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A ‘scary’ side effect
Memantine (aka Namenda) is Food and Drug Administration–approved for Alzheimer’s disease, though its benefits are modest, at best.
It’s also, 18 years after first coming to market, relatively inexpensive.
I occasionally use it off label, as neurologists tend to do with a wide variety of medications. There are small studies that suggest it’s effective for migraine prevention and painful neuropathies. It also has a relatively benign side-effect profile.
As a result, once in a while I prescribe it for migraines or neuropathy where more typical agents haven’t helped. Like any of these drugs, sometimes it works, sometimes it doesn’t. A lot of neurology, as one of my colleagues puts it, is “guessing and voodoo.”
Since I’ve started this, however, I’ve noticed an unusual, and somewhat scary, side effect – one that has nothing to do the drug reactions.
While I don’t use any type of commercial chart system, most doctors in my area do, as well as all the hospitals. So I often see my patients’ notes from their general practitioners or after they’ve been in the hospital for whatever reason.
Those notes often list – as they should – current medications. Which includes the memantine I’ve prescribed.
But in the patient problem list I often then see “Alzheimer’s disease” or “dementia” show up, even in people who clearly have no history of such.
I’ve seen it way too many times to think it’s an accident. So one of two things is happening:
1. The computer chart system, when it sees “memantine” entered, searches its database, finds what it’s FDA-approved for, and automatically puts that in a list of current diagnoses.
2. The person entering the data, upon hearing the patient takes memantine, just enters the more commonly used indication as well, without bothering to ask the patient why they’re taking it.
Neither of these is good.
At the very least, they show a lack of proper history taking (or interest in doing so) by the person entering things in the chart (which these days could be someone with no medical training at all). It doesn’t take that much effort to say “what are you on this for?” I do it several times a day. It’s part of my job.
It’s bad form for any incorrect diagnosis to get into a chart. It can have serious repercussions on someone’s ability to get health, disability, or life insurance, not to mention the immediate impact on their care when that shows up. Someone who doesn’t know the patient opens the chart and immediately assumes it’s what they’ve got. I mean, it’s the chart. People treat it like it’s infallible and inviolable.
This isn’t a new issue – I trained at the VA when sometimes an H&P simply said “see old chart” and there were four volumes of it. But now, in the age of digital records, entries are forever. The toe you fractured surfing 8 years ago still shows up as a “current problem,” and will likely follow you to the grave. The same with any other diagnosis entered – it’s yours to keep, regardless of accuracy.
Medicine, like life, is mostly gray. But computers, and many times those who enter their data, only see things as black and white. In this field that’s liable to backfire. I’m just seeing the tip of the iceberg by using memantine off-label.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
Memantine (aka Namenda) is Food and Drug Administration–approved for Alzheimer’s disease, though its benefits are modest, at best.
It’s also, 18 years after first coming to market, relatively inexpensive.
I occasionally use it off label, as neurologists tend to do with a wide variety of medications. There are small studies that suggest it’s effective for migraine prevention and painful neuropathies. It also has a relatively benign side-effect profile.
As a result, once in a while I prescribe it for migraines or neuropathy where more typical agents haven’t helped. Like any of these drugs, sometimes it works, sometimes it doesn’t. A lot of neurology, as one of my colleagues puts it, is “guessing and voodoo.”
Since I’ve started this, however, I’ve noticed an unusual, and somewhat scary, side effect – one that has nothing to do the drug reactions.
While I don’t use any type of commercial chart system, most doctors in my area do, as well as all the hospitals. So I often see my patients’ notes from their general practitioners or after they’ve been in the hospital for whatever reason.
Those notes often list – as they should – current medications. Which includes the memantine I’ve prescribed.
But in the patient problem list I often then see “Alzheimer’s disease” or “dementia” show up, even in people who clearly have no history of such.
I’ve seen it way too many times to think it’s an accident. So one of two things is happening:
1. The computer chart system, when it sees “memantine” entered, searches its database, finds what it’s FDA-approved for, and automatically puts that in a list of current diagnoses.
2. The person entering the data, upon hearing the patient takes memantine, just enters the more commonly used indication as well, without bothering to ask the patient why they’re taking it.
Neither of these is good.
At the very least, they show a lack of proper history taking (or interest in doing so) by the person entering things in the chart (which these days could be someone with no medical training at all). It doesn’t take that much effort to say “what are you on this for?” I do it several times a day. It’s part of my job.
It’s bad form for any incorrect diagnosis to get into a chart. It can have serious repercussions on someone’s ability to get health, disability, or life insurance, not to mention the immediate impact on their care when that shows up. Someone who doesn’t know the patient opens the chart and immediately assumes it’s what they’ve got. I mean, it’s the chart. People treat it like it’s infallible and inviolable.
This isn’t a new issue – I trained at the VA when sometimes an H&P simply said “see old chart” and there were four volumes of it. But now, in the age of digital records, entries are forever. The toe you fractured surfing 8 years ago still shows up as a “current problem,” and will likely follow you to the grave. The same with any other diagnosis entered – it’s yours to keep, regardless of accuracy.
Medicine, like life, is mostly gray. But computers, and many times those who enter their data, only see things as black and white. In this field that’s liable to backfire. I’m just seeing the tip of the iceberg by using memantine off-label.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
Memantine (aka Namenda) is Food and Drug Administration–approved for Alzheimer’s disease, though its benefits are modest, at best.
It’s also, 18 years after first coming to market, relatively inexpensive.
I occasionally use it off label, as neurologists tend to do with a wide variety of medications. There are small studies that suggest it’s effective for migraine prevention and painful neuropathies. It also has a relatively benign side-effect profile.
As a result, once in a while I prescribe it for migraines or neuropathy where more typical agents haven’t helped. Like any of these drugs, sometimes it works, sometimes it doesn’t. A lot of neurology, as one of my colleagues puts it, is “guessing and voodoo.”
Since I’ve started this, however, I’ve noticed an unusual, and somewhat scary, side effect – one that has nothing to do the drug reactions.
While I don’t use any type of commercial chart system, most doctors in my area do, as well as all the hospitals. So I often see my patients’ notes from their general practitioners or after they’ve been in the hospital for whatever reason.
Those notes often list – as they should – current medications. Which includes the memantine I’ve prescribed.
But in the patient problem list I often then see “Alzheimer’s disease” or “dementia” show up, even in people who clearly have no history of such.
I’ve seen it way too many times to think it’s an accident. So one of two things is happening:
1. The computer chart system, when it sees “memantine” entered, searches its database, finds what it’s FDA-approved for, and automatically puts that in a list of current diagnoses.
2. The person entering the data, upon hearing the patient takes memantine, just enters the more commonly used indication as well, without bothering to ask the patient why they’re taking it.
Neither of these is good.
At the very least, they show a lack of proper history taking (or interest in doing so) by the person entering things in the chart (which these days could be someone with no medical training at all). It doesn’t take that much effort to say “what are you on this for?” I do it several times a day. It’s part of my job.
It’s bad form for any incorrect diagnosis to get into a chart. It can have serious repercussions on someone’s ability to get health, disability, or life insurance, not to mention the immediate impact on their care when that shows up. Someone who doesn’t know the patient opens the chart and immediately assumes it’s what they’ve got. I mean, it’s the chart. People treat it like it’s infallible and inviolable.
This isn’t a new issue – I trained at the VA when sometimes an H&P simply said “see old chart” and there were four volumes of it. But now, in the age of digital records, entries are forever. The toe you fractured surfing 8 years ago still shows up as a “current problem,” and will likely follow you to the grave. The same with any other diagnosis entered – it’s yours to keep, regardless of accuracy.
Medicine, like life, is mostly gray. But computers, and many times those who enter their data, only see things as black and white. In this field that’s liable to backfire. I’m just seeing the tip of the iceberg by using memantine off-label.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
Baricitinib hits mark for severe alopecia areata
in the phase 2/3 BRAVE-AA1 randomized trial, Brett King, MD, PhD, reported at Innovations in Dermatology: Virtual Spring Conference 2021.
The results with the 4-mg/day dose of the Janus kinase (JAK) 1 and -2 inhibitor were even more impressive. However, this higher dose, while approved in Europe and elsewhere for the treatment of rheumatoid arthritis, was rejected by the Food and Drug Administration because of safety concerns and is not available in the United States. The 2-mg dose of baricitinib is approved for RA in the United States.
There are currently no FDA-approved treatments for alopecia areata, noted Dr. King, a dermatologist at Yale University, New Haven, Conn.
He reported on 110 adults with severe alopecia areata as defined by a baseline Severity of Alopecia Tool (SALT) score of 87, meaning they averaged 87% scalp hair loss. They averaged a 16-year history of the autoimmune disease. The duration of the current episode was at least 4 years in more than one-third of participants. Clinicians rated more than three-quarters of patients as having no eyebrow or eyelash hair, or significant gaps and uneven distribution.
The primary outcome in this interim analysis was achievement of a SALT score of 20 or less at week 36, meaning hair loss had shrunk to 20% or less of the scalp. Fifty-two percent of patients on baricitinib 4 mg achieved this outcome, as did 33% of those randomized to baricitinib 2 mg and 4% of placebo-treated controls.
In addition, 60% of patients on the higher dose of the JAK inhibitor and 40% on the lower dose rated themselves as having either full eyebrows and eyelashes on both eyes at 36 weeks, or only minimal gaps with even distribution. None of the controls reported comparable improvement, Dr. King said at the conference, which was sponsored by MedscapeLIVE! and the producers of the Hawaii Dermatology Seminar and Caribbean Dermatology Symposium.
There were no serious adverse events in this relatively small study. Six cases of herpes simplex and two of herpes zoster occurred in baricitinib-treated patients; there were none in controls.
Session moderator Andrea L. Zaenglein, MD, professor of dermatology and pediatric dermatology at Penn State University, Hershey, said that she was very impressed that baricitinib could achieve substantial hair regrowth in patients with a median duration of hair loss of about 16 years.
“It’s very interesting,” agreed comoderator Ashfaq A. Marghoob, MD, director of clinical dermatology at Memorial Sloan Kettering Cancer Center in Hauppauge, N.Y. “Having this kind of hair regrowth goes against what we learned in our residency, that the longer you’ve gone with hair loss, the less likely it is to ever come back.”
Separately, Eli Lilly issued a press release announcing that both the 2- and 4-mg doses of baricitinib had met the primary endpoint in the phase 3 BRAVE-AA2 trial, showing significantly greater hair regrowth compared with placebo in the 546-patient study. However, the company provided no data, instead stating that the full results will be presented at an upcoming medical conference.
in the phase 2/3 BRAVE-AA1 randomized trial, Brett King, MD, PhD, reported at Innovations in Dermatology: Virtual Spring Conference 2021.
The results with the 4-mg/day dose of the Janus kinase (JAK) 1 and -2 inhibitor were even more impressive. However, this higher dose, while approved in Europe and elsewhere for the treatment of rheumatoid arthritis, was rejected by the Food and Drug Administration because of safety concerns and is not available in the United States. The 2-mg dose of baricitinib is approved for RA in the United States.
There are currently no FDA-approved treatments for alopecia areata, noted Dr. King, a dermatologist at Yale University, New Haven, Conn.
He reported on 110 adults with severe alopecia areata as defined by a baseline Severity of Alopecia Tool (SALT) score of 87, meaning they averaged 87% scalp hair loss. They averaged a 16-year history of the autoimmune disease. The duration of the current episode was at least 4 years in more than one-third of participants. Clinicians rated more than three-quarters of patients as having no eyebrow or eyelash hair, or significant gaps and uneven distribution.
The primary outcome in this interim analysis was achievement of a SALT score of 20 or less at week 36, meaning hair loss had shrunk to 20% or less of the scalp. Fifty-two percent of patients on baricitinib 4 mg achieved this outcome, as did 33% of those randomized to baricitinib 2 mg and 4% of placebo-treated controls.
In addition, 60% of patients on the higher dose of the JAK inhibitor and 40% on the lower dose rated themselves as having either full eyebrows and eyelashes on both eyes at 36 weeks, or only minimal gaps with even distribution. None of the controls reported comparable improvement, Dr. King said at the conference, which was sponsored by MedscapeLIVE! and the producers of the Hawaii Dermatology Seminar and Caribbean Dermatology Symposium.
There were no serious adverse events in this relatively small study. Six cases of herpes simplex and two of herpes zoster occurred in baricitinib-treated patients; there were none in controls.
Session moderator Andrea L. Zaenglein, MD, professor of dermatology and pediatric dermatology at Penn State University, Hershey, said that she was very impressed that baricitinib could achieve substantial hair regrowth in patients with a median duration of hair loss of about 16 years.
“It’s very interesting,” agreed comoderator Ashfaq A. Marghoob, MD, director of clinical dermatology at Memorial Sloan Kettering Cancer Center in Hauppauge, N.Y. “Having this kind of hair regrowth goes against what we learned in our residency, that the longer you’ve gone with hair loss, the less likely it is to ever come back.”
Separately, Eli Lilly issued a press release announcing that both the 2- and 4-mg doses of baricitinib had met the primary endpoint in the phase 3 BRAVE-AA2 trial, showing significantly greater hair regrowth compared with placebo in the 546-patient study. However, the company provided no data, instead stating that the full results will be presented at an upcoming medical conference.
in the phase 2/3 BRAVE-AA1 randomized trial, Brett King, MD, PhD, reported at Innovations in Dermatology: Virtual Spring Conference 2021.
The results with the 4-mg/day dose of the Janus kinase (JAK) 1 and -2 inhibitor were even more impressive. However, this higher dose, while approved in Europe and elsewhere for the treatment of rheumatoid arthritis, was rejected by the Food and Drug Administration because of safety concerns and is not available in the United States. The 2-mg dose of baricitinib is approved for RA in the United States.
There are currently no FDA-approved treatments for alopecia areata, noted Dr. King, a dermatologist at Yale University, New Haven, Conn.
He reported on 110 adults with severe alopecia areata as defined by a baseline Severity of Alopecia Tool (SALT) score of 87, meaning they averaged 87% scalp hair loss. They averaged a 16-year history of the autoimmune disease. The duration of the current episode was at least 4 years in more than one-third of participants. Clinicians rated more than three-quarters of patients as having no eyebrow or eyelash hair, or significant gaps and uneven distribution.
The primary outcome in this interim analysis was achievement of a SALT score of 20 or less at week 36, meaning hair loss had shrunk to 20% or less of the scalp. Fifty-two percent of patients on baricitinib 4 mg achieved this outcome, as did 33% of those randomized to baricitinib 2 mg and 4% of placebo-treated controls.
In addition, 60% of patients on the higher dose of the JAK inhibitor and 40% on the lower dose rated themselves as having either full eyebrows and eyelashes on both eyes at 36 weeks, or only minimal gaps with even distribution. None of the controls reported comparable improvement, Dr. King said at the conference, which was sponsored by MedscapeLIVE! and the producers of the Hawaii Dermatology Seminar and Caribbean Dermatology Symposium.
There were no serious adverse events in this relatively small study. Six cases of herpes simplex and two of herpes zoster occurred in baricitinib-treated patients; there were none in controls.
Session moderator Andrea L. Zaenglein, MD, professor of dermatology and pediatric dermatology at Penn State University, Hershey, said that she was very impressed that baricitinib could achieve substantial hair regrowth in patients with a median duration of hair loss of about 16 years.
“It’s very interesting,” agreed comoderator Ashfaq A. Marghoob, MD, director of clinical dermatology at Memorial Sloan Kettering Cancer Center in Hauppauge, N.Y. “Having this kind of hair regrowth goes against what we learned in our residency, that the longer you’ve gone with hair loss, the less likely it is to ever come back.”
Separately, Eli Lilly issued a press release announcing that both the 2- and 4-mg doses of baricitinib had met the primary endpoint in the phase 3 BRAVE-AA2 trial, showing significantly greater hair regrowth compared with placebo in the 546-patient study. However, the company provided no data, instead stating that the full results will be presented at an upcoming medical conference.
FROM INNOVATIONS IN DERMATOLOGY
Systemic racism in medical education
Resources:
"How Medical Education Is Missing the Bull’s-eye" by LaShyra Nolen
Becoming by Michelle Obama
Resources:
"How Medical Education Is Missing the Bull’s-eye" by LaShyra Nolen
Becoming by Michelle Obama
Resources:
"How Medical Education Is Missing the Bull’s-eye" by LaShyra Nolen
Becoming by Michelle Obama
COVID-19 variants now detected in more animals, may find hosts in mice
The new SARS-CoV-2 variants are not just problems for humans.
New research shows they can also infect animals, and for the first time, variants have been able to infect mice, a development that may complicate efforts to rein in the global spread of the virus.
In addition, two new studies have implications for pets. Veterinarians in Texas and the United Kingdom have documented infections of B.1.1.7 – the fast-spreading variant first found in the United Kingdom – in dogs and cats. The animals in the U.K. study also had heart damage, but it’s unclear if the damage was caused by the virus or was already there and was found as a result of their infections.
Animal studies of SARS-CoV-2 and its emerging variants are urgent, said Sarah Hamer, DVM, PhD, a veterinarian and epidemiologist at Texas A&M University, College Station.
She’s part of a network of scientists who are swabbing the pets of people who are diagnosed with COVID-19 to find out how often the virus passes from people to animals.
The collaboration is part of the One Health initiative through the Centers for Disease Control and Prevention. One Health aims to tackle infectious diseases by recognizing that people can’t be fully protected from pathogens unless animals and the environment are also safeguarded. “Over 70% of emerging diseases of humans have their origins in animal populations,” Dr. Hamer said. “So if we are only focusing on studying disease as it emerges in humans and ignoring where those pathogens have been transmitted or circulating for years, then we might miss the ability to detect early emergence. We might miss the ability to control these diseases before they become problems for human health.”
Variants move to mice
In new work, researchers at the Institut Pasteur in Paris have shown that the B.1.351 and P.1 variants of concern, which were first identified in South Africa and Brazil, respectively, can infect mice, giving the virus a potential new host. Older versions of the virus couldn’t infect mice because they weren’t able bind to receptors on their cells. These two variants can.
On one hand, that’s a good thing, because it will help scientists more easily conduct experiments in mice. Before, if they wanted to do an experiment with SARS-CoV-2 in mice, they had to use a special strain of mouse that was bred to carry human ACE2 receptors on their lung cells. Now that mice can become naturally infected, any breed will do, making it less costly and time-consuming to study the virus in animals.
On the other hand, the idea that the virus could have more and different ways to spread isn’t good news.
“From the beginning of the epidemic and since human coronaviruses emerged from animals, it has been very important to establish in which species the virus can replicate, in particular the species that live close to humans,” said Xavier Montagutelli, DVM, PhD, head of the Mouse Genetics Laboratory at the Institut Pasteur. His study was published as a preprint ahead of peer review on BioRXIV.
Once a virus establishes itself within a population of animals, it will continue to spread and change and may eventually be passed back to humans. It’s the reason that birds and pigs are closely monitored for influenza viruses.
So far, with SARS-CoV-2, only one animal has been found to catch and spread the virus and pass it back to people – farmed mink. Researchers have also documented SARS-CoV-2 antibodies in escaped mink living near mink farms in Utah, suggesting the virus has the potential to be transmitted to wild populations.
And the move of the virus into mice suggests that SARS-CoV-2 could establish itself in a population of wild animals that live close to humans.
“At this point, we have no evidence that wild mice are infected, or can become infected from humans,” Dr. Montagutelli said. He added that his findings emphasize the need to regularly test animals for signs of the infection. He said these surveys will need to be updated as more variants emerge.
“So far, we’ve been lucky that our livestock species aren’t really susceptible to this,” said Scott Weese, DVM, a professor at Ontario Veterinary College at the University of Guelph, who studies emerging infectious diseases that pass between animals and people.
While the outbreaks on mink farms have been bad, imagine what would happen, Dr. Weese said, if the virus moved to pigs.
“If this infects a barn with a few thousand pigs – which is like the mink scenario – but we have a lot more pig farms than mink farms,” he said.
“With these variants, we have to reset,” he said. “We’ve figured all this about animals and how it spreads or how it doesn’t, but now we need to repeat all those studies to make sure it’s the same thing.”
Pets catch variants, too
Pets living with people who are infected with SARS-CoV-2 can catch it from their owners, and cats are particularly susceptible, Dr. Weese said.
Contact tracing studies, which also tested animals for signs of the virus, have found that about half of cats living with infected people have signs of infection, while 20%-30% of dogs were sick.
“It’s quite common,” for pets to get COVID, Dr. Weese said.
Now, two new studies have shown that pets can also be infected by the newer B.1.1.7 variant.
The first study, from researchers at Texas A&M, documented the variant in a dog and a cat from Brazos County, Texas. Neither the older black Lab mix or the older domestic shorthair cat had symptoms of COVID-19. They were tested as part of a project funded by the CDC.
Dr. Weese said pets are at risk by people who are infected, but they don’t seem to play a big role in spreading the disease to humans. So if you have pets, there’s no reason to worry that they could bring the virus home to you. You’re more likely to be a risk to them.
The second study, from a specialty animal hospital in southeast England, documented infection by the B.1.1.7 virus variant in 11 dogs and cats. Most of the pets had unusual symptoms, including inflamed hearts and heart damage.
Dr. Weese called this study interesting and said its findings deserve more investigation, but pointed out that the study can’t determine whether the infection caused the heart damage, or whether it was already there.
“This is a human virus. There’s no doubt about it. It can affect other species, but it likes people a lot better,” he said. “If you think about the big picture and what is the potential role of animals, pets are pretty low risk.”
A version of this article first appeared on Medscape.com.
The new SARS-CoV-2 variants are not just problems for humans.
New research shows they can also infect animals, and for the first time, variants have been able to infect mice, a development that may complicate efforts to rein in the global spread of the virus.
In addition, two new studies have implications for pets. Veterinarians in Texas and the United Kingdom have documented infections of B.1.1.7 – the fast-spreading variant first found in the United Kingdom – in dogs and cats. The animals in the U.K. study also had heart damage, but it’s unclear if the damage was caused by the virus or was already there and was found as a result of their infections.
Animal studies of SARS-CoV-2 and its emerging variants are urgent, said Sarah Hamer, DVM, PhD, a veterinarian and epidemiologist at Texas A&M University, College Station.
She’s part of a network of scientists who are swabbing the pets of people who are diagnosed with COVID-19 to find out how often the virus passes from people to animals.
The collaboration is part of the One Health initiative through the Centers for Disease Control and Prevention. One Health aims to tackle infectious diseases by recognizing that people can’t be fully protected from pathogens unless animals and the environment are also safeguarded. “Over 70% of emerging diseases of humans have their origins in animal populations,” Dr. Hamer said. “So if we are only focusing on studying disease as it emerges in humans and ignoring where those pathogens have been transmitted or circulating for years, then we might miss the ability to detect early emergence. We might miss the ability to control these diseases before they become problems for human health.”
Variants move to mice
In new work, researchers at the Institut Pasteur in Paris have shown that the B.1.351 and P.1 variants of concern, which were first identified in South Africa and Brazil, respectively, can infect mice, giving the virus a potential new host. Older versions of the virus couldn’t infect mice because they weren’t able bind to receptors on their cells. These two variants can.
On one hand, that’s a good thing, because it will help scientists more easily conduct experiments in mice. Before, if they wanted to do an experiment with SARS-CoV-2 in mice, they had to use a special strain of mouse that was bred to carry human ACE2 receptors on their lung cells. Now that mice can become naturally infected, any breed will do, making it less costly and time-consuming to study the virus in animals.
On the other hand, the idea that the virus could have more and different ways to spread isn’t good news.
“From the beginning of the epidemic and since human coronaviruses emerged from animals, it has been very important to establish in which species the virus can replicate, in particular the species that live close to humans,” said Xavier Montagutelli, DVM, PhD, head of the Mouse Genetics Laboratory at the Institut Pasteur. His study was published as a preprint ahead of peer review on BioRXIV.
Once a virus establishes itself within a population of animals, it will continue to spread and change and may eventually be passed back to humans. It’s the reason that birds and pigs are closely monitored for influenza viruses.
So far, with SARS-CoV-2, only one animal has been found to catch and spread the virus and pass it back to people – farmed mink. Researchers have also documented SARS-CoV-2 antibodies in escaped mink living near mink farms in Utah, suggesting the virus has the potential to be transmitted to wild populations.
And the move of the virus into mice suggests that SARS-CoV-2 could establish itself in a population of wild animals that live close to humans.
“At this point, we have no evidence that wild mice are infected, or can become infected from humans,” Dr. Montagutelli said. He added that his findings emphasize the need to regularly test animals for signs of the infection. He said these surveys will need to be updated as more variants emerge.
“So far, we’ve been lucky that our livestock species aren’t really susceptible to this,” said Scott Weese, DVM, a professor at Ontario Veterinary College at the University of Guelph, who studies emerging infectious diseases that pass between animals and people.
While the outbreaks on mink farms have been bad, imagine what would happen, Dr. Weese said, if the virus moved to pigs.
“If this infects a barn with a few thousand pigs – which is like the mink scenario – but we have a lot more pig farms than mink farms,” he said.
“With these variants, we have to reset,” he said. “We’ve figured all this about animals and how it spreads or how it doesn’t, but now we need to repeat all those studies to make sure it’s the same thing.”
Pets catch variants, too
Pets living with people who are infected with SARS-CoV-2 can catch it from their owners, and cats are particularly susceptible, Dr. Weese said.
Contact tracing studies, which also tested animals for signs of the virus, have found that about half of cats living with infected people have signs of infection, while 20%-30% of dogs were sick.
“It’s quite common,” for pets to get COVID, Dr. Weese said.
Now, two new studies have shown that pets can also be infected by the newer B.1.1.7 variant.
The first study, from researchers at Texas A&M, documented the variant in a dog and a cat from Brazos County, Texas. Neither the older black Lab mix or the older domestic shorthair cat had symptoms of COVID-19. They were tested as part of a project funded by the CDC.
Dr. Weese said pets are at risk by people who are infected, but they don’t seem to play a big role in spreading the disease to humans. So if you have pets, there’s no reason to worry that they could bring the virus home to you. You’re more likely to be a risk to them.
The second study, from a specialty animal hospital in southeast England, documented infection by the B.1.1.7 virus variant in 11 dogs and cats. Most of the pets had unusual symptoms, including inflamed hearts and heart damage.
Dr. Weese called this study interesting and said its findings deserve more investigation, but pointed out that the study can’t determine whether the infection caused the heart damage, or whether it was already there.
“This is a human virus. There’s no doubt about it. It can affect other species, but it likes people a lot better,” he said. “If you think about the big picture and what is the potential role of animals, pets are pretty low risk.”
A version of this article first appeared on Medscape.com.
The new SARS-CoV-2 variants are not just problems for humans.
New research shows they can also infect animals, and for the first time, variants have been able to infect mice, a development that may complicate efforts to rein in the global spread of the virus.
In addition, two new studies have implications for pets. Veterinarians in Texas and the United Kingdom have documented infections of B.1.1.7 – the fast-spreading variant first found in the United Kingdom – in dogs and cats. The animals in the U.K. study also had heart damage, but it’s unclear if the damage was caused by the virus or was already there and was found as a result of their infections.
Animal studies of SARS-CoV-2 and its emerging variants are urgent, said Sarah Hamer, DVM, PhD, a veterinarian and epidemiologist at Texas A&M University, College Station.
She’s part of a network of scientists who are swabbing the pets of people who are diagnosed with COVID-19 to find out how often the virus passes from people to animals.
The collaboration is part of the One Health initiative through the Centers for Disease Control and Prevention. One Health aims to tackle infectious diseases by recognizing that people can’t be fully protected from pathogens unless animals and the environment are also safeguarded. “Over 70% of emerging diseases of humans have their origins in animal populations,” Dr. Hamer said. “So if we are only focusing on studying disease as it emerges in humans and ignoring where those pathogens have been transmitted or circulating for years, then we might miss the ability to detect early emergence. We might miss the ability to control these diseases before they become problems for human health.”
Variants move to mice
In new work, researchers at the Institut Pasteur in Paris have shown that the B.1.351 and P.1 variants of concern, which were first identified in South Africa and Brazil, respectively, can infect mice, giving the virus a potential new host. Older versions of the virus couldn’t infect mice because they weren’t able bind to receptors on their cells. These two variants can.
On one hand, that’s a good thing, because it will help scientists more easily conduct experiments in mice. Before, if they wanted to do an experiment with SARS-CoV-2 in mice, they had to use a special strain of mouse that was bred to carry human ACE2 receptors on their lung cells. Now that mice can become naturally infected, any breed will do, making it less costly and time-consuming to study the virus in animals.
On the other hand, the idea that the virus could have more and different ways to spread isn’t good news.
“From the beginning of the epidemic and since human coronaviruses emerged from animals, it has been very important to establish in which species the virus can replicate, in particular the species that live close to humans,” said Xavier Montagutelli, DVM, PhD, head of the Mouse Genetics Laboratory at the Institut Pasteur. His study was published as a preprint ahead of peer review on BioRXIV.
Once a virus establishes itself within a population of animals, it will continue to spread and change and may eventually be passed back to humans. It’s the reason that birds and pigs are closely monitored for influenza viruses.
So far, with SARS-CoV-2, only one animal has been found to catch and spread the virus and pass it back to people – farmed mink. Researchers have also documented SARS-CoV-2 antibodies in escaped mink living near mink farms in Utah, suggesting the virus has the potential to be transmitted to wild populations.
And the move of the virus into mice suggests that SARS-CoV-2 could establish itself in a population of wild animals that live close to humans.
“At this point, we have no evidence that wild mice are infected, or can become infected from humans,” Dr. Montagutelli said. He added that his findings emphasize the need to regularly test animals for signs of the infection. He said these surveys will need to be updated as more variants emerge.
“So far, we’ve been lucky that our livestock species aren’t really susceptible to this,” said Scott Weese, DVM, a professor at Ontario Veterinary College at the University of Guelph, who studies emerging infectious diseases that pass between animals and people.
While the outbreaks on mink farms have been bad, imagine what would happen, Dr. Weese said, if the virus moved to pigs.
“If this infects a barn with a few thousand pigs – which is like the mink scenario – but we have a lot more pig farms than mink farms,” he said.
“With these variants, we have to reset,” he said. “We’ve figured all this about animals and how it spreads or how it doesn’t, but now we need to repeat all those studies to make sure it’s the same thing.”
Pets catch variants, too
Pets living with people who are infected with SARS-CoV-2 can catch it from their owners, and cats are particularly susceptible, Dr. Weese said.
Contact tracing studies, which also tested animals for signs of the virus, have found that about half of cats living with infected people have signs of infection, while 20%-30% of dogs were sick.
“It’s quite common,” for pets to get COVID, Dr. Weese said.
Now, two new studies have shown that pets can also be infected by the newer B.1.1.7 variant.
The first study, from researchers at Texas A&M, documented the variant in a dog and a cat from Brazos County, Texas. Neither the older black Lab mix or the older domestic shorthair cat had symptoms of COVID-19. They were tested as part of a project funded by the CDC.
Dr. Weese said pets are at risk by people who are infected, but they don’t seem to play a big role in spreading the disease to humans. So if you have pets, there’s no reason to worry that they could bring the virus home to you. You’re more likely to be a risk to them.
The second study, from a specialty animal hospital in southeast England, documented infection by the B.1.1.7 virus variant in 11 dogs and cats. Most of the pets had unusual symptoms, including inflamed hearts and heart damage.
Dr. Weese called this study interesting and said its findings deserve more investigation, but pointed out that the study can’t determine whether the infection caused the heart damage, or whether it was already there.
“This is a human virus. There’s no doubt about it. It can affect other species, but it likes people a lot better,” he said. “If you think about the big picture and what is the potential role of animals, pets are pretty low risk.”
A version of this article first appeared on Medscape.com.
Reproductive safety of treatments for women with bipolar disorder
Since March 2020, my colleagues and I have conducted Virtual Rounds at the Center for Women’s Mental Health at Massachusetts General Hospital. It has been an opportunity to review the basic tenets of care for reproductive age women before, during, and after pregnancy, and also to learn of extraordinary cases being managed both in the outpatient setting and in the context of the COVID-19 pandemic.
As I’ve noted in previous columns, we have seen a heightening of symptoms of anxiety and insomnia during the pandemic in women who visit our center, and at the centers of the more than 100 clinicians who join Virtual Rounds each week. These colleagues represent people in rural areas, urban environments, and underserved communities across America that have been severely affected by the pandemic. It is clear that the stress of the pandemic is undeniable for patients both with and without psychiatric or mental health issues. We have also seen clinical roughening in women who have been well for a long period of time. In particular, we have noticed that postpartum women are struggling with the stressors of the postpartum period, such as figuring out the logistics of support with respect to childcare, managing maternity leave, and adapting to shifting of anticipated support systems.
Hundreds of women with bipolar disorder come to see us each year about the reproductive safety of the medicines on which they are maintained. Those patients are typically well, and we collaborate with them and their doctors about the safest treatment recommendations. With that said, women with bipolar disorder are at particular risk for postpartum worsening of their mood. The management of their medications during pregnancy requires extremely careful attention because relapse of psychiatric disorder during pregnancy is the strongest predictor of postpartum worsening of underlying psychiatric illness.
This is an opportunity to briefly review the reproductive safety of treatments for these women. We know through initiatives such as the Massachusetts General Hospital National Pregnancy Registry for Psychiatric Medications that the most widely used medicines for bipolar women during pregnancy include lamotrigine, atypical antipsychotics, and lithium carbonate.
Lamotrigine
The last 15 years have generated the most consistent data on the reproductive safety of lamotrigine. One of the issues, however, with respect to lamotrigine is that its use requires very careful and slow titration and it is also more effective in patients who are well and in the maintenance phase of the illness versus those who are more acutely manic or who are suffering from frank bipolar depression.
Critically, the literature does not support the use of lamotrigine for patients with bipolar I or with more manic symptoms. That being said, it remains a mainstay of treatment for many patients with bipolar disorder, is easy to use across pregnancy, and has an attractive side-effect profile and a very strong reproductive safety profile, suggesting the absence of an increased risk for major malformations.
Atypical antipsychotics
We have less information but have a growing body of evidence about atypical antipsychotics. Both data from administrative databases as well a growing literature from pregnancy registries, such as the National Pregnancy Registry for Atypical Antipsychotics, fail to show a signal for teratogenicity with respect to use of the medicines as a class, and also with specific reference to some of the most widely used atypical antipsychotics, particularly quetiapine and aripiprazole. Our comfort level, compared with a decade ago, with using the second-generation antipsychotics is much greater. That’s a good thing considering the extent to which patients presenting on a combination of, for example, lamotrigine and atypical antipsychotics.
Lithium carbonate
Another mainstay of treatment for women with bipolar I disorder and prominent symptoms of mania is lithium carbonate. The data for efficacy of lithium carbonate used both acutely and for maintenance treatment of bipolar disorder has been unequivocal. Concerns about the teratogenicity of lithium go back to the 1970s and indicate a small increased absolute and relative risk for cardiovascular malformations. More recently, a meta-analysis of lithium exposure during pregnancy and the postpartum period supports this older data, which suggests this increased risk, and examines other outcomes concerning to women with bipolar disorder who use lithium, such as preterm labor, low birth weight, miscarriage, and other adverse neonatal outcomes.
In 2021, with the backdrop of the pandemic, what we actually see is that, for our pregnant and postpartum patients with bipolar disorder, the imperative to keep them well, keep them out of the hospital, and keep them safe has often required careful coadministration of drugs like lamotrigine, lithium, and atypical antipsychotics (and even benzodiazepines). Keeping this population well during the perinatal period is so critical. We were all trained to use the least number of medications when possible across psychiatric illnesses. But the years, data, and clinical experience have shown that polypharmacy may be required to sustain euthymia in many patients with bipolar disorder. The reflex historically has been to stop medications during pregnancy. We take pause, particularly during the pandemic, before reverting back to the practice of 25 years ago of abruptly stopping medicines such as lithium or atypical antipsychotics in patients with bipolar disorder because we know that the risk for relapse is very high following a shift from the regimen that got the patient well.
The COVID-19 pandemic in many respects has highlighted a need to clinically thread the needle with respect to developing a regimen that minimizes risk of reproductive safety concerns but maximizes the likelihood that we can sustain the emotional well-being of these women across pregnancy and into the postpartum period.
Dr. Cohen is the director of the Ammon-Pinizzotto Center for Women’s Mental Health at Massachusetts General Hospital, which provides information resources and conducts clinical care and research in reproductive mental health. He has been a consultant to manufacturers of psychiatric medications. Email Dr. Cohen at [email protected].
Since March 2020, my colleagues and I have conducted Virtual Rounds at the Center for Women’s Mental Health at Massachusetts General Hospital. It has been an opportunity to review the basic tenets of care for reproductive age women before, during, and after pregnancy, and also to learn of extraordinary cases being managed both in the outpatient setting and in the context of the COVID-19 pandemic.
As I’ve noted in previous columns, we have seen a heightening of symptoms of anxiety and insomnia during the pandemic in women who visit our center, and at the centers of the more than 100 clinicians who join Virtual Rounds each week. These colleagues represent people in rural areas, urban environments, and underserved communities across America that have been severely affected by the pandemic. It is clear that the stress of the pandemic is undeniable for patients both with and without psychiatric or mental health issues. We have also seen clinical roughening in women who have been well for a long period of time. In particular, we have noticed that postpartum women are struggling with the stressors of the postpartum period, such as figuring out the logistics of support with respect to childcare, managing maternity leave, and adapting to shifting of anticipated support systems.
Hundreds of women with bipolar disorder come to see us each year about the reproductive safety of the medicines on which they are maintained. Those patients are typically well, and we collaborate with them and their doctors about the safest treatment recommendations. With that said, women with bipolar disorder are at particular risk for postpartum worsening of their mood. The management of their medications during pregnancy requires extremely careful attention because relapse of psychiatric disorder during pregnancy is the strongest predictor of postpartum worsening of underlying psychiatric illness.
This is an opportunity to briefly review the reproductive safety of treatments for these women. We know through initiatives such as the Massachusetts General Hospital National Pregnancy Registry for Psychiatric Medications that the most widely used medicines for bipolar women during pregnancy include lamotrigine, atypical antipsychotics, and lithium carbonate.
Lamotrigine
The last 15 years have generated the most consistent data on the reproductive safety of lamotrigine. One of the issues, however, with respect to lamotrigine is that its use requires very careful and slow titration and it is also more effective in patients who are well and in the maintenance phase of the illness versus those who are more acutely manic or who are suffering from frank bipolar depression.
Critically, the literature does not support the use of lamotrigine for patients with bipolar I or with more manic symptoms. That being said, it remains a mainstay of treatment for many patients with bipolar disorder, is easy to use across pregnancy, and has an attractive side-effect profile and a very strong reproductive safety profile, suggesting the absence of an increased risk for major malformations.
Atypical antipsychotics
We have less information but have a growing body of evidence about atypical antipsychotics. Both data from administrative databases as well a growing literature from pregnancy registries, such as the National Pregnancy Registry for Atypical Antipsychotics, fail to show a signal for teratogenicity with respect to use of the medicines as a class, and also with specific reference to some of the most widely used atypical antipsychotics, particularly quetiapine and aripiprazole. Our comfort level, compared with a decade ago, with using the second-generation antipsychotics is much greater. That’s a good thing considering the extent to which patients presenting on a combination of, for example, lamotrigine and atypical antipsychotics.
Lithium carbonate
Another mainstay of treatment for women with bipolar I disorder and prominent symptoms of mania is lithium carbonate. The data for efficacy of lithium carbonate used both acutely and for maintenance treatment of bipolar disorder has been unequivocal. Concerns about the teratogenicity of lithium go back to the 1970s and indicate a small increased absolute and relative risk for cardiovascular malformations. More recently, a meta-analysis of lithium exposure during pregnancy and the postpartum period supports this older data, which suggests this increased risk, and examines other outcomes concerning to women with bipolar disorder who use lithium, such as preterm labor, low birth weight, miscarriage, and other adverse neonatal outcomes.
In 2021, with the backdrop of the pandemic, what we actually see is that, for our pregnant and postpartum patients with bipolar disorder, the imperative to keep them well, keep them out of the hospital, and keep them safe has often required careful coadministration of drugs like lamotrigine, lithium, and atypical antipsychotics (and even benzodiazepines). Keeping this population well during the perinatal period is so critical. We were all trained to use the least number of medications when possible across psychiatric illnesses. But the years, data, and clinical experience have shown that polypharmacy may be required to sustain euthymia in many patients with bipolar disorder. The reflex historically has been to stop medications during pregnancy. We take pause, particularly during the pandemic, before reverting back to the practice of 25 years ago of abruptly stopping medicines such as lithium or atypical antipsychotics in patients with bipolar disorder because we know that the risk for relapse is very high following a shift from the regimen that got the patient well.
The COVID-19 pandemic in many respects has highlighted a need to clinically thread the needle with respect to developing a regimen that minimizes risk of reproductive safety concerns but maximizes the likelihood that we can sustain the emotional well-being of these women across pregnancy and into the postpartum period.
Dr. Cohen is the director of the Ammon-Pinizzotto Center for Women’s Mental Health at Massachusetts General Hospital, which provides information resources and conducts clinical care and research in reproductive mental health. He has been a consultant to manufacturers of psychiatric medications. Email Dr. Cohen at [email protected].
Since March 2020, my colleagues and I have conducted Virtual Rounds at the Center for Women’s Mental Health at Massachusetts General Hospital. It has been an opportunity to review the basic tenets of care for reproductive age women before, during, and after pregnancy, and also to learn of extraordinary cases being managed both in the outpatient setting and in the context of the COVID-19 pandemic.
As I’ve noted in previous columns, we have seen a heightening of symptoms of anxiety and insomnia during the pandemic in women who visit our center, and at the centers of the more than 100 clinicians who join Virtual Rounds each week. These colleagues represent people in rural areas, urban environments, and underserved communities across America that have been severely affected by the pandemic. It is clear that the stress of the pandemic is undeniable for patients both with and without psychiatric or mental health issues. We have also seen clinical roughening in women who have been well for a long period of time. In particular, we have noticed that postpartum women are struggling with the stressors of the postpartum period, such as figuring out the logistics of support with respect to childcare, managing maternity leave, and adapting to shifting of anticipated support systems.
Hundreds of women with bipolar disorder come to see us each year about the reproductive safety of the medicines on which they are maintained. Those patients are typically well, and we collaborate with them and their doctors about the safest treatment recommendations. With that said, women with bipolar disorder are at particular risk for postpartum worsening of their mood. The management of their medications during pregnancy requires extremely careful attention because relapse of psychiatric disorder during pregnancy is the strongest predictor of postpartum worsening of underlying psychiatric illness.
This is an opportunity to briefly review the reproductive safety of treatments for these women. We know through initiatives such as the Massachusetts General Hospital National Pregnancy Registry for Psychiatric Medications that the most widely used medicines for bipolar women during pregnancy include lamotrigine, atypical antipsychotics, and lithium carbonate.
Lamotrigine
The last 15 years have generated the most consistent data on the reproductive safety of lamotrigine. One of the issues, however, with respect to lamotrigine is that its use requires very careful and slow titration and it is also more effective in patients who are well and in the maintenance phase of the illness versus those who are more acutely manic or who are suffering from frank bipolar depression.
Critically, the literature does not support the use of lamotrigine for patients with bipolar I or with more manic symptoms. That being said, it remains a mainstay of treatment for many patients with bipolar disorder, is easy to use across pregnancy, and has an attractive side-effect profile and a very strong reproductive safety profile, suggesting the absence of an increased risk for major malformations.
Atypical antipsychotics
We have less information but have a growing body of evidence about atypical antipsychotics. Both data from administrative databases as well a growing literature from pregnancy registries, such as the National Pregnancy Registry for Atypical Antipsychotics, fail to show a signal for teratogenicity with respect to use of the medicines as a class, and also with specific reference to some of the most widely used atypical antipsychotics, particularly quetiapine and aripiprazole. Our comfort level, compared with a decade ago, with using the second-generation antipsychotics is much greater. That’s a good thing considering the extent to which patients presenting on a combination of, for example, lamotrigine and atypical antipsychotics.
Lithium carbonate
Another mainstay of treatment for women with bipolar I disorder and prominent symptoms of mania is lithium carbonate. The data for efficacy of lithium carbonate used both acutely and for maintenance treatment of bipolar disorder has been unequivocal. Concerns about the teratogenicity of lithium go back to the 1970s and indicate a small increased absolute and relative risk for cardiovascular malformations. More recently, a meta-analysis of lithium exposure during pregnancy and the postpartum period supports this older data, which suggests this increased risk, and examines other outcomes concerning to women with bipolar disorder who use lithium, such as preterm labor, low birth weight, miscarriage, and other adverse neonatal outcomes.
In 2021, with the backdrop of the pandemic, what we actually see is that, for our pregnant and postpartum patients with bipolar disorder, the imperative to keep them well, keep them out of the hospital, and keep them safe has often required careful coadministration of drugs like lamotrigine, lithium, and atypical antipsychotics (and even benzodiazepines). Keeping this population well during the perinatal period is so critical. We were all trained to use the least number of medications when possible across psychiatric illnesses. But the years, data, and clinical experience have shown that polypharmacy may be required to sustain euthymia in many patients with bipolar disorder. The reflex historically has been to stop medications during pregnancy. We take pause, particularly during the pandemic, before reverting back to the practice of 25 years ago of abruptly stopping medicines such as lithium or atypical antipsychotics in patients with bipolar disorder because we know that the risk for relapse is very high following a shift from the regimen that got the patient well.
The COVID-19 pandemic in many respects has highlighted a need to clinically thread the needle with respect to developing a regimen that minimizes risk of reproductive safety concerns but maximizes the likelihood that we can sustain the emotional well-being of these women across pregnancy and into the postpartum period.
Dr. Cohen is the director of the Ammon-Pinizzotto Center for Women’s Mental Health at Massachusetts General Hospital, which provides information resources and conducts clinical care and research in reproductive mental health. He has been a consultant to manufacturers of psychiatric medications. Email Dr. Cohen at [email protected].
Risk factors predict graft failure in pediatric acute leukemia patients
Researchers developed a predictive score for the risk of graft failure in patients with acute leukemia who underwent allogeneic hematopoietic stem cell transplantation (aHSCT) with ex vivo T-cell depletion. T-cell depletion is performed in an effort to prevent subsequent graft-versus-host disease (GVHD) after transplant.
The risk score was based on patient age and the T-lymphocyte population pre-aHSCT with 1 point of risk possible in each category. Patients with 1 point had a graft failure risk of 5% and 13% if they had 2 points, according to the results of the study presented at the virtual meeting of the European Society for Blood and Marrow Transplantation.
Graft failure is a potentially severe complication in patients treated with aHSCT, but there are few studies analyzing risk factors when ex vivo T-cell depletion is used, Ivan López Torija of the Hospital Infantil Universitario Niño Jesús, Madrid, and colleagues noted in their presentation, which won the Best Young Poster Abstract Award at the meeting.
The researchers assessed 148 pediatric patients (64% boys) with acute leukemia who underwent allogeneic HSCT from haploidentical donors using ex vivo T-cell depletion between 2005 and 2020. About 53% of the patients were diagnosed with acute lymphoblastic leukemia, the rest with acute myeloid leukemia. The donor mean age was 40 years, and all transplant patients received toxicity reduction conditioning based on fludarabine busulfan and thiotepa.
Predictive results
Multivariate analysis showed that T-cell count (CD3+/CD8+ ≥ 350/mL: hazard ratio, 2,6; P = .01) and patient age (less than 9 years: HR; 5.0; P = .04) were associated with graft failure. A risk score was established using these results and based on patient age and T lymphocyte pre-aHSCT with 1 point each for each increased risk category. Patients with 1 point had a graft failure risk of 5% and a risk of 13% if they had 2 points.
However, in this particular population, with a mean follow up of 4 years, the overall survival rate was 60%, with no significant differences seen between patients that presented graft failure and those without graft failure.
“Patient age and pretransplant number of CD3+/CD8+ are associated with [graft failure] in pediatric patients with acute leukemia undergoing ex vivo T-cell–depleted haploidentical transplantation. These findings highlight the importance of preexisting cellular immunity in the transplant recipient and support T-cell population analysis as part of a pretransplant working program,” the researchers concluded.
The authors reported that they had no disclosures.
Researchers developed a predictive score for the risk of graft failure in patients with acute leukemia who underwent allogeneic hematopoietic stem cell transplantation (aHSCT) with ex vivo T-cell depletion. T-cell depletion is performed in an effort to prevent subsequent graft-versus-host disease (GVHD) after transplant.
The risk score was based on patient age and the T-lymphocyte population pre-aHSCT with 1 point of risk possible in each category. Patients with 1 point had a graft failure risk of 5% and 13% if they had 2 points, according to the results of the study presented at the virtual meeting of the European Society for Blood and Marrow Transplantation.
Graft failure is a potentially severe complication in patients treated with aHSCT, but there are few studies analyzing risk factors when ex vivo T-cell depletion is used, Ivan López Torija of the Hospital Infantil Universitario Niño Jesús, Madrid, and colleagues noted in their presentation, which won the Best Young Poster Abstract Award at the meeting.
The researchers assessed 148 pediatric patients (64% boys) with acute leukemia who underwent allogeneic HSCT from haploidentical donors using ex vivo T-cell depletion between 2005 and 2020. About 53% of the patients were diagnosed with acute lymphoblastic leukemia, the rest with acute myeloid leukemia. The donor mean age was 40 years, and all transplant patients received toxicity reduction conditioning based on fludarabine busulfan and thiotepa.
Predictive results
Multivariate analysis showed that T-cell count (CD3+/CD8+ ≥ 350/mL: hazard ratio, 2,6; P = .01) and patient age (less than 9 years: HR; 5.0; P = .04) were associated with graft failure. A risk score was established using these results and based on patient age and T lymphocyte pre-aHSCT with 1 point each for each increased risk category. Patients with 1 point had a graft failure risk of 5% and a risk of 13% if they had 2 points.
However, in this particular population, with a mean follow up of 4 years, the overall survival rate was 60%, with no significant differences seen between patients that presented graft failure and those without graft failure.
“Patient age and pretransplant number of CD3+/CD8+ are associated with [graft failure] in pediatric patients with acute leukemia undergoing ex vivo T-cell–depleted haploidentical transplantation. These findings highlight the importance of preexisting cellular immunity in the transplant recipient and support T-cell population analysis as part of a pretransplant working program,” the researchers concluded.
The authors reported that they had no disclosures.
Researchers developed a predictive score for the risk of graft failure in patients with acute leukemia who underwent allogeneic hematopoietic stem cell transplantation (aHSCT) with ex vivo T-cell depletion. T-cell depletion is performed in an effort to prevent subsequent graft-versus-host disease (GVHD) after transplant.
The risk score was based on patient age and the T-lymphocyte population pre-aHSCT with 1 point of risk possible in each category. Patients with 1 point had a graft failure risk of 5% and 13% if they had 2 points, according to the results of the study presented at the virtual meeting of the European Society for Blood and Marrow Transplantation.
Graft failure is a potentially severe complication in patients treated with aHSCT, but there are few studies analyzing risk factors when ex vivo T-cell depletion is used, Ivan López Torija of the Hospital Infantil Universitario Niño Jesús, Madrid, and colleagues noted in their presentation, which won the Best Young Poster Abstract Award at the meeting.
The researchers assessed 148 pediatric patients (64% boys) with acute leukemia who underwent allogeneic HSCT from haploidentical donors using ex vivo T-cell depletion between 2005 and 2020. About 53% of the patients were diagnosed with acute lymphoblastic leukemia, the rest with acute myeloid leukemia. The donor mean age was 40 years, and all transplant patients received toxicity reduction conditioning based on fludarabine busulfan and thiotepa.
Predictive results
Multivariate analysis showed that T-cell count (CD3+/CD8+ ≥ 350/mL: hazard ratio, 2,6; P = .01) and patient age (less than 9 years: HR; 5.0; P = .04) were associated with graft failure. A risk score was established using these results and based on patient age and T lymphocyte pre-aHSCT with 1 point each for each increased risk category. Patients with 1 point had a graft failure risk of 5% and a risk of 13% if they had 2 points.
However, in this particular population, with a mean follow up of 4 years, the overall survival rate was 60%, with no significant differences seen between patients that presented graft failure and those without graft failure.
“Patient age and pretransplant number of CD3+/CD8+ are associated with [graft failure] in pediatric patients with acute leukemia undergoing ex vivo T-cell–depleted haploidentical transplantation. These findings highlight the importance of preexisting cellular immunity in the transplant recipient and support T-cell population analysis as part of a pretransplant working program,” the researchers concluded.
The authors reported that they had no disclosures.
FROM EBMT 2021
Obesity pegged as source of marked increased risk of diabetes in PCOS
The increased risk of type 2 diabetes in women with polycystic ovary syndrome is well established, but a new analysis has shown that obesity is the major mediator and a target for preventing or reversing this comorbidity.
“Most women with PCOS are obese, complicating the effort to understand whether high rates of diabetes in this population are due to PCOS or excess weight, but our study now suggest that obesity isa targetable risk factor,” reported Panagiotis Anagnostis, MD, PhD, a reproductive endocrinologist at the Medical School of Aristotle University, Thessaloniki, Greece.
Obesity is also a known risk factor for type 2 diabetes (T2D), but there is reason to suspect that PCOS, which is associated with abnormal carbohydrate metabolism, has a direct impact on the risk of developing T2D, according to Dr. Anagnostis. It is also reasonable to expect “a synergistic deleterious effect” from PCOS and obesity on adverse changes in glucose metabolism that lead to T2D.
Even though rates of obesity among women with PCOS reach 80% in some studies, Dr. Anagnostis attempted to disentangle the relationship between obesity, PCOS, and risk of T2D using a large set of data drawn from a comprehensive search of published studies.
After screening with predefined criteria, 12 studies provided data on 224,284 women, of whom 45,361 had PCOS and 5,717 had T2D. Not least of the criteria for inclusion in this analysis, all studies stratified women as obese, defined as a body mass index (BMI) greater than 30 kg/m2, or nonobese, he reported at the annual meeting of the Endocrine Society.
Diabetes risk tripled in PCOS
When compared without regard to BMI, the relative risk of having T2D among those with PCOS relative to those without this condition was more than three times greater (RR 3.13; P < .001). When women with PCOS were stratified for BMI, obesity was associated with a more than fourfold increased risk relative to controls without PCOS (RR, 4.06; P < .001).
In women who were nonobese, the risk of T2D was numerically higher for those with PCOS than those without (RR, 2.68), but it was only a trend with a large confidence interval (95% confidence interval, 0.97-7.49).
Among women with PCOS, those who were obese also had a more than fourfold and highly significant increased risk of T2D relative to those who were not obese (RR, 4.20; P < .001).
The message from these data is that obesity is a major and potentially modifiable risk factor for diabetes in women with PCOS, according to Dr. Anagnostis.
He said these data provide the basis for recommending weight loss specifically for managing this common PCOS comorbidity.
Almost the same relative risk of diabetes was derived from an analysis of a women’s health database published 2 years ago in Diabetes Care. In that study with 1,916 person-years of follow-up, the hazard ratio for T2D was also more than three times greater (HR, 3.23; P < .001) for those with PCOS relative to those without the syndrome.
However, normal BMI did not eliminate risk of developing diabetes in this study. Rather, the relative risk of T2D in women with PCOS was higher in those of normal weight, compared with those who were obese (HR, 4.68 vs. 2.36; P < .005). The investigators recommend screening all women with PCOS at least every 3 years with more frequent screening in those with risk factors.
PCOS complexity challenges simple conclusions
The complexity of disturbed metabolic pathways in patients with PCOS and obesity might explain some of the difficulty in unraveling the relationship between these two disease states and diabetes risk. In one recent review, it was suggested that obesity and PCOS share interrelated adverse effects on glucose metabolism. As a result, these associations are “more complex than a simple cause-and-effect process.” the authors of that article concluded.
Furthermore, in their examination of metabolic pathways, genetic susceptibility, and behavioral factors that might link PCOS, weight gain, and T2D, the authors did not ignore the psychological impact of PCOS in causing obesity and, as a byproduct, diabetes. These psychological factors might be relevant to treatment.
For example, depression and stress “might hamper ongoing attempts at lifestyle change and therefore effective weight loss” in at least some women, they cautioned.
However, in encouraging weight loss in overweight women with PCOS, the debate about cause of T2D might be moot in practical terms, according to Michael Dansinger, MD, founding director of the diabetes reversal program at Tufts Medical Center, Boston.
“Reducing excess body fat reduces the risk of type 2 diabetes,” Dr. Dansinger said in an interview. “Since women with obesity and PCOS are clearly at risk for future type 2 diabetes, that’s another reason to lose excess body fat through healthy eating and exercise.”
Dr. Anagnostis and Dr. Dansinger reported no relevant conflicts of interest.
The increased risk of type 2 diabetes in women with polycystic ovary syndrome is well established, but a new analysis has shown that obesity is the major mediator and a target for preventing or reversing this comorbidity.
“Most women with PCOS are obese, complicating the effort to understand whether high rates of diabetes in this population are due to PCOS or excess weight, but our study now suggest that obesity isa targetable risk factor,” reported Panagiotis Anagnostis, MD, PhD, a reproductive endocrinologist at the Medical School of Aristotle University, Thessaloniki, Greece.
Obesity is also a known risk factor for type 2 diabetes (T2D), but there is reason to suspect that PCOS, which is associated with abnormal carbohydrate metabolism, has a direct impact on the risk of developing T2D, according to Dr. Anagnostis. It is also reasonable to expect “a synergistic deleterious effect” from PCOS and obesity on adverse changes in glucose metabolism that lead to T2D.
Even though rates of obesity among women with PCOS reach 80% in some studies, Dr. Anagnostis attempted to disentangle the relationship between obesity, PCOS, and risk of T2D using a large set of data drawn from a comprehensive search of published studies.
After screening with predefined criteria, 12 studies provided data on 224,284 women, of whom 45,361 had PCOS and 5,717 had T2D. Not least of the criteria for inclusion in this analysis, all studies stratified women as obese, defined as a body mass index (BMI) greater than 30 kg/m2, or nonobese, he reported at the annual meeting of the Endocrine Society.
Diabetes risk tripled in PCOS
When compared without regard to BMI, the relative risk of having T2D among those with PCOS relative to those without this condition was more than three times greater (RR 3.13; P < .001). When women with PCOS were stratified for BMI, obesity was associated with a more than fourfold increased risk relative to controls without PCOS (RR, 4.06; P < .001).
In women who were nonobese, the risk of T2D was numerically higher for those with PCOS than those without (RR, 2.68), but it was only a trend with a large confidence interval (95% confidence interval, 0.97-7.49).
Among women with PCOS, those who were obese also had a more than fourfold and highly significant increased risk of T2D relative to those who were not obese (RR, 4.20; P < .001).
The message from these data is that obesity is a major and potentially modifiable risk factor for diabetes in women with PCOS, according to Dr. Anagnostis.
He said these data provide the basis for recommending weight loss specifically for managing this common PCOS comorbidity.
Almost the same relative risk of diabetes was derived from an analysis of a women’s health database published 2 years ago in Diabetes Care. In that study with 1,916 person-years of follow-up, the hazard ratio for T2D was also more than three times greater (HR, 3.23; P < .001) for those with PCOS relative to those without the syndrome.
However, normal BMI did not eliminate risk of developing diabetes in this study. Rather, the relative risk of T2D in women with PCOS was higher in those of normal weight, compared with those who were obese (HR, 4.68 vs. 2.36; P < .005). The investigators recommend screening all women with PCOS at least every 3 years with more frequent screening in those with risk factors.
PCOS complexity challenges simple conclusions
The complexity of disturbed metabolic pathways in patients with PCOS and obesity might explain some of the difficulty in unraveling the relationship between these two disease states and diabetes risk. In one recent review, it was suggested that obesity and PCOS share interrelated adverse effects on glucose metabolism. As a result, these associations are “more complex than a simple cause-and-effect process.” the authors of that article concluded.
Furthermore, in their examination of metabolic pathways, genetic susceptibility, and behavioral factors that might link PCOS, weight gain, and T2D, the authors did not ignore the psychological impact of PCOS in causing obesity and, as a byproduct, diabetes. These psychological factors might be relevant to treatment.
For example, depression and stress “might hamper ongoing attempts at lifestyle change and therefore effective weight loss” in at least some women, they cautioned.
However, in encouraging weight loss in overweight women with PCOS, the debate about cause of T2D might be moot in practical terms, according to Michael Dansinger, MD, founding director of the diabetes reversal program at Tufts Medical Center, Boston.
“Reducing excess body fat reduces the risk of type 2 diabetes,” Dr. Dansinger said in an interview. “Since women with obesity and PCOS are clearly at risk for future type 2 diabetes, that’s another reason to lose excess body fat through healthy eating and exercise.”
Dr. Anagnostis and Dr. Dansinger reported no relevant conflicts of interest.
The increased risk of type 2 diabetes in women with polycystic ovary syndrome is well established, but a new analysis has shown that obesity is the major mediator and a target for preventing or reversing this comorbidity.
“Most women with PCOS are obese, complicating the effort to understand whether high rates of diabetes in this population are due to PCOS or excess weight, but our study now suggest that obesity isa targetable risk factor,” reported Panagiotis Anagnostis, MD, PhD, a reproductive endocrinologist at the Medical School of Aristotle University, Thessaloniki, Greece.
Obesity is also a known risk factor for type 2 diabetes (T2D), but there is reason to suspect that PCOS, which is associated with abnormal carbohydrate metabolism, has a direct impact on the risk of developing T2D, according to Dr. Anagnostis. It is also reasonable to expect “a synergistic deleterious effect” from PCOS and obesity on adverse changes in glucose metabolism that lead to T2D.
Even though rates of obesity among women with PCOS reach 80% in some studies, Dr. Anagnostis attempted to disentangle the relationship between obesity, PCOS, and risk of T2D using a large set of data drawn from a comprehensive search of published studies.
After screening with predefined criteria, 12 studies provided data on 224,284 women, of whom 45,361 had PCOS and 5,717 had T2D. Not least of the criteria for inclusion in this analysis, all studies stratified women as obese, defined as a body mass index (BMI) greater than 30 kg/m2, or nonobese, he reported at the annual meeting of the Endocrine Society.
Diabetes risk tripled in PCOS
When compared without regard to BMI, the relative risk of having T2D among those with PCOS relative to those without this condition was more than three times greater (RR 3.13; P < .001). When women with PCOS were stratified for BMI, obesity was associated with a more than fourfold increased risk relative to controls without PCOS (RR, 4.06; P < .001).
In women who were nonobese, the risk of T2D was numerically higher for those with PCOS than those without (RR, 2.68), but it was only a trend with a large confidence interval (95% confidence interval, 0.97-7.49).
Among women with PCOS, those who were obese also had a more than fourfold and highly significant increased risk of T2D relative to those who were not obese (RR, 4.20; P < .001).
The message from these data is that obesity is a major and potentially modifiable risk factor for diabetes in women with PCOS, according to Dr. Anagnostis.
He said these data provide the basis for recommending weight loss specifically for managing this common PCOS comorbidity.
Almost the same relative risk of diabetes was derived from an analysis of a women’s health database published 2 years ago in Diabetes Care. In that study with 1,916 person-years of follow-up, the hazard ratio for T2D was also more than three times greater (HR, 3.23; P < .001) for those with PCOS relative to those without the syndrome.
However, normal BMI did not eliminate risk of developing diabetes in this study. Rather, the relative risk of T2D in women with PCOS was higher in those of normal weight, compared with those who were obese (HR, 4.68 vs. 2.36; P < .005). The investigators recommend screening all women with PCOS at least every 3 years with more frequent screening in those with risk factors.
PCOS complexity challenges simple conclusions
The complexity of disturbed metabolic pathways in patients with PCOS and obesity might explain some of the difficulty in unraveling the relationship between these two disease states and diabetes risk. In one recent review, it was suggested that obesity and PCOS share interrelated adverse effects on glucose metabolism. As a result, these associations are “more complex than a simple cause-and-effect process.” the authors of that article concluded.
Furthermore, in their examination of metabolic pathways, genetic susceptibility, and behavioral factors that might link PCOS, weight gain, and T2D, the authors did not ignore the psychological impact of PCOS in causing obesity and, as a byproduct, diabetes. These psychological factors might be relevant to treatment.
For example, depression and stress “might hamper ongoing attempts at lifestyle change and therefore effective weight loss” in at least some women, they cautioned.
However, in encouraging weight loss in overweight women with PCOS, the debate about cause of T2D might be moot in practical terms, according to Michael Dansinger, MD, founding director of the diabetes reversal program at Tufts Medical Center, Boston.
“Reducing excess body fat reduces the risk of type 2 diabetes,” Dr. Dansinger said in an interview. “Since women with obesity and PCOS are clearly at risk for future type 2 diabetes, that’s another reason to lose excess body fat through healthy eating and exercise.”
Dr. Anagnostis and Dr. Dansinger reported no relevant conflicts of interest.
FROM ENDO 2021
Match Day 2021: Interest in family medicine remains strong
which were up 3.5% over last year, according to the National Resident Matching Program.
“Rather than faltering in these uncertain times, program fill rates increased across the board,” the NRMP said in a written statement. Overall, the 2021 Main Residency Match offered (35,194) and filled (33,353) more first-year (PGY-1) slots than ever before, for a fill rate of 94.8%, compared with 94.6% the year before.
Family medicine offered 4,823 positions in this year’s Match, up by 3.5% over 2020, and filled 4,472, for a 1-year increase of 3.7% and a fill rate of 92.7%. Just over 63% (3,046) of the available slots were given to U.S. seniors (MDs and DOs), while 25.4% went to international medical graduates. The corresponding PGY-1 numbers for the Match as a whole were 70.4% U.S. and 21.1% international medical graduates, based on NRMP data.
“In the last five years, the Main Residency Match has seen sizable increases in the number of positions offered” in family medicine – up by 1,467 (43.7%) since 2017 – and such growth over time may “be a predictor of future physician workforce supply,” the NRMP said. Family medicine also increased its share of all available residency positions from 11.6% in 2017 to 13.7% this year.
“Concerns about the impact of virtual recruitment on applicants’ matching into PGY-1 positions were not realized,” the NRMP noted, as “growth in registration was seen in every applicant group.” Compared with 2020, submissions of rank-order lists of programs were up by 2.8% for U.S. MD seniors, 7.9% for U.S. DO seniors, 2.5% for U.S.-citizen IMGs, and 15.0% for non–U.S.-citizen IMGs.
“The application and recruitment cycle was upended as a result of the pandemic, yet the results of the Match continue to demonstrate strong and consistent outcomes for participants,” said Donna L. Lamb, DHSc, MBA, who is president and CEO of the NRMP.
which were up 3.5% over last year, according to the National Resident Matching Program.
“Rather than faltering in these uncertain times, program fill rates increased across the board,” the NRMP said in a written statement. Overall, the 2021 Main Residency Match offered (35,194) and filled (33,353) more first-year (PGY-1) slots than ever before, for a fill rate of 94.8%, compared with 94.6% the year before.
Family medicine offered 4,823 positions in this year’s Match, up by 3.5% over 2020, and filled 4,472, for a 1-year increase of 3.7% and a fill rate of 92.7%. Just over 63% (3,046) of the available slots were given to U.S. seniors (MDs and DOs), while 25.4% went to international medical graduates. The corresponding PGY-1 numbers for the Match as a whole were 70.4% U.S. and 21.1% international medical graduates, based on NRMP data.
“In the last five years, the Main Residency Match has seen sizable increases in the number of positions offered” in family medicine – up by 1,467 (43.7%) since 2017 – and such growth over time may “be a predictor of future physician workforce supply,” the NRMP said. Family medicine also increased its share of all available residency positions from 11.6% in 2017 to 13.7% this year.
“Concerns about the impact of virtual recruitment on applicants’ matching into PGY-1 positions were not realized,” the NRMP noted, as “growth in registration was seen in every applicant group.” Compared with 2020, submissions of rank-order lists of programs were up by 2.8% for U.S. MD seniors, 7.9% for U.S. DO seniors, 2.5% for U.S.-citizen IMGs, and 15.0% for non–U.S.-citizen IMGs.
“The application and recruitment cycle was upended as a result of the pandemic, yet the results of the Match continue to demonstrate strong and consistent outcomes for participants,” said Donna L. Lamb, DHSc, MBA, who is president and CEO of the NRMP.
which were up 3.5% over last year, according to the National Resident Matching Program.
“Rather than faltering in these uncertain times, program fill rates increased across the board,” the NRMP said in a written statement. Overall, the 2021 Main Residency Match offered (35,194) and filled (33,353) more first-year (PGY-1) slots than ever before, for a fill rate of 94.8%, compared with 94.6% the year before.
Family medicine offered 4,823 positions in this year’s Match, up by 3.5% over 2020, and filled 4,472, for a 1-year increase of 3.7% and a fill rate of 92.7%. Just over 63% (3,046) of the available slots were given to U.S. seniors (MDs and DOs), while 25.4% went to international medical graduates. The corresponding PGY-1 numbers for the Match as a whole were 70.4% U.S. and 21.1% international medical graduates, based on NRMP data.
“In the last five years, the Main Residency Match has seen sizable increases in the number of positions offered” in family medicine – up by 1,467 (43.7%) since 2017 – and such growth over time may “be a predictor of future physician workforce supply,” the NRMP said. Family medicine also increased its share of all available residency positions from 11.6% in 2017 to 13.7% this year.
“Concerns about the impact of virtual recruitment on applicants’ matching into PGY-1 positions were not realized,” the NRMP noted, as “growth in registration was seen in every applicant group.” Compared with 2020, submissions of rank-order lists of programs were up by 2.8% for U.S. MD seniors, 7.9% for U.S. DO seniors, 2.5% for U.S.-citizen IMGs, and 15.0% for non–U.S.-citizen IMGs.
“The application and recruitment cycle was upended as a result of the pandemic, yet the results of the Match continue to demonstrate strong and consistent outcomes for participants,” said Donna L. Lamb, DHSc, MBA, who is president and CEO of the NRMP.
Pink plaque on the ear
A 4-mm punch biopsy was performed and revealed B-cell lymphoma, consistent with extranodal marginal zone lymphoma. The plaque was palpated carefully and the location of branches of the superficial temporal artery, which usually course anterior to the helix, were mapped, and avoided as a biopsy site.
Marginal zone lymphoma is a relatively indolent B-cell lymphoma that occurs in adults in mucosal associated lymphoid tissue, most often in the gastrointestinal (GI) tract. Neoplasms also occur in the lungs, eyes, and skin. Initial symptoms vary according to the site of manifestation. Patients with GI tumors may present with GI bleeding, abdominal pain, and weight loss. Pulmonary lesions are often asymptomatic and picked up on chest imaging for other indications. Chronic gastritis associated with Helicobacter pylori contributes to cases and occasionally eradication of H. pylori may clear patients of disease. Autoimmune diseases, particularly Sjögren disease and Hashimoto thyroiditis, also have a causative association. Rarely, transformation into high-grade disease occurs.
On the skin, marginal zone lymphoma may be exhibited as soft salmon-colored patches with serpentine vascular markings, as seen here on dermoscopy.1 The differential diagnosis includes keloid scar, basal cell carcinoma, Merkel cell carcinoma, arthropod bites, and amelanotic melanoma.
This patient had been under the care of Medical Oncology for surveillance and was offered observation as a potential treatment strategy because of the relatively indolent nature of the tumor. However, because the tumor was painful and growing, she opted for focal palliative radiation therapy.
Text courtesy of Jonathan Karnes, MD, medical director, MDFMR Dermatology Services, Augusta, ME. Photos courtesy of Jonathan Karnes, MD (copyright retained).
1. Geller S, Marghoob AA, Scope A, et al. Dermoscopy and the diagnosis of primary cutaneous B-cell lymphoma. J Eur Acad Dermatol Venereol. 2018;32:53-56. doi:10.1111/jdv.14549
A 4-mm punch biopsy was performed and revealed B-cell lymphoma, consistent with extranodal marginal zone lymphoma. The plaque was palpated carefully and the location of branches of the superficial temporal artery, which usually course anterior to the helix, were mapped, and avoided as a biopsy site.
Marginal zone lymphoma is a relatively indolent B-cell lymphoma that occurs in adults in mucosal associated lymphoid tissue, most often in the gastrointestinal (GI) tract. Neoplasms also occur in the lungs, eyes, and skin. Initial symptoms vary according to the site of manifestation. Patients with GI tumors may present with GI bleeding, abdominal pain, and weight loss. Pulmonary lesions are often asymptomatic and picked up on chest imaging for other indications. Chronic gastritis associated with Helicobacter pylori contributes to cases and occasionally eradication of H. pylori may clear patients of disease. Autoimmune diseases, particularly Sjögren disease and Hashimoto thyroiditis, also have a causative association. Rarely, transformation into high-grade disease occurs.
On the skin, marginal zone lymphoma may be exhibited as soft salmon-colored patches with serpentine vascular markings, as seen here on dermoscopy.1 The differential diagnosis includes keloid scar, basal cell carcinoma, Merkel cell carcinoma, arthropod bites, and amelanotic melanoma.
This patient had been under the care of Medical Oncology for surveillance and was offered observation as a potential treatment strategy because of the relatively indolent nature of the tumor. However, because the tumor was painful and growing, she opted for focal palliative radiation therapy.
Text courtesy of Jonathan Karnes, MD, medical director, MDFMR Dermatology Services, Augusta, ME. Photos courtesy of Jonathan Karnes, MD (copyright retained).
A 4-mm punch biopsy was performed and revealed B-cell lymphoma, consistent with extranodal marginal zone lymphoma. The plaque was palpated carefully and the location of branches of the superficial temporal artery, which usually course anterior to the helix, were mapped, and avoided as a biopsy site.
Marginal zone lymphoma is a relatively indolent B-cell lymphoma that occurs in adults in mucosal associated lymphoid tissue, most often in the gastrointestinal (GI) tract. Neoplasms also occur in the lungs, eyes, and skin. Initial symptoms vary according to the site of manifestation. Patients with GI tumors may present with GI bleeding, abdominal pain, and weight loss. Pulmonary lesions are often asymptomatic and picked up on chest imaging for other indications. Chronic gastritis associated with Helicobacter pylori contributes to cases and occasionally eradication of H. pylori may clear patients of disease. Autoimmune diseases, particularly Sjögren disease and Hashimoto thyroiditis, also have a causative association. Rarely, transformation into high-grade disease occurs.
On the skin, marginal zone lymphoma may be exhibited as soft salmon-colored patches with serpentine vascular markings, as seen here on dermoscopy.1 The differential diagnosis includes keloid scar, basal cell carcinoma, Merkel cell carcinoma, arthropod bites, and amelanotic melanoma.
This patient had been under the care of Medical Oncology for surveillance and was offered observation as a potential treatment strategy because of the relatively indolent nature of the tumor. However, because the tumor was painful and growing, she opted for focal palliative radiation therapy.
Text courtesy of Jonathan Karnes, MD, medical director, MDFMR Dermatology Services, Augusta, ME. Photos courtesy of Jonathan Karnes, MD (copyright retained).
1. Geller S, Marghoob AA, Scope A, et al. Dermoscopy and the diagnosis of primary cutaneous B-cell lymphoma. J Eur Acad Dermatol Venereol. 2018;32:53-56. doi:10.1111/jdv.14549
1. Geller S, Marghoob AA, Scope A, et al. Dermoscopy and the diagnosis of primary cutaneous B-cell lymphoma. J Eur Acad Dermatol Venereol. 2018;32:53-56. doi:10.1111/jdv.14549
