Stephanie M. Levine, MD, FCCP, is an expert in lung transplantation, and pulmonary and critical care issues in pregnancy and women’s lung health. She is a Professor of Medicine in the Division of Pulmonary Diseases and Critical Care Medicine at the University of Texas Health Science Center in San Antonio, Texas; the Program Director of the Pulmonary and Critical Care Fellowship at the University of Texas Health Science Center; and the Co-Director of the Medical Intensive Care Unit at the University Hospital. She is also a staff physician at the Audie Murphy Veteran Administration Hospital.

Dr. Levine has been Editor for both CHEST SEEK Critical Care Medicine and Pulmonary Medicine editions. In 2009 she received the CHEST Presidential Citation Award; in 2010, the CHEST Distinguished Service Award; and in 2017, the Master Clinician Educator Award. She has also been recognized as a Distinguished CHEST Educator in 2017, 2018, and 2019.

Dr. Levine has been active in CHEST international activities with CHEST World Congress meetings, the 2017 Basel Joint CHEST/SPG Congress in collaboration with the Swiss Lung Association, and with the pulmonary/critical care subspecialty training programs being developed in China. She was President and Chair of the CHEST Foundation from 2010-2014 and is currently on the CHEST Board of Regents.

We asked Dr. Levine for some thoughts on her upcoming CHEST presidency.
 

What would you like to accomplish as President of CHEST?

Every 5 years, the Board of Regents sets forth a new 5-year strategic plan, which is re-evaluated annually. We try to make sure all our decisions and actions align with this strategic plan. As President, I will promote the vision and mission of CHEST while guiding our organization to succeed in our 2018-2022 strategic plan. What will this include? This will include developing new innovative, evidenced-based, education and educational products in the areas of pulmonary, critical care, and sleep medicine; producing evidence-based guidelines; and expanding our educational expertise both nationally and globally. I am committed to actively engage and retain our fellows-in-training (being a longstanding program director), and to mentor our future leaders. I will reach out to engage and educate advanced practice providers, who are an integral part of our patient care teams. We will grow the CHEST Foundation in the areas of patient education and access, clinical research funding, and community service. On the global front, we will continue with our new global strategy of holding congresses based on the annual meeting content and smaller board review format regional conferences in different parts of the world seeking education in pulmonary, critical care, and sleep medicine. Our next meeting is in Bologna, Italy, in June of 2020. I will build on our collaborative inter-societal relationships with our related societies. Some of the specific areas I plan to focus on are defining the true value of CHEST membership, engaging all members of the health-care team, and revisiting the structure and function of our NetWorks to ensure the maximum opportunities for leadership and engagement.

What do you consider to be the greatest strength of CHEST, and how will you build upon this during your Presidency?

Our greatest strengths are the education we deliver; the people at all levels who deliver, learn from, and support the delivery of this core component of our vision and mission; and the culture in which this all takes place. These people include leaders, volunteers, faculty, members and all clinicians on the health-care team, and our top-notch staff (our EVP/CEO, Executive and Operations Team and staff at all levels). To build upon this, we need to strive for continued educational innovation and relevance and creative delivery of our educational products.

What are some challenges facing CHEST, and how will you address these challenges?

Ironically, maintaining our greatest strengths in the setting of a changing health-care environment can also be one of the greatest challenges. We must continue to make our education vibrant, relevant, and experiential. To do this, we need to ensure innovative, year-round education, whether at the annual meeting or through our e-learning platforms, simulation activities, SEEK, state-of the-art guidelines, board review courses, and courses and meetings at CHEST Global Headquarters in Glenview, Illinois, or at a global destination. We also need to stay relevant from the point of view of the value of membership and engagement. We must be cognizant of what members and others who engage with CHEST are looking for and ensure that we are meeting those ongoing expectations. Also, the need to identify, attract, develop, and retain talented and diverse members, volunteers, faculty, and future leaders and staff is imperative. As a program director, I am particularly interested in the retention of our fellows-in-training.

And finally, what is your charge to the members and new Fellows (FCCPs) of CHEST?

Get involved and stay involved. There are so many opportunities to do this! Attend the CHEST Annual Meeting. Join a NetWork. Submit articles to the journal CHEST or abstracts and case reports to the meeting. Participate in a Board Review Course or one of our e-learning opportunities. Come to a live course at headquarters or at a global destination. Participate in a simulation experience. Network at a meeting or a course. Engage with the CHEST Foundation. Connect with us on social media. Sign up to be a moderator and/or grader at the CHEST Annual Meeting. Become an FCCP. Apply for leadership openings, and if you don’t get it the first time, try again! You will be impressed with all that CHEST has to offer!!

Stephanie M. Levine, MD, FCCP, is an expert in lung transplantation, and pulmonary and critical care issues in pregnancy and women’s lung health. She is a Professor of Medicine in the Division of Pulmonary Diseases and Critical Care Medicine at the University of Texas Health Science Center in San Antonio, Texas; the Program Director of the Pulmonary and Critical Care Fellowship at the University of Texas Health Science Center; and the Co-Director of the Medical Intensive Care Unit at the University Hospital. She is also a staff physician at the Audie Murphy Veteran Administration Hospital.

Dr. Levine has been Editor for both CHEST SEEK Critical Care Medicine and Pulmonary Medicine editions. In 2009 she received the CHEST Presidential Citation Award; in 2010, the CHEST Distinguished Service Award; and in 2017, the Master Clinician Educator Award. She has also been recognized as a Distinguished CHEST Educator in 2017, 2018, and 2019.

Dr. Levine has been active in CHEST international activities with CHEST World Congress meetings, the 2017 Basel Joint CHEST/SPG Congress in collaboration with the Swiss Lung Association, and with the pulmonary/critical care subspecialty training programs being developed in China. She was President and Chair of the CHEST Foundation from 2010-2014 and is currently on the CHEST Board of Regents.

We asked Dr. Levine for some thoughts on her upcoming CHEST presidency.
 

What would you like to accomplish as President of CHEST?

Every 5 years, the Board of Regents sets forth a new 5-year strategic plan, which is re-evaluated annually. We try to make sure all our decisions and actions align with this strategic plan. As President, I will promote the vision and mission of CHEST while guiding our organization to succeed in our 2018-2022 strategic plan. What will this include? This will include developing new innovative, evidenced-based, education and educational products in the areas of pulmonary, critical care, and sleep medicine; producing evidence-based guidelines; and expanding our educational expertise both nationally and globally. I am committed to actively engage and retain our fellows-in-training (being a longstanding program director), and to mentor our future leaders. I will reach out to engage and educate advanced practice providers, who are an integral part of our patient care teams. We will grow the CHEST Foundation in the areas of patient education and access, clinical research funding, and community service. On the global front, we will continue with our new global strategy of holding congresses based on the annual meeting content and smaller board review format regional conferences in different parts of the world seeking education in pulmonary, critical care, and sleep medicine. Our next meeting is in Bologna, Italy, in June of 2020. I will build on our collaborative inter-societal relationships with our related societies. Some of the specific areas I plan to focus on are defining the true value of CHEST membership, engaging all members of the health-care team, and revisiting the structure and function of our NetWorks to ensure the maximum opportunities for leadership and engagement.

What do you consider to be the greatest strength of CHEST, and how will you build upon this during your Presidency?

Our greatest strengths are the education we deliver; the people at all levels who deliver, learn from, and support the delivery of this core component of our vision and mission; and the culture in which this all takes place. These people include leaders, volunteers, faculty, members and all clinicians on the health-care team, and our top-notch staff (our EVP/CEO, Executive and Operations Team and staff at all levels). To build upon this, we need to strive for continued educational innovation and relevance and creative delivery of our educational products.

What are some challenges facing CHEST, and how will you address these challenges?

Ironically, maintaining our greatest strengths in the setting of a changing health-care environment can also be one of the greatest challenges. We must continue to make our education vibrant, relevant, and experiential. To do this, we need to ensure innovative, year-round education, whether at the annual meeting or through our e-learning platforms, simulation activities, SEEK, state-of the-art guidelines, board review courses, and courses and meetings at CHEST Global Headquarters in Glenview, Illinois, or at a global destination. We also need to stay relevant from the point of view of the value of membership and engagement. We must be cognizant of what members and others who engage with CHEST are looking for and ensure that we are meeting those ongoing expectations. Also, the need to identify, attract, develop, and retain talented and diverse members, volunteers, faculty, and future leaders and staff is imperative. As a program director, I am particularly interested in the retention of our fellows-in-training.

And finally, what is your charge to the members and new Fellows (FCCPs) of CHEST?

Get involved and stay involved. There are so many opportunities to do this! Attend the CHEST Annual Meeting. Join a NetWork. Submit articles to the journal CHEST or abstracts and case reports to the meeting. Participate in a Board Review Course or one of our e-learning opportunities. Come to a live course at headquarters or at a global destination. Participate in a simulation experience. Network at a meeting or a course. Engage with the CHEST Foundation. Connect with us on social media. Sign up to be a moderator and/or grader at the CHEST Annual Meeting. Become an FCCP. Apply for leadership openings, and if you don’t get it the first time, try again! You will be impressed with all that CHEST has to offer!!

Stephanie M. Levine, MD, FCCP, is an expert in lung transplantation, and pulmonary and critical care issues in pregnancy and women’s lung health. She is a Professor of Medicine in the Division of Pulmonary Diseases and Critical Care Medicine at the University of Texas Health Science Center in San Antonio, Texas; the Program Director of the Pulmonary and Critical Care Fellowship at the University of Texas Health Science Center; and the Co-Director of the Medical Intensive Care Unit at the University Hospital. She is also a staff physician at the Audie Murphy Veteran Administration Hospital.

Dr. Levine has been Editor for both CHEST SEEK Critical Care Medicine and Pulmonary Medicine editions. In 2009 she received the CHEST Presidential Citation Award; in 2010, the CHEST Distinguished Service Award; and in 2017, the Master Clinician Educator Award. She has also been recognized as a Distinguished CHEST Educator in 2017, 2018, and 2019.

Dr. Levine has been active in CHEST international activities with CHEST World Congress meetings, the 2017 Basel Joint CHEST/SPG Congress in collaboration with the Swiss Lung Association, and with the pulmonary/critical care subspecialty training programs being developed in China. She was President and Chair of the CHEST Foundation from 2010-2014 and is currently on the CHEST Board of Regents.

We asked Dr. Levine for some thoughts on her upcoming CHEST presidency.
 

What would you like to accomplish as President of CHEST?

Every 5 years, the Board of Regents sets forth a new 5-year strategic plan, which is re-evaluated annually. We try to make sure all our decisions and actions align with this strategic plan. As President, I will promote the vision and mission of CHEST while guiding our organization to succeed in our 2018-2022 strategic plan. What will this include? This will include developing new innovative, evidenced-based, education and educational products in the areas of pulmonary, critical care, and sleep medicine; producing evidence-based guidelines; and expanding our educational expertise both nationally and globally. I am committed to actively engage and retain our fellows-in-training (being a longstanding program director), and to mentor our future leaders. I will reach out to engage and educate advanced practice providers, who are an integral part of our patient care teams. We will grow the CHEST Foundation in the areas of patient education and access, clinical research funding, and community service. On the global front, we will continue with our new global strategy of holding congresses based on the annual meeting content and smaller board review format regional conferences in different parts of the world seeking education in pulmonary, critical care, and sleep medicine. Our next meeting is in Bologna, Italy, in June of 2020. I will build on our collaborative inter-societal relationships with our related societies. Some of the specific areas I plan to focus on are defining the true value of CHEST membership, engaging all members of the health-care team, and revisiting the structure and function of our NetWorks to ensure the maximum opportunities for leadership and engagement.

What do you consider to be the greatest strength of CHEST, and how will you build upon this during your Presidency?

Our greatest strengths are the education we deliver; the people at all levels who deliver, learn from, and support the delivery of this core component of our vision and mission; and the culture in which this all takes place. These people include leaders, volunteers, faculty, members and all clinicians on the health-care team, and our top-notch staff (our EVP/CEO, Executive and Operations Team and staff at all levels). To build upon this, we need to strive for continued educational innovation and relevance and creative delivery of our educational products.

What are some challenges facing CHEST, and how will you address these challenges?

Ironically, maintaining our greatest strengths in the setting of a changing health-care environment can also be one of the greatest challenges. We must continue to make our education vibrant, relevant, and experiential. To do this, we need to ensure innovative, year-round education, whether at the annual meeting or through our e-learning platforms, simulation activities, SEEK, state-of the-art guidelines, board review courses, and courses and meetings at CHEST Global Headquarters in Glenview, Illinois, or at a global destination. We also need to stay relevant from the point of view of the value of membership and engagement. We must be cognizant of what members and others who engage with CHEST are looking for and ensure that we are meeting those ongoing expectations. Also, the need to identify, attract, develop, and retain talented and diverse members, volunteers, faculty, and future leaders and staff is imperative. As a program director, I am particularly interested in the retention of our fellows-in-training.

And finally, what is your charge to the members and new Fellows (FCCPs) of CHEST?

Get involved and stay involved. There are so many opportunities to do this! Attend the CHEST Annual Meeting. Join a NetWork. Submit articles to the journal CHEST or abstracts and case reports to the meeting. Participate in a Board Review Course or one of our e-learning opportunities. Come to a live course at headquarters or at a global destination. Participate in a simulation experience. Network at a meeting or a course. Engage with the CHEST Foundation. Connect with us on social media. Sign up to be a moderator and/or grader at the CHEST Annual Meeting. Become an FCCP. Apply for leadership openings, and if you don’t get it the first time, try again! You will be impressed with all that CHEST has to offer!!

NAMDRC will host its Annual Educational Conference at the Scottsdale Resort at McCormick Ranch in Scottsdale, Arizona, March 12-14, 2020, and features a wide cross section of clinical, management, and health policy issues.

The NAMDRC Educational Conference is unlike other medical conferences you have attended. Conference sessions begin early each day and conclude by 12:30 so attendees, spouses, and guests can enjoy the venue, this year in Scottsdale, Arizona. All registrants and their guests enjoy numerous complimentary meals, and speakers and corporate partners invariably linger with the attendees during receptions for those more casual opportunities for conversations and less formal Q&A.

The Program Committee has announced its plans to focus the first day of the 3-day event on lung cancer, severe asthma, and pulmonary hypertension. Speakers include Maxwell Smith, MD from the Mayo Clinic, Arizona; James Herman, MD, Co-Director of the Lung Cancer Program at UPMC, and Colleen Channick, MD, FCCP, Director of Interventional Pulmonary at UCLA Medical Center to address timely updates on lung cancer diagnosis and treatment. The morning sessions also include a presentation on severe asthma by Monica Kraft, MD, FCCP, University of Arizona; and Richard Channick, MD, Geffen School of Medicine, UCLA, examining pulmonary hypertension with a concentration on current approaches to diagnosis and treatment.

On Friday, March 13, the focus shifts from the clinical to the changing landscape in the delivery of medicine, with a concentrated focus on innovation and new tools available to guide physicians in treatment of their patients. Claibe Yarbrough, MD, National Program Director of Pulmonary, Critical Care and Sleep at the VA, University of Texas, will examine the growth of telemedicine in the ICU. Steve Peters, MD, FCCP, a past President of NAMDRC and a current Board member, will look at artificial intelligence and the future of medicine. Dr. Peters will also present a practice management update in partnership with Alan Plummer, MD, FCCP, as he addresses coding changes in the practice of pulmonary, critical care, and sleep medicine effective 2020-21.

Shifting back to a clinical focus, the Walter J. O’Donohue memorial lecture will be given by Gerald Criner, MD, FCCP, Temple University, to examine endobronchial valve therapy for emphysema. Rounding out the presentations will be luncheon speaker Susan Tanski, MD, looking at electronic nicotine delivery systems.

On Saturday, the topics turn to sleep and mechanical ventilation. Insomnia is the subject matter for Jennifer Martin, MD, Geffen School of Medicine at UCLA; Sairam Parthasarathy, MD, at the University of Arizona, will address sleep and noninvasive mechanical ventilation. And, in a corollary presentation, home mechanical ventilation is the topic for John Hansen-Flaschen, MD, FCCP, Hospital of the University of Pennsylvania.

The final morning rounds out with controversies in septic shock, Rodrigo Cartin-Ceba, MD, at the Mayo Clinic in Scottsdale, and palliative care in the ICU, Mark Edwin, also from the Mayo Clinic.

For more information about membership in NAMDRC and conference information, visit its website at www.namdrc.org.

NAMDRC will host its Annual Educational Conference at the Scottsdale Resort at McCormick Ranch in Scottsdale, Arizona, March 12-14, 2020, and features a wide cross section of clinical, management, and health policy issues.

The NAMDRC Educational Conference is unlike other medical conferences you have attended. Conference sessions begin early each day and conclude by 12:30 so attendees, spouses, and guests can enjoy the venue, this year in Scottsdale, Arizona. All registrants and their guests enjoy numerous complimentary meals, and speakers and corporate partners invariably linger with the attendees during receptions for those more casual opportunities for conversations and less formal Q&A.

The Program Committee has announced its plans to focus the first day of the 3-day event on lung cancer, severe asthma, and pulmonary hypertension. Speakers include Maxwell Smith, MD from the Mayo Clinic, Arizona; James Herman, MD, Co-Director of the Lung Cancer Program at UPMC, and Colleen Channick, MD, FCCP, Director of Interventional Pulmonary at UCLA Medical Center to address timely updates on lung cancer diagnosis and treatment. The morning sessions also include a presentation on severe asthma by Monica Kraft, MD, FCCP, University of Arizona; and Richard Channick, MD, Geffen School of Medicine, UCLA, examining pulmonary hypertension with a concentration on current approaches to diagnosis and treatment.

On Friday, March 13, the focus shifts from the clinical to the changing landscape in the delivery of medicine, with a concentrated focus on innovation and new tools available to guide physicians in treatment of their patients. Claibe Yarbrough, MD, National Program Director of Pulmonary, Critical Care and Sleep at the VA, University of Texas, will examine the growth of telemedicine in the ICU. Steve Peters, MD, FCCP, a past President of NAMDRC and a current Board member, will look at artificial intelligence and the future of medicine. Dr. Peters will also present a practice management update in partnership with Alan Plummer, MD, FCCP, as he addresses coding changes in the practice of pulmonary, critical care, and sleep medicine effective 2020-21.

Shifting back to a clinical focus, the Walter J. O’Donohue memorial lecture will be given by Gerald Criner, MD, FCCP, Temple University, to examine endobronchial valve therapy for emphysema. Rounding out the presentations will be luncheon speaker Susan Tanski, MD, looking at electronic nicotine delivery systems.

On Saturday, the topics turn to sleep and mechanical ventilation. Insomnia is the subject matter for Jennifer Martin, MD, Geffen School of Medicine at UCLA; Sairam Parthasarathy, MD, at the University of Arizona, will address sleep and noninvasive mechanical ventilation. And, in a corollary presentation, home mechanical ventilation is the topic for John Hansen-Flaschen, MD, FCCP, Hospital of the University of Pennsylvania.

The final morning rounds out with controversies in septic shock, Rodrigo Cartin-Ceba, MD, at the Mayo Clinic in Scottsdale, and palliative care in the ICU, Mark Edwin, also from the Mayo Clinic.

For more information about membership in NAMDRC and conference information, visit its website at www.namdrc.org.

NAMDRC will host its Annual Educational Conference at the Scottsdale Resort at McCormick Ranch in Scottsdale, Arizona, March 12-14, 2020, and features a wide cross section of clinical, management, and health policy issues.

The NAMDRC Educational Conference is unlike other medical conferences you have attended. Conference sessions begin early each day and conclude by 12:30 so attendees, spouses, and guests can enjoy the venue, this year in Scottsdale, Arizona. All registrants and their guests enjoy numerous complimentary meals, and speakers and corporate partners invariably linger with the attendees during receptions for those more casual opportunities for conversations and less formal Q&A.

The Program Committee has announced its plans to focus the first day of the 3-day event on lung cancer, severe asthma, and pulmonary hypertension. Speakers include Maxwell Smith, MD from the Mayo Clinic, Arizona; James Herman, MD, Co-Director of the Lung Cancer Program at UPMC, and Colleen Channick, MD, FCCP, Director of Interventional Pulmonary at UCLA Medical Center to address timely updates on lung cancer diagnosis and treatment. The morning sessions also include a presentation on severe asthma by Monica Kraft, MD, FCCP, University of Arizona; and Richard Channick, MD, Geffen School of Medicine, UCLA, examining pulmonary hypertension with a concentration on current approaches to diagnosis and treatment.

On Friday, March 13, the focus shifts from the clinical to the changing landscape in the delivery of medicine, with a concentrated focus on innovation and new tools available to guide physicians in treatment of their patients. Claibe Yarbrough, MD, National Program Director of Pulmonary, Critical Care and Sleep at the VA, University of Texas, will examine the growth of telemedicine in the ICU. Steve Peters, MD, FCCP, a past President of NAMDRC and a current Board member, will look at artificial intelligence and the future of medicine. Dr. Peters will also present a practice management update in partnership with Alan Plummer, MD, FCCP, as he addresses coding changes in the practice of pulmonary, critical care, and sleep medicine effective 2020-21.

Shifting back to a clinical focus, the Walter J. O’Donohue memorial lecture will be given by Gerald Criner, MD, FCCP, Temple University, to examine endobronchial valve therapy for emphysema. Rounding out the presentations will be luncheon speaker Susan Tanski, MD, looking at electronic nicotine delivery systems.

On Saturday, the topics turn to sleep and mechanical ventilation. Insomnia is the subject matter for Jennifer Martin, MD, Geffen School of Medicine at UCLA; Sairam Parthasarathy, MD, at the University of Arizona, will address sleep and noninvasive mechanical ventilation. And, in a corollary presentation, home mechanical ventilation is the topic for John Hansen-Flaschen, MD, FCCP, Hospital of the University of Pennsylvania.

The final morning rounds out with controversies in septic shock, Rodrigo Cartin-Ceba, MD, at the Mayo Clinic in Scottsdale, and palliative care in the ICU, Mark Edwin, also from the Mayo Clinic.

For more information about membership in NAMDRC and conference information, visit its website at www.namdrc.org.

Although only a small percentage of non–small cell lung cancers are positive for HER2 mutations, HER2-mutant lung cancers are associated with a high incidence of brain metastases, investigators have found.

Among 98 consecutive patients with HER2-mutant non–small cell lung cancer (NSCLC), the incidence of brain metastases at initial diagnosis was comparable with or slightly lower than that seen with other, more common mutations, but the incidence during treatment was significantly higher than in patients with KRAS-mutant NSCLC, and trended higher than the incidence rate of brain metastases in patients with epidermal growth factor receptor (EGFR)–mutated NSCLC, reported Michael Offin, MD, and colleagues from Memorial Sloan Kettering Cancer in New York.

“This finding provides a framework for CNS surveillance and treatment strategies, including radiotherapy, for patients with HER2-mutant lung cancers and underlines the urgent need for the development of novel HER2-targeted agents with activity in the CNS,” they wrote in Cancer.

NSCLC with oncogenic driver mutations in HER2 account for 2% of adenocarcinomas of the lung, but relatively little is known about the risk for brain metastases in patients HER2-mutant lung cancer, the authors wrote.

“Because HER2-amplified breast cancers are more likely to develop brain metastases through constitutive HER2 signaling, we hypothesize that HER2-mutant lung cancers are also more apt to develop brain metastases in comparison with lung cancers driven by other oncogenes,” they wrote.

To explore this hypothesis, they conducted a retrospective record review of 98 patients treated at their center with metastatic HER2-mutant NSCLC, and compared them with 200 patients with metastatic KRAS-mutant NSCLC, and 200 with metastatic, sensitizing EGFR-mutant NSCLC.

They found that at the initial diagnosis of metastatic disease, the percentage of patients with brain metastases was similar between patients with HER2 mutations and those with KRAS mutations (19% vs. 24%; odds ratio for HER2 vs. KRAS, 0.7; P = .33). However significantly more patients with EGFR-mutant tumors had brain metastases at diagnosis, compared with patients HER2 mutations (31% vs. 19%; OR, 0.5; P = .03).

Interestingly, significantly more patients with HER2-mutant tumors developed brain metastases on treatment than patients with KRAS-mutant tumors (28% vs. 8%; hazard ratio, 5.2; P less than .001). There was also a trend toward more on-treatment brain metastases among patients with HER2 mutations, compared with patients with EGFR mutation (28% vs .16%; HR, 1.7), but this difference was not statistically significant.

The risk for on-treatment brain metastases was even higher among patients with a HER2 mutation characterized by a 12 base–pair, in-frame insertion in exon 20 (HER2 YVMA). In these patients, the OR for brain metastases developing during treatment versus patients with KRAS mutations was 5.9 (P less than .001).

The median overall survival was worse for patients with KRAS-mutant NSCLC (1.1 years) and HER2-mutant cancers (1.6 years) versus 3 years for patients with EFGR-mutant cancers (P less than .001 for KRAS; P = .002 for HER2 vs. EGFR).

The use of HER2-targeted therapies did not have an effect on either the development of brain metastases or survival, and overall survival was slightly but significantly worse for patients with HER2-mutant tumors who had radiotherapy of the brain.

The study was supported by the National Institutes of Health through a National Cancer Institute Cancer Center support grant and by the Eloise Briskin Foundation. Dr. Offin reported honoraria from Bristol-Myers Squibb, Merck, PharmaMar, Novartis, and Targeted Oncology. Multiple coauthors had similar disclosures.

SOURCE: Offin M et al. Cancer. 2019 Aug 30. doi: 10.1002/cncr.32461.

Although only a small percentage of non–small cell lung cancers are positive for HER2 mutations, HER2-mutant lung cancers are associated with a high incidence of brain metastases, investigators have found.

Among 98 consecutive patients with HER2-mutant non–small cell lung cancer (NSCLC), the incidence of brain metastases at initial diagnosis was comparable with or slightly lower than that seen with other, more common mutations, but the incidence during treatment was significantly higher than in patients with KRAS-mutant NSCLC, and trended higher than the incidence rate of brain metastases in patients with epidermal growth factor receptor (EGFR)–mutated NSCLC, reported Michael Offin, MD, and colleagues from Memorial Sloan Kettering Cancer in New York.

“This finding provides a framework for CNS surveillance and treatment strategies, including radiotherapy, for patients with HER2-mutant lung cancers and underlines the urgent need for the development of novel HER2-targeted agents with activity in the CNS,” they wrote in Cancer.

NSCLC with oncogenic driver mutations in HER2 account for 2% of adenocarcinomas of the lung, but relatively little is known about the risk for brain metastases in patients HER2-mutant lung cancer, the authors wrote.

“Because HER2-amplified breast cancers are more likely to develop brain metastases through constitutive HER2 signaling, we hypothesize that HER2-mutant lung cancers are also more apt to develop brain metastases in comparison with lung cancers driven by other oncogenes,” they wrote.

To explore this hypothesis, they conducted a retrospective record review of 98 patients treated at their center with metastatic HER2-mutant NSCLC, and compared them with 200 patients with metastatic KRAS-mutant NSCLC, and 200 with metastatic, sensitizing EGFR-mutant NSCLC.

They found that at the initial diagnosis of metastatic disease, the percentage of patients with brain metastases was similar between patients with HER2 mutations and those with KRAS mutations (19% vs. 24%; odds ratio for HER2 vs. KRAS, 0.7; P = .33). However significantly more patients with EGFR-mutant tumors had brain metastases at diagnosis, compared with patients HER2 mutations (31% vs. 19%; OR, 0.5; P = .03).

Interestingly, significantly more patients with HER2-mutant tumors developed brain metastases on treatment than patients with KRAS-mutant tumors (28% vs. 8%; hazard ratio, 5.2; P less than .001). There was also a trend toward more on-treatment brain metastases among patients with HER2 mutations, compared with patients with EGFR mutation (28% vs .16%; HR, 1.7), but this difference was not statistically significant.

The risk for on-treatment brain metastases was even higher among patients with a HER2 mutation characterized by a 12 base–pair, in-frame insertion in exon 20 (HER2 YVMA). In these patients, the OR for brain metastases developing during treatment versus patients with KRAS mutations was 5.9 (P less than .001).

The median overall survival was worse for patients with KRAS-mutant NSCLC (1.1 years) and HER2-mutant cancers (1.6 years) versus 3 years for patients with EFGR-mutant cancers (P less than .001 for KRAS; P = .002 for HER2 vs. EGFR).

The use of HER2-targeted therapies did not have an effect on either the development of brain metastases or survival, and overall survival was slightly but significantly worse for patients with HER2-mutant tumors who had radiotherapy of the brain.

The study was supported by the National Institutes of Health through a National Cancer Institute Cancer Center support grant and by the Eloise Briskin Foundation. Dr. Offin reported honoraria from Bristol-Myers Squibb, Merck, PharmaMar, Novartis, and Targeted Oncology. Multiple coauthors had similar disclosures.

SOURCE: Offin M et al. Cancer. 2019 Aug 30. doi: 10.1002/cncr.32461.

Although only a small percentage of non–small cell lung cancers are positive for HER2 mutations, HER2-mutant lung cancers are associated with a high incidence of brain metastases, investigators have found.

Among 98 consecutive patients with HER2-mutant non–small cell lung cancer (NSCLC), the incidence of brain metastases at initial diagnosis was comparable with or slightly lower than that seen with other, more common mutations, but the incidence during treatment was significantly higher than in patients with KRAS-mutant NSCLC, and trended higher than the incidence rate of brain metastases in patients with epidermal growth factor receptor (EGFR)–mutated NSCLC, reported Michael Offin, MD, and colleagues from Memorial Sloan Kettering Cancer in New York.

“This finding provides a framework for CNS surveillance and treatment strategies, including radiotherapy, for patients with HER2-mutant lung cancers and underlines the urgent need for the development of novel HER2-targeted agents with activity in the CNS,” they wrote in Cancer.

NSCLC with oncogenic driver mutations in HER2 account for 2% of adenocarcinomas of the lung, but relatively little is known about the risk for brain metastases in patients HER2-mutant lung cancer, the authors wrote.

“Because HER2-amplified breast cancers are more likely to develop brain metastases through constitutive HER2 signaling, we hypothesize that HER2-mutant lung cancers are also more apt to develop brain metastases in comparison with lung cancers driven by other oncogenes,” they wrote.

To explore this hypothesis, they conducted a retrospective record review of 98 patients treated at their center with metastatic HER2-mutant NSCLC, and compared them with 200 patients with metastatic KRAS-mutant NSCLC, and 200 with metastatic, sensitizing EGFR-mutant NSCLC.

They found that at the initial diagnosis of metastatic disease, the percentage of patients with brain metastases was similar between patients with HER2 mutations and those with KRAS mutations (19% vs. 24%; odds ratio for HER2 vs. KRAS, 0.7; P = .33). However significantly more patients with EGFR-mutant tumors had brain metastases at diagnosis, compared with patients HER2 mutations (31% vs. 19%; OR, 0.5; P = .03).

Interestingly, significantly more patients with HER2-mutant tumors developed brain metastases on treatment than patients with KRAS-mutant tumors (28% vs. 8%; hazard ratio, 5.2; P less than .001). There was also a trend toward more on-treatment brain metastases among patients with HER2 mutations, compared with patients with EGFR mutation (28% vs .16%; HR, 1.7), but this difference was not statistically significant.

The risk for on-treatment brain metastases was even higher among patients with a HER2 mutation characterized by a 12 base–pair, in-frame insertion in exon 20 (HER2 YVMA). In these patients, the OR for brain metastases developing during treatment versus patients with KRAS mutations was 5.9 (P less than .001).

The median overall survival was worse for patients with KRAS-mutant NSCLC (1.1 years) and HER2-mutant cancers (1.6 years) versus 3 years for patients with EFGR-mutant cancers (P less than .001 for KRAS; P = .002 for HER2 vs. EGFR).

The use of HER2-targeted therapies did not have an effect on either the development of brain metastases or survival, and overall survival was slightly but significantly worse for patients with HER2-mutant tumors who had radiotherapy of the brain.

The study was supported by the National Institutes of Health through a National Cancer Institute Cancer Center support grant and by the Eloise Briskin Foundation. Dr. Offin reported honoraria from Bristol-Myers Squibb, Merck, PharmaMar, Novartis, and Targeted Oncology. Multiple coauthors had similar disclosures.

SOURCE: Offin M et al. Cancer. 2019 Aug 30. doi: 10.1002/cncr.32461.

Background: Despite multiple guidelines that support outpatient management of acute PE in the appropriate patient population, the rate of hospital admission for patients eligible for outpatient management remains high. One explanation is that physicians may have difficulty identifying which patients meet discharge criteria.

Dr. Bordin-Wosk is an assistant clinical professor in the division of hospital medicine at the University of California, San Diego.

Background: Despite multiple guidelines that support outpatient management of acute PE in the appropriate patient population, the rate of hospital admission for patients eligible for outpatient management remains high. One explanation is that physicians may have difficulty identifying which patients meet discharge criteria.

Dr. Bordin-Wosk is an assistant clinical professor in the division of hospital medicine at the University of California, San Diego.

Background: Despite multiple guidelines that support outpatient management of acute PE in the appropriate patient population, the rate of hospital admission for patients eligible for outpatient management remains high. One explanation is that physicians may have difficulty identifying which patients meet discharge criteria.

Dr. Bordin-Wosk is an assistant clinical professor in the division of hospital medicine at the University of California, San Diego.

It is estimated that there are 1.1 million people in the United States living with HIV and that 15% of those people do not know they have HIV. Although the number of new cases reported each year is decreasing, there were still 38,281 new diagnoses in 2017. New cases might be decreasing overall, but the incidence of HIV is rising in some groups including people aged 25-29 years old and American Indian/Alaska Native and Asian populations. In addition, HIV disproportionately affects men who have sex with men, black/African American populations, and Hispanic/Latino populations, according to the USPSTF statement.

Given the prevalence of HIV and rising new cases in certain groups, it is thought that preexposure prophylaxis (PrEP) is being underutilized. The CDC reported that, in 2015, 1.2 million people were candidates for PrEP, but in 2017, only 100,282 people were using PrEP. The USPSTF performed a meta-analysis of 12 RCTs comparing rates of HIV infection in groups treated with PrEP versus those treated with placebo or no treatment and found a risk ratio of 0.46 (95% confidence interval, 0.33-0.66) and absolute risk reduction of –2% (95% CI, –2.8% to –1.2%) after 4 months and 4 years.

With this epidemiologic data and the meta-analysis, the USPSTF offered the following recommendations.
 

Screening

In order to decrease the rates of transmission and incidence of HIV infection, we must appropriately identify those who would be good candidates for PrEP. That begins with taking a complete and thorough sexual and injection drug use history in a manner that does not make patients feel stigmatized or discriminated against. The USPSTF recommends screening for HIV infection in patients aged 15-65 years old, in younger and older patients who have increased risk factors, and all pregnant patients. PrEP is not an appropriate choice in those who have HIV because it can lead to drug resistance.

When screening for HIV and considering starting PrEP, it is recommended that clinicians also test for kidney function, hepatitis B and C, other STIs, and pregnancy. The USPSTF suggests that the following groups be considered for PrEP given the increased risk of HIV infection:

• Men who have sex with men, are sexually active, and have one of these additional characteristics: a serodiscordant sex partner, inconsistent use of condoms during receptive or insertive anal sex, or infection with syphilis, gonorrhea, or chlamydia in the past 6 months.
• Heterosexual men or women who are sexually active with one or more of these additional characteristics: a serodiscordant sex partner, inconsistent use of condoms during sex with a partner whose HIV status is unknown and who is at high risk, and infection with syphilis or gonorrhea in the past 6 months.
• Patients who inject drugs with one or more of the following characteristics: shared use of drug injection equipment and risk of sexual acquisition (as in the categories above).

The USPSTF also notes that those who engage in transactional sex (for money, drugs, or housing) and transgender patients are at an increased risk of HIV infection.

Treatment

The only FDA approved treatment for the prevention HIV infection is once daily oral combined tenofovir disoproxil fumarate and emtricitabine; however, some studies have found that tenofovir disproxil fumarate monotherapy is also effective. Considering these trials, the CDC has suggested that tenofovir disoproxil fumarate monotherapy can be used as an alternative for men and women at high risk and those who inject drugs.

Tenofovir disoproxil fumarate/emtricitabine can also be used in pregnant patients, however the USPSTF notes that no PrEP trials included pregnant women. Additionally, tenofovir disoproxil fumarate/emtricitabine can be used in adolescents who weigh more than 35 kg. It is unknown how much time it takes to achieve protection against HIV infection after starting PrEP, and there is no clear timeline for how long patients should be on PrEP. Patients may discontinue medication because of preference, decreased risk of HIV exposure, or side effects.

Side effects include renal adverse events (serum creatinine rise), gastrointestinal adverse events (mostly nausea), and bone loss and increased fracture risk, although none were statistically significant when PrEP and placebo groups were compared. The USPSTF’s recommendations note that the effectiveness of PrEP is dependent on medication adherence.

While PrEP is an important part of preventing HIV, it is always important to counsel patients on other ways to reduce risk. The USPSTF notes that consistent condom use reduces the risk of HIV infection by around 80% in addition to reducing the risk of other STIs. All trials studied by the USPSTF for these recommendations included counseling on behavior, adherence, and condom use.
 

Bottom Line

It is estimated that 1.1 million Americans are living with HIV and 15% are unaware that they are positive for HIV. Overall cases of new HIV diagnoses are down, but they are rising in some groups. PrEP is an effective medication for reducing the risk of HIV infection, but is currently underutilized. Every patient should be screened for high-risk sexual behavior and drug use with a thorough history. Patients aged 15-65 years should be screened for HIV. If patients are negative for HIV, but participate in high-risk sexual behaviors and drug injection, they should be offered PrEP along with counseling on, medication adherence, condom use, and reduction of high-risk behaviors.
 

Dr. Skolnik is professor of family and community medicine at Jefferson Medical College, Philadelphia, and an associate director of the family medicine residency program at Abington (Pa.) Jefferson Health. Dr. Sprogell is a second-year resident in the Family Medicine Residency Program at Abington Jefferson Health

Reference

Owens DK et al. “Preexposure prophylaxis for the prevention of HIV infection: US Preventive Services Task Force recommendation statement.” JAMA. 2019 Jun 11;321(22):2203-13.

It is estimated that there are 1.1 million people in the United States living with HIV and that 15% of those people do not know they have HIV. Although the number of new cases reported each year is decreasing, there were still 38,281 new diagnoses in 2017. New cases might be decreasing overall, but the incidence of HIV is rising in some groups including people aged 25-29 years old and American Indian/Alaska Native and Asian populations. In addition, HIV disproportionately affects men who have sex with men, black/African American populations, and Hispanic/Latino populations, according to the USPSTF statement.

Given the prevalence of HIV and rising new cases in certain groups, it is thought that preexposure prophylaxis (PrEP) is being underutilized. The CDC reported that, in 2015, 1.2 million people were candidates for PrEP, but in 2017, only 100,282 people were using PrEP. The USPSTF performed a meta-analysis of 12 RCTs comparing rates of HIV infection in groups treated with PrEP versus those treated with placebo or no treatment and found a risk ratio of 0.46 (95% confidence interval, 0.33-0.66) and absolute risk reduction of –2% (95% CI, –2.8% to –1.2%) after 4 months and 4 years.

With this epidemiologic data and the meta-analysis, the USPSTF offered the following recommendations.
 

Screening

In order to decrease the rates of transmission and incidence of HIV infection, we must appropriately identify those who would be good candidates for PrEP. That begins with taking a complete and thorough sexual and injection drug use history in a manner that does not make patients feel stigmatized or discriminated against. The USPSTF recommends screening for HIV infection in patients aged 15-65 years old, in younger and older patients who have increased risk factors, and all pregnant patients. PrEP is not an appropriate choice in those who have HIV because it can lead to drug resistance.

When screening for HIV and considering starting PrEP, it is recommended that clinicians also test for kidney function, hepatitis B and C, other STIs, and pregnancy. The USPSTF suggests that the following groups be considered for PrEP given the increased risk of HIV infection:

• Men who have sex with men, are sexually active, and have one of these additional characteristics: a serodiscordant sex partner, inconsistent use of condoms during receptive or insertive anal sex, or infection with syphilis, gonorrhea, or chlamydia in the past 6 months.
• Heterosexual men or women who are sexually active with one or more of these additional characteristics: a serodiscordant sex partner, inconsistent use of condoms during sex with a partner whose HIV status is unknown and who is at high risk, and infection with syphilis or gonorrhea in the past 6 months.
• Patients who inject drugs with one or more of the following characteristics: shared use of drug injection equipment and risk of sexual acquisition (as in the categories above).

The USPSTF also notes that those who engage in transactional sex (for money, drugs, or housing) and transgender patients are at an increased risk of HIV infection.

Treatment

The only FDA approved treatment for the prevention HIV infection is once daily oral combined tenofovir disoproxil fumarate and emtricitabine; however, some studies have found that tenofovir disproxil fumarate monotherapy is also effective. Considering these trials, the CDC has suggested that tenofovir disoproxil fumarate monotherapy can be used as an alternative for men and women at high risk and those who inject drugs.

Tenofovir disoproxil fumarate/emtricitabine can also be used in pregnant patients, however the USPSTF notes that no PrEP trials included pregnant women. Additionally, tenofovir disoproxil fumarate/emtricitabine can be used in adolescents who weigh more than 35 kg. It is unknown how much time it takes to achieve protection against HIV infection after starting PrEP, and there is no clear timeline for how long patients should be on PrEP. Patients may discontinue medication because of preference, decreased risk of HIV exposure, or side effects.

Side effects include renal adverse events (serum creatinine rise), gastrointestinal adverse events (mostly nausea), and bone loss and increased fracture risk, although none were statistically significant when PrEP and placebo groups were compared. The USPSTF’s recommendations note that the effectiveness of PrEP is dependent on medication adherence.

While PrEP is an important part of preventing HIV, it is always important to counsel patients on other ways to reduce risk. The USPSTF notes that consistent condom use reduces the risk of HIV infection by around 80% in addition to reducing the risk of other STIs. All trials studied by the USPSTF for these recommendations included counseling on behavior, adherence, and condom use.
 

Bottom Line

It is estimated that 1.1 million Americans are living with HIV and 15% are unaware that they are positive for HIV. Overall cases of new HIV diagnoses are down, but they are rising in some groups. PrEP is an effective medication for reducing the risk of HIV infection, but is currently underutilized. Every patient should be screened for high-risk sexual behavior and drug use with a thorough history. Patients aged 15-65 years should be screened for HIV. If patients are negative for HIV, but participate in high-risk sexual behaviors and drug injection, they should be offered PrEP along with counseling on, medication adherence, condom use, and reduction of high-risk behaviors.
 

Dr. Skolnik is professor of family and community medicine at Jefferson Medical College, Philadelphia, and an associate director of the family medicine residency program at Abington (Pa.) Jefferson Health. Dr. Sprogell is a second-year resident in the Family Medicine Residency Program at Abington Jefferson Health

Reference

Owens DK et al. “Preexposure prophylaxis for the prevention of HIV infection: US Preventive Services Task Force recommendation statement.” JAMA. 2019 Jun 11;321(22):2203-13.

It is estimated that there are 1.1 million people in the United States living with HIV and that 15% of those people do not know they have HIV. Although the number of new cases reported each year is decreasing, there were still 38,281 new diagnoses in 2017. New cases might be decreasing overall, but the incidence of HIV is rising in some groups including people aged 25-29 years old and American Indian/Alaska Native and Asian populations. In addition, HIV disproportionately affects men who have sex with men, black/African American populations, and Hispanic/Latino populations, according to the USPSTF statement.

Given the prevalence of HIV and rising new cases in certain groups, it is thought that preexposure prophylaxis (PrEP) is being underutilized. The CDC reported that, in 2015, 1.2 million people were candidates for PrEP, but in 2017, only 100,282 people were using PrEP. The USPSTF performed a meta-analysis of 12 RCTs comparing rates of HIV infection in groups treated with PrEP versus those treated with placebo or no treatment and found a risk ratio of 0.46 (95% confidence interval, 0.33-0.66) and absolute risk reduction of –2% (95% CI, –2.8% to –1.2%) after 4 months and 4 years.

With this epidemiologic data and the meta-analysis, the USPSTF offered the following recommendations.
 

Screening

In order to decrease the rates of transmission and incidence of HIV infection, we must appropriately identify those who would be good candidates for PrEP. That begins with taking a complete and thorough sexual and injection drug use history in a manner that does not make patients feel stigmatized or discriminated against. The USPSTF recommends screening for HIV infection in patients aged 15-65 years old, in younger and older patients who have increased risk factors, and all pregnant patients. PrEP is not an appropriate choice in those who have HIV because it can lead to drug resistance.

When screening for HIV and considering starting PrEP, it is recommended that clinicians also test for kidney function, hepatitis B and C, other STIs, and pregnancy. The USPSTF suggests that the following groups be considered for PrEP given the increased risk of HIV infection:

• Men who have sex with men, are sexually active, and have one of these additional characteristics: a serodiscordant sex partner, inconsistent use of condoms during receptive or insertive anal sex, or infection with syphilis, gonorrhea, or chlamydia in the past 6 months.
• Heterosexual men or women who are sexually active with one or more of these additional characteristics: a serodiscordant sex partner, inconsistent use of condoms during sex with a partner whose HIV status is unknown and who is at high risk, and infection with syphilis or gonorrhea in the past 6 months.
• Patients who inject drugs with one or more of the following characteristics: shared use of drug injection equipment and risk of sexual acquisition (as in the categories above).

The USPSTF also notes that those who engage in transactional sex (for money, drugs, or housing) and transgender patients are at an increased risk of HIV infection.

Treatment

The only FDA approved treatment for the prevention HIV infection is once daily oral combined tenofovir disoproxil fumarate and emtricitabine; however, some studies have found that tenofovir disproxil fumarate monotherapy is also effective. Considering these trials, the CDC has suggested that tenofovir disoproxil fumarate monotherapy can be used as an alternative for men and women at high risk and those who inject drugs.

Tenofovir disoproxil fumarate/emtricitabine can also be used in pregnant patients, however the USPSTF notes that no PrEP trials included pregnant women. Additionally, tenofovir disoproxil fumarate/emtricitabine can be used in adolescents who weigh more than 35 kg. It is unknown how much time it takes to achieve protection against HIV infection after starting PrEP, and there is no clear timeline for how long patients should be on PrEP. Patients may discontinue medication because of preference, decreased risk of HIV exposure, or side effects.

Side effects include renal adverse events (serum creatinine rise), gastrointestinal adverse events (mostly nausea), and bone loss and increased fracture risk, although none were statistically significant when PrEP and placebo groups were compared. The USPSTF’s recommendations note that the effectiveness of PrEP is dependent on medication adherence.

While PrEP is an important part of preventing HIV, it is always important to counsel patients on other ways to reduce risk. The USPSTF notes that consistent condom use reduces the risk of HIV infection by around 80% in addition to reducing the risk of other STIs. All trials studied by the USPSTF for these recommendations included counseling on behavior, adherence, and condom use.
 

Bottom Line

It is estimated that 1.1 million Americans are living with HIV and 15% are unaware that they are positive for HIV. Overall cases of new HIV diagnoses are down, but they are rising in some groups. PrEP is an effective medication for reducing the risk of HIV infection, but is currently underutilized. Every patient should be screened for high-risk sexual behavior and drug use with a thorough history. Patients aged 15-65 years should be screened for HIV. If patients are negative for HIV, but participate in high-risk sexual behaviors and drug injection, they should be offered PrEP along with counseling on, medication adherence, condom use, and reduction of high-risk behaviors.
 

Dr. Skolnik is professor of family and community medicine at Jefferson Medical College, Philadelphia, and an associate director of the family medicine residency program at Abington (Pa.) Jefferson Health. Dr. Sprogell is a second-year resident in the Family Medicine Residency Program at Abington Jefferson Health

Reference

Owens DK et al. “Preexposure prophylaxis for the prevention of HIV infection: US Preventive Services Task Force recommendation statement.” JAMA. 2019 Jun 11;321(22):2203-13.

Four modifiable lifestyle risk factors account for a substantial proportion of gout cases in the United States, suggesting greater public health efforts could reduce the frequency of the condition, according to a paper published Sept. 4 in Arthritis & Rheumatology.

Hyon K. Choi, MD, DrPH, of the department of medicine at Massachusetts General Hospital, Boston, and his coauthors analyzed data from 14,624 adults involved in the third National Health and Nutrition Examination Survey. From this, they calculated prevalence ratios for hyperuricemia, the population attributable risks, and the variance associated with the risk factors of body mass index, alcohol intake, nonadherence to a Dietary Approaches to Stop Hypertension (DASH) diet, and diuretic use.

They found that 21% of men and 19% of women in the study were hyperuricemic, which they defined as having a serum urate level greater than 417 micromol/L (7.0 mg/dL) for men and greater than 340 micromol/L (5.7 mg/dL) for women.

BMI was the most important risk factor for hyperuricemia, accounting for 44% of cases overall. The prevalence of hyperuricemia was 85% higher in individuals with a BMI of 25.0-29.9 kg/m2, 2.72-fold higher in those with a BMI of 30.0-34.9, and 3.53-fold higher for those with a BMI of 35.0 or above when compared against people with a BMI less than 25.0.

The researchers found that adherence to a DASH-style diet could have prevented 9% of hyperuricemia cases, as those in the lowest quintile of DASH-style dietary score had a 22% higher prevalence of hyperuricemia, compared with those in the highest quintile.

There was also a dose-response relationship between alcohol intake and hyperuricemia prevalence, and the authors calculated that 8% of cases could have been avoided through abstaining from alcohol consumption.

Individuals taking diuretics had a 2.24-fold greater risk of gout, and the population attributable risk for diuretic use was 12%.

However the authors noted that the serum urate variance explained by these individual risk factors was very small; for example, the serum urate variance attributed to the DASH diet was just 0.1%.

“How can dietary changes over time (together with a Western lifestyle) be associated with obesity and gout epidemics, yet also paradoxically appear extremely insignificant according to the variance measure?” they asked. “This occurs because the variance measure does not incorporate how common the exposure is (i.e., its prevalence).”

In contrast, the population attributable risk of these factors did reflect the contribution of effect size as well as the high prevalence, particularly with respect to dietary factors, where less than 1% of the U.S. population is believed to be adherent to the DASH diet.

“These data collectively indicate there is substantial room for improvement in dietary factors to help prevent hyperuricemia and gout, as well as hypertension and related cardiovascular outcomes.”

The study and one author were supported by the National Institutes of Health. Two authors were also supported by awards from the Canadian Institutes of Health Research. No conflicts of interest were declared.

SOURCE: Choi H et al. Arthritis Rheumatol. 2019 Sep 4. doi: 10.1002/art.41067.

Four modifiable lifestyle risk factors account for a substantial proportion of gout cases in the United States, suggesting greater public health efforts could reduce the frequency of the condition, according to a paper published Sept. 4 in Arthritis & Rheumatology.

Hyon K. Choi, MD, DrPH, of the department of medicine at Massachusetts General Hospital, Boston, and his coauthors analyzed data from 14,624 adults involved in the third National Health and Nutrition Examination Survey. From this, they calculated prevalence ratios for hyperuricemia, the population attributable risks, and the variance associated with the risk factors of body mass index, alcohol intake, nonadherence to a Dietary Approaches to Stop Hypertension (DASH) diet, and diuretic use.

They found that 21% of men and 19% of women in the study were hyperuricemic, which they defined as having a serum urate level greater than 417 micromol/L (7.0 mg/dL) for men and greater than 340 micromol/L (5.7 mg/dL) for women.

BMI was the most important risk factor for hyperuricemia, accounting for 44% of cases overall. The prevalence of hyperuricemia was 85% higher in individuals with a BMI of 25.0-29.9 kg/m2, 2.72-fold higher in those with a BMI of 30.0-34.9, and 3.53-fold higher for those with a BMI of 35.0 or above when compared against people with a BMI less than 25.0.

The researchers found that adherence to a DASH-style diet could have prevented 9% of hyperuricemia cases, as those in the lowest quintile of DASH-style dietary score had a 22% higher prevalence of hyperuricemia, compared with those in the highest quintile.

There was also a dose-response relationship between alcohol intake and hyperuricemia prevalence, and the authors calculated that 8% of cases could have been avoided through abstaining from alcohol consumption.

Individuals taking diuretics had a 2.24-fold greater risk of gout, and the population attributable risk for diuretic use was 12%.

However the authors noted that the serum urate variance explained by these individual risk factors was very small; for example, the serum urate variance attributed to the DASH diet was just 0.1%.

“How can dietary changes over time (together with a Western lifestyle) be associated with obesity and gout epidemics, yet also paradoxically appear extremely insignificant according to the variance measure?” they asked. “This occurs because the variance measure does not incorporate how common the exposure is (i.e., its prevalence).”

In contrast, the population attributable risk of these factors did reflect the contribution of effect size as well as the high prevalence, particularly with respect to dietary factors, where less than 1% of the U.S. population is believed to be adherent to the DASH diet.

“These data collectively indicate there is substantial room for improvement in dietary factors to help prevent hyperuricemia and gout, as well as hypertension and related cardiovascular outcomes.”

The study and one author were supported by the National Institutes of Health. Two authors were also supported by awards from the Canadian Institutes of Health Research. No conflicts of interest were declared.

SOURCE: Choi H et al. Arthritis Rheumatol. 2019 Sep 4. doi: 10.1002/art.41067.

Four modifiable lifestyle risk factors account for a substantial proportion of gout cases in the United States, suggesting greater public health efforts could reduce the frequency of the condition, according to a paper published Sept. 4 in Arthritis & Rheumatology.

Hyon K. Choi, MD, DrPH, of the department of medicine at Massachusetts General Hospital, Boston, and his coauthors analyzed data from 14,624 adults involved in the third National Health and Nutrition Examination Survey. From this, they calculated prevalence ratios for hyperuricemia, the population attributable risks, and the variance associated with the risk factors of body mass index, alcohol intake, nonadherence to a Dietary Approaches to Stop Hypertension (DASH) diet, and diuretic use.

They found that 21% of men and 19% of women in the study were hyperuricemic, which they defined as having a serum urate level greater than 417 micromol/L (7.0 mg/dL) for men and greater than 340 micromol/L (5.7 mg/dL) for women.

BMI was the most important risk factor for hyperuricemia, accounting for 44% of cases overall. The prevalence of hyperuricemia was 85% higher in individuals with a BMI of 25.0-29.9 kg/m2, 2.72-fold higher in those with a BMI of 30.0-34.9, and 3.53-fold higher for those with a BMI of 35.0 or above when compared against people with a BMI less than 25.0.

The researchers found that adherence to a DASH-style diet could have prevented 9% of hyperuricemia cases, as those in the lowest quintile of DASH-style dietary score had a 22% higher prevalence of hyperuricemia, compared with those in the highest quintile.

There was also a dose-response relationship between alcohol intake and hyperuricemia prevalence, and the authors calculated that 8% of cases could have been avoided through abstaining from alcohol consumption.

Individuals taking diuretics had a 2.24-fold greater risk of gout, and the population attributable risk for diuretic use was 12%.

However the authors noted that the serum urate variance explained by these individual risk factors was very small; for example, the serum urate variance attributed to the DASH diet was just 0.1%.

“How can dietary changes over time (together with a Western lifestyle) be associated with obesity and gout epidemics, yet also paradoxically appear extremely insignificant according to the variance measure?” they asked. “This occurs because the variance measure does not incorporate how common the exposure is (i.e., its prevalence).”

In contrast, the population attributable risk of these factors did reflect the contribution of effect size as well as the high prevalence, particularly with respect to dietary factors, where less than 1% of the U.S. population is believed to be adherent to the DASH diet.

“These data collectively indicate there is substantial room for improvement in dietary factors to help prevent hyperuricemia and gout, as well as hypertension and related cardiovascular outcomes.”

The study and one author were supported by the National Institutes of Health. Two authors were also supported by awards from the Canadian Institutes of Health Research. No conflicts of interest were declared.

SOURCE: Choi H et al. Arthritis Rheumatol. 2019 Sep 4. doi: 10.1002/art.41067.

The white matter hyperintensities (WMH) in patients with sporadic hemiplegic migraine (SHM) is significantly more in the parietal lobe when compared with those with migraine headaches, a new study found. Fifty patients met the criteria for SHM and 100 patients met the criteria for migraine headaches. Patients in the study group were similar to the control groups in terms of age and gender. Researchers found:

• WMH were found in 28 (56%) patients with SHM and 44 (44%) in patients with migraine headache.
• The proportion of patients with WMH was not different between the groups.
• WMH burden was higher in patients with SHM, and larger white matter lesions occurred more frequently in these patients compared to ordinary migraineurs.

Nagarajan E, Bollu PC, Manjamalai S, Yelam A, Quereshi AI. White matter hyperintensities in patients with sporadic hemiplegic migraine. [Published online ahead of print July 15, 2019]. J Neuroimaging. doi: 10.1111/jon.12656.

The white matter hyperintensities (WMH) in patients with sporadic hemiplegic migraine (SHM) is significantly more in the parietal lobe when compared with those with migraine headaches, a new study found. Fifty patients met the criteria for SHM and 100 patients met the criteria for migraine headaches. Patients in the study group were similar to the control groups in terms of age and gender. Researchers found:

• WMH were found in 28 (56%) patients with SHM and 44 (44%) in patients with migraine headache.
• The proportion of patients with WMH was not different between the groups.
• WMH burden was higher in patients with SHM, and larger white matter lesions occurred more frequently in these patients compared to ordinary migraineurs.

Nagarajan E, Bollu PC, Manjamalai S, Yelam A, Quereshi AI. White matter hyperintensities in patients with sporadic hemiplegic migraine. [Published online ahead of print July 15, 2019]. J Neuroimaging. doi: 10.1111/jon.12656.

The white matter hyperintensities (WMH) in patients with sporadic hemiplegic migraine (SHM) is significantly more in the parietal lobe when compared with those with migraine headaches, a new study found. Fifty patients met the criteria for SHM and 100 patients met the criteria for migraine headaches. Patients in the study group were similar to the control groups in terms of age and gender. Researchers found:

• WMH were found in 28 (56%) patients with SHM and 44 (44%) in patients with migraine headache.
• The proportion of patients with WMH was not different between the groups.
• WMH burden was higher in patients with SHM, and larger white matter lesions occurred more frequently in these patients compared to ordinary migraineurs.

Nagarajan E, Bollu PC, Manjamalai S, Yelam A, Quereshi AI. White matter hyperintensities in patients with sporadic hemiplegic migraine. [Published online ahead of print July 15, 2019]. J Neuroimaging. doi: 10.1111/jon.12656.

Individuals who had a median intake of 0.84-1.06 g of tryptophan per day had reduced odds of developing migraine by approximately 54% to 60%, relative to those who consumed ≤0.56 g/day, a new study found. The migraine group (n=514) was recruited from a tertiary headache clinic while controls consisted of 582 sex-matched healthy volunteers randomly selected from the general population. A validated 168-item semi-quantitative food frequency questionnaire was used for dietary intake assessments. Researchers found:

• Multiple regression models were adjusted for age, sex, body mass index, total daily energy intake, dietary intakes of total carbohydrates, animal-based protein, plant-based protein, total fat, saturated fat, and cholesterol.

• There was a negative association between tryptophan intake and migraine risk.

Razeghi Jahromi S, Togha M, Ghorbani Z, et al. The association between dietary tryptophan intake and migraine. [Published online ahead of print June 28, 2019]. Neurol Sci. doi: 10.1007/s10072-019-03984-3.

Individuals who had a median intake of 0.84-1.06 g of tryptophan per day had reduced odds of developing migraine by approximately 54% to 60%, relative to those who consumed ≤0.56 g/day, a new study found. The migraine group (n=514) was recruited from a tertiary headache clinic while controls consisted of 582 sex-matched healthy volunteers randomly selected from the general population. A validated 168-item semi-quantitative food frequency questionnaire was used for dietary intake assessments. Researchers found:

• Multiple regression models were adjusted for age, sex, body mass index, total daily energy intake, dietary intakes of total carbohydrates, animal-based protein, plant-based protein, total fat, saturated fat, and cholesterol.

• There was a negative association between tryptophan intake and migraine risk.

Razeghi Jahromi S, Togha M, Ghorbani Z, et al. The association between dietary tryptophan intake and migraine. [Published online ahead of print June 28, 2019]. Neurol Sci. doi: 10.1007/s10072-019-03984-3.

Individuals who had a median intake of 0.84-1.06 g of tryptophan per day had reduced odds of developing migraine by approximately 54% to 60%, relative to those who consumed ≤0.56 g/day, a new study found. The migraine group (n=514) was recruited from a tertiary headache clinic while controls consisted of 582 sex-matched healthy volunteers randomly selected from the general population. A validated 168-item semi-quantitative food frequency questionnaire was used for dietary intake assessments. Researchers found:

• Multiple regression models were adjusted for age, sex, body mass index, total daily energy intake, dietary intakes of total carbohydrates, animal-based protein, plant-based protein, total fat, saturated fat, and cholesterol.

• There was a negative association between tryptophan intake and migraine risk.

Razeghi Jahromi S, Togha M, Ghorbani Z, et al. The association between dietary tryptophan intake and migraine. [Published online ahead of print June 28, 2019]. Neurol Sci. doi: 10.1007/s10072-019-03984-3.

Migraine is a traumatic brain injury (TBI) risk factor, according to a recent population-based study in Taiwan. Researchers identified 7267 patients with newly diagnosed migraine between 1996 and 2010. The migraineurs to non-migraineurs ratio was 1:4. Multivariate Cox proportional hazard regression models were used to assess the effects of migraines on the risk of TBI after adjusting for potential confounders. Among the findings:

• The overall TBI risk was 1.78 times greater in the migraine group vs the non-migraine group after controlling for covariates.
• Additionally, patients with previous diagnoses of alcohol-attributed disease, mental disorders, and diabetes mellitus had a significantly higher TBI risk compare with those with no history of these diagnoses.

Wang QR, Lu YY, Su YJ, et al. Migraine and traumatic brain injury: a cohort study in Taiwan. [Published online ahead of print July 30, 2019]. BMJ Open. doi: 10.1136/bmjopen-2018-027251.

Migraine is a traumatic brain injury (TBI) risk factor, according to a recent population-based study in Taiwan. Researchers identified 7267 patients with newly diagnosed migraine between 1996 and 2010. The migraineurs to non-migraineurs ratio was 1:4. Multivariate Cox proportional hazard regression models were used to assess the effects of migraines on the risk of TBI after adjusting for potential confounders. Among the findings:

• The overall TBI risk was 1.78 times greater in the migraine group vs the non-migraine group after controlling for covariates.
• Additionally, patients with previous diagnoses of alcohol-attributed disease, mental disorders, and diabetes mellitus had a significantly higher TBI risk compare with those with no history of these diagnoses.

Wang QR, Lu YY, Su YJ, et al. Migraine and traumatic brain injury: a cohort study in Taiwan. [Published online ahead of print July 30, 2019]. BMJ Open. doi: 10.1136/bmjopen-2018-027251.

Migraine is a traumatic brain injury (TBI) risk factor, according to a recent population-based study in Taiwan. Researchers identified 7267 patients with newly diagnosed migraine between 1996 and 2010. The migraineurs to non-migraineurs ratio was 1:4. Multivariate Cox proportional hazard regression models were used to assess the effects of migraines on the risk of TBI after adjusting for potential confounders. Among the findings:

• The overall TBI risk was 1.78 times greater in the migraine group vs the non-migraine group after controlling for covariates.
• Additionally, patients with previous diagnoses of alcohol-attributed disease, mental disorders, and diabetes mellitus had a significantly higher TBI risk compare with those with no history of these diagnoses.

Wang QR, Lu YY, Su YJ, et al. Migraine and traumatic brain injury: a cohort study in Taiwan. [Published online ahead of print July 30, 2019]. BMJ Open. doi: 10.1136/bmjopen-2018-027251.

The presence of complex karyotype (CK) does not affect survival in patients with relapsed/refractory chronic lymphocytic leukemia (CLL) who are treated with idelalisib, according to a new analysis.

Researchers analyzed data from two clinical trials of idelalisib, given alone or in combination with rituximab, and found no significant difference in overall survival (OS) between patients with and without CK.

Karl-Anton Kreuzer, MD, of the University of Cologne (Germany), and colleagues described these findings in a letter to Leukemia.

The researchers evaluated patients with previously treated CLL who were enrolled in a phase 3 trial and received either idelalisib plus rituximab or rituximab plus placebo. Patients from either treatment arm could enroll in an extension study of idelalisib monotherapy.

There were 220 patients randomized to idelalisib plus rituximab (n = 110) or placebo plus rituximab (n = 110) in the primary study, and 161 of these patients were enrolled in the extension study.

The final analysis included 120 patients who were successfully karyotyped – 63 from the idelalisib-rituximab arm and 57 from the placebo-rituximab arm. Less than half of patients in each arm were CK-positive – 41% (26/63) of the idelalisib arm and 42% (24/57) of the placebo arm.

The researchers wrote that baseline characteristics were “mostly balanced” between the CK-positive and CK-negative groups in each treatment arm. The only significant difference was that fewer CK-positive patients in the placebo arm had a creatinine clearance of 30-59 mL/min (P = .0324).

Results

There were no significant differences in outcomes between CK-positive and CK-negative patients who received idelalisib and rituximab. The overall response rate was 81% in CK-positive patients and 89% in CK-negative patients (P = .3509). The median progression-free survival was 20.9 months and 19.4 months, respectively (P = .5848).

The median OS was 28.3 months in the CK-positive group and 49.7 months in the CK-negative group (P = .2099). The copresence of CK and del(17p), TP53 mutation, or del(11q) didn’t significantly affect OS, the researchers noted.

Among all CK-positive patients, the median OS was 28.3 months in the idelalisib-rituximab arm and 9.2 months in the placebo-rituximab arm (P = .0412).

“Our analysis suggests that CK-positive patients treated with idelalisib/rituximab did not exhibit a significantly shortened survival compared with those who were CK negative,” the researchers wrote. “In addition, the primary beneficial effect of adding idelalisib to rituximab treatment in [relapsed/refractory] CLL patients with CK was reflected in OS prolongation compared to those who received only rituximab.”

The researchers noted that this study has limitations, so prospective clinical trials are needed to guide treatment of patients with relapsed/refractory CLL and CK.

Both trials of idelalisib were sponsored by Gilead. The researchers reported relationships, including employment, with Gilead and other companies. They also disclosed funding from the German government and from nonprofit organizations in Germany.

[email protected]

SOURCE: Kreuzer K-A et al. Leukemia. 2019 Aug 19. doi: 10.1038/s41375-019-0533-6.

The presence of complex karyotype (CK) does not affect survival in patients with relapsed/refractory chronic lymphocytic leukemia (CLL) who are treated with idelalisib, according to a new analysis.

Researchers analyzed data from two clinical trials of idelalisib, given alone or in combination with rituximab, and found no significant difference in overall survival (OS) between patients with and without CK.

Karl-Anton Kreuzer, MD, of the University of Cologne (Germany), and colleagues described these findings in a letter to Leukemia.

The researchers evaluated patients with previously treated CLL who were enrolled in a phase 3 trial and received either idelalisib plus rituximab or rituximab plus placebo. Patients from either treatment arm could enroll in an extension study of idelalisib monotherapy.

There were 220 patients randomized to idelalisib plus rituximab (n = 110) or placebo plus rituximab (n = 110) in the primary study, and 161 of these patients were enrolled in the extension study.

The final analysis included 120 patients who were successfully karyotyped – 63 from the idelalisib-rituximab arm and 57 from the placebo-rituximab arm. Less than half of patients in each arm were CK-positive – 41% (26/63) of the idelalisib arm and 42% (24/57) of the placebo arm.

The researchers wrote that baseline characteristics were “mostly balanced” between the CK-positive and CK-negative groups in each treatment arm. The only significant difference was that fewer CK-positive patients in the placebo arm had a creatinine clearance of 30-59 mL/min (P = .0324).

Results

There were no significant differences in outcomes between CK-positive and CK-negative patients who received idelalisib and rituximab. The overall response rate was 81% in CK-positive patients and 89% in CK-negative patients (P = .3509). The median progression-free survival was 20.9 months and 19.4 months, respectively (P = .5848).

The median OS was 28.3 months in the CK-positive group and 49.7 months in the CK-negative group (P = .2099). The copresence of CK and del(17p), TP53 mutation, or del(11q) didn’t significantly affect OS, the researchers noted.

Among all CK-positive patients, the median OS was 28.3 months in the idelalisib-rituximab arm and 9.2 months in the placebo-rituximab arm (P = .0412).

“Our analysis suggests that CK-positive patients treated with idelalisib/rituximab did not exhibit a significantly shortened survival compared with those who were CK negative,” the researchers wrote. “In addition, the primary beneficial effect of adding idelalisib to rituximab treatment in [relapsed/refractory] CLL patients with CK was reflected in OS prolongation compared to those who received only rituximab.”

The researchers noted that this study has limitations, so prospective clinical trials are needed to guide treatment of patients with relapsed/refractory CLL and CK.

Both trials of idelalisib were sponsored by Gilead. The researchers reported relationships, including employment, with Gilead and other companies. They also disclosed funding from the German government and from nonprofit organizations in Germany.

[email protected]

SOURCE: Kreuzer K-A et al. Leukemia. 2019 Aug 19. doi: 10.1038/s41375-019-0533-6.

The presence of complex karyotype (CK) does not affect survival in patients with relapsed/refractory chronic lymphocytic leukemia (CLL) who are treated with idelalisib, according to a new analysis.

Researchers analyzed data from two clinical trials of idelalisib, given alone or in combination with rituximab, and found no significant difference in overall survival (OS) between patients with and without CK.

Karl-Anton Kreuzer, MD, of the University of Cologne (Germany), and colleagues described these findings in a letter to Leukemia.

The researchers evaluated patients with previously treated CLL who were enrolled in a phase 3 trial and received either idelalisib plus rituximab or rituximab plus placebo. Patients from either treatment arm could enroll in an extension study of idelalisib monotherapy.

There were 220 patients randomized to idelalisib plus rituximab (n = 110) or placebo plus rituximab (n = 110) in the primary study, and 161 of these patients were enrolled in the extension study.

The final analysis included 120 patients who were successfully karyotyped – 63 from the idelalisib-rituximab arm and 57 from the placebo-rituximab arm. Less than half of patients in each arm were CK-positive – 41% (26/63) of the idelalisib arm and 42% (24/57) of the placebo arm.

The researchers wrote that baseline characteristics were “mostly balanced” between the CK-positive and CK-negative groups in each treatment arm. The only significant difference was that fewer CK-positive patients in the placebo arm had a creatinine clearance of 30-59 mL/min (P = .0324).

Results

There were no significant differences in outcomes between CK-positive and CK-negative patients who received idelalisib and rituximab. The overall response rate was 81% in CK-positive patients and 89% in CK-negative patients (P = .3509). The median progression-free survival was 20.9 months and 19.4 months, respectively (P = .5848).

The median OS was 28.3 months in the CK-positive group and 49.7 months in the CK-negative group (P = .2099). The copresence of CK and del(17p), TP53 mutation, or del(11q) didn’t significantly affect OS, the researchers noted.

Among all CK-positive patients, the median OS was 28.3 months in the idelalisib-rituximab arm and 9.2 months in the placebo-rituximab arm (P = .0412).

“Our analysis suggests that CK-positive patients treated with idelalisib/rituximab did not exhibit a significantly shortened survival compared with those who were CK negative,” the researchers wrote. “In addition, the primary beneficial effect of adding idelalisib to rituximab treatment in [relapsed/refractory] CLL patients with CK was reflected in OS prolongation compared to those who received only rituximab.”

The researchers noted that this study has limitations, so prospective clinical trials are needed to guide treatment of patients with relapsed/refractory CLL and CK.

Both trials of idelalisib were sponsored by Gilead. The researchers reported relationships, including employment, with Gilead and other companies. They also disclosed funding from the German government and from nonprofit organizations in Germany.

[email protected]

SOURCE: Kreuzer K-A et al. Leukemia. 2019 Aug 19. doi: 10.1038/s41375-019-0533-6.