The American Gastroenterological Association recently released a clinical practice update for endoscopic treatment of Barrett’s esophagus with dysplasia and/or early esophageal adenocarcinoma.

The update offers best practice advice for a range of clinical scenarios based on published evidence, including guidelines and recent systematic reviews, reported lead author Prateek Sharma, MD, of the University of Kansas, Kansas City. Dr. Sharma was accompanied on the authoring review team by three other expert gastroenterologists from the United States and the Netherlands.

Beyond practice advice, the investigators highlighted a research focus for the future.

“Given the expense and time required for careful and continual surveillance after Barrett’s endoscopic therapy, the future must define improved means of risk-stratifying patients for therapy who are at highest risk for cancer development and for risk of recurrence after complete eradication of intestinal metaplasia,” they wrote in Gastroenterology. “Potentially, we may use a panel of patient characteristics (such as the [Progression in Barrett’s] score), preablation tissue characteristics (e.g., baseline grade of dysplasia) and the posttherapy molecular makeup of the epithelium to help risk stratify our patients.”

For now, many of the treatment principles in the update depend upon histologic features.

For instance, either endoscopic therapy or continued surveillance are reasonable options for patients with Barrett’s esophagus who have confirmed and persistent low-grade dysplasia. In contrast, the update recommends that all patients with high-grade dysplasia or esophageal adenocarcinoma (T1a) undergo endoscopic therapy, highlighting that this method is preferred over esophagectomy for patients with T1a cancer. Along the same lines, the investigators noted that endoscopic therapy is a “reasonable alternative” to esophagectomy in cases of T1b esophageal adenocarcinoma in the presence of minimal invasion and good to moderate differentiation, particularly in patients who are poor candidates for surgery.

During the decision-making process, patients with dysplasia should be advised that not undergoing endoscopic therapy may increase cancer risk, the investigators wrote, adding that patients should also be informed about endoscopic therapy–related risks of bleeding and perforation, which occur in less than 1% of patients, and the risk of postprocedural stricture formation, which occurs in approximately 6% of patients.

If endoscopic therapy is elected, the update suggests that the procedure be done by experts who perform at least 10 new cases per year.

Concerning specifics of therapy, the investigators advised that mucosal ablation be applied to all visible esophageal columnar mucosa, 5-10 mm proximal to the squamocolumnar junction, and 5-10 mm distal to the gastroesophageal junction. Ablation should only be performed in cases of flat Barrett’s esophagus in which no visible abnormalities or signs of inflammation are present, the review team wrote.

The investigators went on to lay out some “practical ground rules” for endoscopic therapy, including a potential pitfall.

“Ablation therapy may consist of multiple 2-3 monthly ablation sessions that may extend over a period of more than a year,” the investigators wrote. “The worst adverse outcome during the treatment period is failing to recognize and treat an invasive cancer while continuing the ablation sessions. This occurrence may place the patient outside of the window of opportunity for curative endoscopic treatment. Therefore, every ablation session starts with careful endoscopic inspection using [high-definition white-light endoscopy] and preferably optical chromoendoscopy to exclude the presence of visible abnormalities that require an endoscopic resection instead of the scheduled ablation. Routine biopsies of flat Barrett’s esophagus are not necessary or recommended prior to ablation at these sessions, as the blood may inhibit optimal energy transfer to the tissue.”

Following successfully achieved complete endoscopic and histologic eradication of intestinal metaplasia, the update calls for surveillance endoscopy with biopsies at intervals of 1 and 3 years for cases of low-grade dysplasia and at intervals of 3, 6, and 12 months for high-grade dysplasia or esophageal adenocarcinoma, followed by annual checks thereafter.

The investigators disclosed relationships with Olympus, Ironwood, Erbe, and others.

SOURCE: Sharma P et al. Gastroenterology. 2019 Nov 12. doi: 10.1053/j.gastro.2019.09.051.

The American Gastroenterological Association recently released a clinical practice update for endoscopic treatment of Barrett’s esophagus with dysplasia and/or early esophageal adenocarcinoma.

The update offers best practice advice for a range of clinical scenarios based on published evidence, including guidelines and recent systematic reviews, reported lead author Prateek Sharma, MD, of the University of Kansas, Kansas City. Dr. Sharma was accompanied on the authoring review team by three other expert gastroenterologists from the United States and the Netherlands.

Beyond practice advice, the investigators highlighted a research focus for the future.

“Given the expense and time required for careful and continual surveillance after Barrett’s endoscopic therapy, the future must define improved means of risk-stratifying patients for therapy who are at highest risk for cancer development and for risk of recurrence after complete eradication of intestinal metaplasia,” they wrote in Gastroenterology. “Potentially, we may use a panel of patient characteristics (such as the [Progression in Barrett’s] score), preablation tissue characteristics (e.g., baseline grade of dysplasia) and the posttherapy molecular makeup of the epithelium to help risk stratify our patients.”

For now, many of the treatment principles in the update depend upon histologic features.

For instance, either endoscopic therapy or continued surveillance are reasonable options for patients with Barrett’s esophagus who have confirmed and persistent low-grade dysplasia. In contrast, the update recommends that all patients with high-grade dysplasia or esophageal adenocarcinoma (T1a) undergo endoscopic therapy, highlighting that this method is preferred over esophagectomy for patients with T1a cancer. Along the same lines, the investigators noted that endoscopic therapy is a “reasonable alternative” to esophagectomy in cases of T1b esophageal adenocarcinoma in the presence of minimal invasion and good to moderate differentiation, particularly in patients who are poor candidates for surgery.

During the decision-making process, patients with dysplasia should be advised that not undergoing endoscopic therapy may increase cancer risk, the investigators wrote, adding that patients should also be informed about endoscopic therapy–related risks of bleeding and perforation, which occur in less than 1% of patients, and the risk of postprocedural stricture formation, which occurs in approximately 6% of patients.

If endoscopic therapy is elected, the update suggests that the procedure be done by experts who perform at least 10 new cases per year.

Concerning specifics of therapy, the investigators advised that mucosal ablation be applied to all visible esophageal columnar mucosa, 5-10 mm proximal to the squamocolumnar junction, and 5-10 mm distal to the gastroesophageal junction. Ablation should only be performed in cases of flat Barrett’s esophagus in which no visible abnormalities or signs of inflammation are present, the review team wrote.

The investigators went on to lay out some “practical ground rules” for endoscopic therapy, including a potential pitfall.

“Ablation therapy may consist of multiple 2-3 monthly ablation sessions that may extend over a period of more than a year,” the investigators wrote. “The worst adverse outcome during the treatment period is failing to recognize and treat an invasive cancer while continuing the ablation sessions. This occurrence may place the patient outside of the window of opportunity for curative endoscopic treatment. Therefore, every ablation session starts with careful endoscopic inspection using [high-definition white-light endoscopy] and preferably optical chromoendoscopy to exclude the presence of visible abnormalities that require an endoscopic resection instead of the scheduled ablation. Routine biopsies of flat Barrett’s esophagus are not necessary or recommended prior to ablation at these sessions, as the blood may inhibit optimal energy transfer to the tissue.”

Following successfully achieved complete endoscopic and histologic eradication of intestinal metaplasia, the update calls for surveillance endoscopy with biopsies at intervals of 1 and 3 years for cases of low-grade dysplasia and at intervals of 3, 6, and 12 months for high-grade dysplasia or esophageal adenocarcinoma, followed by annual checks thereafter.

The investigators disclosed relationships with Olympus, Ironwood, Erbe, and others.

SOURCE: Sharma P et al. Gastroenterology. 2019 Nov 12. doi: 10.1053/j.gastro.2019.09.051.

The American Gastroenterological Association recently released a clinical practice update for endoscopic treatment of Barrett’s esophagus with dysplasia and/or early esophageal adenocarcinoma.

The update offers best practice advice for a range of clinical scenarios based on published evidence, including guidelines and recent systematic reviews, reported lead author Prateek Sharma, MD, of the University of Kansas, Kansas City. Dr. Sharma was accompanied on the authoring review team by three other expert gastroenterologists from the United States and the Netherlands.

Beyond practice advice, the investigators highlighted a research focus for the future.

“Given the expense and time required for careful and continual surveillance after Barrett’s endoscopic therapy, the future must define improved means of risk-stratifying patients for therapy who are at highest risk for cancer development and for risk of recurrence after complete eradication of intestinal metaplasia,” they wrote in Gastroenterology. “Potentially, we may use a panel of patient characteristics (such as the [Progression in Barrett’s] score), preablation tissue characteristics (e.g., baseline grade of dysplasia) and the posttherapy molecular makeup of the epithelium to help risk stratify our patients.”

For now, many of the treatment principles in the update depend upon histologic features.

For instance, either endoscopic therapy or continued surveillance are reasonable options for patients with Barrett’s esophagus who have confirmed and persistent low-grade dysplasia. In contrast, the update recommends that all patients with high-grade dysplasia or esophageal adenocarcinoma (T1a) undergo endoscopic therapy, highlighting that this method is preferred over esophagectomy for patients with T1a cancer. Along the same lines, the investigators noted that endoscopic therapy is a “reasonable alternative” to esophagectomy in cases of T1b esophageal adenocarcinoma in the presence of minimal invasion and good to moderate differentiation, particularly in patients who are poor candidates for surgery.

During the decision-making process, patients with dysplasia should be advised that not undergoing endoscopic therapy may increase cancer risk, the investigators wrote, adding that patients should also be informed about endoscopic therapy–related risks of bleeding and perforation, which occur in less than 1% of patients, and the risk of postprocedural stricture formation, which occurs in approximately 6% of patients.

If endoscopic therapy is elected, the update suggests that the procedure be done by experts who perform at least 10 new cases per year.

Concerning specifics of therapy, the investigators advised that mucosal ablation be applied to all visible esophageal columnar mucosa, 5-10 mm proximal to the squamocolumnar junction, and 5-10 mm distal to the gastroesophageal junction. Ablation should only be performed in cases of flat Barrett’s esophagus in which no visible abnormalities or signs of inflammation are present, the review team wrote.

The investigators went on to lay out some “practical ground rules” for endoscopic therapy, including a potential pitfall.

“Ablation therapy may consist of multiple 2-3 monthly ablation sessions that may extend over a period of more than a year,” the investigators wrote. “The worst adverse outcome during the treatment period is failing to recognize and treat an invasive cancer while continuing the ablation sessions. This occurrence may place the patient outside of the window of opportunity for curative endoscopic treatment. Therefore, every ablation session starts with careful endoscopic inspection using [high-definition white-light endoscopy] and preferably optical chromoendoscopy to exclude the presence of visible abnormalities that require an endoscopic resection instead of the scheduled ablation. Routine biopsies of flat Barrett’s esophagus are not necessary or recommended prior to ablation at these sessions, as the blood may inhibit optimal energy transfer to the tissue.”

Following successfully achieved complete endoscopic and histologic eradication of intestinal metaplasia, the update calls for surveillance endoscopy with biopsies at intervals of 1 and 3 years for cases of low-grade dysplasia and at intervals of 3, 6, and 12 months for high-grade dysplasia or esophageal adenocarcinoma, followed by annual checks thereafter.

The investigators disclosed relationships with Olympus, Ironwood, Erbe, and others.

SOURCE: Sharma P et al. Gastroenterology. 2019 Nov 12. doi: 10.1053/j.gastro.2019.09.051.

The Food and Drug Administration has accepted a supplemental New Drug Application and granted Priority Review for dapagliflozin (Farxiga) for the reduction of risk of cardiovascular death or worsening of heart failure in adult patients with heart failure with reduced ejection fraction (HFrEF).

Wikimedia Commons/FitzColinGerald/ Creative Commons License

The application was based on results from the landmark, phase 3 DAPA-HF trial, published in September 2019 in the New England Journal of Medicine. The study showed that dapagliflozin plus standard care reduced the incidence of cardiovascular death and worsening of heart failure versus placebo in patients with HFrEF.

Dapagliflozin was granted Fast Track designation for heart failure by the FDA in September 2019. In August 2019, the FDA also granted Fast Track designation to dapagliflozin for the delayed progression of renal failure and prevention of cardiovascular and renal death in patients with chronic kidney disease.

The drug is currently indicated for the improvement of glycemic control in adults with type 2 diabetes as either monotherapy or in combination. The FDA approved dapagliflozin in October 2019 for the reduction of heart failure hospitalization risk in patients with type 2 diabetes and cardiovascular risk factors.

“Farxiga is well established in the treatment of type 2 diabetes and this Priority Review shows its potential to also impact millions of patients with heart failure. If approved, Farxiga will be the first and only medicine of its kind indicated to treat patients with heart failure,” said Mene Pangalos, executive vice president of biopharmaceutical research and development at AstraZeneca.

Find the full press release on the AstraZeneca website.

[email protected]

The Food and Drug Administration has accepted a supplemental New Drug Application and granted Priority Review for dapagliflozin (Farxiga) for the reduction of risk of cardiovascular death or worsening of heart failure in adult patients with heart failure with reduced ejection fraction (HFrEF).

Wikimedia Commons/FitzColinGerald/ Creative Commons License

The application was based on results from the landmark, phase 3 DAPA-HF trial, published in September 2019 in the New England Journal of Medicine. The study showed that dapagliflozin plus standard care reduced the incidence of cardiovascular death and worsening of heart failure versus placebo in patients with HFrEF.

Dapagliflozin was granted Fast Track designation for heart failure by the FDA in September 2019. In August 2019, the FDA also granted Fast Track designation to dapagliflozin for the delayed progression of renal failure and prevention of cardiovascular and renal death in patients with chronic kidney disease.

The drug is currently indicated for the improvement of glycemic control in adults with type 2 diabetes as either monotherapy or in combination. The FDA approved dapagliflozin in October 2019 for the reduction of heart failure hospitalization risk in patients with type 2 diabetes and cardiovascular risk factors.

“Farxiga is well established in the treatment of type 2 diabetes and this Priority Review shows its potential to also impact millions of patients with heart failure. If approved, Farxiga will be the first and only medicine of its kind indicated to treat patients with heart failure,” said Mene Pangalos, executive vice president of biopharmaceutical research and development at AstraZeneca.

Find the full press release on the AstraZeneca website.

[email protected]

The Food and Drug Administration has accepted a supplemental New Drug Application and granted Priority Review for dapagliflozin (Farxiga) for the reduction of risk of cardiovascular death or worsening of heart failure in adult patients with heart failure with reduced ejection fraction (HFrEF).

Wikimedia Commons/FitzColinGerald/ Creative Commons License

The application was based on results from the landmark, phase 3 DAPA-HF trial, published in September 2019 in the New England Journal of Medicine. The study showed that dapagliflozin plus standard care reduced the incidence of cardiovascular death and worsening of heart failure versus placebo in patients with HFrEF.

Dapagliflozin was granted Fast Track designation for heart failure by the FDA in September 2019. In August 2019, the FDA also granted Fast Track designation to dapagliflozin for the delayed progression of renal failure and prevention of cardiovascular and renal death in patients with chronic kidney disease.

The drug is currently indicated for the improvement of glycemic control in adults with type 2 diabetes as either monotherapy or in combination. The FDA approved dapagliflozin in October 2019 for the reduction of heart failure hospitalization risk in patients with type 2 diabetes and cardiovascular risk factors.

“Farxiga is well established in the treatment of type 2 diabetes and this Priority Review shows its potential to also impact millions of patients with heart failure. If approved, Farxiga will be the first and only medicine of its kind indicated to treat patients with heart failure,” said Mene Pangalos, executive vice president of biopharmaceutical research and development at AstraZeneca.

Find the full press release on the AstraZeneca website.

[email protected]

I was asked recently about the trauma of 9/11 by a teen patient who was too young to remember the terrorist attacks. I was surprised that even today I become teary eyed thinking about it. My son was in his first week of college at Georgetown, and in the early confusion about what was going on I was panicked at reports of bombings in Washington. Fortunately, for me and my family at least, none of us were physically harmed. But the mental trauma still is with us. It was a momentary panic for me, but it’s not so fleeting for many families around the world today.

Joel Carillet/iStock Unreleased

I can’t imagine what it is like today to be a parent in an armed conflict zone, or even in an area with very high levels of criminal violence. At a meeting of the International Society for Social Pediatrics (ISSOP), I learned that an estimated 1.5 billion residents of Earth, or about one in five inhabitants, lived in war zones or in areas of tremendous violence, according to the World Bank’s 2011 World Development Report. And I learned that children are disproportionately affected – physically, mentally, and developmentally – from Stella Tsitoura, MD, of the Network for Children’s Rights, Athens, and others at the ISSOP meeting in Beirut, Lebanon, where pediatricians from around the world gathered in Oct. 2019 to consider what we as a profession should be doing in the context of armed conflict’s impact on so many children. The meeting was held in the Middle East because it is an especially hot conflict area, but children in South Asia, central Africa, South America, Central America, even rough inner-city areas in the United States are also affected.

Child soldiers in some parts of the world particularly are affected, sometimes being forced to commit violence on neighbors and kin. One country that I worked in years ago, Yemen, is a horrifying example of the complex impact of war on children and families. In 2017, over 2,100 children had been recruited as soldiers during the 3-year conflict in Yemen, a UNICEF representative reported. The death toll in Yemen was over 17,500 by Nov. 2018, according to a Human Rights Watch report.

Samuel Perlo-Freeman, PhD, an expert on the economics of arms trade, noted at the ISSOP meeting that two-thirds of civilian casualties in Yemen are caused by Coalition air strikes, whose members include Bahrain, Egypt, Jordan, Kuwait, Saudi Arabia, Sudan, and United Arab Emirates. He also said rebel groups in Yemen and elsewhere acquire their arms by capture, by smuggling, or through the aid of foreign backers. Six countries – the United States, Russia, and several western European countries – account for the majority of war tools used in armed conflict zones. In June 2019, courts in Great Britain ruled that British arms sales to the parties involved in Yemen were illegal without an assessment as to whether any violation of internal humanitarian law had taken place.

Many of us feel impotent when facing the magnitude of this problem, and the lives of despair that affected children lead are sometimes too heart breaking to dwell on. ISSOP, the American Academy of Pediatrics, and the International Pediatric Association (IPA) are teaching us differently: Standing up for the human rights of children living in areas of conflict or refugees from those areas is our responsibility, both as individuals and as members of our pediatric associations. At a basic level we need to witness – we need to share what we see with our patients who have immigrated legally or illegally in our practices, our hospitals, and our communities. It’s important to be knowledgeable of current standards of clinical care outlined by both ISSOP and the AAP to ensure our patients affected by conflict and violence get appropriate treatment.

Some of the most lasting health impacts for children in conflict are their mental health needs; the World Health Organization prevalence estimates of mental disorders in conflict settings is 22%, according to a 2019 report in the Lancet (2019 Jun;394[10194]:240-8). Not only do mental health conditions last throughout a lifetime, the impact of war can affect generations through epigenetic forces.

Arms manufacturers should be held accountable as the courts are doing in Great Britain. Too often American-made armaments are falling into the wrong hands. More can be done to limit the sale of weapons that go into conflict zones. Chemical weapons, cluster bombs, and biologic weapons are banned by international agreement; shouldn’t we do the same with nuclear weapons?

Some pediatric health care facilities are impacted by the needs of traumatized children more than others. Countries at the front line of conflict – like Lebanon, Jordon, Turkey, Greece, Italy, and Mexico – should be supported in their efforts on behalf of child refugees. We need to share the burden and support entities such as Doctors Without Borders, Save the Children, and the Red Cross/Crescent as they present themselves in crisis zones. We recognize that the fundamental human rights of children are being ignored by warring parties. We should join with the global community to support the United Nations Sustainable Development Goals, especially Goal 16, which asks the world community to make real progress in promoting peace and justice by 2030. Pediatricians may not be experts in armed conflict, but we are experts in what warfare does to the health and well-being of young children. It’s time to speak out and act.
 

I was asked recently about the trauma of 9/11 by a teen patient who was too young to remember the terrorist attacks. I was surprised that even today I become teary eyed thinking about it. My son was in his first week of college at Georgetown, and in the early confusion about what was going on I was panicked at reports of bombings in Washington. Fortunately, for me and my family at least, none of us were physically harmed. But the mental trauma still is with us. It was a momentary panic for me, but it’s not so fleeting for many families around the world today.

Joel Carillet/iStock Unreleased

I can’t imagine what it is like today to be a parent in an armed conflict zone, or even in an area with very high levels of criminal violence. At a meeting of the International Society for Social Pediatrics (ISSOP), I learned that an estimated 1.5 billion residents of Earth, or about one in five inhabitants, lived in war zones or in areas of tremendous violence, according to the World Bank’s 2011 World Development Report. And I learned that children are disproportionately affected – physically, mentally, and developmentally – from Stella Tsitoura, MD, of the Network for Children’s Rights, Athens, and others at the ISSOP meeting in Beirut, Lebanon, where pediatricians from around the world gathered in Oct. 2019 to consider what we as a profession should be doing in the context of armed conflict’s impact on so many children. The meeting was held in the Middle East because it is an especially hot conflict area, but children in South Asia, central Africa, South America, Central America, even rough inner-city areas in the United States are also affected.

Child soldiers in some parts of the world particularly are affected, sometimes being forced to commit violence on neighbors and kin. One country that I worked in years ago, Yemen, is a horrifying example of the complex impact of war on children and families. In 2017, over 2,100 children had been recruited as soldiers during the 3-year conflict in Yemen, a UNICEF representative reported. The death toll in Yemen was over 17,500 by Nov. 2018, according to a Human Rights Watch report.

Samuel Perlo-Freeman, PhD, an expert on the economics of arms trade, noted at the ISSOP meeting that two-thirds of civilian casualties in Yemen are caused by Coalition air strikes, whose members include Bahrain, Egypt, Jordan, Kuwait, Saudi Arabia, Sudan, and United Arab Emirates. He also said rebel groups in Yemen and elsewhere acquire their arms by capture, by smuggling, or through the aid of foreign backers. Six countries – the United States, Russia, and several western European countries – account for the majority of war tools used in armed conflict zones. In June 2019, courts in Great Britain ruled that British arms sales to the parties involved in Yemen were illegal without an assessment as to whether any violation of internal humanitarian law had taken place.

Many of us feel impotent when facing the magnitude of this problem, and the lives of despair that affected children lead are sometimes too heart breaking to dwell on. ISSOP, the American Academy of Pediatrics, and the International Pediatric Association (IPA) are teaching us differently: Standing up for the human rights of children living in areas of conflict or refugees from those areas is our responsibility, both as individuals and as members of our pediatric associations. At a basic level we need to witness – we need to share what we see with our patients who have immigrated legally or illegally in our practices, our hospitals, and our communities. It’s important to be knowledgeable of current standards of clinical care outlined by both ISSOP and the AAP to ensure our patients affected by conflict and violence get appropriate treatment.

Some of the most lasting health impacts for children in conflict are their mental health needs; the World Health Organization prevalence estimates of mental disorders in conflict settings is 22%, according to a 2019 report in the Lancet (2019 Jun;394[10194]:240-8). Not only do mental health conditions last throughout a lifetime, the impact of war can affect generations through epigenetic forces.

Arms manufacturers should be held accountable as the courts are doing in Great Britain. Too often American-made armaments are falling into the wrong hands. More can be done to limit the sale of weapons that go into conflict zones. Chemical weapons, cluster bombs, and biologic weapons are banned by international agreement; shouldn’t we do the same with nuclear weapons?

Some pediatric health care facilities are impacted by the needs of traumatized children more than others. Countries at the front line of conflict – like Lebanon, Jordon, Turkey, Greece, Italy, and Mexico – should be supported in their efforts on behalf of child refugees. We need to share the burden and support entities such as Doctors Without Borders, Save the Children, and the Red Cross/Crescent as they present themselves in crisis zones. We recognize that the fundamental human rights of children are being ignored by warring parties. We should join with the global community to support the United Nations Sustainable Development Goals, especially Goal 16, which asks the world community to make real progress in promoting peace and justice by 2030. Pediatricians may not be experts in armed conflict, but we are experts in what warfare does to the health and well-being of young children. It’s time to speak out and act.
 

I was asked recently about the trauma of 9/11 by a teen patient who was too young to remember the terrorist attacks. I was surprised that even today I become teary eyed thinking about it. My son was in his first week of college at Georgetown, and in the early confusion about what was going on I was panicked at reports of bombings in Washington. Fortunately, for me and my family at least, none of us were physically harmed. But the mental trauma still is with us. It was a momentary panic for me, but it’s not so fleeting for many families around the world today.

Joel Carillet/iStock Unreleased

I can’t imagine what it is like today to be a parent in an armed conflict zone, or even in an area with very high levels of criminal violence. At a meeting of the International Society for Social Pediatrics (ISSOP), I learned that an estimated 1.5 billion residents of Earth, or about one in five inhabitants, lived in war zones or in areas of tremendous violence, according to the World Bank’s 2011 World Development Report. And I learned that children are disproportionately affected – physically, mentally, and developmentally – from Stella Tsitoura, MD, of the Network for Children’s Rights, Athens, and others at the ISSOP meeting in Beirut, Lebanon, where pediatricians from around the world gathered in Oct. 2019 to consider what we as a profession should be doing in the context of armed conflict’s impact on so many children. The meeting was held in the Middle East because it is an especially hot conflict area, but children in South Asia, central Africa, South America, Central America, even rough inner-city areas in the United States are also affected.

Child soldiers in some parts of the world particularly are affected, sometimes being forced to commit violence on neighbors and kin. One country that I worked in years ago, Yemen, is a horrifying example of the complex impact of war on children and families. In 2017, over 2,100 children had been recruited as soldiers during the 3-year conflict in Yemen, a UNICEF representative reported. The death toll in Yemen was over 17,500 by Nov. 2018, according to a Human Rights Watch report.

Samuel Perlo-Freeman, PhD, an expert on the economics of arms trade, noted at the ISSOP meeting that two-thirds of civilian casualties in Yemen are caused by Coalition air strikes, whose members include Bahrain, Egypt, Jordan, Kuwait, Saudi Arabia, Sudan, and United Arab Emirates. He also said rebel groups in Yemen and elsewhere acquire their arms by capture, by smuggling, or through the aid of foreign backers. Six countries – the United States, Russia, and several western European countries – account for the majority of war tools used in armed conflict zones. In June 2019, courts in Great Britain ruled that British arms sales to the parties involved in Yemen were illegal without an assessment as to whether any violation of internal humanitarian law had taken place.

Many of us feel impotent when facing the magnitude of this problem, and the lives of despair that affected children lead are sometimes too heart breaking to dwell on. ISSOP, the American Academy of Pediatrics, and the International Pediatric Association (IPA) are teaching us differently: Standing up for the human rights of children living in areas of conflict or refugees from those areas is our responsibility, both as individuals and as members of our pediatric associations. At a basic level we need to witness – we need to share what we see with our patients who have immigrated legally or illegally in our practices, our hospitals, and our communities. It’s important to be knowledgeable of current standards of clinical care outlined by both ISSOP and the AAP to ensure our patients affected by conflict and violence get appropriate treatment.

Some of the most lasting health impacts for children in conflict are their mental health needs; the World Health Organization prevalence estimates of mental disorders in conflict settings is 22%, according to a 2019 report in the Lancet (2019 Jun;394[10194]:240-8). Not only do mental health conditions last throughout a lifetime, the impact of war can affect generations through epigenetic forces.

Arms manufacturers should be held accountable as the courts are doing in Great Britain. Too often American-made armaments are falling into the wrong hands. More can be done to limit the sale of weapons that go into conflict zones. Chemical weapons, cluster bombs, and biologic weapons are banned by international agreement; shouldn’t we do the same with nuclear weapons?

Some pediatric health care facilities are impacted by the needs of traumatized children more than others. Countries at the front line of conflict – like Lebanon, Jordon, Turkey, Greece, Italy, and Mexico – should be supported in their efforts on behalf of child refugees. We need to share the burden and support entities such as Doctors Without Borders, Save the Children, and the Red Cross/Crescent as they present themselves in crisis zones. We recognize that the fundamental human rights of children are being ignored by warring parties. We should join with the global community to support the United Nations Sustainable Development Goals, especially Goal 16, which asks the world community to make real progress in promoting peace and justice by 2030. Pediatricians may not be experts in armed conflict, but we are experts in what warfare does to the health and well-being of young children. It’s time to speak out and act.
 

Receiving clinical care within 1 week of a concussion is associated with faster recovery times, compared with having an initial clinic visit more than 1 week after the injury, according to a study published Jan. 6 in JAMA Neurology.

In addition, more severe visual motion sensitivity symptoms are associated with longer recovery times, said lead author Anthony P. Kontos, PhD, and colleagues. Dr. Kontos is associate professor of orthopedic surgery at the University of Pittsburgh and the research director of the University of Pittsburgh Medical Center Sports Medicine Concussion Program.

“Without clinical guidance and behavioral management recommendations post injury, athletes may have been engaging in counterproductive recovery strategies, such as a strict rest or excessive physical activity,” the authors said. “This explanation is supported by the fact that athletes recovered in a similar amount of time after that first evaluation.”

Various factors may influence recovery after a concussion, including age, sex, and comorbidities. To examine the relationship between time since injury at the start of clinical care and recovery time, the investigators conducted a retrospective, cross-sectional study. They analyzed data from patients seen in a sports medicine clinic between August 2016 and March 2018. Eligible patients were aged 12-22 years and had a diagnosed, symptomatic, sport-related concussion. The researchers excluded patients with incomplete recovery data.

The investigators included 162 patients in their analyses; 98 of these patients were seen within 7 days of the injury, and 64 were seen 8-20 days after a concussion. Both groups had a mean age of 15 years and similar proportions of female patients (52% in the early-care group vs. 62.5% in the late-care group). At the first clinical visit, symptom severity and cognitive, ocular, and vestibular test results were similar in both groups.

The researchers defined recovery time as the number of days from injury until the date of clearance for a full return to play. Physicians cleared patients to return to play when they returned to preinjury levels of symptoms and preinjury performance on cognitive, ocular, and vestibular tests with no increase in symptoms after exertion.

Patients’ recovery times ranged from 9 to 299 days; the average recovery time was 57 days. Fifty-two percent of patients in the early-care group recovered in 30 days or fewer, compared with 19% of patients in late-care group. Patients in the early-care group had a mean recovery of 51.1 days, whereas patients in the late-care group had a mean recovery of 66 days.

In a logistic regression model, late care “was associated with a 5.8-times increased likelihood of a recovery longer than 30 days,” the researchers reported. Visual motion sensitivity symptoms also were associated with increased odds of protracted recovery (adjusted odds ratio, 4.5).

“Once care was established, time to recovery did not differ for athletes evaluated within the first week of injury compared with those evaluated 2-3 weeks post injury,” Dr. Kontos and colleagues concluded. “Education on injury and behavioral recommendations to optimize concussion recovery and earlier initiation of active rehabilitation strategies, including exertion and vestibular therapy, are plausible explanations for the association of a shorter recovery time with earlier care. However, future research should focus on the specific mechanisms by which earlier health care postconcussion promotes faster recovery and determine if these findings apply to other subpopulations, including military personnel.”

The researchers noted that they excluded from their analysis 254 patients who had incomplete recovery data but otherwise met inclusion criteria, which may have led to selection bias.

Dr. Kontos disclosed grants from the National Football League and personal fees from APA Books and University of Pittsburgh projects outside the scope of this study.

[email protected]

SOURCE: Kontos AP et al. JAMA Neurol. 2020 Jan 6. doi: 10.1001/jamaneurol.2019.4552.

Receiving clinical care within 1 week of a concussion is associated with faster recovery times, compared with having an initial clinic visit more than 1 week after the injury, according to a study published Jan. 6 in JAMA Neurology.

In addition, more severe visual motion sensitivity symptoms are associated with longer recovery times, said lead author Anthony P. Kontos, PhD, and colleagues. Dr. Kontos is associate professor of orthopedic surgery at the University of Pittsburgh and the research director of the University of Pittsburgh Medical Center Sports Medicine Concussion Program.

“Without clinical guidance and behavioral management recommendations post injury, athletes may have been engaging in counterproductive recovery strategies, such as a strict rest or excessive physical activity,” the authors said. “This explanation is supported by the fact that athletes recovered in a similar amount of time after that first evaluation.”

Various factors may influence recovery after a concussion, including age, sex, and comorbidities. To examine the relationship between time since injury at the start of clinical care and recovery time, the investigators conducted a retrospective, cross-sectional study. They analyzed data from patients seen in a sports medicine clinic between August 2016 and March 2018. Eligible patients were aged 12-22 years and had a diagnosed, symptomatic, sport-related concussion. The researchers excluded patients with incomplete recovery data.

The investigators included 162 patients in their analyses; 98 of these patients were seen within 7 days of the injury, and 64 were seen 8-20 days after a concussion. Both groups had a mean age of 15 years and similar proportions of female patients (52% in the early-care group vs. 62.5% in the late-care group). At the first clinical visit, symptom severity and cognitive, ocular, and vestibular test results were similar in both groups.

The researchers defined recovery time as the number of days from injury until the date of clearance for a full return to play. Physicians cleared patients to return to play when they returned to preinjury levels of symptoms and preinjury performance on cognitive, ocular, and vestibular tests with no increase in symptoms after exertion.

Patients’ recovery times ranged from 9 to 299 days; the average recovery time was 57 days. Fifty-two percent of patients in the early-care group recovered in 30 days or fewer, compared with 19% of patients in late-care group. Patients in the early-care group had a mean recovery of 51.1 days, whereas patients in the late-care group had a mean recovery of 66 days.

In a logistic regression model, late care “was associated with a 5.8-times increased likelihood of a recovery longer than 30 days,” the researchers reported. Visual motion sensitivity symptoms also were associated with increased odds of protracted recovery (adjusted odds ratio, 4.5).

“Once care was established, time to recovery did not differ for athletes evaluated within the first week of injury compared with those evaluated 2-3 weeks post injury,” Dr. Kontos and colleagues concluded. “Education on injury and behavioral recommendations to optimize concussion recovery and earlier initiation of active rehabilitation strategies, including exertion and vestibular therapy, are plausible explanations for the association of a shorter recovery time with earlier care. However, future research should focus on the specific mechanisms by which earlier health care postconcussion promotes faster recovery and determine if these findings apply to other subpopulations, including military personnel.”

The researchers noted that they excluded from their analysis 254 patients who had incomplete recovery data but otherwise met inclusion criteria, which may have led to selection bias.

Dr. Kontos disclosed grants from the National Football League and personal fees from APA Books and University of Pittsburgh projects outside the scope of this study.

[email protected]

SOURCE: Kontos AP et al. JAMA Neurol. 2020 Jan 6. doi: 10.1001/jamaneurol.2019.4552.

Receiving clinical care within 1 week of a concussion is associated with faster recovery times, compared with having an initial clinic visit more than 1 week after the injury, according to a study published Jan. 6 in JAMA Neurology.

In addition, more severe visual motion sensitivity symptoms are associated with longer recovery times, said lead author Anthony P. Kontos, PhD, and colleagues. Dr. Kontos is associate professor of orthopedic surgery at the University of Pittsburgh and the research director of the University of Pittsburgh Medical Center Sports Medicine Concussion Program.

“Without clinical guidance and behavioral management recommendations post injury, athletes may have been engaging in counterproductive recovery strategies, such as a strict rest or excessive physical activity,” the authors said. “This explanation is supported by the fact that athletes recovered in a similar amount of time after that first evaluation.”

Various factors may influence recovery after a concussion, including age, sex, and comorbidities. To examine the relationship between time since injury at the start of clinical care and recovery time, the investigators conducted a retrospective, cross-sectional study. They analyzed data from patients seen in a sports medicine clinic between August 2016 and March 2018. Eligible patients were aged 12-22 years and had a diagnosed, symptomatic, sport-related concussion. The researchers excluded patients with incomplete recovery data.

The investigators included 162 patients in their analyses; 98 of these patients were seen within 7 days of the injury, and 64 were seen 8-20 days after a concussion. Both groups had a mean age of 15 years and similar proportions of female patients (52% in the early-care group vs. 62.5% in the late-care group). At the first clinical visit, symptom severity and cognitive, ocular, and vestibular test results were similar in both groups.

The researchers defined recovery time as the number of days from injury until the date of clearance for a full return to play. Physicians cleared patients to return to play when they returned to preinjury levels of symptoms and preinjury performance on cognitive, ocular, and vestibular tests with no increase in symptoms after exertion.

Patients’ recovery times ranged from 9 to 299 days; the average recovery time was 57 days. Fifty-two percent of patients in the early-care group recovered in 30 days or fewer, compared with 19% of patients in late-care group. Patients in the early-care group had a mean recovery of 51.1 days, whereas patients in the late-care group had a mean recovery of 66 days.

In a logistic regression model, late care “was associated with a 5.8-times increased likelihood of a recovery longer than 30 days,” the researchers reported. Visual motion sensitivity symptoms also were associated with increased odds of protracted recovery (adjusted odds ratio, 4.5).

“Once care was established, time to recovery did not differ for athletes evaluated within the first week of injury compared with those evaluated 2-3 weeks post injury,” Dr. Kontos and colleagues concluded. “Education on injury and behavioral recommendations to optimize concussion recovery and earlier initiation of active rehabilitation strategies, including exertion and vestibular therapy, are plausible explanations for the association of a shorter recovery time with earlier care. However, future research should focus on the specific mechanisms by which earlier health care postconcussion promotes faster recovery and determine if these findings apply to other subpopulations, including military personnel.”

The researchers noted that they excluded from their analysis 254 patients who had incomplete recovery data but otherwise met inclusion criteria, which may have led to selection bias.

Dr. Kontos disclosed grants from the National Football League and personal fees from APA Books and University of Pittsburgh projects outside the scope of this study.

[email protected]

SOURCE: Kontos AP et al. JAMA Neurol. 2020 Jan 6. doi: 10.1001/jamaneurol.2019.4552.

Key clinical point: In patients with progressive MS, high-dose biotin was not found to offer clear improvement in disability.

Major finding: At 12 months, Expanded Disability Status Scale (EDSS) scores increased from 5.8 ± 1.3 before high-dose biotin initiation to 6.0 ± 1.3 at baseline. EDSS scores increased significantly under high-dose biotin (6.3 ± 1.3 at 12 months vs. 6.1 ± 1.3 at baseline; P less than .0001).

Study details: The data were obtained from a prospective study of 178 patients in routine clinical practice; 26 patients stopped treatment before 12 months and 152 continued for at least 12 months.

Disclosures: The study was supported by MedDay Pharma and by the ANTARES association. The corresponding author received honoraria from Biogen, Sanofi Genzyme, Teva, Roche, Merck, and MSD.

Citation: Couloume L et al. Mult Scler. 2019 Dec 17. doi: 10.1177/1352458519894713.

Key clinical point: In patients with progressive MS, high-dose biotin was not found to offer clear improvement in disability.

Major finding: At 12 months, Expanded Disability Status Scale (EDSS) scores increased from 5.8 ± 1.3 before high-dose biotin initiation to 6.0 ± 1.3 at baseline. EDSS scores increased significantly under high-dose biotin (6.3 ± 1.3 at 12 months vs. 6.1 ± 1.3 at baseline; P less than .0001).

Study details: The data were obtained from a prospective study of 178 patients in routine clinical practice; 26 patients stopped treatment before 12 months and 152 continued for at least 12 months.

Disclosures: The study was supported by MedDay Pharma and by the ANTARES association. The corresponding author received honoraria from Biogen, Sanofi Genzyme, Teva, Roche, Merck, and MSD.

Citation: Couloume L et al. Mult Scler. 2019 Dec 17. doi: 10.1177/1352458519894713.

Key clinical point: In patients with progressive MS, high-dose biotin was not found to offer clear improvement in disability.

Major finding: At 12 months, Expanded Disability Status Scale (EDSS) scores increased from 5.8 ± 1.3 before high-dose biotin initiation to 6.0 ± 1.3 at baseline. EDSS scores increased significantly under high-dose biotin (6.3 ± 1.3 at 12 months vs. 6.1 ± 1.3 at baseline; P less than .0001).

Study details: The data were obtained from a prospective study of 178 patients in routine clinical practice; 26 patients stopped treatment before 12 months and 152 continued for at least 12 months.

Disclosures: The study was supported by MedDay Pharma and by the ANTARES association. The corresponding author received honoraria from Biogen, Sanofi Genzyme, Teva, Roche, Merck, and MSD.

Citation: Couloume L et al. Mult Scler. 2019 Dec 17. doi: 10.1177/1352458519894713.

Key clinical point: Higher serum concentrations of 25-hydroxyvitamin D (25(OH)D) are associated with a reduced risk for multiple sclerosis (MS).

Major finding: Being in the top 25(OH)D quintile was significantly associated with a reduced risk of multiple sclerosis (odds ratio, 0.68; 95% confidence interval, 0.50-0.93).

Study details: A nested case-control study using data from 6 Swedish biobanks (665 cases and an equal number of matched controls).

Disclosures: This study was supported by the Swedish Research Council and through a regional agreement between Umea University and the Vasterbotten County Council. One author received speaking fees from Merck-Serono and served on advisory boards for Merck-Serono and Biogen and another received honoraria for lectures from Genzyme and for advisory board roles from Roche and Novartis.

Citation: Biström M et al. Mult Scler J Exp Transl Clin. 2019 Dec 6. doi: 10.1177/2055217319892291.

Key clinical point: Higher serum concentrations of 25-hydroxyvitamin D (25(OH)D) are associated with a reduced risk for multiple sclerosis (MS).

Major finding: Being in the top 25(OH)D quintile was significantly associated with a reduced risk of multiple sclerosis (odds ratio, 0.68; 95% confidence interval, 0.50-0.93).

Study details: A nested case-control study using data from 6 Swedish biobanks (665 cases and an equal number of matched controls).

Disclosures: This study was supported by the Swedish Research Council and through a regional agreement between Umea University and the Vasterbotten County Council. One author received speaking fees from Merck-Serono and served on advisory boards for Merck-Serono and Biogen and another received honoraria for lectures from Genzyme and for advisory board roles from Roche and Novartis.

Citation: Biström M et al. Mult Scler J Exp Transl Clin. 2019 Dec 6. doi: 10.1177/2055217319892291.

Key clinical point: Higher serum concentrations of 25-hydroxyvitamin D (25(OH)D) are associated with a reduced risk for multiple sclerosis (MS).

Major finding: Being in the top 25(OH)D quintile was significantly associated with a reduced risk of multiple sclerosis (odds ratio, 0.68; 95% confidence interval, 0.50-0.93).

Study details: A nested case-control study using data from 6 Swedish biobanks (665 cases and an equal number of matched controls).

Disclosures: This study was supported by the Swedish Research Council and through a regional agreement between Umea University and the Vasterbotten County Council. One author received speaking fees from Merck-Serono and served on advisory boards for Merck-Serono and Biogen and another received honoraria for lectures from Genzyme and for advisory board roles from Roche and Novartis.

Citation: Biström M et al. Mult Scler J Exp Transl Clin. 2019 Dec 6. doi: 10.1177/2055217319892291.

Key clinical point: In patients with relapsing multiple sclerosis, fingolimod has a superior effect on clinical and magnetic resonance imaging (MRI) outcomes than placebo and presents an acceptable safety profile.

Major finding: Compared with placebo, fingolimod (0.5, 1.25, and 5 mg/day doses) had a significant reduction in annualized relapse rate. Fingolimod demonstrated beneficial effects on MRI outcomes, including the number of gadolinium-enhancing T1 lesions, and improved patient quality of life. No significant difference was found between the groups in terms of adverse events.

Study details: This was a systematic review and meta-analysis of 10 studies, including 6,547 participants.

Disclosures: The authors reported having no conflicts of interest.

Citation: Yang T et al. Br J Clin Pharmacol. 2019 Dec 23. doi: 10.1111/bcp.14198.

Key clinical point: In patients with relapsing multiple sclerosis, fingolimod has a superior effect on clinical and magnetic resonance imaging (MRI) outcomes than placebo and presents an acceptable safety profile.

Major finding: Compared with placebo, fingolimod (0.5, 1.25, and 5 mg/day doses) had a significant reduction in annualized relapse rate. Fingolimod demonstrated beneficial effects on MRI outcomes, including the number of gadolinium-enhancing T1 lesions, and improved patient quality of life. No significant difference was found between the groups in terms of adverse events.

Study details: This was a systematic review and meta-analysis of 10 studies, including 6,547 participants.

Disclosures: The authors reported having no conflicts of interest.

Citation: Yang T et al. Br J Clin Pharmacol. 2019 Dec 23. doi: 10.1111/bcp.14198.

Key clinical point: In patients with relapsing multiple sclerosis, fingolimod has a superior effect on clinical and magnetic resonance imaging (MRI) outcomes than placebo and presents an acceptable safety profile.

Major finding: Compared with placebo, fingolimod (0.5, 1.25, and 5 mg/day doses) had a significant reduction in annualized relapse rate. Fingolimod demonstrated beneficial effects on MRI outcomes, including the number of gadolinium-enhancing T1 lesions, and improved patient quality of life. No significant difference was found between the groups in terms of adverse events.

Study details: This was a systematic review and meta-analysis of 10 studies, including 6,547 participants.

Disclosures: The authors reported having no conflicts of interest.

Citation: Yang T et al. Br J Clin Pharmacol. 2019 Dec 23. doi: 10.1111/bcp.14198.

Key clinical point: The discontinuation of natalizumab (NTZ) therapy may lead to a marked reactivation of multiple sclerosis (MS); high disease activity and a high level of disability before NTZ initiation predicted multiple sclerosis reactivation.

Major finding: Clinical reactivation was reported in 20.2% of patients within 6 months after NTZ discontinuation. A higher number of relapses during the year before NTZ initiation was significantly associated with an increased risk of reactivation at 6 and 12 months. At 6 months, an Expanded Disability Status Scale (EDSS) of 5.5 or higher before NTZ initiation was associated with a higher reactivation risk.

Study details: The findings are based on the results of a retrospective study of 89 patients with MS who had discontinued NTZ treatment.

Disclosures: The study was in part supported by a VTR grant from Kuopio University Hospital and personal grants from Ilkka Rauma, MD, from Orion Research Foundation and The Finnish Medical Foundation.

Citation: Mustonen T BM et al. Mult Scler Relat Disord. 2019 Nov 5. doi: 10.1016/j.msard.2019.101498.

Key clinical point: The discontinuation of natalizumab (NTZ) therapy may lead to a marked reactivation of multiple sclerosis (MS); high disease activity and a high level of disability before NTZ initiation predicted multiple sclerosis reactivation.

Major finding: Clinical reactivation was reported in 20.2% of patients within 6 months after NTZ discontinuation. A higher number of relapses during the year before NTZ initiation was significantly associated with an increased risk of reactivation at 6 and 12 months. At 6 months, an Expanded Disability Status Scale (EDSS) of 5.5 or higher before NTZ initiation was associated with a higher reactivation risk.

Study details: The findings are based on the results of a retrospective study of 89 patients with MS who had discontinued NTZ treatment.

Disclosures: The study was in part supported by a VTR grant from Kuopio University Hospital and personal grants from Ilkka Rauma, MD, from Orion Research Foundation and The Finnish Medical Foundation.

Citation: Mustonen T BM et al. Mult Scler Relat Disord. 2019 Nov 5. doi: 10.1016/j.msard.2019.101498.

Key clinical point: The discontinuation of natalizumab (NTZ) therapy may lead to a marked reactivation of multiple sclerosis (MS); high disease activity and a high level of disability before NTZ initiation predicted multiple sclerosis reactivation.

Major finding: Clinical reactivation was reported in 20.2% of patients within 6 months after NTZ discontinuation. A higher number of relapses during the year before NTZ initiation was significantly associated with an increased risk of reactivation at 6 and 12 months. At 6 months, an Expanded Disability Status Scale (EDSS) of 5.5 or higher before NTZ initiation was associated with a higher reactivation risk.

Study details: The findings are based on the results of a retrospective study of 89 patients with MS who had discontinued NTZ treatment.

Disclosures: The study was in part supported by a VTR grant from Kuopio University Hospital and personal grants from Ilkka Rauma, MD, from Orion Research Foundation and The Finnish Medical Foundation.

Citation: Mustonen T BM et al. Mult Scler Relat Disord. 2019 Nov 5. doi: 10.1016/j.msard.2019.101498.

Key clinical point: Older age at onset and presence of clinical or radiological disease activity was found to correlate with disability progression in patients with primary progressive multiple sclerosis (MS).

Major finding: The analysis of age at onset showed that for every 10-year increase, the risk of reaching Expanded Disability Status Scale (EDSS) scores of 4 and 6 increased by 26% and 31%, respectively. Patients with clinical exacerbations reached EDSS scores of 6, 7, and 8 faster than those without associated exacerbations; patients with gadolinium-enhancing lesions reached EDSS scores of 7 earlier.

Study details: A retrospective study conducted at 2 multiple sclerosis clinics in Argentina that included 178 patients with a median age of MS onset of 42 years.

Disclosures: This study was partially financed by an unrestricted grant from Merck Argentina (JC) and supported by internal funds from the Neuroimmunology Department of Fleni. The corresponding author is a board member of Merck-Serono Argentina, Biogen-Idec LATAM, and Merck-Serono LATAM.

Citation: Marrodan M, et al. Mult Scler Relat Disord. 2019 Dec 14. doi: 10.1016/j.msard.2019.101892.

Key clinical point: Older age at onset and presence of clinical or radiological disease activity was found to correlate with disability progression in patients with primary progressive multiple sclerosis (MS).

Major finding: The analysis of age at onset showed that for every 10-year increase, the risk of reaching Expanded Disability Status Scale (EDSS) scores of 4 and 6 increased by 26% and 31%, respectively. Patients with clinical exacerbations reached EDSS scores of 6, 7, and 8 faster than those without associated exacerbations; patients with gadolinium-enhancing lesions reached EDSS scores of 7 earlier.

Study details: A retrospective study conducted at 2 multiple sclerosis clinics in Argentina that included 178 patients with a median age of MS onset of 42 years.

Disclosures: This study was partially financed by an unrestricted grant from Merck Argentina (JC) and supported by internal funds from the Neuroimmunology Department of Fleni. The corresponding author is a board member of Merck-Serono Argentina, Biogen-Idec LATAM, and Merck-Serono LATAM.

Citation: Marrodan M, et al. Mult Scler Relat Disord. 2019 Dec 14. doi: 10.1016/j.msard.2019.101892.

Key clinical point: Older age at onset and presence of clinical or radiological disease activity was found to correlate with disability progression in patients with primary progressive multiple sclerosis (MS).

Major finding: The analysis of age at onset showed that for every 10-year increase, the risk of reaching Expanded Disability Status Scale (EDSS) scores of 4 and 6 increased by 26% and 31%, respectively. Patients with clinical exacerbations reached EDSS scores of 6, 7, and 8 faster than those without associated exacerbations; patients with gadolinium-enhancing lesions reached EDSS scores of 7 earlier.

Study details: A retrospective study conducted at 2 multiple sclerosis clinics in Argentina that included 178 patients with a median age of MS onset of 42 years.

Disclosures: This study was partially financed by an unrestricted grant from Merck Argentina (JC) and supported by internal funds from the Neuroimmunology Department of Fleni. The corresponding author is a board member of Merck-Serono Argentina, Biogen-Idec LATAM, and Merck-Serono LATAM.

Citation: Marrodan M, et al. Mult Scler Relat Disord. 2019 Dec 14. doi: 10.1016/j.msard.2019.101892.

Key clinical point: Poor sleep and sleep disorders are prevalent in patients with mild to moderately severe multiple sclerosis (MS) and are associated with other comorbidities.

Main finding: Poor sleep was reported in 66% of patients with MS, sleep apnea in 31%, insomnia in 29%, and restless legs in 26%. Poor sleep and insomnia were independent predictors of fatigue (odds ratio, 2.63; P = .046) and depression (odds ratio, 5.62; P = .003), respectively.

Study details: A sleep substudy of a randomized controlled trial, including 111 adults with MS and an expanded disability status scale score between 2 and 6.

Disclosures: The study was supported by a grant from the National Health and Medical Research Council-Motor Impairment Program.

Citation: Hensen HA, et al. Sleep Med. 2019 Dec 16. doi: 10.1016/j.sleep.2019.11.415.

Key clinical point: Poor sleep and sleep disorders are prevalent in patients with mild to moderately severe multiple sclerosis (MS) and are associated with other comorbidities.

Main finding: Poor sleep was reported in 66% of patients with MS, sleep apnea in 31%, insomnia in 29%, and restless legs in 26%. Poor sleep and insomnia were independent predictors of fatigue (odds ratio, 2.63; P = .046) and depression (odds ratio, 5.62; P = .003), respectively.

Study details: A sleep substudy of a randomized controlled trial, including 111 adults with MS and an expanded disability status scale score between 2 and 6.

Disclosures: The study was supported by a grant from the National Health and Medical Research Council-Motor Impairment Program.

Citation: Hensen HA, et al. Sleep Med. 2019 Dec 16. doi: 10.1016/j.sleep.2019.11.415.

Key clinical point: Poor sleep and sleep disorders are prevalent in patients with mild to moderately severe multiple sclerosis (MS) and are associated with other comorbidities.

Main finding: Poor sleep was reported in 66% of patients with MS, sleep apnea in 31%, insomnia in 29%, and restless legs in 26%. Poor sleep and insomnia were independent predictors of fatigue (odds ratio, 2.63; P = .046) and depression (odds ratio, 5.62; P = .003), respectively.

Study details: A sleep substudy of a randomized controlled trial, including 111 adults with MS and an expanded disability status scale score between 2 and 6.

Disclosures: The study was supported by a grant from the National Health and Medical Research Council-Motor Impairment Program.

Citation: Hensen HA, et al. Sleep Med. 2019 Dec 16. doi: 10.1016/j.sleep.2019.11.415.