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CDC: Prevalence of ALS is 4 per 100,000 in U.S.
The U.S. prevalence of amyotrophic lateral sclerosis, also known as Lou Gehrig’s disease, is about 4 cases per 100,000 Americans, according to the Centers for Disease Control and Prevention.
Amyotrophic lateral sclerosis (ALS) is a progressive neuromuscular disorder that is usually fatal within 2-5 years of diagnosis. A hereditary form of the disease accounts for between 10% and 15% of cases. In the rest, the cause or causes are unknown, although chemical and infectious exposures are among the suspected triggers.
The new prevalence figures, which the CDC published in its Morbidity and Mortality Weekly Report issued July 25 (MMWR 2014;63[SS07]:1-14), represent the first national prevalence findings for ALS in the United States, and derive from surveillance begun in 2009 by the federal Agency for Toxic Substances and Disease Registry in Atlanta, where Dr. Paul Mehta led the investigation.
Dr. Mehta and his colleagues identified cases from Medicare, Medicaid, Veterans Heath Administration, and Veterans Benefits Administration databases, as well a secure public website through which ALS patients could self-report to the CDC by answering a series of screening questions.
Between October 2010 and the end of 2011, the registry identified 12,187 people 18 years and older with ALS, for a prevalence of 3.9 cases of ALS per 100,000 – findings that are consistent, the researchers said, with those from long-running European ALS registries.
As in other studies, men had a higher prevalence of ALS than did women (4.8 per 100,000 vs. 3.0 per 100,000). "Factors such as occupational history and environmental exposures might be associated with this finding," the researchers wrote in their analysis.
The prevalence of ALS among whites was more than double that of blacks (4.2 per vs. 2.0). "The reason for this difference in prevalence by race is unknown and needs to be investigated further," Dr. Mehta and his associates wrote. However, they noted, the race findings were also consistent with other studies.
The age group 70-79 was associated with the highest prevalence rate, at 17.0 per 100,000, followed by 60-69 at about 12.
Dr. Mehta and his colleagues acknowledged that their study had several limitations, including the fact that the ALS registry was relatively new; that ALS is not a notifiable disease in most states, making it difficult to capture all cases; that data errors or file duplication could have occurred; and that it was not possible to calculate ALS incidence, only prevalence, because most cases in the registry did not have a diagnosis date.
No conflicts of interest were mentioned in the report.
The U.S. prevalence of amyotrophic lateral sclerosis, also known as Lou Gehrig’s disease, is about 4 cases per 100,000 Americans, according to the Centers for Disease Control and Prevention.
Amyotrophic lateral sclerosis (ALS) is a progressive neuromuscular disorder that is usually fatal within 2-5 years of diagnosis. A hereditary form of the disease accounts for between 10% and 15% of cases. In the rest, the cause or causes are unknown, although chemical and infectious exposures are among the suspected triggers.
The new prevalence figures, which the CDC published in its Morbidity and Mortality Weekly Report issued July 25 (MMWR 2014;63[SS07]:1-14), represent the first national prevalence findings for ALS in the United States, and derive from surveillance begun in 2009 by the federal Agency for Toxic Substances and Disease Registry in Atlanta, where Dr. Paul Mehta led the investigation.
Dr. Mehta and his colleagues identified cases from Medicare, Medicaid, Veterans Heath Administration, and Veterans Benefits Administration databases, as well a secure public website through which ALS patients could self-report to the CDC by answering a series of screening questions.
Between October 2010 and the end of 2011, the registry identified 12,187 people 18 years and older with ALS, for a prevalence of 3.9 cases of ALS per 100,000 – findings that are consistent, the researchers said, with those from long-running European ALS registries.
As in other studies, men had a higher prevalence of ALS than did women (4.8 per 100,000 vs. 3.0 per 100,000). "Factors such as occupational history and environmental exposures might be associated with this finding," the researchers wrote in their analysis.
The prevalence of ALS among whites was more than double that of blacks (4.2 per vs. 2.0). "The reason for this difference in prevalence by race is unknown and needs to be investigated further," Dr. Mehta and his associates wrote. However, they noted, the race findings were also consistent with other studies.
The age group 70-79 was associated with the highest prevalence rate, at 17.0 per 100,000, followed by 60-69 at about 12.
Dr. Mehta and his colleagues acknowledged that their study had several limitations, including the fact that the ALS registry was relatively new; that ALS is not a notifiable disease in most states, making it difficult to capture all cases; that data errors or file duplication could have occurred; and that it was not possible to calculate ALS incidence, only prevalence, because most cases in the registry did not have a diagnosis date.
No conflicts of interest were mentioned in the report.
The U.S. prevalence of amyotrophic lateral sclerosis, also known as Lou Gehrig’s disease, is about 4 cases per 100,000 Americans, according to the Centers for Disease Control and Prevention.
Amyotrophic lateral sclerosis (ALS) is a progressive neuromuscular disorder that is usually fatal within 2-5 years of diagnosis. A hereditary form of the disease accounts for between 10% and 15% of cases. In the rest, the cause or causes are unknown, although chemical and infectious exposures are among the suspected triggers.
The new prevalence figures, which the CDC published in its Morbidity and Mortality Weekly Report issued July 25 (MMWR 2014;63[SS07]:1-14), represent the first national prevalence findings for ALS in the United States, and derive from surveillance begun in 2009 by the federal Agency for Toxic Substances and Disease Registry in Atlanta, where Dr. Paul Mehta led the investigation.
Dr. Mehta and his colleagues identified cases from Medicare, Medicaid, Veterans Heath Administration, and Veterans Benefits Administration databases, as well a secure public website through which ALS patients could self-report to the CDC by answering a series of screening questions.
Between October 2010 and the end of 2011, the registry identified 12,187 people 18 years and older with ALS, for a prevalence of 3.9 cases of ALS per 100,000 – findings that are consistent, the researchers said, with those from long-running European ALS registries.
As in other studies, men had a higher prevalence of ALS than did women (4.8 per 100,000 vs. 3.0 per 100,000). "Factors such as occupational history and environmental exposures might be associated with this finding," the researchers wrote in their analysis.
The prevalence of ALS among whites was more than double that of blacks (4.2 per vs. 2.0). "The reason for this difference in prevalence by race is unknown and needs to be investigated further," Dr. Mehta and his associates wrote. However, they noted, the race findings were also consistent with other studies.
The age group 70-79 was associated with the highest prevalence rate, at 17.0 per 100,000, followed by 60-69 at about 12.
Dr. Mehta and his colleagues acknowledged that their study had several limitations, including the fact that the ALS registry was relatively new; that ALS is not a notifiable disease in most states, making it difficult to capture all cases; that data errors or file duplication could have occurred; and that it was not possible to calculate ALS incidence, only prevalence, because most cases in the registry did not have a diagnosis date.
No conflicts of interest were mentioned in the report.
FROM MORBIDITY AND MORTALITY WEEKLY REPORT
Damage control resuscitation practices improving combat casualty outcomes
Damage control resuscitation practices, adopted by the U.S. military in 2006, appear to have resulted in fewer deaths of salvageable patients in combat hospitals, according to results of a new study.
DCR, based on the principle that the coagulopathy of trauma is worsened when the balance of whole blood is disrupted, involves early administration of blood products in a balanced ratio, aggressive correction of coagulopathy, and minimization of the use of crystalloid fluids. DCR was first introduced in U.S. combat hospitals in Iraq and Afghanistan in 2005, and widely adopted the following year.
In research published online July 16 in JAMA Surgery (doi: 10.1001/jamasurg.2014.940), Dr. Nicholas R. Langan and his colleagues at Madigan Army Medical Center in Tacoma, Wash., used data from the military’s Joint Theater Trauma Registry database to analyze records from 2,565 soldiers who died in forward combat hospitals between 2002 and 2011. The researchers looked at injury types and Injury Severity Scores (ISSs); the timing and location of death; and initial (24-hour) and total volume of blood products and fluid administered before and after DCR became standard care.
The investigators found that the wide adoption of DCR resulted in a decrease in mean 24-hour crystalloid infusion volume (6.1-3.2 L) and an increase in fresh frozen plasma use (3.2-10.1 U) (P less than .05 for both). The mean ratio of packed red blood cells to fresh frozen plasma changed from 2.6:1 during the pre-DCR period to 1.4:1 (P less than .01). The researchers also saw mean ISS increase between cohorts (23 before DCR vs. 27; P less than .05), and a shift in injury patterns favoring more severe head trauma in the DCR-era cohort.
"We believe that this represents a logical second-order effect of improved early care and resuscitation (namely, that there is improved salvage of less severely injured patients and a decreased number of deaths among those with potentially survivable injuries)," Dr. Langan and his colleagues wrote in their analysis.
Comparing the pre-DCR and DCR periods, the researchers found that both the mean ISS and the percentage of patients with severe injury increased (from a mean ISS of 22.5 to 26.7 and from 63.5% to 79.7%, respectively; P less than .05). The mean Revised Trauma Score was lower (indicating more severe injury) for the DCR cohort (4.76) than for the pre-DCR cohort (5.67) (P less than .001). And the mean probability of survival based on trauma and injury scores dropped from 77% in the pre-DCR period to 64% after 2006 (P less than .001).
There remains "significant debate about the efficacy and application of DCR that will require prospective controlled studies to resolve," the researchers wrote.
Dr. Langan and his colleagues disclosed no conflicts of interest.
While many changes occurred during this decade of war, perhaps the most significant was how resuscitation evolved. Crystalloid use plummeted, and a balanced approach to blood products transfusion became the norm.
As a strong testament to the power of the Joint Trauma System, it is important to note that research teams were deployed; protocols approved; data collected, entered into a database, and analyzed; guidelines promulgated; articles published; and changes made, all while the war was ongoing. Literally hundreds of civilians, U.S. military personnel, and collation partners worked tirelessly to accomplishment this feat.
Clearly published but unfortunately largely overlooked by the military leadership is the finding that a large percentage of both prehospital and hospital combat deaths are potentially preventable. In addition, there are less-than-optimal outcomes (not resulting in death) that routinely occur. Both of these findings deserve to be given equal attention and to receive an immediate response. Data on these potentially preventable adverse outcomes should be compiled on a weekly basis by the Joint Trauma System. They then need to be reviewed by the U.S. Secretary of Defense, and each adverse outcome should serve as an immediate catalyst for focused research efforts and rapid system change.
Dr. John B. Holcomb is with the University of Texas Health Science Center in Houston. He disclosed no conflicts of interest.
While many changes occurred during this decade of war, perhaps the most significant was how resuscitation evolved. Crystalloid use plummeted, and a balanced approach to blood products transfusion became the norm.
As a strong testament to the power of the Joint Trauma System, it is important to note that research teams were deployed; protocols approved; data collected, entered into a database, and analyzed; guidelines promulgated; articles published; and changes made, all while the war was ongoing. Literally hundreds of civilians, U.S. military personnel, and collation partners worked tirelessly to accomplishment this feat.
Clearly published but unfortunately largely overlooked by the military leadership is the finding that a large percentage of both prehospital and hospital combat deaths are potentially preventable. In addition, there are less-than-optimal outcomes (not resulting in death) that routinely occur. Both of these findings deserve to be given equal attention and to receive an immediate response. Data on these potentially preventable adverse outcomes should be compiled on a weekly basis by the Joint Trauma System. They then need to be reviewed by the U.S. Secretary of Defense, and each adverse outcome should serve as an immediate catalyst for focused research efforts and rapid system change.
Dr. John B. Holcomb is with the University of Texas Health Science Center in Houston. He disclosed no conflicts of interest.
While many changes occurred during this decade of war, perhaps the most significant was how resuscitation evolved. Crystalloid use plummeted, and a balanced approach to blood products transfusion became the norm.
As a strong testament to the power of the Joint Trauma System, it is important to note that research teams were deployed; protocols approved; data collected, entered into a database, and analyzed; guidelines promulgated; articles published; and changes made, all while the war was ongoing. Literally hundreds of civilians, U.S. military personnel, and collation partners worked tirelessly to accomplishment this feat.
Clearly published but unfortunately largely overlooked by the military leadership is the finding that a large percentage of both prehospital and hospital combat deaths are potentially preventable. In addition, there are less-than-optimal outcomes (not resulting in death) that routinely occur. Both of these findings deserve to be given equal attention and to receive an immediate response. Data on these potentially preventable adverse outcomes should be compiled on a weekly basis by the Joint Trauma System. They then need to be reviewed by the U.S. Secretary of Defense, and each adverse outcome should serve as an immediate catalyst for focused research efforts and rapid system change.
Dr. John B. Holcomb is with the University of Texas Health Science Center in Houston. He disclosed no conflicts of interest.
Damage control resuscitation practices, adopted by the U.S. military in 2006, appear to have resulted in fewer deaths of salvageable patients in combat hospitals, according to results of a new study.
DCR, based on the principle that the coagulopathy of trauma is worsened when the balance of whole blood is disrupted, involves early administration of blood products in a balanced ratio, aggressive correction of coagulopathy, and minimization of the use of crystalloid fluids. DCR was first introduced in U.S. combat hospitals in Iraq and Afghanistan in 2005, and widely adopted the following year.
In research published online July 16 in JAMA Surgery (doi: 10.1001/jamasurg.2014.940), Dr. Nicholas R. Langan and his colleagues at Madigan Army Medical Center in Tacoma, Wash., used data from the military’s Joint Theater Trauma Registry database to analyze records from 2,565 soldiers who died in forward combat hospitals between 2002 and 2011. The researchers looked at injury types and Injury Severity Scores (ISSs); the timing and location of death; and initial (24-hour) and total volume of blood products and fluid administered before and after DCR became standard care.
The investigators found that the wide adoption of DCR resulted in a decrease in mean 24-hour crystalloid infusion volume (6.1-3.2 L) and an increase in fresh frozen plasma use (3.2-10.1 U) (P less than .05 for both). The mean ratio of packed red blood cells to fresh frozen plasma changed from 2.6:1 during the pre-DCR period to 1.4:1 (P less than .01). The researchers also saw mean ISS increase between cohorts (23 before DCR vs. 27; P less than .05), and a shift in injury patterns favoring more severe head trauma in the DCR-era cohort.
"We believe that this represents a logical second-order effect of improved early care and resuscitation (namely, that there is improved salvage of less severely injured patients and a decreased number of deaths among those with potentially survivable injuries)," Dr. Langan and his colleagues wrote in their analysis.
Comparing the pre-DCR and DCR periods, the researchers found that both the mean ISS and the percentage of patients with severe injury increased (from a mean ISS of 22.5 to 26.7 and from 63.5% to 79.7%, respectively; P less than .05). The mean Revised Trauma Score was lower (indicating more severe injury) for the DCR cohort (4.76) than for the pre-DCR cohort (5.67) (P less than .001). And the mean probability of survival based on trauma and injury scores dropped from 77% in the pre-DCR period to 64% after 2006 (P less than .001).
There remains "significant debate about the efficacy and application of DCR that will require prospective controlled studies to resolve," the researchers wrote.
Dr. Langan and his colleagues disclosed no conflicts of interest.
Damage control resuscitation practices, adopted by the U.S. military in 2006, appear to have resulted in fewer deaths of salvageable patients in combat hospitals, according to results of a new study.
DCR, based on the principle that the coagulopathy of trauma is worsened when the balance of whole blood is disrupted, involves early administration of blood products in a balanced ratio, aggressive correction of coagulopathy, and minimization of the use of crystalloid fluids. DCR was first introduced in U.S. combat hospitals in Iraq and Afghanistan in 2005, and widely adopted the following year.
In research published online July 16 in JAMA Surgery (doi: 10.1001/jamasurg.2014.940), Dr. Nicholas R. Langan and his colleagues at Madigan Army Medical Center in Tacoma, Wash., used data from the military’s Joint Theater Trauma Registry database to analyze records from 2,565 soldiers who died in forward combat hospitals between 2002 and 2011. The researchers looked at injury types and Injury Severity Scores (ISSs); the timing and location of death; and initial (24-hour) and total volume of blood products and fluid administered before and after DCR became standard care.
The investigators found that the wide adoption of DCR resulted in a decrease in mean 24-hour crystalloid infusion volume (6.1-3.2 L) and an increase in fresh frozen plasma use (3.2-10.1 U) (P less than .05 for both). The mean ratio of packed red blood cells to fresh frozen plasma changed from 2.6:1 during the pre-DCR period to 1.4:1 (P less than .01). The researchers also saw mean ISS increase between cohorts (23 before DCR vs. 27; P less than .05), and a shift in injury patterns favoring more severe head trauma in the DCR-era cohort.
"We believe that this represents a logical second-order effect of improved early care and resuscitation (namely, that there is improved salvage of less severely injured patients and a decreased number of deaths among those with potentially survivable injuries)," Dr. Langan and his colleagues wrote in their analysis.
Comparing the pre-DCR and DCR periods, the researchers found that both the mean ISS and the percentage of patients with severe injury increased (from a mean ISS of 22.5 to 26.7 and from 63.5% to 79.7%, respectively; P less than .05). The mean Revised Trauma Score was lower (indicating more severe injury) for the DCR cohort (4.76) than for the pre-DCR cohort (5.67) (P less than .001). And the mean probability of survival based on trauma and injury scores dropped from 77% in the pre-DCR period to 64% after 2006 (P less than .001).
There remains "significant debate about the efficacy and application of DCR that will require prospective controlled studies to resolve," the researchers wrote.
Dr. Langan and his colleagues disclosed no conflicts of interest.
FROM JAMA SURGERY
Major finding: Both the mean ISS and the percentage of patients with severe injury increased (from a mean ISS of 22.5 to 26.7 and from 63.5% to 79.7%, respectively; P less than .05), suggesting that patients who died in a hospital during the DCR period were more likely to be severely injured, with a decrease in deaths among potentially salvageable patients.
Data source: Joint Theater Trauma Registry data from 2,565 combat deaths.
Disclosures: The researchers and discussant reported no conflicts.
Mild TBI may predict PTSD, not postconcussion syndrome
Patients with certain symptoms after mild traumatic brain injury should be considered to have a form of posttraumatic stress disorder, rather than postconcussion syndrome, a prospective study of more than 1,300 patients shows.
Several published diagnostic criteria exist for postconcussion syndrome (PCS), but it is defined in the DSM-IV as a head trauma causing concussion followed by cognitive problems and at least three of eight symptoms – among them headache, dizziness, and personality change – lasting 3 months or longer. Several studies have questioned the specificity of the PCS diagnosis, finding overlap of symptoms among patients with head injuries and other types of injuries. And as traumatic brain injury is strongly associated with PTSD, researchers have suggested that certain symptoms thought to be indicative of brain injury might instead reflect stress reactions stemming from trauma.
In a study published online July 16 in JAMA Psychiatry (doi:10.1001/jamapsychiatry.2014.666), Emmanuel Lagarde, Ph.D., of the INSERM Research Center in Bordeaux, France, and colleagues, analyzed data from 1,361 patients recruited from a hospital emergency department, of whom 534 had head injuries and 827 had injuries to other parts of the body. At 3 months’ follow-up, 21.2% of the mild traumatic brain injury (MTBI) patients and 16.3% of controls without head injuries could be diagnosed with PCS based on the DSM-IV criteria.
Moreover, 8.8% of patients with head injuries fulfilled diagnostic criteria for PTSD, compared with only 2.2% of controls. In the study group as a whole, MTBI was seen as a strong predictor of PTSD (odds ratio 4.47; 95% CI 2.38-8.4) but not of PCS (OR, 1.13; 95% CI 0.82-1.55). MTBI predicted PTSD regardless of whether the injury occurred as a result of a road crash, assault, or fall.
Assault was seen as a predictor of PCS as defined by DSM-IV, while severity of injury was not, suggesting that "psychological stress, and not potential brain injury, causes these symptoms, reinforcing the idea that they should be considered part of PTSD and not PCS," the researchers wrote.
They also found that symptoms suggestive of PCS under the DSM-IV criteria clustered in a way that paralleled a group of PTSD symptoms categorized as hyperarousal.
"The rationale to define a PCS that is specific to head-trauma patients is weak," Dr. Lagarde and colleagues wrote in their analysis. "Our results also suggested that the misunderstanding related to the relevance of defining such a syndrome could be explained by the overlapping pattern with symptoms of the PTSD hyperarousal dimension."
Available evidence does not support the use of PCS, they concluded, adding that clinicians should consider PTSD risk and treatment for patients with MTBI.
Dr. Lagarde and colleagues acknowledged as limitations of their study the fact that PTSD diagnoses were not made through formal clinical exams and that researchers focused on the traumatic events that landed subjects in the emergency department without capturing information on past traumatic events.
INSERM, the REUNICA Group, and Bordeaux University Hospital funded the study. None of the authors disclosed conflicts of interest.
Patients with certain symptoms after mild traumatic brain injury should be considered to have a form of posttraumatic stress disorder, rather than postconcussion syndrome, a prospective study of more than 1,300 patients shows.
Several published diagnostic criteria exist for postconcussion syndrome (PCS), but it is defined in the DSM-IV as a head trauma causing concussion followed by cognitive problems and at least three of eight symptoms – among them headache, dizziness, and personality change – lasting 3 months or longer. Several studies have questioned the specificity of the PCS diagnosis, finding overlap of symptoms among patients with head injuries and other types of injuries. And as traumatic brain injury is strongly associated with PTSD, researchers have suggested that certain symptoms thought to be indicative of brain injury might instead reflect stress reactions stemming from trauma.
In a study published online July 16 in JAMA Psychiatry (doi:10.1001/jamapsychiatry.2014.666), Emmanuel Lagarde, Ph.D., of the INSERM Research Center in Bordeaux, France, and colleagues, analyzed data from 1,361 patients recruited from a hospital emergency department, of whom 534 had head injuries and 827 had injuries to other parts of the body. At 3 months’ follow-up, 21.2% of the mild traumatic brain injury (MTBI) patients and 16.3% of controls without head injuries could be diagnosed with PCS based on the DSM-IV criteria.
Moreover, 8.8% of patients with head injuries fulfilled diagnostic criteria for PTSD, compared with only 2.2% of controls. In the study group as a whole, MTBI was seen as a strong predictor of PTSD (odds ratio 4.47; 95% CI 2.38-8.4) but not of PCS (OR, 1.13; 95% CI 0.82-1.55). MTBI predicted PTSD regardless of whether the injury occurred as a result of a road crash, assault, or fall.
Assault was seen as a predictor of PCS as defined by DSM-IV, while severity of injury was not, suggesting that "psychological stress, and not potential brain injury, causes these symptoms, reinforcing the idea that they should be considered part of PTSD and not PCS," the researchers wrote.
They also found that symptoms suggestive of PCS under the DSM-IV criteria clustered in a way that paralleled a group of PTSD symptoms categorized as hyperarousal.
"The rationale to define a PCS that is specific to head-trauma patients is weak," Dr. Lagarde and colleagues wrote in their analysis. "Our results also suggested that the misunderstanding related to the relevance of defining such a syndrome could be explained by the overlapping pattern with symptoms of the PTSD hyperarousal dimension."
Available evidence does not support the use of PCS, they concluded, adding that clinicians should consider PTSD risk and treatment for patients with MTBI.
Dr. Lagarde and colleagues acknowledged as limitations of their study the fact that PTSD diagnoses were not made through formal clinical exams and that researchers focused on the traumatic events that landed subjects in the emergency department without capturing information on past traumatic events.
INSERM, the REUNICA Group, and Bordeaux University Hospital funded the study. None of the authors disclosed conflicts of interest.
Patients with certain symptoms after mild traumatic brain injury should be considered to have a form of posttraumatic stress disorder, rather than postconcussion syndrome, a prospective study of more than 1,300 patients shows.
Several published diagnostic criteria exist for postconcussion syndrome (PCS), but it is defined in the DSM-IV as a head trauma causing concussion followed by cognitive problems and at least three of eight symptoms – among them headache, dizziness, and personality change – lasting 3 months or longer. Several studies have questioned the specificity of the PCS diagnosis, finding overlap of symptoms among patients with head injuries and other types of injuries. And as traumatic brain injury is strongly associated with PTSD, researchers have suggested that certain symptoms thought to be indicative of brain injury might instead reflect stress reactions stemming from trauma.
In a study published online July 16 in JAMA Psychiatry (doi:10.1001/jamapsychiatry.2014.666), Emmanuel Lagarde, Ph.D., of the INSERM Research Center in Bordeaux, France, and colleagues, analyzed data from 1,361 patients recruited from a hospital emergency department, of whom 534 had head injuries and 827 had injuries to other parts of the body. At 3 months’ follow-up, 21.2% of the mild traumatic brain injury (MTBI) patients and 16.3% of controls without head injuries could be diagnosed with PCS based on the DSM-IV criteria.
Moreover, 8.8% of patients with head injuries fulfilled diagnostic criteria for PTSD, compared with only 2.2% of controls. In the study group as a whole, MTBI was seen as a strong predictor of PTSD (odds ratio 4.47; 95% CI 2.38-8.4) but not of PCS (OR, 1.13; 95% CI 0.82-1.55). MTBI predicted PTSD regardless of whether the injury occurred as a result of a road crash, assault, or fall.
Assault was seen as a predictor of PCS as defined by DSM-IV, while severity of injury was not, suggesting that "psychological stress, and not potential brain injury, causes these symptoms, reinforcing the idea that they should be considered part of PTSD and not PCS," the researchers wrote.
They also found that symptoms suggestive of PCS under the DSM-IV criteria clustered in a way that paralleled a group of PTSD symptoms categorized as hyperarousal.
"The rationale to define a PCS that is specific to head-trauma patients is weak," Dr. Lagarde and colleagues wrote in their analysis. "Our results also suggested that the misunderstanding related to the relevance of defining such a syndrome could be explained by the overlapping pattern with symptoms of the PTSD hyperarousal dimension."
Available evidence does not support the use of PCS, they concluded, adding that clinicians should consider PTSD risk and treatment for patients with MTBI.
Dr. Lagarde and colleagues acknowledged as limitations of their study the fact that PTSD diagnoses were not made through formal clinical exams and that researchers focused on the traumatic events that landed subjects in the emergency department without capturing information on past traumatic events.
INSERM, the REUNICA Group, and Bordeaux University Hospital funded the study. None of the authors disclosed conflicts of interest.
FROM JAMA PSYCHIATRY
Key clinical point: Head trauma often occurs within the context of a psychologically distressing event.
Major finding: Injured patients with persistent symptoms 3 months after a traumatic event should be considered as having the hyperarousal dimension of PTSD rather than postconcussion syndrome.
Data source: A prospective study of 1,361 patients with mild traumatic injuries who were recruited from a hospital emergency department from Dec. 4, 2007, to Feb. 25, 2009.
Disclosures: INSERM, the REUNICA Group, and Bordeaux University Hospital funded the study. None of the authors disclosed conflicts of interest.
USPSTF: Screen older women smokers for AAA
The U.S. Preventive Services Task Force says that women between ages 65 and 75 years who have smoked 100 or more cigarettes in their lives could benefit from one-time ultrasonography screening for abdominal aortic aneurysm (AAA).
The AAA guidelines replace those published by USPSTF in 2005, which had recommended against screening women regardless of their smoking history.
The new guidelines, published online June 23 in Annals of Internal Medicine (doi:10.7326/M14-1204), do not recommend screening women who have never smoked, citing the very low prevalence of AAA in this group.
Nevertheless, the task force’s systematic review, led by current chair Dr. Michael L. LeFevre of the University of Missouri in Columbia, revealed that screening women aged 65-75 years who have smoked or currently smoke – a group for which AAA prevalence is between 0.8% and 2% – could potentially be beneficial, though current evidence remains insufficient to recommend it.
"Prevalence of AAA in women who currently smoke approaches that of men who have never smoked," Dr. LeFevre and his colleagues wrote in the guidelines.
"As such, a small net benefit might exist for this population and appropriate, high-quality research designs should be used to address this question," they added.
The task force continues to recommend that men between the ages of 65 and 75 years who have ever smoked be offered one-time screening with ultrasonography for AAA. Men in this age group who have never smoked may be offered screening if they have certain risk factors, such as advanced age or a family history of AAA.
AAA – a dilation in the wall of the abdominal section of the aorta of 3 cm or larger – is seen in 4% and 7% of men and about 1% of women over the age of 50, USPSTF said. Most AAAs remain asymptomatic until they rupture, in which case the mortality risk has been shown to be higher than 75%.
Women who develop AAA tend to do so at a later age than do men, the task force noted, with most ruptures occurring past age 80 years.
The task force is a voluntary advisory body independent of the U.S. government but supported by the Agency for Healthcare Research and Quality. One of the study’s co-authors, Dr. Douglas Owens of Stanford (Calif.) University disclosed travel support from the agency during the course of the review.
The other task force members declared no conflicts of interest.
The U.S. Preventive Services Task Force says that women between ages 65 and 75 years who have smoked 100 or more cigarettes in their lives could benefit from one-time ultrasonography screening for abdominal aortic aneurysm (AAA).
The AAA guidelines replace those published by USPSTF in 2005, which had recommended against screening women regardless of their smoking history.
The new guidelines, published online June 23 in Annals of Internal Medicine (doi:10.7326/M14-1204), do not recommend screening women who have never smoked, citing the very low prevalence of AAA in this group.
Nevertheless, the task force’s systematic review, led by current chair Dr. Michael L. LeFevre of the University of Missouri in Columbia, revealed that screening women aged 65-75 years who have smoked or currently smoke – a group for which AAA prevalence is between 0.8% and 2% – could potentially be beneficial, though current evidence remains insufficient to recommend it.
"Prevalence of AAA in women who currently smoke approaches that of men who have never smoked," Dr. LeFevre and his colleagues wrote in the guidelines.
"As such, a small net benefit might exist for this population and appropriate, high-quality research designs should be used to address this question," they added.
The task force continues to recommend that men between the ages of 65 and 75 years who have ever smoked be offered one-time screening with ultrasonography for AAA. Men in this age group who have never smoked may be offered screening if they have certain risk factors, such as advanced age or a family history of AAA.
AAA – a dilation in the wall of the abdominal section of the aorta of 3 cm or larger – is seen in 4% and 7% of men and about 1% of women over the age of 50, USPSTF said. Most AAAs remain asymptomatic until they rupture, in which case the mortality risk has been shown to be higher than 75%.
Women who develop AAA tend to do so at a later age than do men, the task force noted, with most ruptures occurring past age 80 years.
The task force is a voluntary advisory body independent of the U.S. government but supported by the Agency for Healthcare Research and Quality. One of the study’s co-authors, Dr. Douglas Owens of Stanford (Calif.) University disclosed travel support from the agency during the course of the review.
The other task force members declared no conflicts of interest.
The U.S. Preventive Services Task Force says that women between ages 65 and 75 years who have smoked 100 or more cigarettes in their lives could benefit from one-time ultrasonography screening for abdominal aortic aneurysm (AAA).
The AAA guidelines replace those published by USPSTF in 2005, which had recommended against screening women regardless of their smoking history.
The new guidelines, published online June 23 in Annals of Internal Medicine (doi:10.7326/M14-1204), do not recommend screening women who have never smoked, citing the very low prevalence of AAA in this group.
Nevertheless, the task force’s systematic review, led by current chair Dr. Michael L. LeFevre of the University of Missouri in Columbia, revealed that screening women aged 65-75 years who have smoked or currently smoke – a group for which AAA prevalence is between 0.8% and 2% – could potentially be beneficial, though current evidence remains insufficient to recommend it.
"Prevalence of AAA in women who currently smoke approaches that of men who have never smoked," Dr. LeFevre and his colleagues wrote in the guidelines.
"As such, a small net benefit might exist for this population and appropriate, high-quality research designs should be used to address this question," they added.
The task force continues to recommend that men between the ages of 65 and 75 years who have ever smoked be offered one-time screening with ultrasonography for AAA. Men in this age group who have never smoked may be offered screening if they have certain risk factors, such as advanced age or a family history of AAA.
AAA – a dilation in the wall of the abdominal section of the aorta of 3 cm or larger – is seen in 4% and 7% of men and about 1% of women over the age of 50, USPSTF said. Most AAAs remain asymptomatic until they rupture, in which case the mortality risk has been shown to be higher than 75%.
Women who develop AAA tend to do so at a later age than do men, the task force noted, with most ruptures occurring past age 80 years.
The task force is a voluntary advisory body independent of the U.S. government but supported by the Agency for Healthcare Research and Quality. One of the study’s co-authors, Dr. Douglas Owens of Stanford (Calif.) University disclosed travel support from the agency during the course of the review.
The other task force members declared no conflicts of interest.
Key clinical point: Women aged 65-75 years who have smoked more than 100 cigarettes ever could benefit from one-time ultrasonography screening for AAA.
Major finding: Screening in women aged 65-75 years who have smoked or currently smoke – a group for which AAA prevalence is between 0.8% and 2% – could potentially be beneficial.
Data source: The USPSTF commissioned a systematic review that assessed the evidence on the benefits and harms of screening for AAA and strategies for managing small (3.0-5.4 cm) screen-detected AAAs.
Disclosures: Dr. Douglas Owens of the Stanford (Calif.) University, disclosed travel support from the agency during the course of the review.
Sternal approach optimal in mitral valve surgeries
NEW YORK – The conventional sternal approach in treating mitral valve disease remains the safest and most flexible, said Dr. Patrick McCarthy, who used his talk at the AATS annual meeting’s adult cardiac surgery symposium, "Becoming a Master Valve Surgeon," to defend its virtues as the "gold standard" for mitral valve operations.
"Patients don’t have much pain, and most are concerned about the risks of open heart surgery, not the cosmetic aspects. Even so, the scar heals to a thin white line," Dr. McCarthy said in an interview. And with a sternal approach, compared with robotic or minimally invasive procedures, "you’re prepared to fix anything," he said.
"So if there’s a technical complication – an aortic dissection, unusual bleeding, a circumflex coronary injury – or you encounter unrecognized aortic valve disease, then you can safely treat it."
Dr. McCarthy said that his own practice has evolved to perform fewer, not more, minimally invasive mitral valve surgeries in recent years.
"Ten years ago about half of my mitral valve operations were minimally invasive, and over time I saw less and less benefit. The length of time on the heart-lung machine and the potential safety issues made me evolve away from that approach."
Many centers and individual surgeons do right thoracotomy or robotic surgery very well and safely, Dr. McCarthy said.
"But the national data would indicate that the perioperative risk of stroke is twice as high with those approaches," he said, and they are not performed as often as they are talked about.
Surgeons who elect not to perform a minimally invasive mitral valve procedure "should not feel that they’re somehow shortchanging the patient. For safety and long-term outcomes we need to focus less on how we approach the mitral valve and more on what operation we do. Can you do a good durable repair, and not a replacement? Can you minimize the risks of open heart surgery?" he said.
"Generations of cardiac surgeons worked hard to minimize those risks and optimize the outcomes of repair, to the point that we now operate with minimal risk on asymptomatic patients with normal ventricles and expect a 95% or greater chance for a durable repair. Don’t compromise the operation for a perceived cosmetic advantage," Dr. McCarthy said.
Also during the course, Dr. Marc Moon of Washington University School of Medicine in St. Louis, Missouri, discussed surgical triggers for patients with aortic stenosis in several nonstandard clinical scenarios. These scenarios include frail patients, patients with severe aortic stenosis, and asymptomatic patients who need major noncardiac surgery.
In addition to drawing from his own center’s experience, Dr. Moon attempted to condense and summarize the most recent guideline and surgical review recommendations for performing – or not performing – aortic valve replacement (AVR) in these and other tricky patient groups.
Patients with aortic stenosis (AS) are initially classed as asymptomatic or symptomatic based on a history and physical exam, and those with symptomatic aortic stenosis should undergo AVR, Dr. Moon said.
Asymptomatic patients can have normal ejection fraction (EF), but generally display left ventricle hypertrophy or diastolic dysfunction once AS becomes severe. In asymptomatic patients, once left ventricle EF falls below 50% (independent of associated coronary artery disease) or pulmonary hypertension appears, AVR should be considered."
However, frailty will make surgical intervention futile in some of these patients. Dr. Moon described new assessment tools to replace the "eyeball test" for frailty that surgeons have been using for years.
"A 6-minute walk test can predict a poor outcome in patients following AVR," he said, so long as the mobility limitations are not mainly due to the AS itself. Slow walkers, who need 6 seconds or more to walk 5 meters, have a significantly increased risk of morbidity or mortality independent of other factors affecting surgical risk.
Other measures of frailty include unintended weight loss of 10 pounds or more over a year, self-reported exhaustion, and weak grip strength.
Patients whose underlying AS is the main contributor to frailty can benefit from AVR, Dr. Moon said, but determining this can be difficult. One approach Dr. Moon and colleagues use is to begin with balloon aortic valvuloplasty in frail patients whose valves are amenable to BAV. For these patients, "we initiate an appropriate heart failure regimen, perform BAV, and reevaluate functional status in 4-6 weeks."
In these difficult cases, BAV is used to determine the contribution of aortic stenosis to the patient’s symptoms associated with underlying chronic lung disease, hepatorenal dysfunction, or poor left ventricular function, he said.
"If there is improvement after BAV, then AS is a contributing, causative factor to the patient’s disability and AVR is recommended. If there is no improvement in functional status, medical therapy is continued or hospice care initiated as appropriate."
NEW YORK – The conventional sternal approach in treating mitral valve disease remains the safest and most flexible, said Dr. Patrick McCarthy, who used his talk at the AATS annual meeting’s adult cardiac surgery symposium, "Becoming a Master Valve Surgeon," to defend its virtues as the "gold standard" for mitral valve operations.
"Patients don’t have much pain, and most are concerned about the risks of open heart surgery, not the cosmetic aspects. Even so, the scar heals to a thin white line," Dr. McCarthy said in an interview. And with a sternal approach, compared with robotic or minimally invasive procedures, "you’re prepared to fix anything," he said.
"So if there’s a technical complication – an aortic dissection, unusual bleeding, a circumflex coronary injury – or you encounter unrecognized aortic valve disease, then you can safely treat it."
Dr. McCarthy said that his own practice has evolved to perform fewer, not more, minimally invasive mitral valve surgeries in recent years.
"Ten years ago about half of my mitral valve operations were minimally invasive, and over time I saw less and less benefit. The length of time on the heart-lung machine and the potential safety issues made me evolve away from that approach."
Many centers and individual surgeons do right thoracotomy or robotic surgery very well and safely, Dr. McCarthy said.
"But the national data would indicate that the perioperative risk of stroke is twice as high with those approaches," he said, and they are not performed as often as they are talked about.
Surgeons who elect not to perform a minimally invasive mitral valve procedure "should not feel that they’re somehow shortchanging the patient. For safety and long-term outcomes we need to focus less on how we approach the mitral valve and more on what operation we do. Can you do a good durable repair, and not a replacement? Can you minimize the risks of open heart surgery?" he said.
"Generations of cardiac surgeons worked hard to minimize those risks and optimize the outcomes of repair, to the point that we now operate with minimal risk on asymptomatic patients with normal ventricles and expect a 95% or greater chance for a durable repair. Don’t compromise the operation for a perceived cosmetic advantage," Dr. McCarthy said.
Also during the course, Dr. Marc Moon of Washington University School of Medicine in St. Louis, Missouri, discussed surgical triggers for patients with aortic stenosis in several nonstandard clinical scenarios. These scenarios include frail patients, patients with severe aortic stenosis, and asymptomatic patients who need major noncardiac surgery.
In addition to drawing from his own center’s experience, Dr. Moon attempted to condense and summarize the most recent guideline and surgical review recommendations for performing – or not performing – aortic valve replacement (AVR) in these and other tricky patient groups.
Patients with aortic stenosis (AS) are initially classed as asymptomatic or symptomatic based on a history and physical exam, and those with symptomatic aortic stenosis should undergo AVR, Dr. Moon said.
Asymptomatic patients can have normal ejection fraction (EF), but generally display left ventricle hypertrophy or diastolic dysfunction once AS becomes severe. In asymptomatic patients, once left ventricle EF falls below 50% (independent of associated coronary artery disease) or pulmonary hypertension appears, AVR should be considered."
However, frailty will make surgical intervention futile in some of these patients. Dr. Moon described new assessment tools to replace the "eyeball test" for frailty that surgeons have been using for years.
"A 6-minute walk test can predict a poor outcome in patients following AVR," he said, so long as the mobility limitations are not mainly due to the AS itself. Slow walkers, who need 6 seconds or more to walk 5 meters, have a significantly increased risk of morbidity or mortality independent of other factors affecting surgical risk.
Other measures of frailty include unintended weight loss of 10 pounds or more over a year, self-reported exhaustion, and weak grip strength.
Patients whose underlying AS is the main contributor to frailty can benefit from AVR, Dr. Moon said, but determining this can be difficult. One approach Dr. Moon and colleagues use is to begin with balloon aortic valvuloplasty in frail patients whose valves are amenable to BAV. For these patients, "we initiate an appropriate heart failure regimen, perform BAV, and reevaluate functional status in 4-6 weeks."
In these difficult cases, BAV is used to determine the contribution of aortic stenosis to the patient’s symptoms associated with underlying chronic lung disease, hepatorenal dysfunction, or poor left ventricular function, he said.
"If there is improvement after BAV, then AS is a contributing, causative factor to the patient’s disability and AVR is recommended. If there is no improvement in functional status, medical therapy is continued or hospice care initiated as appropriate."
NEW YORK – The conventional sternal approach in treating mitral valve disease remains the safest and most flexible, said Dr. Patrick McCarthy, who used his talk at the AATS annual meeting’s adult cardiac surgery symposium, "Becoming a Master Valve Surgeon," to defend its virtues as the "gold standard" for mitral valve operations.
"Patients don’t have much pain, and most are concerned about the risks of open heart surgery, not the cosmetic aspects. Even so, the scar heals to a thin white line," Dr. McCarthy said in an interview. And with a sternal approach, compared with robotic or minimally invasive procedures, "you’re prepared to fix anything," he said.
"So if there’s a technical complication – an aortic dissection, unusual bleeding, a circumflex coronary injury – or you encounter unrecognized aortic valve disease, then you can safely treat it."
Dr. McCarthy said that his own practice has evolved to perform fewer, not more, minimally invasive mitral valve surgeries in recent years.
"Ten years ago about half of my mitral valve operations were minimally invasive, and over time I saw less and less benefit. The length of time on the heart-lung machine and the potential safety issues made me evolve away from that approach."
Many centers and individual surgeons do right thoracotomy or robotic surgery very well and safely, Dr. McCarthy said.
"But the national data would indicate that the perioperative risk of stroke is twice as high with those approaches," he said, and they are not performed as often as they are talked about.
Surgeons who elect not to perform a minimally invasive mitral valve procedure "should not feel that they’re somehow shortchanging the patient. For safety and long-term outcomes we need to focus less on how we approach the mitral valve and more on what operation we do. Can you do a good durable repair, and not a replacement? Can you minimize the risks of open heart surgery?" he said.
"Generations of cardiac surgeons worked hard to minimize those risks and optimize the outcomes of repair, to the point that we now operate with minimal risk on asymptomatic patients with normal ventricles and expect a 95% or greater chance for a durable repair. Don’t compromise the operation for a perceived cosmetic advantage," Dr. McCarthy said.
Also during the course, Dr. Marc Moon of Washington University School of Medicine in St. Louis, Missouri, discussed surgical triggers for patients with aortic stenosis in several nonstandard clinical scenarios. These scenarios include frail patients, patients with severe aortic stenosis, and asymptomatic patients who need major noncardiac surgery.
In addition to drawing from his own center’s experience, Dr. Moon attempted to condense and summarize the most recent guideline and surgical review recommendations for performing – or not performing – aortic valve replacement (AVR) in these and other tricky patient groups.
Patients with aortic stenosis (AS) are initially classed as asymptomatic or symptomatic based on a history and physical exam, and those with symptomatic aortic stenosis should undergo AVR, Dr. Moon said.
Asymptomatic patients can have normal ejection fraction (EF), but generally display left ventricle hypertrophy or diastolic dysfunction once AS becomes severe. In asymptomatic patients, once left ventricle EF falls below 50% (independent of associated coronary artery disease) or pulmonary hypertension appears, AVR should be considered."
However, frailty will make surgical intervention futile in some of these patients. Dr. Moon described new assessment tools to replace the "eyeball test" for frailty that surgeons have been using for years.
"A 6-minute walk test can predict a poor outcome in patients following AVR," he said, so long as the mobility limitations are not mainly due to the AS itself. Slow walkers, who need 6 seconds or more to walk 5 meters, have a significantly increased risk of morbidity or mortality independent of other factors affecting surgical risk.
Other measures of frailty include unintended weight loss of 10 pounds or more over a year, self-reported exhaustion, and weak grip strength.
Patients whose underlying AS is the main contributor to frailty can benefit from AVR, Dr. Moon said, but determining this can be difficult. One approach Dr. Moon and colleagues use is to begin with balloon aortic valvuloplasty in frail patients whose valves are amenable to BAV. For these patients, "we initiate an appropriate heart failure regimen, perform BAV, and reevaluate functional status in 4-6 weeks."
In these difficult cases, BAV is used to determine the contribution of aortic stenosis to the patient’s symptoms associated with underlying chronic lung disease, hepatorenal dysfunction, or poor left ventricular function, he said.
"If there is improvement after BAV, then AS is a contributing, causative factor to the patient’s disability and AVR is recommended. If there is no improvement in functional status, medical therapy is continued or hospice care initiated as appropriate."
SSTI guidelines stress diagnostic skill, careful treatment
New practice guidelines on skin and soft tissue infections from the Infectious Diseases Society of America stress careful clinical attention to the type of infection, the epidemiological setting in which the infection occurred, the health status of the patient, and the selection and dosage of the most appropriate treatment agents.
The guidelines, published online June 18 in Clinical Infectious Diseases (doi:10.1093/cid/ciu296), update those issued by IDSA in 2005 and cover everything from preventing infections caused by animal bites in healthy hosts to life-threatening infections in immunocompromised patients. They also emphasize accurate identification of pathogens, stressing that clinical presentations can be very similar.
"This is not one of those guidelines that boils complex issues down to a choice between a couple of different drugs or combinations of drugs," said Dr. Dennis Stevens of the Department of Veterans Affairs in Boise, Idaho, the guidelines’ lead author. "Skin and soft tissue infections [SSTIs] have multiple causes and different presentations, depending upon the immune status of the host. Here it’s much more complicated and really requires an astute physician to consider a number of things."
The guidelines, drafted by a 10-member panel, offer a novel algorithm for management of nonpurulent and purulent infections that aims to define a pathway for mild, moderate, and severe infections in each category. For example, no antibiotic is recommended for a purulent infection – only incision and drainage – if the patient has no signs of systemic involvement.
For moderate cases of purulent infection with some systemic involvement, incision and drainage should be followed by culture and sensitivity testing, the guidelines say, listing two antibiotics, trimethoprim-sulfamethoxazole and doxycycline, as appropriate for empiric treatment, while trimethoprim-sulfamethoxazole is recommended if the pathogen is found to be methicillin-resistant Staphylococcus aureus (MRSA) and dicloxacillin or cephalexin if it is methicillin-susceptible S. aureus (MSSA).
The purpose of the algorithm, expressed in the guidelines in chart form, "is to make the physician think," Dr. Stevens said in an interview. "There is a huge move to try and monitor antibiotic stewardship to prevent resistance, and we’re just trying to get the clinician to think of tier 1, tier 2, and tier 3 approaches, depending not only on the bug, but on how sick the patient is. Instead of a knee-jerk approach treating everybody with highly expensive IV antibiotics, [the algorithm] provides a clear pathway to treat appropriately."
In people with an abscess who have failed antibiotic treatment, are immunocompromised, or have fever and elevated white blood cell counts or other evidence of severe infection, "we’re not going to gamble," Dr. Stevens said, adding that the guidelines recommend prompt treatment using "an antibiotic that gets all of these organisms, including resistant ones." Newly approved agents dalbavancin and tedizolid are effective in treating SSTIs caused by MRSA, the guidelines note.
The guidelines are intended for use by clinicians in emergency departments, family practice, internal medicine, general surgery, orthopedics, gynecology, dermatology, infectious disease, and oncology.
Another algorithm charted in the guidelines covers wound infections following surgeries, which can involve multiple pathogens. The algorithm provides simple clinical clues as to which require antibiotics, a simple opening of the suture line, "or a full-court press for the kind of devastating infections that occur within the first 48 hours," Dr. Stevens said. Additional recommendations address infections that can occur in individuals receiving treatment for cancer or receiving immunosuppressant medications, or those who have had an organ transplant or who have HIV/AIDS.
Immunocompromised patients, Dr. Stevens said, are among the most challenging to treat because they may have a history of extensive antibiotic exposure, are likely to have infections with resistant bacteria, and often see involvement with fungal and parasitic agents that might be considered innocuous in normal individuals. "This is the first time physicians will have some decent guidelines about how to approach the problem of skin and soft tissue infections in these kinds of patients," he noted.
The guidelines’ development was funded by the IDSA. Dr. Stevens reported no conflicts of interest. Panel member Alan L. Bisno disclosed receiving honoraria from UpToDate, while five other members – Dr. Henry F. Chambers, Dr. E. Patchen Dellinger, Dr. Ellie J. C. Goldstein, Dr. Sherwood L. Gorbach, and Dr. Sheldon L. Kaplan – disclosed financial relationships with pharmaceutical manufacturers.
Skin and soft tissue infections are one of the most common causes for patient evaluation in emergency departments and are common reasons for consultations by surgeons. SSTIs occur across a broad continuum of severity and often require only antimicrobial therapy (such as cellulitis), but they may be fulminate and life-threatening necrotizing infections that require aggressive surgical intervention. The guidelines provided by a distinguished group of clinicians from the Infectious Diseases Society of America provide an excellent organizational framework to understand this heterogenous collection of infections and provide a meaningful structure to direct management.
Several points in these guidelines deserve emphasis. First, considerable discussion in the guidelines has focused on the immunocompromised patient with SSTIs, and appropriately so. A broader consideration might have been to also include those patients with health care-associated exposure in addition to clinical immunosuppression. About 40 million hospitalizations occur annually in the United State, which makes over 3 million patients within 30 days of discharge. A larger number of patients have had recent antibiotic exposure. About 1.5 million patients are in chronic care facilities and nearly 500,000 are receiving chronic hemodialysis. Accordingly, immunocompromised and health care-associated patient exposures require that assumptions about the microbiology of SSTIs have "sensitivity" to the resistant pathogens (such as MRSA) not traditionally typical of community-acquired infections.
Second, the guidelines refer to the use of Gram stains for directing antimicrobial therapy. Although the Gram stain does not have the high-technology flare of contemporary health care, it remains a useful tool in differentiating pathogens, especially in necrotizing SSTIs.
Of the major microbiological presentations of necrotizing SSTIs, Streptococcus pyogenes is a gram-positive cocci in chains, Staphylococcus aureus is a gram-positive cocci in clusters, Clostridium perfringens is a gram-positive rod, and polymicrobial infections will have an assortment of different morphologic and gram-staining characteristics in identified bacteria. Aeromonas hydrophilia and Vibrio vulnificus will appear as gram-negative rods in those necrotizing SSTIs associated with fresh or salt-water recreational exposure. The Gram stain provides immediate direction for therapy when culture results will often be too late for a meaningful impact on patient care. Unfortunately, many hospitals have abandoned the use of Gram stains for clinical specimens.
Finally, prompt diagnosis of necrotizing SSTIs is essential. A cause of potentially preventable morbidity and deaths is a delay in the recognition of necrotizing SSTIs and the need for urgent surgical debridement. Necrotizing SSTIs are common issues in medicolegal actions because of the issue of failure to make the timely diagnosis. The hallmark of necrotizing SSTIs is pain out of proportion to the inciting injury. Trivial cutaneous injuries that are associated with an advancing perimeter of palpable tenderness and induration are necrotizing SSTIs until proven otherwise. Importantly, S. pyogenes in particular is associated with "metastatic" infection. Patients with soft-tissue contusions, joint effusions, and even fractures may have blood-borne streptococcal contamination of the injury site and yield a necrotizing infection without any cutaneous source of microbial contamination.
Because monitoring the progression of SSTIs is so important in differentiating necrotizing infections, I would only take to task the recommendation for the use of corticosteroids in treatment of cellulitic infections. Pharmacologic immunosuppression of the patient with an active SSTI in the interest of providing symptomatic relief compromises the clinical evaluation of disease progression.
In summary, the guidelines and the two algorithms for managing community-acquired and surgical incision infections are very useful for providing surgical clinicians direction in patient management. The increased incidence of S. aureus-associated necrotizing SSTIs and the emergence of community-associated MRSA over the last 20 years indicate that this is a dynamic area with changing characteristics. The changing pattern of pathogens and antimicrobial choices require a more frequent updating of these important guidelines for patient management.
Dr. Donald E. Fry is an ACS Fellow, executive vice-president for clinical outcomes management of MPA Inc. of Chicago, adjunct professor of surgery at the Northwestern University in Chicago, and professor emeritus of surgery at the University of New Mexico. He is a fellow of the Infectious Diseases Society of America, a past president of the Surgical Infection Society, and associate editor of the journal Surgical Infections.
Skin and soft tissue infections are one of the most common causes for patient evaluation in emergency departments and are common reasons for consultations by surgeons. SSTIs occur across a broad continuum of severity and often require only antimicrobial therapy (such as cellulitis), but they may be fulminate and life-threatening necrotizing infections that require aggressive surgical intervention. The guidelines provided by a distinguished group of clinicians from the Infectious Diseases Society of America provide an excellent organizational framework to understand this heterogenous collection of infections and provide a meaningful structure to direct management.
Several points in these guidelines deserve emphasis. First, considerable discussion in the guidelines has focused on the immunocompromised patient with SSTIs, and appropriately so. A broader consideration might have been to also include those patients with health care-associated exposure in addition to clinical immunosuppression. About 40 million hospitalizations occur annually in the United State, which makes over 3 million patients within 30 days of discharge. A larger number of patients have had recent antibiotic exposure. About 1.5 million patients are in chronic care facilities and nearly 500,000 are receiving chronic hemodialysis. Accordingly, immunocompromised and health care-associated patient exposures require that assumptions about the microbiology of SSTIs have "sensitivity" to the resistant pathogens (such as MRSA) not traditionally typical of community-acquired infections.
Second, the guidelines refer to the use of Gram stains for directing antimicrobial therapy. Although the Gram stain does not have the high-technology flare of contemporary health care, it remains a useful tool in differentiating pathogens, especially in necrotizing SSTIs.
Of the major microbiological presentations of necrotizing SSTIs, Streptococcus pyogenes is a gram-positive cocci in chains, Staphylococcus aureus is a gram-positive cocci in clusters, Clostridium perfringens is a gram-positive rod, and polymicrobial infections will have an assortment of different morphologic and gram-staining characteristics in identified bacteria. Aeromonas hydrophilia and Vibrio vulnificus will appear as gram-negative rods in those necrotizing SSTIs associated with fresh or salt-water recreational exposure. The Gram stain provides immediate direction for therapy when culture results will often be too late for a meaningful impact on patient care. Unfortunately, many hospitals have abandoned the use of Gram stains for clinical specimens.
Finally, prompt diagnosis of necrotizing SSTIs is essential. A cause of potentially preventable morbidity and deaths is a delay in the recognition of necrotizing SSTIs and the need for urgent surgical debridement. Necrotizing SSTIs are common issues in medicolegal actions because of the issue of failure to make the timely diagnosis. The hallmark of necrotizing SSTIs is pain out of proportion to the inciting injury. Trivial cutaneous injuries that are associated with an advancing perimeter of palpable tenderness and induration are necrotizing SSTIs until proven otherwise. Importantly, S. pyogenes in particular is associated with "metastatic" infection. Patients with soft-tissue contusions, joint effusions, and even fractures may have blood-borne streptococcal contamination of the injury site and yield a necrotizing infection without any cutaneous source of microbial contamination.
Because monitoring the progression of SSTIs is so important in differentiating necrotizing infections, I would only take to task the recommendation for the use of corticosteroids in treatment of cellulitic infections. Pharmacologic immunosuppression of the patient with an active SSTI in the interest of providing symptomatic relief compromises the clinical evaluation of disease progression.
In summary, the guidelines and the two algorithms for managing community-acquired and surgical incision infections are very useful for providing surgical clinicians direction in patient management. The increased incidence of S. aureus-associated necrotizing SSTIs and the emergence of community-associated MRSA over the last 20 years indicate that this is a dynamic area with changing characteristics. The changing pattern of pathogens and antimicrobial choices require a more frequent updating of these important guidelines for patient management.
Dr. Donald E. Fry is an ACS Fellow, executive vice-president for clinical outcomes management of MPA Inc. of Chicago, adjunct professor of surgery at the Northwestern University in Chicago, and professor emeritus of surgery at the University of New Mexico. He is a fellow of the Infectious Diseases Society of America, a past president of the Surgical Infection Society, and associate editor of the journal Surgical Infections.
Skin and soft tissue infections are one of the most common causes for patient evaluation in emergency departments and are common reasons for consultations by surgeons. SSTIs occur across a broad continuum of severity and often require only antimicrobial therapy (such as cellulitis), but they may be fulminate and life-threatening necrotizing infections that require aggressive surgical intervention. The guidelines provided by a distinguished group of clinicians from the Infectious Diseases Society of America provide an excellent organizational framework to understand this heterogenous collection of infections and provide a meaningful structure to direct management.
Several points in these guidelines deserve emphasis. First, considerable discussion in the guidelines has focused on the immunocompromised patient with SSTIs, and appropriately so. A broader consideration might have been to also include those patients with health care-associated exposure in addition to clinical immunosuppression. About 40 million hospitalizations occur annually in the United State, which makes over 3 million patients within 30 days of discharge. A larger number of patients have had recent antibiotic exposure. About 1.5 million patients are in chronic care facilities and nearly 500,000 are receiving chronic hemodialysis. Accordingly, immunocompromised and health care-associated patient exposures require that assumptions about the microbiology of SSTIs have "sensitivity" to the resistant pathogens (such as MRSA) not traditionally typical of community-acquired infections.
Second, the guidelines refer to the use of Gram stains for directing antimicrobial therapy. Although the Gram stain does not have the high-technology flare of contemporary health care, it remains a useful tool in differentiating pathogens, especially in necrotizing SSTIs.
Of the major microbiological presentations of necrotizing SSTIs, Streptococcus pyogenes is a gram-positive cocci in chains, Staphylococcus aureus is a gram-positive cocci in clusters, Clostridium perfringens is a gram-positive rod, and polymicrobial infections will have an assortment of different morphologic and gram-staining characteristics in identified bacteria. Aeromonas hydrophilia and Vibrio vulnificus will appear as gram-negative rods in those necrotizing SSTIs associated with fresh or salt-water recreational exposure. The Gram stain provides immediate direction for therapy when culture results will often be too late for a meaningful impact on patient care. Unfortunately, many hospitals have abandoned the use of Gram stains for clinical specimens.
Finally, prompt diagnosis of necrotizing SSTIs is essential. A cause of potentially preventable morbidity and deaths is a delay in the recognition of necrotizing SSTIs and the need for urgent surgical debridement. Necrotizing SSTIs are common issues in medicolegal actions because of the issue of failure to make the timely diagnosis. The hallmark of necrotizing SSTIs is pain out of proportion to the inciting injury. Trivial cutaneous injuries that are associated with an advancing perimeter of palpable tenderness and induration are necrotizing SSTIs until proven otherwise. Importantly, S. pyogenes in particular is associated with "metastatic" infection. Patients with soft-tissue contusions, joint effusions, and even fractures may have blood-borne streptococcal contamination of the injury site and yield a necrotizing infection without any cutaneous source of microbial contamination.
Because monitoring the progression of SSTIs is so important in differentiating necrotizing infections, I would only take to task the recommendation for the use of corticosteroids in treatment of cellulitic infections. Pharmacologic immunosuppression of the patient with an active SSTI in the interest of providing symptomatic relief compromises the clinical evaluation of disease progression.
In summary, the guidelines and the two algorithms for managing community-acquired and surgical incision infections are very useful for providing surgical clinicians direction in patient management. The increased incidence of S. aureus-associated necrotizing SSTIs and the emergence of community-associated MRSA over the last 20 years indicate that this is a dynamic area with changing characteristics. The changing pattern of pathogens and antimicrobial choices require a more frequent updating of these important guidelines for patient management.
Dr. Donald E. Fry is an ACS Fellow, executive vice-president for clinical outcomes management of MPA Inc. of Chicago, adjunct professor of surgery at the Northwestern University in Chicago, and professor emeritus of surgery at the University of New Mexico. He is a fellow of the Infectious Diseases Society of America, a past president of the Surgical Infection Society, and associate editor of the journal Surgical Infections.
New practice guidelines on skin and soft tissue infections from the Infectious Diseases Society of America stress careful clinical attention to the type of infection, the epidemiological setting in which the infection occurred, the health status of the patient, and the selection and dosage of the most appropriate treatment agents.
The guidelines, published online June 18 in Clinical Infectious Diseases (doi:10.1093/cid/ciu296), update those issued by IDSA in 2005 and cover everything from preventing infections caused by animal bites in healthy hosts to life-threatening infections in immunocompromised patients. They also emphasize accurate identification of pathogens, stressing that clinical presentations can be very similar.
"This is not one of those guidelines that boils complex issues down to a choice between a couple of different drugs or combinations of drugs," said Dr. Dennis Stevens of the Department of Veterans Affairs in Boise, Idaho, the guidelines’ lead author. "Skin and soft tissue infections [SSTIs] have multiple causes and different presentations, depending upon the immune status of the host. Here it’s much more complicated and really requires an astute physician to consider a number of things."
The guidelines, drafted by a 10-member panel, offer a novel algorithm for management of nonpurulent and purulent infections that aims to define a pathway for mild, moderate, and severe infections in each category. For example, no antibiotic is recommended for a purulent infection – only incision and drainage – if the patient has no signs of systemic involvement.
For moderate cases of purulent infection with some systemic involvement, incision and drainage should be followed by culture and sensitivity testing, the guidelines say, listing two antibiotics, trimethoprim-sulfamethoxazole and doxycycline, as appropriate for empiric treatment, while trimethoprim-sulfamethoxazole is recommended if the pathogen is found to be methicillin-resistant Staphylococcus aureus (MRSA) and dicloxacillin or cephalexin if it is methicillin-susceptible S. aureus (MSSA).
The purpose of the algorithm, expressed in the guidelines in chart form, "is to make the physician think," Dr. Stevens said in an interview. "There is a huge move to try and monitor antibiotic stewardship to prevent resistance, and we’re just trying to get the clinician to think of tier 1, tier 2, and tier 3 approaches, depending not only on the bug, but on how sick the patient is. Instead of a knee-jerk approach treating everybody with highly expensive IV antibiotics, [the algorithm] provides a clear pathway to treat appropriately."
In people with an abscess who have failed antibiotic treatment, are immunocompromised, or have fever and elevated white blood cell counts or other evidence of severe infection, "we’re not going to gamble," Dr. Stevens said, adding that the guidelines recommend prompt treatment using "an antibiotic that gets all of these organisms, including resistant ones." Newly approved agents dalbavancin and tedizolid are effective in treating SSTIs caused by MRSA, the guidelines note.
The guidelines are intended for use by clinicians in emergency departments, family practice, internal medicine, general surgery, orthopedics, gynecology, dermatology, infectious disease, and oncology.
Another algorithm charted in the guidelines covers wound infections following surgeries, which can involve multiple pathogens. The algorithm provides simple clinical clues as to which require antibiotics, a simple opening of the suture line, "or a full-court press for the kind of devastating infections that occur within the first 48 hours," Dr. Stevens said. Additional recommendations address infections that can occur in individuals receiving treatment for cancer or receiving immunosuppressant medications, or those who have had an organ transplant or who have HIV/AIDS.
Immunocompromised patients, Dr. Stevens said, are among the most challenging to treat because they may have a history of extensive antibiotic exposure, are likely to have infections with resistant bacteria, and often see involvement with fungal and parasitic agents that might be considered innocuous in normal individuals. "This is the first time physicians will have some decent guidelines about how to approach the problem of skin and soft tissue infections in these kinds of patients," he noted.
The guidelines’ development was funded by the IDSA. Dr. Stevens reported no conflicts of interest. Panel member Alan L. Bisno disclosed receiving honoraria from UpToDate, while five other members – Dr. Henry F. Chambers, Dr. E. Patchen Dellinger, Dr. Ellie J. C. Goldstein, Dr. Sherwood L. Gorbach, and Dr. Sheldon L. Kaplan – disclosed financial relationships with pharmaceutical manufacturers.
New practice guidelines on skin and soft tissue infections from the Infectious Diseases Society of America stress careful clinical attention to the type of infection, the epidemiological setting in which the infection occurred, the health status of the patient, and the selection and dosage of the most appropriate treatment agents.
The guidelines, published online June 18 in Clinical Infectious Diseases (doi:10.1093/cid/ciu296), update those issued by IDSA in 2005 and cover everything from preventing infections caused by animal bites in healthy hosts to life-threatening infections in immunocompromised patients. They also emphasize accurate identification of pathogens, stressing that clinical presentations can be very similar.
"This is not one of those guidelines that boils complex issues down to a choice between a couple of different drugs or combinations of drugs," said Dr. Dennis Stevens of the Department of Veterans Affairs in Boise, Idaho, the guidelines’ lead author. "Skin and soft tissue infections [SSTIs] have multiple causes and different presentations, depending upon the immune status of the host. Here it’s much more complicated and really requires an astute physician to consider a number of things."
The guidelines, drafted by a 10-member panel, offer a novel algorithm for management of nonpurulent and purulent infections that aims to define a pathway for mild, moderate, and severe infections in each category. For example, no antibiotic is recommended for a purulent infection – only incision and drainage – if the patient has no signs of systemic involvement.
For moderate cases of purulent infection with some systemic involvement, incision and drainage should be followed by culture and sensitivity testing, the guidelines say, listing two antibiotics, trimethoprim-sulfamethoxazole and doxycycline, as appropriate for empiric treatment, while trimethoprim-sulfamethoxazole is recommended if the pathogen is found to be methicillin-resistant Staphylococcus aureus (MRSA) and dicloxacillin or cephalexin if it is methicillin-susceptible S. aureus (MSSA).
The purpose of the algorithm, expressed in the guidelines in chart form, "is to make the physician think," Dr. Stevens said in an interview. "There is a huge move to try and monitor antibiotic stewardship to prevent resistance, and we’re just trying to get the clinician to think of tier 1, tier 2, and tier 3 approaches, depending not only on the bug, but on how sick the patient is. Instead of a knee-jerk approach treating everybody with highly expensive IV antibiotics, [the algorithm] provides a clear pathway to treat appropriately."
In people with an abscess who have failed antibiotic treatment, are immunocompromised, or have fever and elevated white blood cell counts or other evidence of severe infection, "we’re not going to gamble," Dr. Stevens said, adding that the guidelines recommend prompt treatment using "an antibiotic that gets all of these organisms, including resistant ones." Newly approved agents dalbavancin and tedizolid are effective in treating SSTIs caused by MRSA, the guidelines note.
The guidelines are intended for use by clinicians in emergency departments, family practice, internal medicine, general surgery, orthopedics, gynecology, dermatology, infectious disease, and oncology.
Another algorithm charted in the guidelines covers wound infections following surgeries, which can involve multiple pathogens. The algorithm provides simple clinical clues as to which require antibiotics, a simple opening of the suture line, "or a full-court press for the kind of devastating infections that occur within the first 48 hours," Dr. Stevens said. Additional recommendations address infections that can occur in individuals receiving treatment for cancer or receiving immunosuppressant medications, or those who have had an organ transplant or who have HIV/AIDS.
Immunocompromised patients, Dr. Stevens said, are among the most challenging to treat because they may have a history of extensive antibiotic exposure, are likely to have infections with resistant bacteria, and often see involvement with fungal and parasitic agents that might be considered innocuous in normal individuals. "This is the first time physicians will have some decent guidelines about how to approach the problem of skin and soft tissue infections in these kinds of patients," he noted.
The guidelines’ development was funded by the IDSA. Dr. Stevens reported no conflicts of interest. Panel member Alan L. Bisno disclosed receiving honoraria from UpToDate, while five other members – Dr. Henry F. Chambers, Dr. E. Patchen Dellinger, Dr. Ellie J. C. Goldstein, Dr. Sherwood L. Gorbach, and Dr. Sheldon L. Kaplan – disclosed financial relationships with pharmaceutical manufacturers.
FROM CLINICAL INFECTIOUS DISEASES
Calcium and vitamin D improve metabolic profile in gestational diabetes
Calcium and vitamin D can improve the metabolic profile of women with gestational diabetes mellitus, according to investigators in Iran who found significant reductions in fasting glucose, serum insulin levels, and low-density lipoprotein cholesterol associated with combined use of the supplements.
For their research, published June 23 in Diabetologia (doi:10.1007/s00125-014-3293-x), Zatollah Asemi, Ph.D., of Kashan (Iran) University and colleagues, randomized 56 women diagnosed with gestational diabetes mellitus (GDM) at between 24 and 28 weeks’ gestation to 1,000 mg calcium daily and to a 50,000 IU pearl of vitamin D3 at baseline and day 21 or placebo. Women and providers were blinded to treatment assignment.
At 6 weeks, compared with placebo, women assigned to the calcium-vitamin D group (n = 28) saw significantly lower fasting glucose (-0.89 ± 0.69 vs. +0.26 ± 0.92 mmol/L), serum insulin levels (-13.55 ± 35.25 vs. +9.17 ± 38.50 pmol/L) and homeostatic model assessment insulin resistance (-0.91 ± 1.18 vs + 0.63 ± 2.01).
They also saw a significant reduction in LDL cholesterol (-0.23 ± 0.79 vs. +0.26 ± 0.74 mmol/L). The treatment group saw increases in plasma glutathione, and supplementation was seen to prevent a rise in plasma malondialdehyde levels.
C-reactive protein and total antioxidant capacity were not affected by calcium and Vitamin D supplementation in this study, researchers wrote.
Dr. Asemi and colleagues, who have previously studied vitamin D supplementation in women with GDM and found it associated with improved insulin function and decreased total and LDL cholesterol (Am. J. Clin. Nutr. 2013;98:1425-32), hypothesized that calcium and vitamin D together would be more efficient in influencing metabolic profiles, possibly through their combined effects on cell cycle regulation, activation of antioxidant enzymes, and suppression of parathyroid hormone.
"GDM is associated with insulin resistance, increased inflammatory factors, and oxidative stress. Elevated circulating levels of inflammatory markers and impaired insulin metabolism in GDM can predict the progression to type 2 diabetes later in life and neonatal complications," investigators explained.
The researchers noted as weaknesses of their study that it did not capture pregnancy outcomes or certain biomarkers of inflammation and oxidative stress and that two subjects in the placebo group and three in the treatment group were lost to follow-up. The study was funded by Kashan University. None of the researchers disclosed conflicts of interest.
Calcium and vitamin D can improve the metabolic profile of women with gestational diabetes mellitus, according to investigators in Iran who found significant reductions in fasting glucose, serum insulin levels, and low-density lipoprotein cholesterol associated with combined use of the supplements.
For their research, published June 23 in Diabetologia (doi:10.1007/s00125-014-3293-x), Zatollah Asemi, Ph.D., of Kashan (Iran) University and colleagues, randomized 56 women diagnosed with gestational diabetes mellitus (GDM) at between 24 and 28 weeks’ gestation to 1,000 mg calcium daily and to a 50,000 IU pearl of vitamin D3 at baseline and day 21 or placebo. Women and providers were blinded to treatment assignment.
At 6 weeks, compared with placebo, women assigned to the calcium-vitamin D group (n = 28) saw significantly lower fasting glucose (-0.89 ± 0.69 vs. +0.26 ± 0.92 mmol/L), serum insulin levels (-13.55 ± 35.25 vs. +9.17 ± 38.50 pmol/L) and homeostatic model assessment insulin resistance (-0.91 ± 1.18 vs + 0.63 ± 2.01).
They also saw a significant reduction in LDL cholesterol (-0.23 ± 0.79 vs. +0.26 ± 0.74 mmol/L). The treatment group saw increases in plasma glutathione, and supplementation was seen to prevent a rise in plasma malondialdehyde levels.
C-reactive protein and total antioxidant capacity were not affected by calcium and Vitamin D supplementation in this study, researchers wrote.
Dr. Asemi and colleagues, who have previously studied vitamin D supplementation in women with GDM and found it associated with improved insulin function and decreased total and LDL cholesterol (Am. J. Clin. Nutr. 2013;98:1425-32), hypothesized that calcium and vitamin D together would be more efficient in influencing metabolic profiles, possibly through their combined effects on cell cycle regulation, activation of antioxidant enzymes, and suppression of parathyroid hormone.
"GDM is associated with insulin resistance, increased inflammatory factors, and oxidative stress. Elevated circulating levels of inflammatory markers and impaired insulin metabolism in GDM can predict the progression to type 2 diabetes later in life and neonatal complications," investigators explained.
The researchers noted as weaknesses of their study that it did not capture pregnancy outcomes or certain biomarkers of inflammation and oxidative stress and that two subjects in the placebo group and three in the treatment group were lost to follow-up. The study was funded by Kashan University. None of the researchers disclosed conflicts of interest.
Calcium and vitamin D can improve the metabolic profile of women with gestational diabetes mellitus, according to investigators in Iran who found significant reductions in fasting glucose, serum insulin levels, and low-density lipoprotein cholesterol associated with combined use of the supplements.
For their research, published June 23 in Diabetologia (doi:10.1007/s00125-014-3293-x), Zatollah Asemi, Ph.D., of Kashan (Iran) University and colleagues, randomized 56 women diagnosed with gestational diabetes mellitus (GDM) at between 24 and 28 weeks’ gestation to 1,000 mg calcium daily and to a 50,000 IU pearl of vitamin D3 at baseline and day 21 or placebo. Women and providers were blinded to treatment assignment.
At 6 weeks, compared with placebo, women assigned to the calcium-vitamin D group (n = 28) saw significantly lower fasting glucose (-0.89 ± 0.69 vs. +0.26 ± 0.92 mmol/L), serum insulin levels (-13.55 ± 35.25 vs. +9.17 ± 38.50 pmol/L) and homeostatic model assessment insulin resistance (-0.91 ± 1.18 vs + 0.63 ± 2.01).
They also saw a significant reduction in LDL cholesterol (-0.23 ± 0.79 vs. +0.26 ± 0.74 mmol/L). The treatment group saw increases in plasma glutathione, and supplementation was seen to prevent a rise in plasma malondialdehyde levels.
C-reactive protein and total antioxidant capacity were not affected by calcium and Vitamin D supplementation in this study, researchers wrote.
Dr. Asemi and colleagues, who have previously studied vitamin D supplementation in women with GDM and found it associated with improved insulin function and decreased total and LDL cholesterol (Am. J. Clin. Nutr. 2013;98:1425-32), hypothesized that calcium and vitamin D together would be more efficient in influencing metabolic profiles, possibly through their combined effects on cell cycle regulation, activation of antioxidant enzymes, and suppression of parathyroid hormone.
"GDM is associated with insulin resistance, increased inflammatory factors, and oxidative stress. Elevated circulating levels of inflammatory markers and impaired insulin metabolism in GDM can predict the progression to type 2 diabetes later in life and neonatal complications," investigators explained.
The researchers noted as weaknesses of their study that it did not capture pregnancy outcomes or certain biomarkers of inflammation and oxidative stress and that two subjects in the placebo group and three in the treatment group were lost to follow-up. The study was funded by Kashan University. None of the researchers disclosed conflicts of interest.
FROM DIABETOLOGIA
Key clinical point: Calcium and vitamin D improved levels of fasting glucose, serum insulin, and LDL cholesterol in women with GDM.
Major finding: At 6 weeks, women taking supplements in the calcium-vitamin D group saw significantly lower fasting glucose (-0.89 ± 0.69 vs. +0.26 ± 0.92 mmol/L) than those taking placebo.
Data source: A double-blind trial randomized 56 women diagnosed with gestational diabetes at between 24 and 28 weeks’ gestation to 1,000 mg calcium daily and to 50,000 IU vitamin D3 at baseline and day 21, or placebo.
Disclosures: The study was funded by Kashan University. None of the researchers disclosed conflicts of interest. The investigators reported having no financial disclosures
USPSTF: Women smokers might benefit from AAA screening
The U.S. Preventive Services Task Force says that women between ages 65 and 75 years who have smoked 100 or more cigarettes in their lives could benefit from one-time ultrasonography screening for abdominal aortic aneurysm (AAA).
The AAA guidelines replace those published by USPSTS in 2005, which had recommended against screening in women regardless of smoking history.
The new guidelines, published online June 23 in Annals of Internal Medicine (doi:10.7326/M14-1204), do not recommend screening in women who have never smoked, citing the very low prevalence of AAA in this group.
Nevertheless, the task force’s systematic review, led by current chair Dr. Michael L. LeFevre of the University of Missouri in Columbia, revealed that screening in women aged 65-75 years who have smoked or currently smoke – a group for which AAA prevalence is between 0.8% and 2% – could potentially be beneficial, though current evidence remains insufficient to recommend it.
"Prevalence of AAA in women who currently smoke approaches that of men who have never smoked," Dr. LeFevre and his colleagues wrote in the guidelines. "As such, a small net benefit might exist for this population and appropriate, high-quality research designs should be used to address this question."
The task force continues to recommend that men between the ages of 65 and 75 years who have ever smoked be offered one-time screening with ultrasonography for AAA. Men in this age group who have never smoked may be offered screening if they have certain risk factors, such as advanced age or a family history of AAA.
AAA – a dilation in the wall of the abdominal section of the aorta of 3 cm or larger – is seen in 4% and 7% of men and about 1% of women over the age of 50, USPSTF said. Most AAAs remain asymptomatic until they rupture, in which case the mortality risk has been shown to be higher than 75%. Women who develop AAA tend to do so at a later age than do men, the task force noted, with most ruptures occurring past age 80 years.
The task force is a voluntary advisory body independent of the U.S. government but supported by the Agency for Healthcare Research and Quality. One of the study’s coauthors, Dr. Douglas Owens of the Stanford (Calif.) University, disclosed travel support from the agency during the course of the review. The other task force members declared no conflicts of interest.
The U.S. Preventive Services Task Force says that women between ages 65 and 75 years who have smoked 100 or more cigarettes in their lives could benefit from one-time ultrasonography screening for abdominal aortic aneurysm (AAA).
The AAA guidelines replace those published by USPSTS in 2005, which had recommended against screening in women regardless of smoking history.
The new guidelines, published online June 23 in Annals of Internal Medicine (doi:10.7326/M14-1204), do not recommend screening in women who have never smoked, citing the very low prevalence of AAA in this group.
Nevertheless, the task force’s systematic review, led by current chair Dr. Michael L. LeFevre of the University of Missouri in Columbia, revealed that screening in women aged 65-75 years who have smoked or currently smoke – a group for which AAA prevalence is between 0.8% and 2% – could potentially be beneficial, though current evidence remains insufficient to recommend it.
"Prevalence of AAA in women who currently smoke approaches that of men who have never smoked," Dr. LeFevre and his colleagues wrote in the guidelines. "As such, a small net benefit might exist for this population and appropriate, high-quality research designs should be used to address this question."
The task force continues to recommend that men between the ages of 65 and 75 years who have ever smoked be offered one-time screening with ultrasonography for AAA. Men in this age group who have never smoked may be offered screening if they have certain risk factors, such as advanced age or a family history of AAA.
AAA – a dilation in the wall of the abdominal section of the aorta of 3 cm or larger – is seen in 4% and 7% of men and about 1% of women over the age of 50, USPSTF said. Most AAAs remain asymptomatic until they rupture, in which case the mortality risk has been shown to be higher than 75%. Women who develop AAA tend to do so at a later age than do men, the task force noted, with most ruptures occurring past age 80 years.
The task force is a voluntary advisory body independent of the U.S. government but supported by the Agency for Healthcare Research and Quality. One of the study’s coauthors, Dr. Douglas Owens of the Stanford (Calif.) University, disclosed travel support from the agency during the course of the review. The other task force members declared no conflicts of interest.
The U.S. Preventive Services Task Force says that women between ages 65 and 75 years who have smoked 100 or more cigarettes in their lives could benefit from one-time ultrasonography screening for abdominal aortic aneurysm (AAA).
The AAA guidelines replace those published by USPSTS in 2005, which had recommended against screening in women regardless of smoking history.
The new guidelines, published online June 23 in Annals of Internal Medicine (doi:10.7326/M14-1204), do not recommend screening in women who have never smoked, citing the very low prevalence of AAA in this group.
Nevertheless, the task force’s systematic review, led by current chair Dr. Michael L. LeFevre of the University of Missouri in Columbia, revealed that screening in women aged 65-75 years who have smoked or currently smoke – a group for which AAA prevalence is between 0.8% and 2% – could potentially be beneficial, though current evidence remains insufficient to recommend it.
"Prevalence of AAA in women who currently smoke approaches that of men who have never smoked," Dr. LeFevre and his colleagues wrote in the guidelines. "As such, a small net benefit might exist for this population and appropriate, high-quality research designs should be used to address this question."
The task force continues to recommend that men between the ages of 65 and 75 years who have ever smoked be offered one-time screening with ultrasonography for AAA. Men in this age group who have never smoked may be offered screening if they have certain risk factors, such as advanced age or a family history of AAA.
AAA – a dilation in the wall of the abdominal section of the aorta of 3 cm or larger – is seen in 4% and 7% of men and about 1% of women over the age of 50, USPSTF said. Most AAAs remain asymptomatic until they rupture, in which case the mortality risk has been shown to be higher than 75%. Women who develop AAA tend to do so at a later age than do men, the task force noted, with most ruptures occurring past age 80 years.
The task force is a voluntary advisory body independent of the U.S. government but supported by the Agency for Healthcare Research and Quality. One of the study’s coauthors, Dr. Douglas Owens of the Stanford (Calif.) University, disclosed travel support from the agency during the course of the review. The other task force members declared no conflicts of interest.
FROM ANNALS OF INTERNAL MEDICINE
Key clinical point: Women aged 65-75 years who have smoked more than 100 cigarettes ever could benefit from one-time ultrasonography screening for AAA.
Major finding: Screening in women aged 65-75 years who have smoked or currently smoke – a group for which AAA prevalence is between 0.8% and 2% – could potentially be beneficial.
Data source: The USPSTF commissioned a systematic review that assessed the evidence on the benefits and harms of screening for AAA and strategies for managing small (3.0-5.4 cm) screen-detected AAAs.
Disclosures: Dr. Douglas Owens of the Stanford (Calif.) University, disclosed travel support from the agency during the course of the review.
Frail women less likely to initiate hormonal therapy for breast cancer
Older women with breast cancer are less likely to initiate adjuvant hormonal therapy if they are frail, according to researchers.
In a prospective cohort study of women aged 65 and older diagnosed with invasive, nonmetastatic estrogen receptor–positive breast cancers (n = 1,062), about a quarter of the women were frail or prefrail (4.9% and 18.7%, respectively) based on a validated frailty score determined at baseline, reported Vanessa Sheppard, Ph.D., of Georgetown University Medical Center, Washington (J. Clin. Oncol. 2014 June 16 [doi:10.1200/JCO.2013.51.7367]).
Overall, 14% of the women in the study did not initiate hormonal therapy. Women considered prefrail or frail were significantly less likely to initiate therapy than were those considered "robust" or nonfrail (odds ratio, 1.63; 95% CI, 1.11-2.40; P =.013). Nonwhite race was also significantly associated with noninitiation of therapy (OR, 1.71; CI, 1.04-2.80; P = 0.33).
Baseline frailty was not predictive of discontinuation of therapy after a median follow-up of 3 years, Dr. Sheppard and colleagues reported.
The findings suggest "women and/or their providers are making informed judgments about the risks and benefits," the researchers wrote. "An alternative explanation is that women with greater frailty may have been concerned about adverse effects based on interactions of hormonal therapy and specific comorbidities, such as cardio- and/or cerebrovascular disease and risk of thromboembolic events," they added.
Limitations of the study include a potential for bias associated with self-reporting (discontinuation of therapy was measured only through self-report) and measurement of frailty only at baseline, the investigators said.
The National Institutes of Health, Amgen, and the Cancer and Leukemia Group B (CALGB) Foundation funded the study. Four of Dr. Sheppard’s coauthors, Dr. Gretchen Kimmick, Dr. Eric Winer, Dr. Arti Hurria, and Dr. Claudine Isaacs reported ties with pharmaceutical manufacturers.
Older women with breast cancer are less likely to initiate adjuvant hormonal therapy if they are frail, according to researchers.
In a prospective cohort study of women aged 65 and older diagnosed with invasive, nonmetastatic estrogen receptor–positive breast cancers (n = 1,062), about a quarter of the women were frail or prefrail (4.9% and 18.7%, respectively) based on a validated frailty score determined at baseline, reported Vanessa Sheppard, Ph.D., of Georgetown University Medical Center, Washington (J. Clin. Oncol. 2014 June 16 [doi:10.1200/JCO.2013.51.7367]).
Overall, 14% of the women in the study did not initiate hormonal therapy. Women considered prefrail or frail were significantly less likely to initiate therapy than were those considered "robust" or nonfrail (odds ratio, 1.63; 95% CI, 1.11-2.40; P =.013). Nonwhite race was also significantly associated with noninitiation of therapy (OR, 1.71; CI, 1.04-2.80; P = 0.33).
Baseline frailty was not predictive of discontinuation of therapy after a median follow-up of 3 years, Dr. Sheppard and colleagues reported.
The findings suggest "women and/or their providers are making informed judgments about the risks and benefits," the researchers wrote. "An alternative explanation is that women with greater frailty may have been concerned about adverse effects based on interactions of hormonal therapy and specific comorbidities, such as cardio- and/or cerebrovascular disease and risk of thromboembolic events," they added.
Limitations of the study include a potential for bias associated with self-reporting (discontinuation of therapy was measured only through self-report) and measurement of frailty only at baseline, the investigators said.
The National Institutes of Health, Amgen, and the Cancer and Leukemia Group B (CALGB) Foundation funded the study. Four of Dr. Sheppard’s coauthors, Dr. Gretchen Kimmick, Dr. Eric Winer, Dr. Arti Hurria, and Dr. Claudine Isaacs reported ties with pharmaceutical manufacturers.
Older women with breast cancer are less likely to initiate adjuvant hormonal therapy if they are frail, according to researchers.
In a prospective cohort study of women aged 65 and older diagnosed with invasive, nonmetastatic estrogen receptor–positive breast cancers (n = 1,062), about a quarter of the women were frail or prefrail (4.9% and 18.7%, respectively) based on a validated frailty score determined at baseline, reported Vanessa Sheppard, Ph.D., of Georgetown University Medical Center, Washington (J. Clin. Oncol. 2014 June 16 [doi:10.1200/JCO.2013.51.7367]).
Overall, 14% of the women in the study did not initiate hormonal therapy. Women considered prefrail or frail were significantly less likely to initiate therapy than were those considered "robust" or nonfrail (odds ratio, 1.63; 95% CI, 1.11-2.40; P =.013). Nonwhite race was also significantly associated with noninitiation of therapy (OR, 1.71; CI, 1.04-2.80; P = 0.33).
Baseline frailty was not predictive of discontinuation of therapy after a median follow-up of 3 years, Dr. Sheppard and colleagues reported.
The findings suggest "women and/or their providers are making informed judgments about the risks and benefits," the researchers wrote. "An alternative explanation is that women with greater frailty may have been concerned about adverse effects based on interactions of hormonal therapy and specific comorbidities, such as cardio- and/or cerebrovascular disease and risk of thromboembolic events," they added.
Limitations of the study include a potential for bias associated with self-reporting (discontinuation of therapy was measured only through self-report) and measurement of frailty only at baseline, the investigators said.
The National Institutes of Health, Amgen, and the Cancer and Leukemia Group B (CALGB) Foundation funded the study. Four of Dr. Sheppard’s coauthors, Dr. Gretchen Kimmick, Dr. Eric Winer, Dr. Arti Hurria, and Dr. Claudine Isaacs reported ties with pharmaceutical manufacturers.
FROM JOURNAL OF CLINICAL ONCOLOGY
Key clinical point: Older women with breast cancer are less likely to initiate adjuvant hormonal therapy if they are frail.
Major finding: Odds ratio for noninitiation of hormonal therapy was 1.63 for frail women compared with nonfrail women (95% CI, 1.11 to 2.40; P = .013) after covariate adjustment.
Data source: A prospective cohort of 1,288 older women diagnosed with invasive, nonmetastatic breast cancer recruited from 78 sites from 2004 to 2011, of which 1,062 had estrogen receptor–positive tumors.
Disclosures: The National Institutes of Health, Amgen, and the Cancer and Leukemia Group B (CALGB) Foundation funded the study. Four of Dr. Sheppard’s coauthors, Dr. Gretchen Kimmick, Dr. Eric Winer, Dr. Arti Hurria, and Dr. Claudine Isaacs reported ties with pharmaceutical manufacturers.
Higher risk of death seen with oral steroids in RA interstitial lung disease
The use of prednisone for 3 or more months at a time was associated with a significantly elevated risk of death in patients with rheumatoid arthritis and interstitial lung disease in a retrospective cohort study.
Interstitial lung disease is present in about 5% of patients with rheumatoid arthritis. For years, oral steroids were commonly used in patients with the disease, but today’s rheumatologists "no longer view oral steroids as optimal treatment in RA-ILD [rheumatoid arthritis–associated interstitial lung disease], and our data now confirm that," said Dr. Clive Kelly of Queen Elizabeth Hospital in Gateshead, England, senior investigator of the study. He added that clinicians should avoid long-term treatment with steroids in this patient group whenever possible.
Dr. Kelly led the British Rheumatoid Interstitial Lung (BRILL) Network’s cohort study of 260 patients with RA-ILD diagnosed over a 25-year period. The BRILL study compared patients with RA-ILD and an equal number of RA controls without lung involvement who were matched for age, sex, and time of diagnosis.
At the annual European Congress of Rheumatology, Dr. Kelly reported that steroid-treated RA-ILD patients, who represented nearly 60% of the cohort, had an elevated relative risk of all-cause death, compared with those who had never been treated with steroids (RR, 1.65; 95% confidence interval, 1.2-2.3; P = .002). Although the relative risk of respiratory death was significantly increased for RA-ILD patients, regardless of treatment, when compared with RA patients without ILD, the risk was higher in those who had been on steroids (RR, 2.75; 95% CI, 1.6-4.7; P = .0002) than in those who had not received steroids (RR, 2.06; 95% CI, 1.1-3.8; P = .02), the investigators found.
The comparison also revealed other important findings related to RA-ILD. Patients with RA-ILD had significantly higher mortality than did those with RA alone. Over the course of the 25-year study period, however, mortality progressively improved among the RA-ILD patients, with median age at death rising from 63 to 76 years. This steady improvement, Dr. Kelly said, is partly the result of better and earlier diagnosis of lung involvement.
"It’s one of my many missions in life to get rheumatologists to listen to the lungs when they examine the joints in patients with rheumatoid arthritis," he said. "I think we are getting better. We’ve persuaded the British Society for Rheumatology to incorporate lung function testing and clinical examination of the chest into their basic assessment of a rheumatoid patient."
Also likely affecting the improved mortality seen over the cohort’s study period is a change in therapeutic approach. While RA-ILD patients diagnosed in the first half of the study period were likely to have been treated with only prednisone and azathioprine, in the latter half they were more likely to have received cyclophosphamide and methylprednisolone or mycophenolate. Over the last 12 years, more were treated with biologics, and in the final 6 years of the cohort, patients requiring biologics tended to be treated with rituximab, a B-cell inhibitor, rather than anti–tumor necrosis factor (anti-TNF) agents, the BRILL investigators found.
Mortality was lower among RA-ILD patients treated with mycophenolate than in those treated with other immunosuppressive agents. Among biologic agents used in the cohort, rituximab treatment was associated with improved mortality, but anti-TNF inhibitors were seen to be associated with elevated risk of death.
About 95% of RA-ILD patients are anticyclic citrullinated peptide (anti-CCP) antibody positive, compared with 55%-60% of the RA population as a whole, Dr. Kelly said, "so there’s a strong statistical association of seropositivity, and in those who are seropositive, rituximab works well."
The finding that rituximab was associated with improved survival in the cohort not only has implications for RA-ILD, he said, but also, potentially, for people with idiopathic pulmonary fibrosis (IPF) who are anti-CCP antibody positive. "What [rheumatologists] have, and chest physicians traditionally don’t, is access to rituximab and mycophenolate. But these might be worth trying in IPF as well," he said.
Dr. Kelly noted that prospective trials in RA-ILD are beginning to enroll patients with progressive disease to compare azathioprine and mycophenolate, allowing for the use of oral steroids, as well as patients with active RA and ILD to compare anti-TNF inhibitors against rituximab, also allowing oral steroids.
Dr. Kelly reported that he had no conflicts of interest related to his findings and that none of his fellow BRILL investigators had conflicts.
The use of prednisone for 3 or more months at a time was associated with a significantly elevated risk of death in patients with rheumatoid arthritis and interstitial lung disease in a retrospective cohort study.
Interstitial lung disease is present in about 5% of patients with rheumatoid arthritis. For years, oral steroids were commonly used in patients with the disease, but today’s rheumatologists "no longer view oral steroids as optimal treatment in RA-ILD [rheumatoid arthritis–associated interstitial lung disease], and our data now confirm that," said Dr. Clive Kelly of Queen Elizabeth Hospital in Gateshead, England, senior investigator of the study. He added that clinicians should avoid long-term treatment with steroids in this patient group whenever possible.
Dr. Kelly led the British Rheumatoid Interstitial Lung (BRILL) Network’s cohort study of 260 patients with RA-ILD diagnosed over a 25-year period. The BRILL study compared patients with RA-ILD and an equal number of RA controls without lung involvement who were matched for age, sex, and time of diagnosis.
At the annual European Congress of Rheumatology, Dr. Kelly reported that steroid-treated RA-ILD patients, who represented nearly 60% of the cohort, had an elevated relative risk of all-cause death, compared with those who had never been treated with steroids (RR, 1.65; 95% confidence interval, 1.2-2.3; P = .002). Although the relative risk of respiratory death was significantly increased for RA-ILD patients, regardless of treatment, when compared with RA patients without ILD, the risk was higher in those who had been on steroids (RR, 2.75; 95% CI, 1.6-4.7; P = .0002) than in those who had not received steroids (RR, 2.06; 95% CI, 1.1-3.8; P = .02), the investigators found.
The comparison also revealed other important findings related to RA-ILD. Patients with RA-ILD had significantly higher mortality than did those with RA alone. Over the course of the 25-year study period, however, mortality progressively improved among the RA-ILD patients, with median age at death rising from 63 to 76 years. This steady improvement, Dr. Kelly said, is partly the result of better and earlier diagnosis of lung involvement.
"It’s one of my many missions in life to get rheumatologists to listen to the lungs when they examine the joints in patients with rheumatoid arthritis," he said. "I think we are getting better. We’ve persuaded the British Society for Rheumatology to incorporate lung function testing and clinical examination of the chest into their basic assessment of a rheumatoid patient."
Also likely affecting the improved mortality seen over the cohort’s study period is a change in therapeutic approach. While RA-ILD patients diagnosed in the first half of the study period were likely to have been treated with only prednisone and azathioprine, in the latter half they were more likely to have received cyclophosphamide and methylprednisolone or mycophenolate. Over the last 12 years, more were treated with biologics, and in the final 6 years of the cohort, patients requiring biologics tended to be treated with rituximab, a B-cell inhibitor, rather than anti–tumor necrosis factor (anti-TNF) agents, the BRILL investigators found.
Mortality was lower among RA-ILD patients treated with mycophenolate than in those treated with other immunosuppressive agents. Among biologic agents used in the cohort, rituximab treatment was associated with improved mortality, but anti-TNF inhibitors were seen to be associated with elevated risk of death.
About 95% of RA-ILD patients are anticyclic citrullinated peptide (anti-CCP) antibody positive, compared with 55%-60% of the RA population as a whole, Dr. Kelly said, "so there’s a strong statistical association of seropositivity, and in those who are seropositive, rituximab works well."
The finding that rituximab was associated with improved survival in the cohort not only has implications for RA-ILD, he said, but also, potentially, for people with idiopathic pulmonary fibrosis (IPF) who are anti-CCP antibody positive. "What [rheumatologists] have, and chest physicians traditionally don’t, is access to rituximab and mycophenolate. But these might be worth trying in IPF as well," he said.
Dr. Kelly noted that prospective trials in RA-ILD are beginning to enroll patients with progressive disease to compare azathioprine and mycophenolate, allowing for the use of oral steroids, as well as patients with active RA and ILD to compare anti-TNF inhibitors against rituximab, also allowing oral steroids.
Dr. Kelly reported that he had no conflicts of interest related to his findings and that none of his fellow BRILL investigators had conflicts.
The use of prednisone for 3 or more months at a time was associated with a significantly elevated risk of death in patients with rheumatoid arthritis and interstitial lung disease in a retrospective cohort study.
Interstitial lung disease is present in about 5% of patients with rheumatoid arthritis. For years, oral steroids were commonly used in patients with the disease, but today’s rheumatologists "no longer view oral steroids as optimal treatment in RA-ILD [rheumatoid arthritis–associated interstitial lung disease], and our data now confirm that," said Dr. Clive Kelly of Queen Elizabeth Hospital in Gateshead, England, senior investigator of the study. He added that clinicians should avoid long-term treatment with steroids in this patient group whenever possible.
Dr. Kelly led the British Rheumatoid Interstitial Lung (BRILL) Network’s cohort study of 260 patients with RA-ILD diagnosed over a 25-year period. The BRILL study compared patients with RA-ILD and an equal number of RA controls without lung involvement who were matched for age, sex, and time of diagnosis.
At the annual European Congress of Rheumatology, Dr. Kelly reported that steroid-treated RA-ILD patients, who represented nearly 60% of the cohort, had an elevated relative risk of all-cause death, compared with those who had never been treated with steroids (RR, 1.65; 95% confidence interval, 1.2-2.3; P = .002). Although the relative risk of respiratory death was significantly increased for RA-ILD patients, regardless of treatment, when compared with RA patients without ILD, the risk was higher in those who had been on steroids (RR, 2.75; 95% CI, 1.6-4.7; P = .0002) than in those who had not received steroids (RR, 2.06; 95% CI, 1.1-3.8; P = .02), the investigators found.
The comparison also revealed other important findings related to RA-ILD. Patients with RA-ILD had significantly higher mortality than did those with RA alone. Over the course of the 25-year study period, however, mortality progressively improved among the RA-ILD patients, with median age at death rising from 63 to 76 years. This steady improvement, Dr. Kelly said, is partly the result of better and earlier diagnosis of lung involvement.
"It’s one of my many missions in life to get rheumatologists to listen to the lungs when they examine the joints in patients with rheumatoid arthritis," he said. "I think we are getting better. We’ve persuaded the British Society for Rheumatology to incorporate lung function testing and clinical examination of the chest into their basic assessment of a rheumatoid patient."
Also likely affecting the improved mortality seen over the cohort’s study period is a change in therapeutic approach. While RA-ILD patients diagnosed in the first half of the study period were likely to have been treated with only prednisone and azathioprine, in the latter half they were more likely to have received cyclophosphamide and methylprednisolone or mycophenolate. Over the last 12 years, more were treated with biologics, and in the final 6 years of the cohort, patients requiring biologics tended to be treated with rituximab, a B-cell inhibitor, rather than anti–tumor necrosis factor (anti-TNF) agents, the BRILL investigators found.
Mortality was lower among RA-ILD patients treated with mycophenolate than in those treated with other immunosuppressive agents. Among biologic agents used in the cohort, rituximab treatment was associated with improved mortality, but anti-TNF inhibitors were seen to be associated with elevated risk of death.
About 95% of RA-ILD patients are anticyclic citrullinated peptide (anti-CCP) antibody positive, compared with 55%-60% of the RA population as a whole, Dr. Kelly said, "so there’s a strong statistical association of seropositivity, and in those who are seropositive, rituximab works well."
The finding that rituximab was associated with improved survival in the cohort not only has implications for RA-ILD, he said, but also, potentially, for people with idiopathic pulmonary fibrosis (IPF) who are anti-CCP antibody positive. "What [rheumatologists] have, and chest physicians traditionally don’t, is access to rituximab and mycophenolate. But these might be worth trying in IPF as well," he said.
Dr. Kelly noted that prospective trials in RA-ILD are beginning to enroll patients with progressive disease to compare azathioprine and mycophenolate, allowing for the use of oral steroids, as well as patients with active RA and ILD to compare anti-TNF inhibitors against rituximab, also allowing oral steroids.
Dr. Kelly reported that he had no conflicts of interest related to his findings and that none of his fellow BRILL investigators had conflicts.
FROM THE EULAR CONGRESS 2014
Key clinical point: Rather than corticosteroids, consider using mycophenolate or rituximab in patients with RA-ILD.
Major finding: Steroid-treated RA-ILD patients had an elevated relative risk of all-cause death, compared with those who had never been treated with steroids (RR, 1.65; 95% confidence interval, 1.2-2.3; P = .002).
Data source: A retrospective study of 260 patients with RA-ILD in the British Rheumatoid Interstitial Lung Network.
Disclosures: Dr. Kelly reported that he had no conflicts of interest related to his findings and that none of his fellow BRILL investigators had conflicts.