and in cases where surgery was not performed.

Doug Brunk/MDedge News

Those are key findings from a study that set out to investigate the incidence of pediatric melanoma over the last 2 decades and factors influencing survival. At the annual meeting of the Society for Pediatric Dermatology, one of the study authors, Spandana Maddukuri, said that pediatric melanoma is the most common skin cancer in the pediatric population, accounting for 1-3% of all pediatric malignancies and 1%-4% of all cases of melanoma (Pediatr Surg. 2013;48[11]:2207-13).

“Nonmodifiable risk factors are similar to those in adult melanoma and include fair skin, light hair and eye color, increased number of congenital nevi, and family history of melanoma,” said Ms. Maddukuri, a third-year student at New Jersey Medical School, Newark. “Environmental risk factors are similar to those in adult melanoma and include exposure to UV radiation. About 60% of children do not meet standard ABCDE [asymmetrical, border, color, diameter, evolving] diagnosis criteria, which often leads to delayed diagnosis.”

Some of the characteristics that are more commonly found in pediatric lesions include amelanosis, bleeding, uniform color, and variable diameter (J Am Acad Dermatol. 2013; 68[6]:913-25).

Ms. Maddukuri and colleagues queried the National Cancer Institute Surveillance, Epidemiology, and End Results (SEER) database for cases of malignant melanoma that were diagnosed in individuals aged younger than 20 years between 2002 and 2015. After excluding all cases of adult melanoma and all cases of in situ melanoma, they included 1,620 patients in the final analysis and divided them into five age groups: less than 1 year, 1-4 years, 5-9 years, 10-14 years, and 15-19 years. They calculated the overall incidence rate per 100,000 population of pediatric melanoma based on data from the 2000 U.S. Census. Age-, sex-, and race-specific incidence rates were also calculated. Kaplan-Meier and Cox regression analyses to investigate disease-specific survival and risk factors.

With each successive age group, the investigators observed that incidence rate was significantly higher than that of the previous age group (P less than .005). “However, the most striking increase in incidence occurs between the age group of 10-14 and 15-19,” she said. “Sex also influenced incidence rates. Males had an incidence rate of 0.396 per 100,000 population while females had an incidence rate of 0.579 per 100,000 population.”


Race also influenced incidence rates. White patients had the highest incidence rate of 0.605 per 100,000 population, while blacks had the lowest incident rate at 0.042 per 100,000 population. American Indian and Alaska Native patients had incidence rates of 0.046 per 100,000 population, while Asians and Pacific Islanders had an incidence rate of 0.127 per 100,000 population.

The researchers found that increased survival was associated with white race, female sex, treatment with surgical intervention, and age older than 5 years. No differences in survival were observed regarding the primary anatomic location or extent of disease. The hazard ratio of death from invasive melanoma was significantly increased in males (HR, 2.34), black patients (HR, 3.96), other nonwhite patients (HR, 3.64), and in cases where surgery was not performed (HR, 6.04).

“It is surprising that, although incidence is significantly higher in white patients and females, compared to black patients and males, respectively, the risk of dying from melanoma is much higher in black patients and males,” Ms. Maddukuri said in an interview at the meeting. “Overall, the dermatologic community is on the right track in screening and diagnosing pediatric melanoma, as seen by the decreased incidence over the last 2 decades. However, increased awareness regarding pediatric melanoma is still encouraged. I believe we were able to identify certain populations that need more attention in terms of screening, diagnosis, and treatment, which are patients less than 5 years old, black and other nonwhite patients, and males.”

She acknowledged certain shortcomings of the study, including a limited clinical history of the patient population because of the nature of the database. She also said that further studies are required to investigate the contributing factors to decreasing incidence and to evaluate the relationship of the favorable prognostic factors to increased survival. The researchers are currently working on correlating incidence rates with UV exposure and geographical location.

They reported having no financial disclosures.

[email protected]

AUSTIN – After searching online for information about a suspected pediatric dermatologic condition, one in five parents and/or pediatric patients make dermatology appointments sooner than they normally would, results from a novel survey showed.

In an interview at the annual meeting of the Society for Pediatric Dermatology, study author Jamie P. Schlarbaum noted that about one-third of Americans use the Internet to research their condition or symptoms prior to visiting a physician, mostly through Google. “While nearly 50% of parents look up health care information online for their children, rashes were the most common search in pediatrics in 2011,” said Mr. Schlarbaum, who is a fourth-year medical student at the University of Minnesota, Minneapolis. “However, no studies have examined the characteristics and implications of these searches; our study is the first in pediatric dermatology and also adds a new dimension to concern in an online era: How these searches influence health care behaviors.”

During February 2018–February 2019, Kristen Hook, MD, a pediatric dermatologist in Minneapolis and the study’s principal investigator, and Mr. Schlarbaum administered a survey to 220 parents/guardians and pediatric patients who had appointments in pediatric dermatology at a University of Minnesota clinic. The survey consisted of questions about demographics, search tools, search terms, and health care decisions based on this information.

Of the 220 respondents, more than half (59%) did not use an online search engine/tool prior to their appointment. Compared with parents who did not use an online search tool, those who did were slightly younger (34 vs. 36 years, respectively), more likely to be college educated (68% vs. 48%), and less likely to have the patient in question be their first child (37% vs. 52%).

Google ranked as the most common search engine used by the survey respondents (92%), followed distantly by WebMD (18%). About 15% of respondents became more concerned about the pediatric skin condition after searching online, and 20% made appointments sooner because of the information they gleaned from their searches. “Online dermatology clearly has an influence on care today,” Mr. Schlarbaum said. “As we become an even more technologically advanced and dependent society, we anticipate that both of these numbers will grow.”

The researchers also found that survey respondents self-diagnosed a number of dermatologic conditions based on their time spent online, including eczema (33%), moles (15%), and infections (11%). “The big takeaway [from this study] is to ask your parents and teenagers if they’ve looked up information online,” Mr. Schlarbaum said. “Whether it’s photos of the ‘worst cases’ or concerning differentials that might pop up, it’s worth it to take a few seconds to ask what they’re worried about and why.”

He acknowledged certain limitations of the study, including its small sample size and single-center design. The researchers reported having no financial disclosures.

[email protected]

AUSTIN – After searching online for information about a suspected pediatric dermatologic condition, one in five parents and/or pediatric patients make dermatology appointments sooner than they normally would, results from a novel survey showed.

In an interview at the annual meeting of the Society for Pediatric Dermatology, study author Jamie P. Schlarbaum noted that about one-third of Americans use the Internet to research their condition or symptoms prior to visiting a physician, mostly through Google. “While nearly 50% of parents look up health care information online for their children, rashes were the most common search in pediatrics in 2011,” said Mr. Schlarbaum, who is a fourth-year medical student at the University of Minnesota, Minneapolis. “However, no studies have examined the characteristics and implications of these searches; our study is the first in pediatric dermatology and also adds a new dimension to concern in an online era: How these searches influence health care behaviors.”

During February 2018–February 2019, Kristen Hook, MD, a pediatric dermatologist in Minneapolis and the study’s principal investigator, and Mr. Schlarbaum administered a survey to 220 parents/guardians and pediatric patients who had appointments in pediatric dermatology at a University of Minnesota clinic. The survey consisted of questions about demographics, search tools, search terms, and health care decisions based on this information.

Of the 220 respondents, more than half (59%) did not use an online search engine/tool prior to their appointment. Compared with parents who did not use an online search tool, those who did were slightly younger (34 vs. 36 years, respectively), more likely to be college educated (68% vs. 48%), and less likely to have the patient in question be their first child (37% vs. 52%).

Google ranked as the most common search engine used by the survey respondents (92%), followed distantly by WebMD (18%). About 15% of respondents became more concerned about the pediatric skin condition after searching online, and 20% made appointments sooner because of the information they gleaned from their searches. “Online dermatology clearly has an influence on care today,” Mr. Schlarbaum said. “As we become an even more technologically advanced and dependent society, we anticipate that both of these numbers will grow.”

The researchers also found that survey respondents self-diagnosed a number of dermatologic conditions based on their time spent online, including eczema (33%), moles (15%), and infections (11%). “The big takeaway [from this study] is to ask your parents and teenagers if they’ve looked up information online,” Mr. Schlarbaum said. “Whether it’s photos of the ‘worst cases’ or concerning differentials that might pop up, it’s worth it to take a few seconds to ask what they’re worried about and why.”

He acknowledged certain limitations of the study, including its small sample size and single-center design. The researchers reported having no financial disclosures.

[email protected]

AUSTIN – After searching online for information about a suspected pediatric dermatologic condition, one in five parents and/or pediatric patients make dermatology appointments sooner than they normally would, results from a novel survey showed.

In an interview at the annual meeting of the Society for Pediatric Dermatology, study author Jamie P. Schlarbaum noted that about one-third of Americans use the Internet to research their condition or symptoms prior to visiting a physician, mostly through Google. “While nearly 50% of parents look up health care information online for their children, rashes were the most common search in pediatrics in 2011,” said Mr. Schlarbaum, who is a fourth-year medical student at the University of Minnesota, Minneapolis. “However, no studies have examined the characteristics and implications of these searches; our study is the first in pediatric dermatology and also adds a new dimension to concern in an online era: How these searches influence health care behaviors.”

During February 2018–February 2019, Kristen Hook, MD, a pediatric dermatologist in Minneapolis and the study’s principal investigator, and Mr. Schlarbaum administered a survey to 220 parents/guardians and pediatric patients who had appointments in pediatric dermatology at a University of Minnesota clinic. The survey consisted of questions about demographics, search tools, search terms, and health care decisions based on this information.

Of the 220 respondents, more than half (59%) did not use an online search engine/tool prior to their appointment. Compared with parents who did not use an online search tool, those who did were slightly younger (34 vs. 36 years, respectively), more likely to be college educated (68% vs. 48%), and less likely to have the patient in question be their first child (37% vs. 52%).

Google ranked as the most common search engine used by the survey respondents (92%), followed distantly by WebMD (18%). About 15% of respondents became more concerned about the pediatric skin condition after searching online, and 20% made appointments sooner because of the information they gleaned from their searches. “Online dermatology clearly has an influence on care today,” Mr. Schlarbaum said. “As we become an even more technologically advanced and dependent society, we anticipate that both of these numbers will grow.”

The researchers also found that survey respondents self-diagnosed a number of dermatologic conditions based on their time spent online, including eczema (33%), moles (15%), and infections (11%). “The big takeaway [from this study] is to ask your parents and teenagers if they’ve looked up information online,” Mr. Schlarbaum said. “Whether it’s photos of the ‘worst cases’ or concerning differentials that might pop up, it’s worth it to take a few seconds to ask what they’re worried about and why.”

He acknowledged certain limitations of the study, including its small sample size and single-center design. The researchers reported having no financial disclosures.

[email protected]

AUSTIN, TEX. – Topical calcineurin inhibitors (TCIs) are an effective therapeutic option for pediatric patients with periorificial dermatitis (POD), as monotherapy or as part of a combination regimen, results from a retrospective cohort study showed.

The mainstays of treatment for POD include topical and oral antibiotics. In an interview prior to the annual meeting of the Society for Pediatric Dermatology, Ayelet Ollech, MD, said that the most common systemic agents used include erythromycin, azithromycin, and, in patients older than 8-10 years of age, minocycline or doxycycline. Topical agents, which are often used as monotherapy in mild disease, include metronidazole, clindamycin, erythromycin, sodium sulfacetamide, and, less often, azelaic acid, topical retinoids, and ivermectin. “TCIs (pimecrolimus 1% cream and tacrolimus 0.03% or 0.1% ointment) are a good steroid sparing option for POD,” said Dr. Ollech, a pediatric dermatology fellow at Ann & Robert H. Lurie Children’s Hospital of Chicago. “In the adult population, two randomized controlled studies of pimecrolimus 1% cream showed good results. In the pediatric population, there are only a few case series and case reports of TCIs for the treatment of POD.”

In what is believed to be the largest study of its kind, Dr. Ollech, Anthony J. Mancini, MD, and colleagues assessed the clinical utility of TCI in 132 pediatric patients with POD who were treated in the division of dermatology at Children’s Hospital of Chicago between 2008 and 2018. The researchers made note of epidemiologic variables, personal and family medical histories, possible triggers, duration of illness, previous treatments, distribution (periocular, perinasal, perioral, extra facial regions), severity of POD, treatment(s) prescribed, duration of therapy, clinical response, recurrences, and side effects. In an effort to capture missing data, the researchers performed follow-up via telephone for all patients who lacked appropriate follow-up documentation in the medical record.

Of the 132 patients, the female: male ratio was 1.2:1 and the median age at diagnosis was 4.2 years. About one-third of patients (33%) had involvement of one region, 38% had involvement of two regions, 26% had involvement of three regions, and 3% patients had involvement of all regions. The most common disorders on medical history were atopic dermatitis and asthma (in 29% and 17% of patients, respectively).


Dr. Ollech reported that 72 of the 132 patients (55%) had evaluable follow up data via either medical record documentation or the phone questionnaire. Of these, 67% were treated with TCI alone, 19% were treated with a combination of TCI and topical metronidazole, and 10% were treated with a combination of TCI and a systemic antibiotic. The median duration of treatment was 60 days. The researchers observed complete response in 65% of patients treated with TCI alone, in 64% of those treated with TCI and metronidazole, and in 70% of those treated with TCI and a systemic antibiotic. Adverse events attributed to TCI were rare and mild in severity.

“We were surprised that there were almost no reported side effects from the usage of TCIs as it is known that these agents can cause a burning or stinging sensation,” Dr. Ollech said. “Only one case described this side effect. We found 30% of the patients to have associated atopic dermatitis (AD) as well as a few patients with irritant dermatitis. We were also surprised how convenient the TCI treatment was for a patient who had POD and concomitant facial AD or even irritant dermatitis as an agent that can treat both. This can be very helpful for the parents that apply the medication to have a single solution to more than one rash.”

The researchers noted recurrence of POD in 14% of patients overall, including 6% of patients treated with TCI alone, 29% of patients treated with TCI and metronidazole, and 30% of patients treated with TCI and a systemic antibiotic.

Dr. Ollech acknowledged certain limitations of the study, including its retrospective design and lack of a control group. She and her colleagues reported having no financial disclosures.

[email protected]

SOURCE: Ollech A et al. SPD 2019, poster 23.

AUSTIN, TEX. – Topical calcineurin inhibitors (TCIs) are an effective therapeutic option for pediatric patients with periorificial dermatitis (POD), as monotherapy or as part of a combination regimen, results from a retrospective cohort study showed.

The mainstays of treatment for POD include topical and oral antibiotics. In an interview prior to the annual meeting of the Society for Pediatric Dermatology, Ayelet Ollech, MD, said that the most common systemic agents used include erythromycin, azithromycin, and, in patients older than 8-10 years of age, minocycline or doxycycline. Topical agents, which are often used as monotherapy in mild disease, include metronidazole, clindamycin, erythromycin, sodium sulfacetamide, and, less often, azelaic acid, topical retinoids, and ivermectin. “TCIs (pimecrolimus 1% cream and tacrolimus 0.03% or 0.1% ointment) are a good steroid sparing option for POD,” said Dr. Ollech, a pediatric dermatology fellow at Ann & Robert H. Lurie Children’s Hospital of Chicago. “In the adult population, two randomized controlled studies of pimecrolimus 1% cream showed good results. In the pediatric population, there are only a few case series and case reports of TCIs for the treatment of POD.”

In what is believed to be the largest study of its kind, Dr. Ollech, Anthony J. Mancini, MD, and colleagues assessed the clinical utility of TCI in 132 pediatric patients with POD who were treated in the division of dermatology at Children’s Hospital of Chicago between 2008 and 2018. The researchers made note of epidemiologic variables, personal and family medical histories, possible triggers, duration of illness, previous treatments, distribution (periocular, perinasal, perioral, extra facial regions), severity of POD, treatment(s) prescribed, duration of therapy, clinical response, recurrences, and side effects. In an effort to capture missing data, the researchers performed follow-up via telephone for all patients who lacked appropriate follow-up documentation in the medical record.

Of the 132 patients, the female: male ratio was 1.2:1 and the median age at diagnosis was 4.2 years. About one-third of patients (33%) had involvement of one region, 38% had involvement of two regions, 26% had involvement of three regions, and 3% patients had involvement of all regions. The most common disorders on medical history were atopic dermatitis and asthma (in 29% and 17% of patients, respectively).


Dr. Ollech reported that 72 of the 132 patients (55%) had evaluable follow up data via either medical record documentation or the phone questionnaire. Of these, 67% were treated with TCI alone, 19% were treated with a combination of TCI and topical metronidazole, and 10% were treated with a combination of TCI and a systemic antibiotic. The median duration of treatment was 60 days. The researchers observed complete response in 65% of patients treated with TCI alone, in 64% of those treated with TCI and metronidazole, and in 70% of those treated with TCI and a systemic antibiotic. Adverse events attributed to TCI were rare and mild in severity.

“We were surprised that there were almost no reported side effects from the usage of TCIs as it is known that these agents can cause a burning or stinging sensation,” Dr. Ollech said. “Only one case described this side effect. We found 30% of the patients to have associated atopic dermatitis (AD) as well as a few patients with irritant dermatitis. We were also surprised how convenient the TCI treatment was for a patient who had POD and concomitant facial AD or even irritant dermatitis as an agent that can treat both. This can be very helpful for the parents that apply the medication to have a single solution to more than one rash.”

The researchers noted recurrence of POD in 14% of patients overall, including 6% of patients treated with TCI alone, 29% of patients treated with TCI and metronidazole, and 30% of patients treated with TCI and a systemic antibiotic.

Dr. Ollech acknowledged certain limitations of the study, including its retrospective design and lack of a control group. She and her colleagues reported having no financial disclosures.

[email protected]

SOURCE: Ollech A et al. SPD 2019, poster 23.

AUSTIN, TEX. – Topical calcineurin inhibitors (TCIs) are an effective therapeutic option for pediatric patients with periorificial dermatitis (POD), as monotherapy or as part of a combination regimen, results from a retrospective cohort study showed.

The mainstays of treatment for POD include topical and oral antibiotics. In an interview prior to the annual meeting of the Society for Pediatric Dermatology, Ayelet Ollech, MD, said that the most common systemic agents used include erythromycin, azithromycin, and, in patients older than 8-10 years of age, minocycline or doxycycline. Topical agents, which are often used as monotherapy in mild disease, include metronidazole, clindamycin, erythromycin, sodium sulfacetamide, and, less often, azelaic acid, topical retinoids, and ivermectin. “TCIs (pimecrolimus 1% cream and tacrolimus 0.03% or 0.1% ointment) are a good steroid sparing option for POD,” said Dr. Ollech, a pediatric dermatology fellow at Ann & Robert H. Lurie Children’s Hospital of Chicago. “In the adult population, two randomized controlled studies of pimecrolimus 1% cream showed good results. In the pediatric population, there are only a few case series and case reports of TCIs for the treatment of POD.”

In what is believed to be the largest study of its kind, Dr. Ollech, Anthony J. Mancini, MD, and colleagues assessed the clinical utility of TCI in 132 pediatric patients with POD who were treated in the division of dermatology at Children’s Hospital of Chicago between 2008 and 2018. The researchers made note of epidemiologic variables, personal and family medical histories, possible triggers, duration of illness, previous treatments, distribution (periocular, perinasal, perioral, extra facial regions), severity of POD, treatment(s) prescribed, duration of therapy, clinical response, recurrences, and side effects. In an effort to capture missing data, the researchers performed follow-up via telephone for all patients who lacked appropriate follow-up documentation in the medical record.

Of the 132 patients, the female: male ratio was 1.2:1 and the median age at diagnosis was 4.2 years. About one-third of patients (33%) had involvement of one region, 38% had involvement of two regions, 26% had involvement of three regions, and 3% patients had involvement of all regions. The most common disorders on medical history were atopic dermatitis and asthma (in 29% and 17% of patients, respectively).


Dr. Ollech reported that 72 of the 132 patients (55%) had evaluable follow up data via either medical record documentation or the phone questionnaire. Of these, 67% were treated with TCI alone, 19% were treated with a combination of TCI and topical metronidazole, and 10% were treated with a combination of TCI and a systemic antibiotic. The median duration of treatment was 60 days. The researchers observed complete response in 65% of patients treated with TCI alone, in 64% of those treated with TCI and metronidazole, and in 70% of those treated with TCI and a systemic antibiotic. Adverse events attributed to TCI were rare and mild in severity.

“We were surprised that there were almost no reported side effects from the usage of TCIs as it is known that these agents can cause a burning or stinging sensation,” Dr. Ollech said. “Only one case described this side effect. We found 30% of the patients to have associated atopic dermatitis (AD) as well as a few patients with irritant dermatitis. We were also surprised how convenient the TCI treatment was for a patient who had POD and concomitant facial AD or even irritant dermatitis as an agent that can treat both. This can be very helpful for the parents that apply the medication to have a single solution to more than one rash.”

The researchers noted recurrence of POD in 14% of patients overall, including 6% of patients treated with TCI alone, 29% of patients treated with TCI and metronidazole, and 30% of patients treated with TCI and a systemic antibiotic.

Dr. Ollech acknowledged certain limitations of the study, including its retrospective design and lack of a control group. She and her colleagues reported having no financial disclosures.

[email protected]

SOURCE: Ollech A et al. SPD 2019, poster 23.

AUSTIN, TEX. – The majority of skin-related pediatric inpatient admissions in the United States involve treatment for cellulitis, results from a large study of national data showed.

“Skin conditions significantly affect pediatric inpatients, and dermatologists ought be accessible for consultation to enhance care and costs,” the study’s first author, Marcus L. Elias, said in an interview prior to the annual meeting of the Society for Pediatric Dermatology.

According to Mr. Elias, who is a 4th-year medical student at Rutgers New Jersey Medical School–Newark, few national studies on skin diseases for pediatric inpatients have been published in the medical literature. Earlier this year, researchers examined inpatient dermatologic conditions in patients aged 18 years and older (J Am Acad Dermatol 2019;80[2]:425-32), but Mr. Elias and associates set out to analyze the burden of inpatient pediatric dermatologic conditions on a national basis. “We wanted to see if the same conditions that were hospitalizing adults were also hospitalizing kids,” he said. “We found that this was indeed the case.”

The researchers queried the National Inpatient Sample database for all cases involving patients aged 18 years and younger during 2001-2013. The search yielded a sample of 16,837,857 patients. From this, the researchers analyzed diagnosis-related groups for dermatologic conditions denoting the principal diagnosis at discharge, which left a final sample of 84,090 patients. Frequency and chi-squared tests were used to analyze categorical variables.

More than half of patients (54%) were male, 36% were white, 48% had Medicaid insurance, and 43% had private insurance. Mr. Elias reported that the median length of stay for patients was 2 days and the median cost of care was $6,289.50 for each case. More than three-quarters of pediatric inpatients with dermatologic diagnoses were treated for “cellulitis” (66,147 cases, or 79%), with most cases involving the legs (16,875 cases, or 20%). Other pediatric inpatients were admitted for “minor skin disorder without complications” (5,458 cases, or 7%), and “minor skin disorder with complications” (2,822 cases, or 3%). A total of 64 patients died during the study period. Of these, 31 cases (50%) involved “skin graft and/or debridement of skin ulcer or cellulitis without complications,” the study found.

“We were surprised that the major cause of mortality for our patients was classified as ‘skin graft and/or debridement of skin ulcer or cellulitis without complications,’ as a similar diagnosis-related groupings exist denoting that complications did arise,” Mr. Elias said. “Still, it is not possible for us to determine if the mortality was from the skin graft/debridement or another cause entirely. It is possible that the procedure was without complications, only to have the patient succumb to an ancillary process.”

He acknowledged certain limitations of the study, including the fact that the function of dermatologic consults for hospitalized patients was not examined. “We also cannot draw conclusions as to whether improved outpatient therapy reduces the need for hospitalization,” he said. Mr. Elias reported having no financial disclosures.

[email protected]

AUSTIN, TEX. – The majority of skin-related pediatric inpatient admissions in the United States involve treatment for cellulitis, results from a large study of national data showed.

“Skin conditions significantly affect pediatric inpatients, and dermatologists ought be accessible for consultation to enhance care and costs,” the study’s first author, Marcus L. Elias, said in an interview prior to the annual meeting of the Society for Pediatric Dermatology.

According to Mr. Elias, who is a 4th-year medical student at Rutgers New Jersey Medical School–Newark, few national studies on skin diseases for pediatric inpatients have been published in the medical literature. Earlier this year, researchers examined inpatient dermatologic conditions in patients aged 18 years and older (J Am Acad Dermatol 2019;80[2]:425-32), but Mr. Elias and associates set out to analyze the burden of inpatient pediatric dermatologic conditions on a national basis. “We wanted to see if the same conditions that were hospitalizing adults were also hospitalizing kids,” he said. “We found that this was indeed the case.”

The researchers queried the National Inpatient Sample database for all cases involving patients aged 18 years and younger during 2001-2013. The search yielded a sample of 16,837,857 patients. From this, the researchers analyzed diagnosis-related groups for dermatologic conditions denoting the principal diagnosis at discharge, which left a final sample of 84,090 patients. Frequency and chi-squared tests were used to analyze categorical variables.

More than half of patients (54%) were male, 36% were white, 48% had Medicaid insurance, and 43% had private insurance. Mr. Elias reported that the median length of stay for patients was 2 days and the median cost of care was $6,289.50 for each case. More than three-quarters of pediatric inpatients with dermatologic diagnoses were treated for “cellulitis” (66,147 cases, or 79%), with most cases involving the legs (16,875 cases, or 20%). Other pediatric inpatients were admitted for “minor skin disorder without complications” (5,458 cases, or 7%), and “minor skin disorder with complications” (2,822 cases, or 3%). A total of 64 patients died during the study period. Of these, 31 cases (50%) involved “skin graft and/or debridement of skin ulcer or cellulitis without complications,” the study found.

“We were surprised that the major cause of mortality for our patients was classified as ‘skin graft and/or debridement of skin ulcer or cellulitis without complications,’ as a similar diagnosis-related groupings exist denoting that complications did arise,” Mr. Elias said. “Still, it is not possible for us to determine if the mortality was from the skin graft/debridement or another cause entirely. It is possible that the procedure was without complications, only to have the patient succumb to an ancillary process.”

He acknowledged certain limitations of the study, including the fact that the function of dermatologic consults for hospitalized patients was not examined. “We also cannot draw conclusions as to whether improved outpatient therapy reduces the need for hospitalization,” he said. Mr. Elias reported having no financial disclosures.

[email protected]

AUSTIN, TEX. – The majority of skin-related pediatric inpatient admissions in the United States involve treatment for cellulitis, results from a large study of national data showed.

“Skin conditions significantly affect pediatric inpatients, and dermatologists ought be accessible for consultation to enhance care and costs,” the study’s first author, Marcus L. Elias, said in an interview prior to the annual meeting of the Society for Pediatric Dermatology.

According to Mr. Elias, who is a 4th-year medical student at Rutgers New Jersey Medical School–Newark, few national studies on skin diseases for pediatric inpatients have been published in the medical literature. Earlier this year, researchers examined inpatient dermatologic conditions in patients aged 18 years and older (J Am Acad Dermatol 2019;80[2]:425-32), but Mr. Elias and associates set out to analyze the burden of inpatient pediatric dermatologic conditions on a national basis. “We wanted to see if the same conditions that were hospitalizing adults were also hospitalizing kids,” he said. “We found that this was indeed the case.”

The researchers queried the National Inpatient Sample database for all cases involving patients aged 18 years and younger during 2001-2013. The search yielded a sample of 16,837,857 patients. From this, the researchers analyzed diagnosis-related groups for dermatologic conditions denoting the principal diagnosis at discharge, which left a final sample of 84,090 patients. Frequency and chi-squared tests were used to analyze categorical variables.

More than half of patients (54%) were male, 36% were white, 48% had Medicaid insurance, and 43% had private insurance. Mr. Elias reported that the median length of stay for patients was 2 days and the median cost of care was $6,289.50 for each case. More than three-quarters of pediatric inpatients with dermatologic diagnoses were treated for “cellulitis” (66,147 cases, or 79%), with most cases involving the legs (16,875 cases, or 20%). Other pediatric inpatients were admitted for “minor skin disorder without complications” (5,458 cases, or 7%), and “minor skin disorder with complications” (2,822 cases, or 3%). A total of 64 patients died during the study period. Of these, 31 cases (50%) involved “skin graft and/or debridement of skin ulcer or cellulitis without complications,” the study found.

“We were surprised that the major cause of mortality for our patients was classified as ‘skin graft and/or debridement of skin ulcer or cellulitis without complications,’ as a similar diagnosis-related groupings exist denoting that complications did arise,” Mr. Elias said. “Still, it is not possible for us to determine if the mortality was from the skin graft/debridement or another cause entirely. It is possible that the procedure was without complications, only to have the patient succumb to an ancillary process.”

He acknowledged certain limitations of the study, including the fact that the function of dermatologic consults for hospitalized patients was not examined. “We also cannot draw conclusions as to whether improved outpatient therapy reduces the need for hospitalization,” he said. Mr. Elias reported having no financial disclosures.

[email protected]

AUSTIN – The duration of neonatal intensive care unit (NICU) exposure decreases the risk of atopic dermatitis (AD), results from a large single-center study demonstrated.

“While more time in the NICU is associated with a lesser risk of developing atopic dermatitis, we certainly do not want to keep infants in the NICU longer in order to lower their risk of atopic dermatitis,” the study’s first author, Jennifer J. Schoch, MD, said in an interview prior to the annual meeting of the Society for Pediatric Dermatology. “Instead, we need to work on understanding the mechanisms behind this relationship. For example, are there certain exposures in the NICU that influence the cutaneous immunity to ultimately reduce the risk of atopic dermatitis?”

According to Dr. Schoch, a pediatric dermatologist at the University of Florida, Gainesville, the medical literature has been conflicted regarding the relationship between prematurity and eczema. A recent meta-analysis of 18 studies found an association between very preterm birth and a decreased risk of eczema, yet the risk became insignificant among children born moderately preterm (J Am Acad Dermatol. 2018;78[6]:1142-8). However, the factors contributing to this relationship are not well understood.

In an effort to explore the infant, maternal, and environmental factors of infants who developed AD, compared with infants who did not, Dr. Schoch and colleagues evaluated infants who were born at University of Florida Health from June 1, 2011, to April 30, 2017; had at least two well-child visits; and had at least one visit at 300 days old or later. The researchers included 4,016 mother-infant dyads in the study. Atopic dermatitis was diagnosed in 26.5% of the infants. Factors significantly associated with the incidence of AD were delivery mode (P = .0127), NICU stay (P = .0001), gestational age (P = .0006), and birth weight (P = .0020). Specifically, infants had a higher risk of developing AD if they were delivered vaginally, did not stay in the NICU, had a higher gestational age, or had a higher birth weight. Extremely preterm (less than 28 weeks’ gestation) and very preterm (28 to less than 32 weeks’ gestation) infants had the lowest rates of AD, at 10.9% and 19%, respectively.

When the researchers adjusted for other variables to their model, only length of stay in the NICU was related to the development of AD. Specifically, infants who spent more time in the NICU had a lower risk of developing atopic dermatitis (P = .0039).

“We were surprised to find that the length of stay in the neonatal intensive care unit was the strongest protective factor against the future development of eczema,” Dr. Schoch said. “Instead of this relationship being mediated by gestational age or birth weight, it was how much time the infants spent in the NICU that seemed to ‘protect’ from future eczema.”

She acknowledged certain limitations of the study, including its retrospective design with data gathered from electronic medical records. Also, “diagnosis was determined by ICD-9 or ICD-10 code, and not confirmed by dermatologists,” she said.

In their abstract, the researchers wrote that the finding highlights “the importance of early life interactions between the microbiome, developing cutaneous immunity, and the evolving skin barrier of the preterm infant. The skin microbiome of premature infants differs from full-term infants, in that the premature infant cutaneous microbiome is dominated by Staphylococcus species” (Microbiome. 2018;6[1]:98). They added that “the early presence of Staphylococcus on the skin may confer protection.”

Dr. Schoch reported having no relevant financial disclosures.

[email protected]

SOURCE: Schoch J et al. SPD 2019, Poster 2.

AUSTIN – The duration of neonatal intensive care unit (NICU) exposure decreases the risk of atopic dermatitis (AD), results from a large single-center study demonstrated.

“While more time in the NICU is associated with a lesser risk of developing atopic dermatitis, we certainly do not want to keep infants in the NICU longer in order to lower their risk of atopic dermatitis,” the study’s first author, Jennifer J. Schoch, MD, said in an interview prior to the annual meeting of the Society for Pediatric Dermatology. “Instead, we need to work on understanding the mechanisms behind this relationship. For example, are there certain exposures in the NICU that influence the cutaneous immunity to ultimately reduce the risk of atopic dermatitis?”

According to Dr. Schoch, a pediatric dermatologist at the University of Florida, Gainesville, the medical literature has been conflicted regarding the relationship between prematurity and eczema. A recent meta-analysis of 18 studies found an association between very preterm birth and a decreased risk of eczema, yet the risk became insignificant among children born moderately preterm (J Am Acad Dermatol. 2018;78[6]:1142-8). However, the factors contributing to this relationship are not well understood.

In an effort to explore the infant, maternal, and environmental factors of infants who developed AD, compared with infants who did not, Dr. Schoch and colleagues evaluated infants who were born at University of Florida Health from June 1, 2011, to April 30, 2017; had at least two well-child visits; and had at least one visit at 300 days old or later. The researchers included 4,016 mother-infant dyads in the study. Atopic dermatitis was diagnosed in 26.5% of the infants. Factors significantly associated with the incidence of AD were delivery mode (P = .0127), NICU stay (P = .0001), gestational age (P = .0006), and birth weight (P = .0020). Specifically, infants had a higher risk of developing AD if they were delivered vaginally, did not stay in the NICU, had a higher gestational age, or had a higher birth weight. Extremely preterm (less than 28 weeks’ gestation) and very preterm (28 to less than 32 weeks’ gestation) infants had the lowest rates of AD, at 10.9% and 19%, respectively.

When the researchers adjusted for other variables to their model, only length of stay in the NICU was related to the development of AD. Specifically, infants who spent more time in the NICU had a lower risk of developing atopic dermatitis (P = .0039).

“We were surprised to find that the length of stay in the neonatal intensive care unit was the strongest protective factor against the future development of eczema,” Dr. Schoch said. “Instead of this relationship being mediated by gestational age or birth weight, it was how much time the infants spent in the NICU that seemed to ‘protect’ from future eczema.”

She acknowledged certain limitations of the study, including its retrospective design with data gathered from electronic medical records. Also, “diagnosis was determined by ICD-9 or ICD-10 code, and not confirmed by dermatologists,” she said.

In their abstract, the researchers wrote that the finding highlights “the importance of early life interactions between the microbiome, developing cutaneous immunity, and the evolving skin barrier of the preterm infant. The skin microbiome of premature infants differs from full-term infants, in that the premature infant cutaneous microbiome is dominated by Staphylococcus species” (Microbiome. 2018;6[1]:98). They added that “the early presence of Staphylococcus on the skin may confer protection.”

Dr. Schoch reported having no relevant financial disclosures.

[email protected]

SOURCE: Schoch J et al. SPD 2019, Poster 2.

AUSTIN – The duration of neonatal intensive care unit (NICU) exposure decreases the risk of atopic dermatitis (AD), results from a large single-center study demonstrated.

“While more time in the NICU is associated with a lesser risk of developing atopic dermatitis, we certainly do not want to keep infants in the NICU longer in order to lower their risk of atopic dermatitis,” the study’s first author, Jennifer J. Schoch, MD, said in an interview prior to the annual meeting of the Society for Pediatric Dermatology. “Instead, we need to work on understanding the mechanisms behind this relationship. For example, are there certain exposures in the NICU that influence the cutaneous immunity to ultimately reduce the risk of atopic dermatitis?”

According to Dr. Schoch, a pediatric dermatologist at the University of Florida, Gainesville, the medical literature has been conflicted regarding the relationship between prematurity and eczema. A recent meta-analysis of 18 studies found an association between very preterm birth and a decreased risk of eczema, yet the risk became insignificant among children born moderately preterm (J Am Acad Dermatol. 2018;78[6]:1142-8). However, the factors contributing to this relationship are not well understood.

In an effort to explore the infant, maternal, and environmental factors of infants who developed AD, compared with infants who did not, Dr. Schoch and colleagues evaluated infants who were born at University of Florida Health from June 1, 2011, to April 30, 2017; had at least two well-child visits; and had at least one visit at 300 days old or later. The researchers included 4,016 mother-infant dyads in the study. Atopic dermatitis was diagnosed in 26.5% of the infants. Factors significantly associated with the incidence of AD were delivery mode (P = .0127), NICU stay (P = .0001), gestational age (P = .0006), and birth weight (P = .0020). Specifically, infants had a higher risk of developing AD if they were delivered vaginally, did not stay in the NICU, had a higher gestational age, or had a higher birth weight. Extremely preterm (less than 28 weeks’ gestation) and very preterm (28 to less than 32 weeks’ gestation) infants had the lowest rates of AD, at 10.9% and 19%, respectively.

When the researchers adjusted for other variables to their model, only length of stay in the NICU was related to the development of AD. Specifically, infants who spent more time in the NICU had a lower risk of developing atopic dermatitis (P = .0039).

“We were surprised to find that the length of stay in the neonatal intensive care unit was the strongest protective factor against the future development of eczema,” Dr. Schoch said. “Instead of this relationship being mediated by gestational age or birth weight, it was how much time the infants spent in the NICU that seemed to ‘protect’ from future eczema.”

She acknowledged certain limitations of the study, including its retrospective design with data gathered from electronic medical records. Also, “diagnosis was determined by ICD-9 or ICD-10 code, and not confirmed by dermatologists,” she said.

In their abstract, the researchers wrote that the finding highlights “the importance of early life interactions between the microbiome, developing cutaneous immunity, and the evolving skin barrier of the preterm infant. The skin microbiome of premature infants differs from full-term infants, in that the premature infant cutaneous microbiome is dominated by Staphylococcus species” (Microbiome. 2018;6[1]:98). They added that “the early presence of Staphylococcus on the skin may confer protection.”

Dr. Schoch reported having no relevant financial disclosures.

[email protected]

SOURCE: Schoch J et al. SPD 2019, Poster 2.

SAN ANTONIO – Continuous positive airway pressure (CPAP) adherence varies by age, sex, and date of setup, results from an analysis of national data showed.

Courtesy Dr. Krishna Sundar

However, whether the sources of variability stem from patient factors such as disease severity and socioeconomic status, provider factors, environmental factors, or selection biases in those who are diagnosed with obstructive sleep apnea and treated with CPAP remains to be understood, lead study author Sanjay R. Patel, MD, said at the annual meeting of the Associated Professional Sleep Societies.

In 2015, the American Academy of Sleep Medicine (AASM) endorsed CPAP adherence as a process measure, and the Centers for Medicare and Medicaid Services has used CPAP adherence as an outcome measure to limit long-term coverage of the therapy. It defines CPAP adherence as 4 or more hours of use on greater than 70% of nights in a consecutive 30-day period within the first 90 days. “Strengths of CPAP adherence as an outcome measure include the fact that it is easy to measure and it predicts improvement in sleepiness, quality of life, and blood pressure control,” said Dr. Patel, who directs the University of Pittsburgh’s Center for Sleep and Cardiovascular Outcomes Research. “One issue as to whether we should use CPAP adherence as an outcome-based quality of care measure is, does variability reflect performance at the provider and/or health care system?”

In an effort to describe CPAP adherence rates in general clinical practice as well as sources of variability, Dr. Patel and colleagues evaluated telemonitoring data maintained by Philips Respironics. The study population consisted of 714,270 patients initiated on CPAP therapy between November 2015 and August 2018 who had at least one usage session of CPAP or APAP.

Overall, 90-day adherence to CPAP was 72.5%. Age, sex, and state of residence were all significantly associated with adherence rates (P less than .05). Specifically, adherence rates ranged from 54.8% among those 18-30 years of age to 79.1% among those 61-70 years of age. “There was a plateauing of adherence rates among those in their 70s, and men tended to have a higher adherence level than women across all age groups (73.3% vs. 71.4%, respectively),” he said. “Also, people who got started on CPAP in January had a higher level of adherence than people who got started in May. The differences are relatively small compared to the large age differences, but there was a consistent trend.”


When the researchers carried out age- and sex-adjusted analyses, they observed that adherence rates were lowest in the Northeast and Southwest and highest in the Upper Midwest and Mountain West. Adherence rates ranged from 50.8% in the District of Columbia and 60.5% in New York up to 81.2% in Idaho and 81.9% in South Dakota.

“The question is, is this variability explained by quality measures?” Dr. Patel asked. “We tried to answer this question by seeing whether the variability in adherence by location correlated with other metrics of health care quality.” To accomplish this, they used Dartmouth Atlas, a project that uses Medicare data to understand drivers of health care spending and quality. To understand geographic variability in CPAP adherence, they mapped ZIP codes onto hospital referral regions (HRRs), which are regional health care markets for tertiary medical care. Each HRR has at least one hospital that performs major cardiovascular procedures and neurosurgery. ZIP codes were mapped to 306 HRRs where the majority of residents get their tertiary care.

The researchers observed that Medicare enrollees who saw a primary care physician in the past 12 months had higher rates of adherence, compared with those who did not. “Twenty-three percent of the variance in CPAP adherence across the country can be explained by this measure of having a primary care doctor,” Dr. Patel said. In addition, patients who received care from HRRs located in the middle of the United States had high adherence rates. Top performers were facilities located in Madison, Wis.; Wausau, Wis.; Dubuque, Iowa; and Bloomington, Ill. Poor performers included facilities located in the boroughs of Manhattan and the Bronx, in New York; Muskegon, Mich.; Miami; and Buffalo, N.Y.

“Some of the geographical variability may be due to patient factors such as race, income, and education level,” Dr. Patel said. “That will need to be appropriately addressed in developing a quality of care measure. Nevertheless, some of the geographic variability appears to be related to health care system and provider factors. This variability could be potentially reduced through implementation of a CPAP adherence quality outcome measure.”

Dr. Patel disclosed that he has received grant/research support from Bayer Pharmaceuticals and Philips Respironics, and has served as a consultant to the American Academy of Sleep Medicine.

[email protected]

SOURCE: Patel SR et al. SLEEP 2019, Abstract 0513.

SAN ANTONIO – Continuous positive airway pressure (CPAP) adherence varies by age, sex, and date of setup, results from an analysis of national data showed.

Courtesy Dr. Krishna Sundar

However, whether the sources of variability stem from patient factors such as disease severity and socioeconomic status, provider factors, environmental factors, or selection biases in those who are diagnosed with obstructive sleep apnea and treated with CPAP remains to be understood, lead study author Sanjay R. Patel, MD, said at the annual meeting of the Associated Professional Sleep Societies.

In 2015, the American Academy of Sleep Medicine (AASM) endorsed CPAP adherence as a process measure, and the Centers for Medicare and Medicaid Services has used CPAP adherence as an outcome measure to limit long-term coverage of the therapy. It defines CPAP adherence as 4 or more hours of use on greater than 70% of nights in a consecutive 30-day period within the first 90 days. “Strengths of CPAP adherence as an outcome measure include the fact that it is easy to measure and it predicts improvement in sleepiness, quality of life, and blood pressure control,” said Dr. Patel, who directs the University of Pittsburgh’s Center for Sleep and Cardiovascular Outcomes Research. “One issue as to whether we should use CPAP adherence as an outcome-based quality of care measure is, does variability reflect performance at the provider and/or health care system?”

In an effort to describe CPAP adherence rates in general clinical practice as well as sources of variability, Dr. Patel and colleagues evaluated telemonitoring data maintained by Philips Respironics. The study population consisted of 714,270 patients initiated on CPAP therapy between November 2015 and August 2018 who had at least one usage session of CPAP or APAP.

Overall, 90-day adherence to CPAP was 72.5%. Age, sex, and state of residence were all significantly associated with adherence rates (P less than .05). Specifically, adherence rates ranged from 54.8% among those 18-30 years of age to 79.1% among those 61-70 years of age. “There was a plateauing of adherence rates among those in their 70s, and men tended to have a higher adherence level than women across all age groups (73.3% vs. 71.4%, respectively),” he said. “Also, people who got started on CPAP in January had a higher level of adherence than people who got started in May. The differences are relatively small compared to the large age differences, but there was a consistent trend.”


When the researchers carried out age- and sex-adjusted analyses, they observed that adherence rates were lowest in the Northeast and Southwest and highest in the Upper Midwest and Mountain West. Adherence rates ranged from 50.8% in the District of Columbia and 60.5% in New York up to 81.2% in Idaho and 81.9% in South Dakota.

“The question is, is this variability explained by quality measures?” Dr. Patel asked. “We tried to answer this question by seeing whether the variability in adherence by location correlated with other metrics of health care quality.” To accomplish this, they used Dartmouth Atlas, a project that uses Medicare data to understand drivers of health care spending and quality. To understand geographic variability in CPAP adherence, they mapped ZIP codes onto hospital referral regions (HRRs), which are regional health care markets for tertiary medical care. Each HRR has at least one hospital that performs major cardiovascular procedures and neurosurgery. ZIP codes were mapped to 306 HRRs where the majority of residents get their tertiary care.

The researchers observed that Medicare enrollees who saw a primary care physician in the past 12 months had higher rates of adherence, compared with those who did not. “Twenty-three percent of the variance in CPAP adherence across the country can be explained by this measure of having a primary care doctor,” Dr. Patel said. In addition, patients who received care from HRRs located in the middle of the United States had high adherence rates. Top performers were facilities located in Madison, Wis.; Wausau, Wis.; Dubuque, Iowa; and Bloomington, Ill. Poor performers included facilities located in the boroughs of Manhattan and the Bronx, in New York; Muskegon, Mich.; Miami; and Buffalo, N.Y.

“Some of the geographical variability may be due to patient factors such as race, income, and education level,” Dr. Patel said. “That will need to be appropriately addressed in developing a quality of care measure. Nevertheless, some of the geographic variability appears to be related to health care system and provider factors. This variability could be potentially reduced through implementation of a CPAP adherence quality outcome measure.”

Dr. Patel disclosed that he has received grant/research support from Bayer Pharmaceuticals and Philips Respironics, and has served as a consultant to the American Academy of Sleep Medicine.

[email protected]

SOURCE: Patel SR et al. SLEEP 2019, Abstract 0513.

SAN ANTONIO – Continuous positive airway pressure (CPAP) adherence varies by age, sex, and date of setup, results from an analysis of national data showed.

Courtesy Dr. Krishna Sundar

However, whether the sources of variability stem from patient factors such as disease severity and socioeconomic status, provider factors, environmental factors, or selection biases in those who are diagnosed with obstructive sleep apnea and treated with CPAP remains to be understood, lead study author Sanjay R. Patel, MD, said at the annual meeting of the Associated Professional Sleep Societies.

In 2015, the American Academy of Sleep Medicine (AASM) endorsed CPAP adherence as a process measure, and the Centers for Medicare and Medicaid Services has used CPAP adherence as an outcome measure to limit long-term coverage of the therapy. It defines CPAP adherence as 4 or more hours of use on greater than 70% of nights in a consecutive 30-day period within the first 90 days. “Strengths of CPAP adherence as an outcome measure include the fact that it is easy to measure and it predicts improvement in sleepiness, quality of life, and blood pressure control,” said Dr. Patel, who directs the University of Pittsburgh’s Center for Sleep and Cardiovascular Outcomes Research. “One issue as to whether we should use CPAP adherence as an outcome-based quality of care measure is, does variability reflect performance at the provider and/or health care system?”

In an effort to describe CPAP adherence rates in general clinical practice as well as sources of variability, Dr. Patel and colleagues evaluated telemonitoring data maintained by Philips Respironics. The study population consisted of 714,270 patients initiated on CPAP therapy between November 2015 and August 2018 who had at least one usage session of CPAP or APAP.

Overall, 90-day adherence to CPAP was 72.5%. Age, sex, and state of residence were all significantly associated with adherence rates (P less than .05). Specifically, adherence rates ranged from 54.8% among those 18-30 years of age to 79.1% among those 61-70 years of age. “There was a plateauing of adherence rates among those in their 70s, and men tended to have a higher adherence level than women across all age groups (73.3% vs. 71.4%, respectively),” he said. “Also, people who got started on CPAP in January had a higher level of adherence than people who got started in May. The differences are relatively small compared to the large age differences, but there was a consistent trend.”


When the researchers carried out age- and sex-adjusted analyses, they observed that adherence rates were lowest in the Northeast and Southwest and highest in the Upper Midwest and Mountain West. Adherence rates ranged from 50.8% in the District of Columbia and 60.5% in New York up to 81.2% in Idaho and 81.9% in South Dakota.

“The question is, is this variability explained by quality measures?” Dr. Patel asked. “We tried to answer this question by seeing whether the variability in adherence by location correlated with other metrics of health care quality.” To accomplish this, they used Dartmouth Atlas, a project that uses Medicare data to understand drivers of health care spending and quality. To understand geographic variability in CPAP adherence, they mapped ZIP codes onto hospital referral regions (HRRs), which are regional health care markets for tertiary medical care. Each HRR has at least one hospital that performs major cardiovascular procedures and neurosurgery. ZIP codes were mapped to 306 HRRs where the majority of residents get their tertiary care.

The researchers observed that Medicare enrollees who saw a primary care physician in the past 12 months had higher rates of adherence, compared with those who did not. “Twenty-three percent of the variance in CPAP adherence across the country can be explained by this measure of having a primary care doctor,” Dr. Patel said. In addition, patients who received care from HRRs located in the middle of the United States had high adherence rates. Top performers were facilities located in Madison, Wis.; Wausau, Wis.; Dubuque, Iowa; and Bloomington, Ill. Poor performers included facilities located in the boroughs of Manhattan and the Bronx, in New York; Muskegon, Mich.; Miami; and Buffalo, N.Y.

“Some of the geographical variability may be due to patient factors such as race, income, and education level,” Dr. Patel said. “That will need to be appropriately addressed in developing a quality of care measure. Nevertheless, some of the geographic variability appears to be related to health care system and provider factors. This variability could be potentially reduced through implementation of a CPAP adherence quality outcome measure.”

Dr. Patel disclosed that he has received grant/research support from Bayer Pharmaceuticals and Philips Respironics, and has served as a consultant to the American Academy of Sleep Medicine.

[email protected]

SOURCE: Patel SR et al. SLEEP 2019, Abstract 0513.

SAN DIEGO – The prevalence of obstructive sleep apnea (OSA) is substantially lower using the Centers for Medicare & Medicaid Services apnea-hypopnea index definition of OSA than using the one recommended by the American Academy of Sleep Medicine.

Doug Brunk/MDedge News

In addition, among individuals who did not have OSA using the CMS definition but met criteria using the AASM definition of OSA, an apnea-hypopnea index (AHI) of five events or greater per hour was associated with a greater likelihood of having hypertension.

The findings come from an analysis which set out to assess the relationship between OSA and hypertension using the AASM-recommended definition and the 2018 American Heart Association/American College of Cardiology blood pressure guidelines, and to determine if there is an association between hypertension and OSA among individuals who did not meet the CMS definition of OSA.

“Given the substantial morbidity associated with hypertension, these results suggest that universal adoption of the AASM AHI definition would be a reasonable step in ensuring appropriate diagnosis and treatment of OSA,” lead study author Stuart F. Quan, MD, said at the annual meeting of the Associated Professional Sleep Societies.

Dr. Quan, of the division of sleep and circadian disorders at Brigham and Women’s Hospital in Boston, noted that a number of studies have demonstrated that OSA is a risk factor for hypertension and a variety of other medical conditions. “Rightly or wrongly, the most important metric for determining whether OSA is present and determining its severity, is the apnea-hypopnea index,” he said. “It’s the most common metric used for determining OSA severity, and mostly importantly, Medicare and some other insurers use this metric to determine whether a person is eligible for treatment. If a person falls above the line, they can get continuous positive airway pressure, for example. If they’re below the line, that’s too bad; they don’t have OSA insofar as the insurance company is concerned.”

There is no controversy as to what constitutes apnea, he continued, but some disagreement exists on the definition of hypopnea. The AASM recommends using a 3% oxygen desaturation or an arousal, while Medicare uses a definition of hypopnea requiring only a 4% oxygen desaturation. Hypertension definitions have changed recently as well. Before 2018, the definition of hypertension was greater than 140/90 mm Hg for people younger than age 65 years and 150/80 mm Hg for people age 65 years and older. In 2018, the AHA and ACC changed the hypertension guidelines, defining normal as less than 120/80 mm Hg.

“Previous studies linking OSA and hypertension used older definitions, but to my knowledge there are no current studies examining the association between OSA and hypertension using new definitions,” Dr. Quan said.

He reported on results from an analysis of 6,307 participants in the Sleep Heart Health Study who underwent home polysomnography. Their AHI defined by a 3% oxygen desaturation or an arousal was classified into four categories of OSA severity: fewer than 5 events per hour (normal sleep), 5-14 events per hour (mild sleep apnea), 15-29 events per hour (moderate sleep apnea), and 30 or more events per hour (severe sleep apnea).

The researchers used three definitions of dichotomous BP elevation: elevated (greater than 120/80 mm Hg or use of hypertension medications [meds]), stage 1 (greater than 130/80 mm Hg or meds), or stage 2 (greater than 140/90 mm Hg or meds). They used logistic regression to assess the association between elevated BP and/or hypertension and OSA severity, controlling for demographics and body mass index. Additional analyses utilized multiple linear regression to determine the relationship between natural log AHI and systolic and diastolic BP, controlling for the same covariates.

For all definitions of elevated BP, increasing OSA severity was associated with greater likelihood of an elevated or hypertensive status in fully adjusted models. Specifically, the odds ratios among those with elevated BP was 1.30 (95% confidence interval, 1.10-1.54), 1.41 (95% CI, 1.15-1.72), and 1.69 (95% CI, 1.32-2.17) for mild, moderate, and severe sleep apnea, respectively. The ORs among those with stage 1 BP was 1.27 (95% CI, 1.09-1.49), 1.36 (95% CI, 1.13-1.63), 1.58 (95% CI, 1.27-1.97) for mild, moderate, and severe sleep apnea, while the OR among those with stage 2 BP was 1.07 (95% CI, 0.92-1.26), 1.22 (95% CI, 1.02-1.45), 1.38 (95% CI, 1.12-1.69) for mild, moderate, and severe sleep apnea. Linear regression found that AHI was associated with both systolic and diastolic BP in fully adjusted models.

“Using the AASM and CMS AHI definitions, increasing severity of AHI is associated with greater likelihood of having an elevated blood pressure or hypertension,” Dr. Quan concluded. “However, the prevalence of OSA was substantially lower using the CMS definition of OSA. In fact, 218 of these individuals had moderate to severe OSA when the AASM definition was applied.”

He characterized the study as “a practical analysis, a way to help identify patients who might benefit from treatment. This is not the issue of whether the science of 3% AHI is better than 4%.”

The Sleep Heart Health Study was supported by the National Heart, Lung, and Blood Institute. Dr. Quan reported that he helped draft the AASM AHI recommendations but had no other relevant disclosures.

[email protected]

SOURCE: Quan SF et al. SLEEP 2019, Abstract 0501.

SAN DIEGO – The prevalence of obstructive sleep apnea (OSA) is substantially lower using the Centers for Medicare & Medicaid Services apnea-hypopnea index definition of OSA than using the one recommended by the American Academy of Sleep Medicine.

Doug Brunk/MDedge News

In addition, among individuals who did not have OSA using the CMS definition but met criteria using the AASM definition of OSA, an apnea-hypopnea index (AHI) of five events or greater per hour was associated with a greater likelihood of having hypertension.

The findings come from an analysis which set out to assess the relationship between OSA and hypertension using the AASM-recommended definition and the 2018 American Heart Association/American College of Cardiology blood pressure guidelines, and to determine if there is an association between hypertension and OSA among individuals who did not meet the CMS definition of OSA.

“Given the substantial morbidity associated with hypertension, these results suggest that universal adoption of the AASM AHI definition would be a reasonable step in ensuring appropriate diagnosis and treatment of OSA,” lead study author Stuart F. Quan, MD, said at the annual meeting of the Associated Professional Sleep Societies.

Dr. Quan, of the division of sleep and circadian disorders at Brigham and Women’s Hospital in Boston, noted that a number of studies have demonstrated that OSA is a risk factor for hypertension and a variety of other medical conditions. “Rightly or wrongly, the most important metric for determining whether OSA is present and determining its severity, is the apnea-hypopnea index,” he said. “It’s the most common metric used for determining OSA severity, and mostly importantly, Medicare and some other insurers use this metric to determine whether a person is eligible for treatment. If a person falls above the line, they can get continuous positive airway pressure, for example. If they’re below the line, that’s too bad; they don’t have OSA insofar as the insurance company is concerned.”

There is no controversy as to what constitutes apnea, he continued, but some disagreement exists on the definition of hypopnea. The AASM recommends using a 3% oxygen desaturation or an arousal, while Medicare uses a definition of hypopnea requiring only a 4% oxygen desaturation. Hypertension definitions have changed recently as well. Before 2018, the definition of hypertension was greater than 140/90 mm Hg for people younger than age 65 years and 150/80 mm Hg for people age 65 years and older. In 2018, the AHA and ACC changed the hypertension guidelines, defining normal as less than 120/80 mm Hg.

“Previous studies linking OSA and hypertension used older definitions, but to my knowledge there are no current studies examining the association between OSA and hypertension using new definitions,” Dr. Quan said.

He reported on results from an analysis of 6,307 participants in the Sleep Heart Health Study who underwent home polysomnography. Their AHI defined by a 3% oxygen desaturation or an arousal was classified into four categories of OSA severity: fewer than 5 events per hour (normal sleep), 5-14 events per hour (mild sleep apnea), 15-29 events per hour (moderate sleep apnea), and 30 or more events per hour (severe sleep apnea).

The researchers used three definitions of dichotomous BP elevation: elevated (greater than 120/80 mm Hg or use of hypertension medications [meds]), stage 1 (greater than 130/80 mm Hg or meds), or stage 2 (greater than 140/90 mm Hg or meds). They used logistic regression to assess the association between elevated BP and/or hypertension and OSA severity, controlling for demographics and body mass index. Additional analyses utilized multiple linear regression to determine the relationship between natural log AHI and systolic and diastolic BP, controlling for the same covariates.

For all definitions of elevated BP, increasing OSA severity was associated with greater likelihood of an elevated or hypertensive status in fully adjusted models. Specifically, the odds ratios among those with elevated BP was 1.30 (95% confidence interval, 1.10-1.54), 1.41 (95% CI, 1.15-1.72), and 1.69 (95% CI, 1.32-2.17) for mild, moderate, and severe sleep apnea, respectively. The ORs among those with stage 1 BP was 1.27 (95% CI, 1.09-1.49), 1.36 (95% CI, 1.13-1.63), 1.58 (95% CI, 1.27-1.97) for mild, moderate, and severe sleep apnea, while the OR among those with stage 2 BP was 1.07 (95% CI, 0.92-1.26), 1.22 (95% CI, 1.02-1.45), 1.38 (95% CI, 1.12-1.69) for mild, moderate, and severe sleep apnea. Linear regression found that AHI was associated with both systolic and diastolic BP in fully adjusted models.

“Using the AASM and CMS AHI definitions, increasing severity of AHI is associated with greater likelihood of having an elevated blood pressure or hypertension,” Dr. Quan concluded. “However, the prevalence of OSA was substantially lower using the CMS definition of OSA. In fact, 218 of these individuals had moderate to severe OSA when the AASM definition was applied.”

He characterized the study as “a practical analysis, a way to help identify patients who might benefit from treatment. This is not the issue of whether the science of 3% AHI is better than 4%.”

The Sleep Heart Health Study was supported by the National Heart, Lung, and Blood Institute. Dr. Quan reported that he helped draft the AASM AHI recommendations but had no other relevant disclosures.

[email protected]

SOURCE: Quan SF et al. SLEEP 2019, Abstract 0501.

SAN DIEGO – The prevalence of obstructive sleep apnea (OSA) is substantially lower using the Centers for Medicare & Medicaid Services apnea-hypopnea index definition of OSA than using the one recommended by the American Academy of Sleep Medicine.

Doug Brunk/MDedge News

In addition, among individuals who did not have OSA using the CMS definition but met criteria using the AASM definition of OSA, an apnea-hypopnea index (AHI) of five events or greater per hour was associated with a greater likelihood of having hypertension.

The findings come from an analysis which set out to assess the relationship between OSA and hypertension using the AASM-recommended definition and the 2018 American Heart Association/American College of Cardiology blood pressure guidelines, and to determine if there is an association between hypertension and OSA among individuals who did not meet the CMS definition of OSA.

“Given the substantial morbidity associated with hypertension, these results suggest that universal adoption of the AASM AHI definition would be a reasonable step in ensuring appropriate diagnosis and treatment of OSA,” lead study author Stuart F. Quan, MD, said at the annual meeting of the Associated Professional Sleep Societies.

Dr. Quan, of the division of sleep and circadian disorders at Brigham and Women’s Hospital in Boston, noted that a number of studies have demonstrated that OSA is a risk factor for hypertension and a variety of other medical conditions. “Rightly or wrongly, the most important metric for determining whether OSA is present and determining its severity, is the apnea-hypopnea index,” he said. “It’s the most common metric used for determining OSA severity, and mostly importantly, Medicare and some other insurers use this metric to determine whether a person is eligible for treatment. If a person falls above the line, they can get continuous positive airway pressure, for example. If they’re below the line, that’s too bad; they don’t have OSA insofar as the insurance company is concerned.”

There is no controversy as to what constitutes apnea, he continued, but some disagreement exists on the definition of hypopnea. The AASM recommends using a 3% oxygen desaturation or an arousal, while Medicare uses a definition of hypopnea requiring only a 4% oxygen desaturation. Hypertension definitions have changed recently as well. Before 2018, the definition of hypertension was greater than 140/90 mm Hg for people younger than age 65 years and 150/80 mm Hg for people age 65 years and older. In 2018, the AHA and ACC changed the hypertension guidelines, defining normal as less than 120/80 mm Hg.

“Previous studies linking OSA and hypertension used older definitions, but to my knowledge there are no current studies examining the association between OSA and hypertension using new definitions,” Dr. Quan said.

He reported on results from an analysis of 6,307 participants in the Sleep Heart Health Study who underwent home polysomnography. Their AHI defined by a 3% oxygen desaturation or an arousal was classified into four categories of OSA severity: fewer than 5 events per hour (normal sleep), 5-14 events per hour (mild sleep apnea), 15-29 events per hour (moderate sleep apnea), and 30 or more events per hour (severe sleep apnea).

The researchers used three definitions of dichotomous BP elevation: elevated (greater than 120/80 mm Hg or use of hypertension medications [meds]), stage 1 (greater than 130/80 mm Hg or meds), or stage 2 (greater than 140/90 mm Hg or meds). They used logistic regression to assess the association between elevated BP and/or hypertension and OSA severity, controlling for demographics and body mass index. Additional analyses utilized multiple linear regression to determine the relationship between natural log AHI and systolic and diastolic BP, controlling for the same covariates.

For all definitions of elevated BP, increasing OSA severity was associated with greater likelihood of an elevated or hypertensive status in fully adjusted models. Specifically, the odds ratios among those with elevated BP was 1.30 (95% confidence interval, 1.10-1.54), 1.41 (95% CI, 1.15-1.72), and 1.69 (95% CI, 1.32-2.17) for mild, moderate, and severe sleep apnea, respectively. The ORs among those with stage 1 BP was 1.27 (95% CI, 1.09-1.49), 1.36 (95% CI, 1.13-1.63), 1.58 (95% CI, 1.27-1.97) for mild, moderate, and severe sleep apnea, while the OR among those with stage 2 BP was 1.07 (95% CI, 0.92-1.26), 1.22 (95% CI, 1.02-1.45), 1.38 (95% CI, 1.12-1.69) for mild, moderate, and severe sleep apnea. Linear regression found that AHI was associated with both systolic and diastolic BP in fully adjusted models.

“Using the AASM and CMS AHI definitions, increasing severity of AHI is associated with greater likelihood of having an elevated blood pressure or hypertension,” Dr. Quan concluded. “However, the prevalence of OSA was substantially lower using the CMS definition of OSA. In fact, 218 of these individuals had moderate to severe OSA when the AASM definition was applied.”

He characterized the study as “a practical analysis, a way to help identify patients who might benefit from treatment. This is not the issue of whether the science of 3% AHI is better than 4%.”

The Sleep Heart Health Study was supported by the National Heart, Lung, and Blood Institute. Dr. Quan reported that he helped draft the AASM AHI recommendations but had no other relevant disclosures.

[email protected]

SOURCE: Quan SF et al. SLEEP 2019, Abstract 0501.

From 2007 to 2017, the age-standardized cirrhosis and hepatocellular carcinoma–related mortality among individuals with diabetes in the United States increased 1.2% and 1.9% each year, respectively, results from a large database analysis showed.

“While diabetes-related mortality has been reported to be decreasing due to improved awareness and management, our results highlight the need to better address NAFLD [nonalcoholic fatty liver disease] and end-stage liver disease among individuals with diabetes,” researchers led by Donghee Kim, MD, PhD, wrote in an article published in Clinical Gastroenterology and Hepatology.

In an effort to estimate the trends in chronic liver disease–related mortality among individuals with diabetes from 2007 to 2017 in the United States, Dr. Kim, of the division of gastroenterology and hepatology at Stanford (Calif.) University, and colleagues analyzed mortality records from the National Vital Statistic System database. They calculated age-specific mortality by dividing the number of deaths by the total U.S. census population for each year and standardized them according to age distribution of 2010 U.S. standard population. The researchers used joinpoint regression analysis to determine trends.

Of 2,686,590 individuals with diabetes identified, 48,761 had chronic liver disease as the underlying cause of death listed on the death certificate. Among individuals who had diabetes listed on their death certificate, the age-standardized mortality for cirrhosis and hepatocellular carcinoma as an underlying cause of death increased with an annual rate of 1.2% and 1.9%, respectively. Based on etiology, age-standardized mortality for hepatitis C and hepatitis B viral infections decreased at an annual rate of 4.4% and 5.1%, respectively. On the other hand, mortality among individuals with NAFLD and alcoholic liver disease increased at annual rates of 11.6% and 1.4%, respectively.


“When we defined chronic liver disease as an underlying or contributing cause of death among individuals with diabetes listed on the death certificate, the overall results remained similar,” the researchers wrote. They acknowledged certain limitations of the analysis, including the fact that using death certificates and ICD-10 codes “has the potential for misclassification and underestimation for diabetes and chronic liver disease–related mortality. However, the coding method has been constant over time, so it is unlikely to account for present trends. Increasing obesity and associated insulin resistance likely explain the link between diabetes and NAFLD and end-stage liver disease through hepatic inflammation and various proinflammatory cytokines.”

One of the study authors was supported by the National Institutes of Health. None of the other authors reported having relevant disclosures.

[email protected]

SOURCE: Kim D et al. Clin Gastroenterol Hepatol. 2019 Jun 17. doi: 10.1016/j.cgh.2019.06.011.

From 2007 to 2017, the age-standardized cirrhosis and hepatocellular carcinoma–related mortality among individuals with diabetes in the United States increased 1.2% and 1.9% each year, respectively, results from a large database analysis showed.

“While diabetes-related mortality has been reported to be decreasing due to improved awareness and management, our results highlight the need to better address NAFLD [nonalcoholic fatty liver disease] and end-stage liver disease among individuals with diabetes,” researchers led by Donghee Kim, MD, PhD, wrote in an article published in Clinical Gastroenterology and Hepatology.

In an effort to estimate the trends in chronic liver disease–related mortality among individuals with diabetes from 2007 to 2017 in the United States, Dr. Kim, of the division of gastroenterology and hepatology at Stanford (Calif.) University, and colleagues analyzed mortality records from the National Vital Statistic System database. They calculated age-specific mortality by dividing the number of deaths by the total U.S. census population for each year and standardized them according to age distribution of 2010 U.S. standard population. The researchers used joinpoint regression analysis to determine trends.

Of 2,686,590 individuals with diabetes identified, 48,761 had chronic liver disease as the underlying cause of death listed on the death certificate. Among individuals who had diabetes listed on their death certificate, the age-standardized mortality for cirrhosis and hepatocellular carcinoma as an underlying cause of death increased with an annual rate of 1.2% and 1.9%, respectively. Based on etiology, age-standardized mortality for hepatitis C and hepatitis B viral infections decreased at an annual rate of 4.4% and 5.1%, respectively. On the other hand, mortality among individuals with NAFLD and alcoholic liver disease increased at annual rates of 11.6% and 1.4%, respectively.


“When we defined chronic liver disease as an underlying or contributing cause of death among individuals with diabetes listed on the death certificate, the overall results remained similar,” the researchers wrote. They acknowledged certain limitations of the analysis, including the fact that using death certificates and ICD-10 codes “has the potential for misclassification and underestimation for diabetes and chronic liver disease–related mortality. However, the coding method has been constant over time, so it is unlikely to account for present trends. Increasing obesity and associated insulin resistance likely explain the link between diabetes and NAFLD and end-stage liver disease through hepatic inflammation and various proinflammatory cytokines.”

One of the study authors was supported by the National Institutes of Health. None of the other authors reported having relevant disclosures.

[email protected]

SOURCE: Kim D et al. Clin Gastroenterol Hepatol. 2019 Jun 17. doi: 10.1016/j.cgh.2019.06.011.

From 2007 to 2017, the age-standardized cirrhosis and hepatocellular carcinoma–related mortality among individuals with diabetes in the United States increased 1.2% and 1.9% each year, respectively, results from a large database analysis showed.

“While diabetes-related mortality has been reported to be decreasing due to improved awareness and management, our results highlight the need to better address NAFLD [nonalcoholic fatty liver disease] and end-stage liver disease among individuals with diabetes,” researchers led by Donghee Kim, MD, PhD, wrote in an article published in Clinical Gastroenterology and Hepatology.

In an effort to estimate the trends in chronic liver disease–related mortality among individuals with diabetes from 2007 to 2017 in the United States, Dr. Kim, of the division of gastroenterology and hepatology at Stanford (Calif.) University, and colleagues analyzed mortality records from the National Vital Statistic System database. They calculated age-specific mortality by dividing the number of deaths by the total U.S. census population for each year and standardized them according to age distribution of 2010 U.S. standard population. The researchers used joinpoint regression analysis to determine trends.

Of 2,686,590 individuals with diabetes identified, 48,761 had chronic liver disease as the underlying cause of death listed on the death certificate. Among individuals who had diabetes listed on their death certificate, the age-standardized mortality for cirrhosis and hepatocellular carcinoma as an underlying cause of death increased with an annual rate of 1.2% and 1.9%, respectively. Based on etiology, age-standardized mortality for hepatitis C and hepatitis B viral infections decreased at an annual rate of 4.4% and 5.1%, respectively. On the other hand, mortality among individuals with NAFLD and alcoholic liver disease increased at annual rates of 11.6% and 1.4%, respectively.


“When we defined chronic liver disease as an underlying or contributing cause of death among individuals with diabetes listed on the death certificate, the overall results remained similar,” the researchers wrote. They acknowledged certain limitations of the analysis, including the fact that using death certificates and ICD-10 codes “has the potential for misclassification and underestimation for diabetes and chronic liver disease–related mortality. However, the coding method has been constant over time, so it is unlikely to account for present trends. Increasing obesity and associated insulin resistance likely explain the link between diabetes and NAFLD and end-stage liver disease through hepatic inflammation and various proinflammatory cytokines.”

One of the study authors was supported by the National Institutes of Health. None of the other authors reported having relevant disclosures.

[email protected]

SOURCE: Kim D et al. Clin Gastroenterol Hepatol. 2019 Jun 17. doi: 10.1016/j.cgh.2019.06.011.

SAN ANTONIO – Patients with obstructive sleep apnea who complain of feeling tired when they wake up, being sleepy during the day, and have a high score on the Epworth Sleepiness Scale face an increased risk for cardiovascular disease, results from a population-based analysis suggest.

Doug Brunk/MDedge News

“OSA is a highly heterogeneous disease, with multiple clinical presentations and consequences,” the study’s first author, Diego R. Mazzotti, PhD, said at the annual meeting of the Associated Professional Sleep Societies. “These patients also have diverse comorbidities, and there are arbitrary severity definitions and variable therapeutic responses. It’s difficult to lump these patients together.”

Symptom subtypes of OSA were originally described in the Icelandic Sleep Apnea Cohort, and defined as excessively sleepy, minimally symptomatic, and disturbed sleep (Eur Respir J. 2014; 44[6]:1600-7). These distinct clusters were identified based on symptom experiences and the existence of major comorbidities. “This concept is more popular today, trying to identify symptom clusters, or groups of individuals, that share similar polysomnographic data, and then compare differences in prevalence or incidence of cardiovascular disease,” said Dr. Mazzotti, a research associate at the University of Pennsylvania, Philadelphia. “That’s a concept that needs to be moving forward.”

Dr. Mazzotti and colleagues set out to determine if OSA symptom subtypes are present in the Sleep Heart Health Study, a multicenter, prospective, community-based cohort of individuals aged 40 years and older designed to assess the cardiovascular (CV) consequences of OSA. They also wanted to know if there is additional evidence of the relevance of OSA symptom subtypes, particularly with respect to cardiovascular disease .

Participant-reported symptoms, such as difficulty falling and staying asleep, snoring, fatigue, drowsy driving and daytime sleepiness, and responses to the Epworth Sleepiness Scale were used to determine the patient’s subtype. Assessments including questionnaires and in-home polysomnography were conducted at baseline (between 1995 and 1998) and follow-up (between 2001 and 2003), while CV outcomes were assessed until the end of follow-up (between 2008 and 2011).

In all, 1,207 patients from the Sleep Heart Health Study met criteria for moderate to severe OSA (apnea-hypopnea index, or AHI, of 15 or greater) and were included in the final analysis. They were followed for a mean of 12 years. Based on the clustering of symptoms, the researchers identified four OSA symptom subtypes: disturbed sleep (12%), minimally symptomatic (33%), excessively sleepy (17%), and moderately sleepy (38%) – proportions that were similar to those observed in prior studies.

The disturbed sleep subtype presented with increased prevalence of “insomnialike” symptoms, such as difficulty initiating or maintaining sleep, according to Dr. Mazzotti. “On the other hand, the excessively sleepy subtype presented with a very high prevalence of several symptoms related to excessive daytime sleepiness, while the moderately sleepy showed a moderately high prevalence of such symptoms, but not as much when compared to the excessively sleepy subtype,” he explained. “Finally, the minimally symptomatic subtype was found to have the lowest prevalence of all investigated symptoms, suggesting that these patients have low symptom burden. They do not complain as much, even though they have moderate-to-severe OSA.”

Next, Dr. Mazzotti and colleagues used Kaplan-Meier survival analysis and Cox proportional hazards models to evaluate whether subtypes were associated with incident coronary heart disease (CHD), heart failure, and CV disease, including CV mortality. Similar analyses were performed comparing each symptom subtype with 2,830 individuals without OSA (AHI less than 5).

Compared with other subtypes, the excessively sleepy group had a more than threefold increased odds of prevalent heart failure, after adjustment for other CV risk factors. They also had a 1.7- to 2.3-fold increased risk for incident CV disease (P less than .001), CHD (P = .015) and heart failure (P = 0.018), after adjustment for other CV risk factors.

“Compared to individuals without OSA, the excessively sleepy subtype is the only subtype with increased risk of incident CV disease and CHD,” Dr. Mazzotti said. “It is possible that excessively sleepy OSA patients are more likely to benefit from CPAP therapy in preventing CV disease.” These results were published online earlier this year (Am J Respir Crit Care Med. 2019 Feb 15. doi: 10.1164/rccm.201808-1509OC).

Dr. Mazzotti reported having no financial disclosures.

[email protected]

SOURCE: Mazzotti D et al. SLEEP 2019, Abstract 0586.

SAN ANTONIO – Patients with obstructive sleep apnea who complain of feeling tired when they wake up, being sleepy during the day, and have a high score on the Epworth Sleepiness Scale face an increased risk for cardiovascular disease, results from a population-based analysis suggest.

Doug Brunk/MDedge News

“OSA is a highly heterogeneous disease, with multiple clinical presentations and consequences,” the study’s first author, Diego R. Mazzotti, PhD, said at the annual meeting of the Associated Professional Sleep Societies. “These patients also have diverse comorbidities, and there are arbitrary severity definitions and variable therapeutic responses. It’s difficult to lump these patients together.”

Symptom subtypes of OSA were originally described in the Icelandic Sleep Apnea Cohort, and defined as excessively sleepy, minimally symptomatic, and disturbed sleep (Eur Respir J. 2014; 44[6]:1600-7). These distinct clusters were identified based on symptom experiences and the existence of major comorbidities. “This concept is more popular today, trying to identify symptom clusters, or groups of individuals, that share similar polysomnographic data, and then compare differences in prevalence or incidence of cardiovascular disease,” said Dr. Mazzotti, a research associate at the University of Pennsylvania, Philadelphia. “That’s a concept that needs to be moving forward.”

Dr. Mazzotti and colleagues set out to determine if OSA symptom subtypes are present in the Sleep Heart Health Study, a multicenter, prospective, community-based cohort of individuals aged 40 years and older designed to assess the cardiovascular (CV) consequences of OSA. They also wanted to know if there is additional evidence of the relevance of OSA symptom subtypes, particularly with respect to cardiovascular disease .

Participant-reported symptoms, such as difficulty falling and staying asleep, snoring, fatigue, drowsy driving and daytime sleepiness, and responses to the Epworth Sleepiness Scale were used to determine the patient’s subtype. Assessments including questionnaires and in-home polysomnography were conducted at baseline (between 1995 and 1998) and follow-up (between 2001 and 2003), while CV outcomes were assessed until the end of follow-up (between 2008 and 2011).

In all, 1,207 patients from the Sleep Heart Health Study met criteria for moderate to severe OSA (apnea-hypopnea index, or AHI, of 15 or greater) and were included in the final analysis. They were followed for a mean of 12 years. Based on the clustering of symptoms, the researchers identified four OSA symptom subtypes: disturbed sleep (12%), minimally symptomatic (33%), excessively sleepy (17%), and moderately sleepy (38%) – proportions that were similar to those observed in prior studies.

The disturbed sleep subtype presented with increased prevalence of “insomnialike” symptoms, such as difficulty initiating or maintaining sleep, according to Dr. Mazzotti. “On the other hand, the excessively sleepy subtype presented with a very high prevalence of several symptoms related to excessive daytime sleepiness, while the moderately sleepy showed a moderately high prevalence of such symptoms, but not as much when compared to the excessively sleepy subtype,” he explained. “Finally, the minimally symptomatic subtype was found to have the lowest prevalence of all investigated symptoms, suggesting that these patients have low symptom burden. They do not complain as much, even though they have moderate-to-severe OSA.”

Next, Dr. Mazzotti and colleagues used Kaplan-Meier survival analysis and Cox proportional hazards models to evaluate whether subtypes were associated with incident coronary heart disease (CHD), heart failure, and CV disease, including CV mortality. Similar analyses were performed comparing each symptom subtype with 2,830 individuals without OSA (AHI less than 5).

Compared with other subtypes, the excessively sleepy group had a more than threefold increased odds of prevalent heart failure, after adjustment for other CV risk factors. They also had a 1.7- to 2.3-fold increased risk for incident CV disease (P less than .001), CHD (P = .015) and heart failure (P = 0.018), after adjustment for other CV risk factors.

“Compared to individuals without OSA, the excessively sleepy subtype is the only subtype with increased risk of incident CV disease and CHD,” Dr. Mazzotti said. “It is possible that excessively sleepy OSA patients are more likely to benefit from CPAP therapy in preventing CV disease.” These results were published online earlier this year (Am J Respir Crit Care Med. 2019 Feb 15. doi: 10.1164/rccm.201808-1509OC).

Dr. Mazzotti reported having no financial disclosures.

[email protected]

SOURCE: Mazzotti D et al. SLEEP 2019, Abstract 0586.

SAN ANTONIO – Patients with obstructive sleep apnea who complain of feeling tired when they wake up, being sleepy during the day, and have a high score on the Epworth Sleepiness Scale face an increased risk for cardiovascular disease, results from a population-based analysis suggest.

Doug Brunk/MDedge News

“OSA is a highly heterogeneous disease, with multiple clinical presentations and consequences,” the study’s first author, Diego R. Mazzotti, PhD, said at the annual meeting of the Associated Professional Sleep Societies. “These patients also have diverse comorbidities, and there are arbitrary severity definitions and variable therapeutic responses. It’s difficult to lump these patients together.”

Symptom subtypes of OSA were originally described in the Icelandic Sleep Apnea Cohort, and defined as excessively sleepy, minimally symptomatic, and disturbed sleep (Eur Respir J. 2014; 44[6]:1600-7). These distinct clusters were identified based on symptom experiences and the existence of major comorbidities. “This concept is more popular today, trying to identify symptom clusters, or groups of individuals, that share similar polysomnographic data, and then compare differences in prevalence or incidence of cardiovascular disease,” said Dr. Mazzotti, a research associate at the University of Pennsylvania, Philadelphia. “That’s a concept that needs to be moving forward.”

Dr. Mazzotti and colleagues set out to determine if OSA symptom subtypes are present in the Sleep Heart Health Study, a multicenter, prospective, community-based cohort of individuals aged 40 years and older designed to assess the cardiovascular (CV) consequences of OSA. They also wanted to know if there is additional evidence of the relevance of OSA symptom subtypes, particularly with respect to cardiovascular disease .

Participant-reported symptoms, such as difficulty falling and staying asleep, snoring, fatigue, drowsy driving and daytime sleepiness, and responses to the Epworth Sleepiness Scale were used to determine the patient’s subtype. Assessments including questionnaires and in-home polysomnography were conducted at baseline (between 1995 and 1998) and follow-up (between 2001 and 2003), while CV outcomes were assessed until the end of follow-up (between 2008 and 2011).

In all, 1,207 patients from the Sleep Heart Health Study met criteria for moderate to severe OSA (apnea-hypopnea index, or AHI, of 15 or greater) and were included in the final analysis. They were followed for a mean of 12 years. Based on the clustering of symptoms, the researchers identified four OSA symptom subtypes: disturbed sleep (12%), minimally symptomatic (33%), excessively sleepy (17%), and moderately sleepy (38%) – proportions that were similar to those observed in prior studies.

The disturbed sleep subtype presented with increased prevalence of “insomnialike” symptoms, such as difficulty initiating or maintaining sleep, according to Dr. Mazzotti. “On the other hand, the excessively sleepy subtype presented with a very high prevalence of several symptoms related to excessive daytime sleepiness, while the moderately sleepy showed a moderately high prevalence of such symptoms, but not as much when compared to the excessively sleepy subtype,” he explained. “Finally, the minimally symptomatic subtype was found to have the lowest prevalence of all investigated symptoms, suggesting that these patients have low symptom burden. They do not complain as much, even though they have moderate-to-severe OSA.”

Next, Dr. Mazzotti and colleagues used Kaplan-Meier survival analysis and Cox proportional hazards models to evaluate whether subtypes were associated with incident coronary heart disease (CHD), heart failure, and CV disease, including CV mortality. Similar analyses were performed comparing each symptom subtype with 2,830 individuals without OSA (AHI less than 5).

Compared with other subtypes, the excessively sleepy group had a more than threefold increased odds of prevalent heart failure, after adjustment for other CV risk factors. They also had a 1.7- to 2.3-fold increased risk for incident CV disease (P less than .001), CHD (P = .015) and heart failure (P = 0.018), after adjustment for other CV risk factors.

“Compared to individuals without OSA, the excessively sleepy subtype is the only subtype with increased risk of incident CV disease and CHD,” Dr. Mazzotti said. “It is possible that excessively sleepy OSA patients are more likely to benefit from CPAP therapy in preventing CV disease.” These results were published online earlier this year (Am J Respir Crit Care Med. 2019 Feb 15. doi: 10.1164/rccm.201808-1509OC).

Dr. Mazzotti reported having no financial disclosures.

[email protected]

SOURCE: Mazzotti D et al. SLEEP 2019, Abstract 0586.