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Genetics, neurobiology of borderline personality disorder remain uncertain
CRYSTAL CITY, VA. – Borderline personality disorder has a genetic and neurobiological component, but researchers remain unable to discern exactly why specific genetic markers are attributed to the disease, Emil F. Coccaro, MD, said at Focus on Neuropsychiatry presented by Current Psychiatry and the American Academy of Clinical Psychiatrists.
“The neurobiology at this point gives us clues that what’s going on with borderline personality disorder isn’t simply developmental or environmental. That’s all that it tells us,” said Dr. Coccaro, director of the Clinical Neuroscience & Psychopharmacology Research Unit at the University of Chicago.
Similarly, studies in twins that show heritability of borderline personal disorder at rates between 31% and 49% “only show there’s something in the DNA,” he added. Dr. Coccaro called the evidence for the neurobiology of borderline personality disorder “hazy.” said Dr. Coccaro, also chairman of the university’s department of psychiatry and behavioral neuroscience.
That is true of a lot of disorders, he said, so only the details explain why patients with borderline personality disorder look different from those who might have “similar types of circuitry abnormalities,” he said.
For example, genomewide association studies have found links between borderline personality disorder and the genes DPYD and PKP4, indicating problems with pyrimidine metabolism and myelin production. The study also found a strong association between borderline personality disorder, bipolar disorder, major depression, and schizophrenia (Transl Psychiatry. 2017 Jun. doi: 10.1038/tp.2017.115). DPYD has been associated with schizophrenia, but the relationship between DPYD and borderline personality disorder is unknown, Dr. Coccaro said.
“These [associations] are suggestive of what’s going on genetically, but it hardly makes a story that’s coherent enough to sink your teeth into,” he said.
The neuroscience behind borderline personality disorder, meanwhile, appears more promising, Dr. Coccaro noted. Studies of brain function have shown that negative emotions in patients with borderline personality disorder lead to increased amygdala reactivity. With regard to the neuroendocrinology of borderline personality disorder, trauma in those patients appears similar to what can be seen in patients with posttraumatic stress disorder (PTSD) with “increased central and decreased peripheral stress hormone response.” In fact, he said, 75% of people with borderline personality disorder experienced childhood physical, sexual, or emotional abuse (Curr Psychiatry Rep. 2005 Mar;7[1]:39).
Dr. Coccaro noted that, although the prevalence of borderline personality disorder is likely between 2% and 3%, the illness is encountered at a rate of 20% for patients in clinic and 40% for those in hospitals and emergency departments. Borderline personality disorder is more prevalent and more severe in women, but no gender differences are apparent in affective disturbance, impulsivity, or suicidality. Borderline personality disorder also is likely to be comorbid with at least two conditions: Men with borderline personality disorder tend to have narcissistic and antisocial personality disorders; women with borderline personality disorder have higher rates of major depression, anorexia and bulimia, and PTSD.
Borderline personality was traditionally associated with a “dismal prognosis,” but the lifetime course of the disorder appears to be more promising. In the Collaborative Longitudinal Personality Disorder Study (CLPS), 25% of 668 patients had achieved remission after 2 years, which was defined as having fewer than two symptoms for more than 2 months. After a decade, 85% of those patients had reached remission for at least 12 months (JAMA Psychiatry. 2011;68[8]:827-37). Another trial, the McLean Study of Adult Development, analyzed 290 patients who had a remission rate at 16 years of 78% that lasted for at least 8 years (J Pers Disord. 2005 Oct;19[5]:505-23).
However, Dr. Coccaro noted, patients with borderline personality disorder likely do not achieve true remission. Instead, he said, patients simply fail to meet all the criteria to be diagnosed with borderline personality disorder. “They still have some of the features, but they are less intense,” Dr. Coccaro said.
Dr. Coccaro reported serving as a consultant to Azevan, Avanir Pharma, and Brackett. He also reported receiving grants from the National Institute on Mental Illness and the National Institute on Alcoholic Abuse and Alcoholism, and receiving royalties from UpToDate.
The meeting was presented by Global Academy for Medical Education. Global Academy and this news organization are owned by the same parent company.
CRYSTAL CITY, VA. – Borderline personality disorder has a genetic and neurobiological component, but researchers remain unable to discern exactly why specific genetic markers are attributed to the disease, Emil F. Coccaro, MD, said at Focus on Neuropsychiatry presented by Current Psychiatry and the American Academy of Clinical Psychiatrists.
“The neurobiology at this point gives us clues that what’s going on with borderline personality disorder isn’t simply developmental or environmental. That’s all that it tells us,” said Dr. Coccaro, director of the Clinical Neuroscience & Psychopharmacology Research Unit at the University of Chicago.
Similarly, studies in twins that show heritability of borderline personal disorder at rates between 31% and 49% “only show there’s something in the DNA,” he added. Dr. Coccaro called the evidence for the neurobiology of borderline personality disorder “hazy.” said Dr. Coccaro, also chairman of the university’s department of psychiatry and behavioral neuroscience.
That is true of a lot of disorders, he said, so only the details explain why patients with borderline personality disorder look different from those who might have “similar types of circuitry abnormalities,” he said.
For example, genomewide association studies have found links between borderline personality disorder and the genes DPYD and PKP4, indicating problems with pyrimidine metabolism and myelin production. The study also found a strong association between borderline personality disorder, bipolar disorder, major depression, and schizophrenia (Transl Psychiatry. 2017 Jun. doi: 10.1038/tp.2017.115). DPYD has been associated with schizophrenia, but the relationship between DPYD and borderline personality disorder is unknown, Dr. Coccaro said.
“These [associations] are suggestive of what’s going on genetically, but it hardly makes a story that’s coherent enough to sink your teeth into,” he said.
The neuroscience behind borderline personality disorder, meanwhile, appears more promising, Dr. Coccaro noted. Studies of brain function have shown that negative emotions in patients with borderline personality disorder lead to increased amygdala reactivity. With regard to the neuroendocrinology of borderline personality disorder, trauma in those patients appears similar to what can be seen in patients with posttraumatic stress disorder (PTSD) with “increased central and decreased peripheral stress hormone response.” In fact, he said, 75% of people with borderline personality disorder experienced childhood physical, sexual, or emotional abuse (Curr Psychiatry Rep. 2005 Mar;7[1]:39).
Dr. Coccaro noted that, although the prevalence of borderline personality disorder is likely between 2% and 3%, the illness is encountered at a rate of 20% for patients in clinic and 40% for those in hospitals and emergency departments. Borderline personality disorder is more prevalent and more severe in women, but no gender differences are apparent in affective disturbance, impulsivity, or suicidality. Borderline personality disorder also is likely to be comorbid with at least two conditions: Men with borderline personality disorder tend to have narcissistic and antisocial personality disorders; women with borderline personality disorder have higher rates of major depression, anorexia and bulimia, and PTSD.
Borderline personality was traditionally associated with a “dismal prognosis,” but the lifetime course of the disorder appears to be more promising. In the Collaborative Longitudinal Personality Disorder Study (CLPS), 25% of 668 patients had achieved remission after 2 years, which was defined as having fewer than two symptoms for more than 2 months. After a decade, 85% of those patients had reached remission for at least 12 months (JAMA Psychiatry. 2011;68[8]:827-37). Another trial, the McLean Study of Adult Development, analyzed 290 patients who had a remission rate at 16 years of 78% that lasted for at least 8 years (J Pers Disord. 2005 Oct;19[5]:505-23).
However, Dr. Coccaro noted, patients with borderline personality disorder likely do not achieve true remission. Instead, he said, patients simply fail to meet all the criteria to be diagnosed with borderline personality disorder. “They still have some of the features, but they are less intense,” Dr. Coccaro said.
Dr. Coccaro reported serving as a consultant to Azevan, Avanir Pharma, and Brackett. He also reported receiving grants from the National Institute on Mental Illness and the National Institute on Alcoholic Abuse and Alcoholism, and receiving royalties from UpToDate.
The meeting was presented by Global Academy for Medical Education. Global Academy and this news organization are owned by the same parent company.
CRYSTAL CITY, VA. – Borderline personality disorder has a genetic and neurobiological component, but researchers remain unable to discern exactly why specific genetic markers are attributed to the disease, Emil F. Coccaro, MD, said at Focus on Neuropsychiatry presented by Current Psychiatry and the American Academy of Clinical Psychiatrists.
“The neurobiology at this point gives us clues that what’s going on with borderline personality disorder isn’t simply developmental or environmental. That’s all that it tells us,” said Dr. Coccaro, director of the Clinical Neuroscience & Psychopharmacology Research Unit at the University of Chicago.
Similarly, studies in twins that show heritability of borderline personal disorder at rates between 31% and 49% “only show there’s something in the DNA,” he added. Dr. Coccaro called the evidence for the neurobiology of borderline personality disorder “hazy.” said Dr. Coccaro, also chairman of the university’s department of psychiatry and behavioral neuroscience.
That is true of a lot of disorders, he said, so only the details explain why patients with borderline personality disorder look different from those who might have “similar types of circuitry abnormalities,” he said.
For example, genomewide association studies have found links between borderline personality disorder and the genes DPYD and PKP4, indicating problems with pyrimidine metabolism and myelin production. The study also found a strong association between borderline personality disorder, bipolar disorder, major depression, and schizophrenia (Transl Psychiatry. 2017 Jun. doi: 10.1038/tp.2017.115). DPYD has been associated with schizophrenia, but the relationship between DPYD and borderline personality disorder is unknown, Dr. Coccaro said.
“These [associations] are suggestive of what’s going on genetically, but it hardly makes a story that’s coherent enough to sink your teeth into,” he said.
The neuroscience behind borderline personality disorder, meanwhile, appears more promising, Dr. Coccaro noted. Studies of brain function have shown that negative emotions in patients with borderline personality disorder lead to increased amygdala reactivity. With regard to the neuroendocrinology of borderline personality disorder, trauma in those patients appears similar to what can be seen in patients with posttraumatic stress disorder (PTSD) with “increased central and decreased peripheral stress hormone response.” In fact, he said, 75% of people with borderline personality disorder experienced childhood physical, sexual, or emotional abuse (Curr Psychiatry Rep. 2005 Mar;7[1]:39).
Dr. Coccaro noted that, although the prevalence of borderline personality disorder is likely between 2% and 3%, the illness is encountered at a rate of 20% for patients in clinic and 40% for those in hospitals and emergency departments. Borderline personality disorder is more prevalent and more severe in women, but no gender differences are apparent in affective disturbance, impulsivity, or suicidality. Borderline personality disorder also is likely to be comorbid with at least two conditions: Men with borderline personality disorder tend to have narcissistic and antisocial personality disorders; women with borderline personality disorder have higher rates of major depression, anorexia and bulimia, and PTSD.
Borderline personality was traditionally associated with a “dismal prognosis,” but the lifetime course of the disorder appears to be more promising. In the Collaborative Longitudinal Personality Disorder Study (CLPS), 25% of 668 patients had achieved remission after 2 years, which was defined as having fewer than two symptoms for more than 2 months. After a decade, 85% of those patients had reached remission for at least 12 months (JAMA Psychiatry. 2011;68[8]:827-37). Another trial, the McLean Study of Adult Development, analyzed 290 patients who had a remission rate at 16 years of 78% that lasted for at least 8 years (J Pers Disord. 2005 Oct;19[5]:505-23).
However, Dr. Coccaro noted, patients with borderline personality disorder likely do not achieve true remission. Instead, he said, patients simply fail to meet all the criteria to be diagnosed with borderline personality disorder. “They still have some of the features, but they are less intense,” Dr. Coccaro said.
Dr. Coccaro reported serving as a consultant to Azevan, Avanir Pharma, and Brackett. He also reported receiving grants from the National Institute on Mental Illness and the National Institute on Alcoholic Abuse and Alcoholism, and receiving royalties from UpToDate.
The meeting was presented by Global Academy for Medical Education. Global Academy and this news organization are owned by the same parent company.
REPORTING FROM FOCUS ON NEUROPSYCHIATRY 2019
Platelet glycoprotein genotypes predict responses to ITP therapy
AMSTERDAM – For patients with immune thrombocytopenia (ITP), platelet glycoprotein genotypes may predict effectiveness of specific therapies, according to investigators.
Significant relationships were detected between allelic polymorphisms of glycoprotein genes and durable responses to corticosteroids, thrombopoietin receptor agonists (aTPOr), and splenectomy, reported lead author Irina Zotova, MD, of the Russian Research Institute of Hematology and Transfusiology, Federal Biomedical Agency, in Saint Petersburg and colleagues.
These findings could guide clinical decision making in ITP, according to Dr. Zotova.
“Currently, the choice of therapeutic approach to ITP treatment, especially the second-line, is empirical, and often based on the experience of the clinician,” Dr. Zotova said during her presentation at the annual congress of the European Hematology Association. “Recent studies have shown that ... genes coding for glycoprotein are involved in platelet function and are associated with different responses to ITP treatment. This provides an opportunity for an individual approach and personalization of ITP therapy in accordance with the genetic status of the patient.”
In the present study, the investigators used PCR-RFLP (polymerase chain reaction–restriction fragment length polymorphism) to determine GPIa A1648G and GPIIb 2622TG gene status in 81 patients with primary ITP and compared these genotypes with clinical responses.
All patients received first-line corticosteroid therapy. If necessary, second-line treatment was delivered. In total, 37 patients (46%) received aTPOr, while 22 patients (27%) underwent splenectomy. Responses were classified as durable response, nondurable response, or no response.
Analysis showed that a significantly greater proportion of patients who had durable responses to corticosteroid therapy exhibited a heterozygous GPIIb 2622TG genotype, compared with patients who had nondurable responses (72.2% vs. 30.9%; odds ratio, 5.8; P = .005).
For second-line responses, patients who had durable response to aTPOr were much more likely to be homozygous for the GPIa A1648G than nonresponders (87.5% vs. 20.0%; OR, 28.0; P = .005). More strikingly, all patients who achieved durable responses to splenectomy had the GPIa A1648G genotype, compared with just 44% of nonresponders (OR, 33.0; P = .005).
“Gentoyping for the GPIIb T2622G and GPIa A1648G polymorphisms allows [clinicians] to predict the response to first-line and second-line treatment, giving the possibility to stratify patients to groups with favorable and unfavorable courses of the disease,” Dr. Zotova concluded.
Session moderator János Kappelmayer, MD, of the University of Debrecen (Hungary) highlighted a key opportunity presented by the study. “I think that one important aspect of these findings could be that splenectomy is an irreversible procedure, so one can exclude those patients who will not benefit from splenectomy,” he said. “I think this is a real advantage.”
The investigators reported no study funding or conflicts of interest.
SOURCE: Zotova I et al. EHA Congress, Abstract S848.
AMSTERDAM – For patients with immune thrombocytopenia (ITP), platelet glycoprotein genotypes may predict effectiveness of specific therapies, according to investigators.
Significant relationships were detected between allelic polymorphisms of glycoprotein genes and durable responses to corticosteroids, thrombopoietin receptor agonists (aTPOr), and splenectomy, reported lead author Irina Zotova, MD, of the Russian Research Institute of Hematology and Transfusiology, Federal Biomedical Agency, in Saint Petersburg and colleagues.
These findings could guide clinical decision making in ITP, according to Dr. Zotova.
“Currently, the choice of therapeutic approach to ITP treatment, especially the second-line, is empirical, and often based on the experience of the clinician,” Dr. Zotova said during her presentation at the annual congress of the European Hematology Association. “Recent studies have shown that ... genes coding for glycoprotein are involved in platelet function and are associated with different responses to ITP treatment. This provides an opportunity for an individual approach and personalization of ITP therapy in accordance with the genetic status of the patient.”
In the present study, the investigators used PCR-RFLP (polymerase chain reaction–restriction fragment length polymorphism) to determine GPIa A1648G and GPIIb 2622TG gene status in 81 patients with primary ITP and compared these genotypes with clinical responses.
All patients received first-line corticosteroid therapy. If necessary, second-line treatment was delivered. In total, 37 patients (46%) received aTPOr, while 22 patients (27%) underwent splenectomy. Responses were classified as durable response, nondurable response, or no response.
Analysis showed that a significantly greater proportion of patients who had durable responses to corticosteroid therapy exhibited a heterozygous GPIIb 2622TG genotype, compared with patients who had nondurable responses (72.2% vs. 30.9%; odds ratio, 5.8; P = .005).
For second-line responses, patients who had durable response to aTPOr were much more likely to be homozygous for the GPIa A1648G than nonresponders (87.5% vs. 20.0%; OR, 28.0; P = .005). More strikingly, all patients who achieved durable responses to splenectomy had the GPIa A1648G genotype, compared with just 44% of nonresponders (OR, 33.0; P = .005).
“Gentoyping for the GPIIb T2622G and GPIa A1648G polymorphisms allows [clinicians] to predict the response to first-line and second-line treatment, giving the possibility to stratify patients to groups with favorable and unfavorable courses of the disease,” Dr. Zotova concluded.
Session moderator János Kappelmayer, MD, of the University of Debrecen (Hungary) highlighted a key opportunity presented by the study. “I think that one important aspect of these findings could be that splenectomy is an irreversible procedure, so one can exclude those patients who will not benefit from splenectomy,” he said. “I think this is a real advantage.”
The investigators reported no study funding or conflicts of interest.
SOURCE: Zotova I et al. EHA Congress, Abstract S848.
AMSTERDAM – For patients with immune thrombocytopenia (ITP), platelet glycoprotein genotypes may predict effectiveness of specific therapies, according to investigators.
Significant relationships were detected between allelic polymorphisms of glycoprotein genes and durable responses to corticosteroids, thrombopoietin receptor agonists (aTPOr), and splenectomy, reported lead author Irina Zotova, MD, of the Russian Research Institute of Hematology and Transfusiology, Federal Biomedical Agency, in Saint Petersburg and colleagues.
These findings could guide clinical decision making in ITP, according to Dr. Zotova.
“Currently, the choice of therapeutic approach to ITP treatment, especially the second-line, is empirical, and often based on the experience of the clinician,” Dr. Zotova said during her presentation at the annual congress of the European Hematology Association. “Recent studies have shown that ... genes coding for glycoprotein are involved in platelet function and are associated with different responses to ITP treatment. This provides an opportunity for an individual approach and personalization of ITP therapy in accordance with the genetic status of the patient.”
In the present study, the investigators used PCR-RFLP (polymerase chain reaction–restriction fragment length polymorphism) to determine GPIa A1648G and GPIIb 2622TG gene status in 81 patients with primary ITP and compared these genotypes with clinical responses.
All patients received first-line corticosteroid therapy. If necessary, second-line treatment was delivered. In total, 37 patients (46%) received aTPOr, while 22 patients (27%) underwent splenectomy. Responses were classified as durable response, nondurable response, or no response.
Analysis showed that a significantly greater proportion of patients who had durable responses to corticosteroid therapy exhibited a heterozygous GPIIb 2622TG genotype, compared with patients who had nondurable responses (72.2% vs. 30.9%; odds ratio, 5.8; P = .005).
For second-line responses, patients who had durable response to aTPOr were much more likely to be homozygous for the GPIa A1648G than nonresponders (87.5% vs. 20.0%; OR, 28.0; P = .005). More strikingly, all patients who achieved durable responses to splenectomy had the GPIa A1648G genotype, compared with just 44% of nonresponders (OR, 33.0; P = .005).
“Gentoyping for the GPIIb T2622G and GPIa A1648G polymorphisms allows [clinicians] to predict the response to first-line and second-line treatment, giving the possibility to stratify patients to groups with favorable and unfavorable courses of the disease,” Dr. Zotova concluded.
Session moderator János Kappelmayer, MD, of the University of Debrecen (Hungary) highlighted a key opportunity presented by the study. “I think that one important aspect of these findings could be that splenectomy is an irreversible procedure, so one can exclude those patients who will not benefit from splenectomy,” he said. “I think this is a real advantage.”
The investigators reported no study funding or conflicts of interest.
SOURCE: Zotova I et al. EHA Congress, Abstract S848.
REPORTING FROM EHA CONGRESS
MRI-guided revascularization noninferior to FFR
Myocardial perfusion cardiovascular MRI is as good as invasive angiography and measurement of fractional flow reserve to guide revascularization in patients with angina, research suggests.
In the New England Journal of Medicine, researchers present the outcomes of an unblinded, multicenter, clinical effectiveness trial comparing the two revascularization strategies in 918 patients who had typical angina and either two or more cardiovascular risk factors or a positive exercise treadmill test.
In the fractional flow reserve method, revascularization was recommended in all vessels with an FFR of 0.8 or less. In the MRI-guided method, all patients underwent myocardial perfusion cardiovascular MRI, and patients with clinically significant inducible ischemia then underwent invasive angiography, and revascularization if required.
Significantly fewer patients in the cardiovascular MRI group underwent index revascularization, compared with the fractional flow reserve group (36% vs. 45% respectively; P = .005), and only 48% in the cardiovascular MRI group underwent invasive angiography, compared with 97% of patients in the fractional flow reserve arm.
However, there was no significant difference between the two groups in the incidence of major cardiac adverse events after 1 year, signifying that the MRI approach met the criteria for noninferiority.
There was also no significant difference between the two groups in the percentage of patients who were free from angina after 12 months (49.2% in the MRI group and 43.8% in the FFR group).
“Current guidelines on the management of the care of patients with suspected coronary artery disease separate diagnostic strategies from therapeutic strategies owing to a lack of evidence comparing combined diagnostic and therapeutic pathways,” wrote Eike Nagel, MD, of the Goethe University Frankfurt Institute for Experimental and Translational Cardiovascular Imaging and coauthors. “The MR-INFORM trial closes this knowledge gap by comparing two frequently used, well-defined, standardized, and validated clinical management strategies.”
However, they pointed out that one limitation of their study was the lack of a third group of patients who received medical therapy without planned revascularization. They also noted that the incidence of the primary outcome of major adverse cardiac events was lower than expected at 1 year.
The study was supported by the Guy’s and St. Thomas’ Biomedical Research Centre of the National Institute for Health Research. Three authors declared support from study supporters related to the study, three declared grants, personal fees, and other support from the private sector unrelated to the study. No other conflicts of interest were declared.
SOURCE: Nagel E et al. New Engl J Med. 2019;380:2418-28. doi: 10.1056/NEJMoa1716734.
Myocardial perfusion cardiovascular MRI is as good as invasive angiography and measurement of fractional flow reserve to guide revascularization in patients with angina, research suggests.
In the New England Journal of Medicine, researchers present the outcomes of an unblinded, multicenter, clinical effectiveness trial comparing the two revascularization strategies in 918 patients who had typical angina and either two or more cardiovascular risk factors or a positive exercise treadmill test.
In the fractional flow reserve method, revascularization was recommended in all vessels with an FFR of 0.8 or less. In the MRI-guided method, all patients underwent myocardial perfusion cardiovascular MRI, and patients with clinically significant inducible ischemia then underwent invasive angiography, and revascularization if required.
Significantly fewer patients in the cardiovascular MRI group underwent index revascularization, compared with the fractional flow reserve group (36% vs. 45% respectively; P = .005), and only 48% in the cardiovascular MRI group underwent invasive angiography, compared with 97% of patients in the fractional flow reserve arm.
However, there was no significant difference between the two groups in the incidence of major cardiac adverse events after 1 year, signifying that the MRI approach met the criteria for noninferiority.
There was also no significant difference between the two groups in the percentage of patients who were free from angina after 12 months (49.2% in the MRI group and 43.8% in the FFR group).
“Current guidelines on the management of the care of patients with suspected coronary artery disease separate diagnostic strategies from therapeutic strategies owing to a lack of evidence comparing combined diagnostic and therapeutic pathways,” wrote Eike Nagel, MD, of the Goethe University Frankfurt Institute for Experimental and Translational Cardiovascular Imaging and coauthors. “The MR-INFORM trial closes this knowledge gap by comparing two frequently used, well-defined, standardized, and validated clinical management strategies.”
However, they pointed out that one limitation of their study was the lack of a third group of patients who received medical therapy without planned revascularization. They also noted that the incidence of the primary outcome of major adverse cardiac events was lower than expected at 1 year.
The study was supported by the Guy’s and St. Thomas’ Biomedical Research Centre of the National Institute for Health Research. Three authors declared support from study supporters related to the study, three declared grants, personal fees, and other support from the private sector unrelated to the study. No other conflicts of interest were declared.
SOURCE: Nagel E et al. New Engl J Med. 2019;380:2418-28. doi: 10.1056/NEJMoa1716734.
Myocardial perfusion cardiovascular MRI is as good as invasive angiography and measurement of fractional flow reserve to guide revascularization in patients with angina, research suggests.
In the New England Journal of Medicine, researchers present the outcomes of an unblinded, multicenter, clinical effectiveness trial comparing the two revascularization strategies in 918 patients who had typical angina and either two or more cardiovascular risk factors or a positive exercise treadmill test.
In the fractional flow reserve method, revascularization was recommended in all vessels with an FFR of 0.8 or less. In the MRI-guided method, all patients underwent myocardial perfusion cardiovascular MRI, and patients with clinically significant inducible ischemia then underwent invasive angiography, and revascularization if required.
Significantly fewer patients in the cardiovascular MRI group underwent index revascularization, compared with the fractional flow reserve group (36% vs. 45% respectively; P = .005), and only 48% in the cardiovascular MRI group underwent invasive angiography, compared with 97% of patients in the fractional flow reserve arm.
However, there was no significant difference between the two groups in the incidence of major cardiac adverse events after 1 year, signifying that the MRI approach met the criteria for noninferiority.
There was also no significant difference between the two groups in the percentage of patients who were free from angina after 12 months (49.2% in the MRI group and 43.8% in the FFR group).
“Current guidelines on the management of the care of patients with suspected coronary artery disease separate diagnostic strategies from therapeutic strategies owing to a lack of evidence comparing combined diagnostic and therapeutic pathways,” wrote Eike Nagel, MD, of the Goethe University Frankfurt Institute for Experimental and Translational Cardiovascular Imaging and coauthors. “The MR-INFORM trial closes this knowledge gap by comparing two frequently used, well-defined, standardized, and validated clinical management strategies.”
However, they pointed out that one limitation of their study was the lack of a third group of patients who received medical therapy without planned revascularization. They also noted that the incidence of the primary outcome of major adverse cardiac events was lower than expected at 1 year.
The study was supported by the Guy’s and St. Thomas’ Biomedical Research Centre of the National Institute for Health Research. Three authors declared support from study supporters related to the study, three declared grants, personal fees, and other support from the private sector unrelated to the study. No other conflicts of interest were declared.
SOURCE: Nagel E et al. New Engl J Med. 2019;380:2418-28. doi: 10.1056/NEJMoa1716734.
FROM NEW ENGLAND JOURNAL OF MEDICINE
Key clinical point: .
Major finding: The incidence of major cardiac adverse events similar at 1 year with cardiovascular MRI and invasive angiography.
Study details: MR-INFORM, an unblinded, multicenter, clinical effectiveness trial in 918 patients with angina.
Disclosures: The study was supported by the Guy’s and St. Thomas’ Biomedical Research Centre of the National Institute for Health Research. Three authors declared support from study supporters related to the study, three declared grants, personal fees and other support from the private sector unrelated to the study. No other conflicts of interest were declared.
Source: Nagel E et al. New Engl J Med. 2019;380:2418-28. doi: 10.1056/NEJMoa1716734.
Real-world data confirm nonacog alfa efficacy in hemophilia B
The recombinant factor IX product nonacog alfa appears safe and effective for patients with hemophilia B, according to results from a recent postmarketing study in Japan.
While nonacog alfa was approved in the United States and Europe in 1997, the product wasn’t approved in Japan until 2009. Since it was the first recombinant factor IX product available there, and only a small number of patients were enrolled in domestic clinical trials, the Japanese government required additional real-world studies.
“In the last couple of years, several extended half‐life blood coagulation factor products gained regulatory approval for the treatment of hemophilia B. However, access to this most advanced treatment option remains limited to developed countries, and the need for standard half‐life recombinant or plasma‐derived FIX products is still high,” wrote Katsuyuki Fukutake, MD, PhD, of Tokyo Medical University, Japan, and colleagues.
The researchers conducted an observational postmarketing surveillance study of 312 patients with hemophilia B who received nonacog alfa therapy from 2010 to 2014. The team evaluated the real-world safety, including the incidence of inhibitors and adverse events, and effectiveness of the recombinant product in Japan.
The findings were published in Haemophilia.
The study included both previously treated and untreated participants who were followed for 1 and 2 years, respectively, after starting recombinant factor IX therapy.
The primary safety outcome was the incidence and number of adverse drug reactions. Effectiveness was measured using clinical effectiveness rates and annualized bleeding rates (ABR).
After analysis, the researchers found that the effectiveness rates were 95.5% and 93.7% for patients who received routine prophylaxis and on-demand treatment, respectively.
The median ABR was lower during routine prophylaxis – 2.0 – versus the rest of the observation period – 8.3. “This difference was prominent among patients with severe haemophilia B or haemophilic arthropathy,” the researchers wrote.
With respect to safety, 11 adverse drug reactions were seen in seven previously treated patients. New inhibitor development was not observed in any participants, but recurrence was seen in one patient.
“Our results are consistent with those of previous studies where the incidence of inhibitor antibody development in hemophilia B has been reported as 1%-5%,” Dr. Fukutake and colleagues wrote.
The researchers acknowledged that one key limitation of the study was the observational design.
“The results suggest that nonacog alfa was well tolerated and appropriately used under routine clinical practice,” the authors concluded.
The study was funded and conducted by Pfizer Japan. The authors reported financial relationships with Pfizer and several other companies. One coauthor is an employee of Pfizer Japan.
SOURCE: Fukutake K et al. Haemophilia. 2019 Jun 6. doi: 10.1111/hae.13783.
The recombinant factor IX product nonacog alfa appears safe and effective for patients with hemophilia B, according to results from a recent postmarketing study in Japan.
While nonacog alfa was approved in the United States and Europe in 1997, the product wasn’t approved in Japan until 2009. Since it was the first recombinant factor IX product available there, and only a small number of patients were enrolled in domestic clinical trials, the Japanese government required additional real-world studies.
“In the last couple of years, several extended half‐life blood coagulation factor products gained regulatory approval for the treatment of hemophilia B. However, access to this most advanced treatment option remains limited to developed countries, and the need for standard half‐life recombinant or plasma‐derived FIX products is still high,” wrote Katsuyuki Fukutake, MD, PhD, of Tokyo Medical University, Japan, and colleagues.
The researchers conducted an observational postmarketing surveillance study of 312 patients with hemophilia B who received nonacog alfa therapy from 2010 to 2014. The team evaluated the real-world safety, including the incidence of inhibitors and adverse events, and effectiveness of the recombinant product in Japan.
The findings were published in Haemophilia.
The study included both previously treated and untreated participants who were followed for 1 and 2 years, respectively, after starting recombinant factor IX therapy.
The primary safety outcome was the incidence and number of adverse drug reactions. Effectiveness was measured using clinical effectiveness rates and annualized bleeding rates (ABR).
After analysis, the researchers found that the effectiveness rates were 95.5% and 93.7% for patients who received routine prophylaxis and on-demand treatment, respectively.
The median ABR was lower during routine prophylaxis – 2.0 – versus the rest of the observation period – 8.3. “This difference was prominent among patients with severe haemophilia B or haemophilic arthropathy,” the researchers wrote.
With respect to safety, 11 adverse drug reactions were seen in seven previously treated patients. New inhibitor development was not observed in any participants, but recurrence was seen in one patient.
“Our results are consistent with those of previous studies where the incidence of inhibitor antibody development in hemophilia B has been reported as 1%-5%,” Dr. Fukutake and colleagues wrote.
The researchers acknowledged that one key limitation of the study was the observational design.
“The results suggest that nonacog alfa was well tolerated and appropriately used under routine clinical practice,” the authors concluded.
The study was funded and conducted by Pfizer Japan. The authors reported financial relationships with Pfizer and several other companies. One coauthor is an employee of Pfizer Japan.
SOURCE: Fukutake K et al. Haemophilia. 2019 Jun 6. doi: 10.1111/hae.13783.
The recombinant factor IX product nonacog alfa appears safe and effective for patients with hemophilia B, according to results from a recent postmarketing study in Japan.
While nonacog alfa was approved in the United States and Europe in 1997, the product wasn’t approved in Japan until 2009. Since it was the first recombinant factor IX product available there, and only a small number of patients were enrolled in domestic clinical trials, the Japanese government required additional real-world studies.
“In the last couple of years, several extended half‐life blood coagulation factor products gained regulatory approval for the treatment of hemophilia B. However, access to this most advanced treatment option remains limited to developed countries, and the need for standard half‐life recombinant or plasma‐derived FIX products is still high,” wrote Katsuyuki Fukutake, MD, PhD, of Tokyo Medical University, Japan, and colleagues.
The researchers conducted an observational postmarketing surveillance study of 312 patients with hemophilia B who received nonacog alfa therapy from 2010 to 2014. The team evaluated the real-world safety, including the incidence of inhibitors and adverse events, and effectiveness of the recombinant product in Japan.
The findings were published in Haemophilia.
The study included both previously treated and untreated participants who were followed for 1 and 2 years, respectively, after starting recombinant factor IX therapy.
The primary safety outcome was the incidence and number of adverse drug reactions. Effectiveness was measured using clinical effectiveness rates and annualized bleeding rates (ABR).
After analysis, the researchers found that the effectiveness rates were 95.5% and 93.7% for patients who received routine prophylaxis and on-demand treatment, respectively.
The median ABR was lower during routine prophylaxis – 2.0 – versus the rest of the observation period – 8.3. “This difference was prominent among patients with severe haemophilia B or haemophilic arthropathy,” the researchers wrote.
With respect to safety, 11 adverse drug reactions were seen in seven previously treated patients. New inhibitor development was not observed in any participants, but recurrence was seen in one patient.
“Our results are consistent with those of previous studies where the incidence of inhibitor antibody development in hemophilia B has been reported as 1%-5%,” Dr. Fukutake and colleagues wrote.
The researchers acknowledged that one key limitation of the study was the observational design.
“The results suggest that nonacog alfa was well tolerated and appropriately used under routine clinical practice,” the authors concluded.
The study was funded and conducted by Pfizer Japan. The authors reported financial relationships with Pfizer and several other companies. One coauthor is an employee of Pfizer Japan.
SOURCE: Fukutake K et al. Haemophilia. 2019 Jun 6. doi: 10.1111/hae.13783.
FROM HAEMOPHILIA
BET inhibitors may target oncogene in ABC-like DLBCL
(ABC-like DLBCL).
Researchers found the TCF4 (E2-2) transcription factor is an oncogene in ABC-like DLBCL, and TCF4 can be targeted via BET inhibition.
The BET protein degrader ARV771 reduced TCF4 expression and exhibited activity against ABC-like DLBCL in vitro and in vivo.
Neeraj Jain, PhD, of the University of Texas MD Anderson Cancer Center in Houston and colleagues reported these findings in Science Translational Medicine.
The researchers performed a genomic analysis of 1,000 DLBCL tumors and discovered that gains of 18q21.2 were the most frequent genetic alteration in ABC-like DLBCL. In analyzing another 249 tumors, the researchers found that TCF4 was the target of the 18q21.2 gains.
Additional experiments with primary DLBCL tumors and DLBCL cell lines indicated that TCF4 regulates IGHM and MYC expression. The researchers also found that the TCF4 gene was “one of the most highly BRD4-loaded genes in DLBCL,” and knocking down BRD4 in DLBCL cell lines reduced TCF4 expression.
These findings prompted the team to test small-molecule BET inhibitors – JQ1 and OTX015 – and a BET protein degrader – ARV771 – in ABC-like DLBCL cell lines with a high TCF4 copy number.
Treatment with JQ1 and OTX015 resulted in upregulation of BRD4, but ARV771 treatment did not. As a result, subsequent experiments were performed with ARV771.
The researchers found that ARV771 induced apoptosis in the cell lines and reduced the expression of TCF4, IgM, and MYC. However, enforced TCF4 expression during ARV771 treatment rescued IgM and MYC expression. This suggests that “reduction of TCF4 is one of the mechanisms by which BET inhibition reduces IgM and MYC expression and induces apoptosis,” according to the researchers.
The team also tested ARV771 in mouse models of ABC-like DLBCL with high TCF4 expression. ARV771 significantly reduced tumor growth and prolonged survival (P less than .05 for both), and there were no signs of toxicity in ARV771-treated mice.
“Our data provide a clear functional rationale for BET inhibition in ABC-like DLBCL,” the researchers wrote. They did note, however, that BCL2 overexpression is associated with resistance to BET inhibitors, and most of the 18q DNA copy number gains the researchers observed in DLBCL encompass TCF4 and BCL2. The team therefore theorized that combining a BET inhibitor with a BCL2 inhibitor could be a promising treatment approach in ABC-like DLBCL and is worthy of further investigation.
This research was supported by the Nebraska Department of Health & Human Services, the Schweitzer Family Fund, the Fred & Pamela Buffet Cancer Center Support Grant, and the MD Anderson Cancer Center NCI CORE Grant. The authors reported having no conflicts of interest related to the study.
SOURCE: Jain N et al. Sci. Transl. Med. 2019 Jun 19. doi: 10.1126/scitranslmed.aav5599.
(ABC-like DLBCL).
Researchers found the TCF4 (E2-2) transcription factor is an oncogene in ABC-like DLBCL, and TCF4 can be targeted via BET inhibition.
The BET protein degrader ARV771 reduced TCF4 expression and exhibited activity against ABC-like DLBCL in vitro and in vivo.
Neeraj Jain, PhD, of the University of Texas MD Anderson Cancer Center in Houston and colleagues reported these findings in Science Translational Medicine.
The researchers performed a genomic analysis of 1,000 DLBCL tumors and discovered that gains of 18q21.2 were the most frequent genetic alteration in ABC-like DLBCL. In analyzing another 249 tumors, the researchers found that TCF4 was the target of the 18q21.2 gains.
Additional experiments with primary DLBCL tumors and DLBCL cell lines indicated that TCF4 regulates IGHM and MYC expression. The researchers also found that the TCF4 gene was “one of the most highly BRD4-loaded genes in DLBCL,” and knocking down BRD4 in DLBCL cell lines reduced TCF4 expression.
These findings prompted the team to test small-molecule BET inhibitors – JQ1 and OTX015 – and a BET protein degrader – ARV771 – in ABC-like DLBCL cell lines with a high TCF4 copy number.
Treatment with JQ1 and OTX015 resulted in upregulation of BRD4, but ARV771 treatment did not. As a result, subsequent experiments were performed with ARV771.
The researchers found that ARV771 induced apoptosis in the cell lines and reduced the expression of TCF4, IgM, and MYC. However, enforced TCF4 expression during ARV771 treatment rescued IgM and MYC expression. This suggests that “reduction of TCF4 is one of the mechanisms by which BET inhibition reduces IgM and MYC expression and induces apoptosis,” according to the researchers.
The team also tested ARV771 in mouse models of ABC-like DLBCL with high TCF4 expression. ARV771 significantly reduced tumor growth and prolonged survival (P less than .05 for both), and there were no signs of toxicity in ARV771-treated mice.
“Our data provide a clear functional rationale for BET inhibition in ABC-like DLBCL,” the researchers wrote. They did note, however, that BCL2 overexpression is associated with resistance to BET inhibitors, and most of the 18q DNA copy number gains the researchers observed in DLBCL encompass TCF4 and BCL2. The team therefore theorized that combining a BET inhibitor with a BCL2 inhibitor could be a promising treatment approach in ABC-like DLBCL and is worthy of further investigation.
This research was supported by the Nebraska Department of Health & Human Services, the Schweitzer Family Fund, the Fred & Pamela Buffet Cancer Center Support Grant, and the MD Anderson Cancer Center NCI CORE Grant. The authors reported having no conflicts of interest related to the study.
SOURCE: Jain N et al. Sci. Transl. Med. 2019 Jun 19. doi: 10.1126/scitranslmed.aav5599.
(ABC-like DLBCL).
Researchers found the TCF4 (E2-2) transcription factor is an oncogene in ABC-like DLBCL, and TCF4 can be targeted via BET inhibition.
The BET protein degrader ARV771 reduced TCF4 expression and exhibited activity against ABC-like DLBCL in vitro and in vivo.
Neeraj Jain, PhD, of the University of Texas MD Anderson Cancer Center in Houston and colleagues reported these findings in Science Translational Medicine.
The researchers performed a genomic analysis of 1,000 DLBCL tumors and discovered that gains of 18q21.2 were the most frequent genetic alteration in ABC-like DLBCL. In analyzing another 249 tumors, the researchers found that TCF4 was the target of the 18q21.2 gains.
Additional experiments with primary DLBCL tumors and DLBCL cell lines indicated that TCF4 regulates IGHM and MYC expression. The researchers also found that the TCF4 gene was “one of the most highly BRD4-loaded genes in DLBCL,” and knocking down BRD4 in DLBCL cell lines reduced TCF4 expression.
These findings prompted the team to test small-molecule BET inhibitors – JQ1 and OTX015 – and a BET protein degrader – ARV771 – in ABC-like DLBCL cell lines with a high TCF4 copy number.
Treatment with JQ1 and OTX015 resulted in upregulation of BRD4, but ARV771 treatment did not. As a result, subsequent experiments were performed with ARV771.
The researchers found that ARV771 induced apoptosis in the cell lines and reduced the expression of TCF4, IgM, and MYC. However, enforced TCF4 expression during ARV771 treatment rescued IgM and MYC expression. This suggests that “reduction of TCF4 is one of the mechanisms by which BET inhibition reduces IgM and MYC expression and induces apoptosis,” according to the researchers.
The team also tested ARV771 in mouse models of ABC-like DLBCL with high TCF4 expression. ARV771 significantly reduced tumor growth and prolonged survival (P less than .05 for both), and there were no signs of toxicity in ARV771-treated mice.
“Our data provide a clear functional rationale for BET inhibition in ABC-like DLBCL,” the researchers wrote. They did note, however, that BCL2 overexpression is associated with resistance to BET inhibitors, and most of the 18q DNA copy number gains the researchers observed in DLBCL encompass TCF4 and BCL2. The team therefore theorized that combining a BET inhibitor with a BCL2 inhibitor could be a promising treatment approach in ABC-like DLBCL and is worthy of further investigation.
This research was supported by the Nebraska Department of Health & Human Services, the Schweitzer Family Fund, the Fred & Pamela Buffet Cancer Center Support Grant, and the MD Anderson Cancer Center NCI CORE Grant. The authors reported having no conflicts of interest related to the study.
SOURCE: Jain N et al. Sci. Transl. Med. 2019 Jun 19. doi: 10.1126/scitranslmed.aav5599.
FROM SCIENCE TRANSLATIONAL MEDICINE
Appeals court allows Title X restrictions to take effect
The panel ruled that the Trump administration’s funding restrictions were a reasonable interpretation of the federal Title X statute and that the administration is likely to prevail in its argument that lower courts erroneously halted the rules from taking effect. The ruling means the restrictions can take effect in every state except for Maryland, which passed a 2019 measure approving the use of state funds to replace federal Title X money if the new rule is enacted.
Alex Azar, secretary of the Department of Health & Human Services, said agency officials were pleased the 9th Circuit recognized there was no need to hold up the new family planning rules that simply enforce laws already on the books.
“We are also pleased that the [9th] Circuit agreed that the three preliminary injunctions against the new rules, including two nationwide injunctions, were inappropriate,” Mr. Azar said in the statement. “This decision is a major step toward the Trump administration being able to ensure that all Title X projects comply with the Title X statute and do not support abortion as a method of family planning.”
Leana Wen, MD, president for the Planned Parenthood Federation of America called the court ruling “devastating” for the millions of patients who rely on Title X health centers for cancer screenings, HIV tests, affordable birth control, and other critical primary and preventive care.
“We will be immediately seeking emergency relief from the [U.S.] Court of Appeals,” Dr. Wen said in a statement. “Planned Parenthood will not let the government censor our doctors and nurses from informing patients where and how they can access health care. We will continue to fight the Trump administration in the courts and alongside champions in Congress to protect everyone’s fundamental right to health care.”
The changes to the Title X program – originally scheduled to take effect May 3 – make health clinics ineligible for Title X funding if they offer, promote, or support abortion as a method of family planning. Title X grants generally go to health centers that provide reproductive health care – such as STD testing, cancer screenings, and contraception – to low-income families. Under the rule, the government would withdraw financial assistance to clinics if they allow counseling or referrals associated with abortion, regardless of whether the money is used for other health care services.
More than 20 states and several abortion rights organizations sued over the rules in four separate states. District judges in Oregon, Washington, and California temporarily blocked the rules from taking effect. The 9th Circuit ruling overturns these injunctions.
The American College of Physicians, the American Academy of Family Physicians, the American College of Obstetricians and Gynecologists, the American Academy of Pediatrics, and other groups have voiced their opposition to the Title X restrictions.
In a joint court brief, the medical societies wrote that the Trump administration’s limitations to the Title X program will create cultural, geographic, and financial barriers to care; erode the physician-patient relationship; and cause extreme, immediate, and irreparable harm to millions of patients.
The panel ruled that the Trump administration’s funding restrictions were a reasonable interpretation of the federal Title X statute and that the administration is likely to prevail in its argument that lower courts erroneously halted the rules from taking effect. The ruling means the restrictions can take effect in every state except for Maryland, which passed a 2019 measure approving the use of state funds to replace federal Title X money if the new rule is enacted.
Alex Azar, secretary of the Department of Health & Human Services, said agency officials were pleased the 9th Circuit recognized there was no need to hold up the new family planning rules that simply enforce laws already on the books.
“We are also pleased that the [9th] Circuit agreed that the three preliminary injunctions against the new rules, including two nationwide injunctions, were inappropriate,” Mr. Azar said in the statement. “This decision is a major step toward the Trump administration being able to ensure that all Title X projects comply with the Title X statute and do not support abortion as a method of family planning.”
Leana Wen, MD, president for the Planned Parenthood Federation of America called the court ruling “devastating” for the millions of patients who rely on Title X health centers for cancer screenings, HIV tests, affordable birth control, and other critical primary and preventive care.
“We will be immediately seeking emergency relief from the [U.S.] Court of Appeals,” Dr. Wen said in a statement. “Planned Parenthood will not let the government censor our doctors and nurses from informing patients where and how they can access health care. We will continue to fight the Trump administration in the courts and alongside champions in Congress to protect everyone’s fundamental right to health care.”
The changes to the Title X program – originally scheduled to take effect May 3 – make health clinics ineligible for Title X funding if they offer, promote, or support abortion as a method of family planning. Title X grants generally go to health centers that provide reproductive health care – such as STD testing, cancer screenings, and contraception – to low-income families. Under the rule, the government would withdraw financial assistance to clinics if they allow counseling or referrals associated with abortion, regardless of whether the money is used for other health care services.
More than 20 states and several abortion rights organizations sued over the rules in four separate states. District judges in Oregon, Washington, and California temporarily blocked the rules from taking effect. The 9th Circuit ruling overturns these injunctions.
The American College of Physicians, the American Academy of Family Physicians, the American College of Obstetricians and Gynecologists, the American Academy of Pediatrics, and other groups have voiced their opposition to the Title X restrictions.
In a joint court brief, the medical societies wrote that the Trump administration’s limitations to the Title X program will create cultural, geographic, and financial barriers to care; erode the physician-patient relationship; and cause extreme, immediate, and irreparable harm to millions of patients.
The panel ruled that the Trump administration’s funding restrictions were a reasonable interpretation of the federal Title X statute and that the administration is likely to prevail in its argument that lower courts erroneously halted the rules from taking effect. The ruling means the restrictions can take effect in every state except for Maryland, which passed a 2019 measure approving the use of state funds to replace federal Title X money if the new rule is enacted.
Alex Azar, secretary of the Department of Health & Human Services, said agency officials were pleased the 9th Circuit recognized there was no need to hold up the new family planning rules that simply enforce laws already on the books.
“We are also pleased that the [9th] Circuit agreed that the three preliminary injunctions against the new rules, including two nationwide injunctions, were inappropriate,” Mr. Azar said in the statement. “This decision is a major step toward the Trump administration being able to ensure that all Title X projects comply with the Title X statute and do not support abortion as a method of family planning.”
Leana Wen, MD, president for the Planned Parenthood Federation of America called the court ruling “devastating” for the millions of patients who rely on Title X health centers for cancer screenings, HIV tests, affordable birth control, and other critical primary and preventive care.
“We will be immediately seeking emergency relief from the [U.S.] Court of Appeals,” Dr. Wen said in a statement. “Planned Parenthood will not let the government censor our doctors and nurses from informing patients where and how they can access health care. We will continue to fight the Trump administration in the courts and alongside champions in Congress to protect everyone’s fundamental right to health care.”
The changes to the Title X program – originally scheduled to take effect May 3 – make health clinics ineligible for Title X funding if they offer, promote, or support abortion as a method of family planning. Title X grants generally go to health centers that provide reproductive health care – such as STD testing, cancer screenings, and contraception – to low-income families. Under the rule, the government would withdraw financial assistance to clinics if they allow counseling or referrals associated with abortion, regardless of whether the money is used for other health care services.
More than 20 states and several abortion rights organizations sued over the rules in four separate states. District judges in Oregon, Washington, and California temporarily blocked the rules from taking effect. The 9th Circuit ruling overturns these injunctions.
The American College of Physicians, the American Academy of Family Physicians, the American College of Obstetricians and Gynecologists, the American Academy of Pediatrics, and other groups have voiced their opposition to the Title X restrictions.
In a joint court brief, the medical societies wrote that the Trump administration’s limitations to the Title X program will create cultural, geographic, and financial barriers to care; erode the physician-patient relationship; and cause extreme, immediate, and irreparable harm to millions of patients.
Many doubt Medicare-for-all would bring universal coverage
Does Medicare-for-all mean that everyone gets health insurance coverage?
The public is not convinced that this would be the case, and Republicans are even more skeptical, according to a new survey from the Kaiser Family Foundation.
and there is a sizable split between Republicans and Democrats on the issue. Republicans, in fact, were more likely to say that all residents would not have coverage, with less than 49% of people identifying as Republican having answered “no” to the question and 45% having answered “yes”, Kaiser reported in its latest Health Tracking Poll.
Democrats were much more optimistic but not all were certain that all U.S. residents would have health insurance coverage. While 76% of Democrats responded yes when queried about whether all residents would get coverage, 21% answered no to the question. Responses to the question from independents – 61% said yes and 35% said no – very closely reflected the overall vote of 62% yes and 34% no, Kaiser said.
The partisan divide appeared again when respondents were asked if physicians and hospitals would be paid less under a national health plan: 64% of Republicans said payments would be reduced versus 42% of Democrats. Similarly, more than half of Republicans (53%) said that people who buy their own insurance would not be able to keep their current plans, compared with 24% of Democrats, the poll data show.
Those looking for common ground can point to responses regarding a couple of other potential effects of a national health plan. Republicans (57%) and Democrats (52%) largely agreed that private health insurance companies would not be the primary way Americans get health coverage, and they agreed that people would continue to pay deductibles and copays when they used health care services (68% for Republicans, 71% for Democrats), Kaiser said.
The poll was conducted from May 30 to June 4, 2019, and involved responses from 1,206 adults. The margin of sampling error was plus or minus 3 percentage points.
Does Medicare-for-all mean that everyone gets health insurance coverage?
The public is not convinced that this would be the case, and Republicans are even more skeptical, according to a new survey from the Kaiser Family Foundation.
and there is a sizable split between Republicans and Democrats on the issue. Republicans, in fact, were more likely to say that all residents would not have coverage, with less than 49% of people identifying as Republican having answered “no” to the question and 45% having answered “yes”, Kaiser reported in its latest Health Tracking Poll.
Democrats were much more optimistic but not all were certain that all U.S. residents would have health insurance coverage. While 76% of Democrats responded yes when queried about whether all residents would get coverage, 21% answered no to the question. Responses to the question from independents – 61% said yes and 35% said no – very closely reflected the overall vote of 62% yes and 34% no, Kaiser said.
The partisan divide appeared again when respondents were asked if physicians and hospitals would be paid less under a national health plan: 64% of Republicans said payments would be reduced versus 42% of Democrats. Similarly, more than half of Republicans (53%) said that people who buy their own insurance would not be able to keep their current plans, compared with 24% of Democrats, the poll data show.
Those looking for common ground can point to responses regarding a couple of other potential effects of a national health plan. Republicans (57%) and Democrats (52%) largely agreed that private health insurance companies would not be the primary way Americans get health coverage, and they agreed that people would continue to pay deductibles and copays when they used health care services (68% for Republicans, 71% for Democrats), Kaiser said.
The poll was conducted from May 30 to June 4, 2019, and involved responses from 1,206 adults. The margin of sampling error was plus or minus 3 percentage points.
Does Medicare-for-all mean that everyone gets health insurance coverage?
The public is not convinced that this would be the case, and Republicans are even more skeptical, according to a new survey from the Kaiser Family Foundation.
and there is a sizable split between Republicans and Democrats on the issue. Republicans, in fact, were more likely to say that all residents would not have coverage, with less than 49% of people identifying as Republican having answered “no” to the question and 45% having answered “yes”, Kaiser reported in its latest Health Tracking Poll.
Democrats were much more optimistic but not all were certain that all U.S. residents would have health insurance coverage. While 76% of Democrats responded yes when queried about whether all residents would get coverage, 21% answered no to the question. Responses to the question from independents – 61% said yes and 35% said no – very closely reflected the overall vote of 62% yes and 34% no, Kaiser said.
The partisan divide appeared again when respondents were asked if physicians and hospitals would be paid less under a national health plan: 64% of Republicans said payments would be reduced versus 42% of Democrats. Similarly, more than half of Republicans (53%) said that people who buy their own insurance would not be able to keep their current plans, compared with 24% of Democrats, the poll data show.
Those looking for common ground can point to responses regarding a couple of other potential effects of a national health plan. Republicans (57%) and Democrats (52%) largely agreed that private health insurance companies would not be the primary way Americans get health coverage, and they agreed that people would continue to pay deductibles and copays when they used health care services (68% for Republicans, 71% for Democrats), Kaiser said.
The poll was conducted from May 30 to June 4, 2019, and involved responses from 1,206 adults. The margin of sampling error was plus or minus 3 percentage points.
Case shows power of collaborative care for depression
Remission rate for Boeing employees climbed from 10% to 35%
SAN FRANCISCO – Under an accountable care contract with airplane maker Boeing, the University of Washington, Seattle, increased the rate of depression remission from about 10% to 35%, and the number of people in remission improved, based on Patient Health Questionnaire (PHQ-9) scores, from 20% to 70% – both in less than a year.
Boeing was particularly concerned about depression among its roughly 27,000 Puget Sound–area employees when it entered a contract with the University of Washington (UW) a few years ago for health services. Workers with depression are less likely to show up to work, and when they do, they are more likely to make mistakes and cause safety problems. To ensure that the university addressed the problem, Boeing tied payments to improved depression scores.
It didn’t take UW long to meet the PHQ-9 targets for improvement and remission, meaning a score below 5 points. Boeing also wanted its employees to be screened annually for depression and repeated testing of patients with depression to track how well they were doing. The university increased the number of patients rescreened within 8 weeks of their first PHQ-9 from about 45% to 75% – also in less than a year.
It simply scaled up the approach to meet Boeing’s targets.
“This has been an interesting journey,” said Jürgen Unützer, MD, MPH, who has been key to the efforts. “It’s required quite a bit of work, but it can be done. We’ve made a lot of progress,” he said at the American Psychiatric Association annual meeting.
Key components, besides the primary care provider, include evidence-based treatment, a mental health case manager, a system to track outcomes, and a psychiatrist to consult when patients do not improve. It’s a team approach.
Dr. Unützer and his colleagues have proved that it can work among older adults with depression and, in the end, save money (Am J Manag Care. 2008 Feb;14[2]:95-100). They’ve even published a how-to book, “Integrated Care: Creating Effective Mental and Primary Health Care Teams” (John Wiley & Sons, 2016).
A key challenge with Boeing was making sure that depressed patients returned for follow-up care and repeat PHQ-9s, and that they did not languish on ineffective treatments.
“We explain [to them that] this is not just a one-time thing,” said Dr. Unützer, chair of psychiatry and behavioral sciences at UW. “We [will] keep with them until they are well.”
Patients are enrolled in the patient portal on UW’s Epic records system to facilitate communication. The system sends out follow-up reminders, and sometimes it is used to send PHQ-9s directly to patients.
“We have automated this as much as possible.” When there’s no response, patients often are sent text messages or called by phone to make sure that they are doing OK and taking their medicine, he said.
Chart reviews are used to identify patients who are not improving. “We reach out to primary care and say, ‘We think you could use some help.’ It’s not always ”a comfortable conversation. “A lot of us like to assume our patients are getting better,” Dr. Unützer said.
Overall, “this notion of population-based care – the idea that ... you have a whole bucket of patients out there you might have seen at some point” but are still responsible for – “is a total change for most of us who are practicing clinicians,” he said.
Dr. Unützer did not report any disclosures.
Remission rate for Boeing employees climbed from 10% to 35%
Remission rate for Boeing employees climbed from 10% to 35%
SAN FRANCISCO – Under an accountable care contract with airplane maker Boeing, the University of Washington, Seattle, increased the rate of depression remission from about 10% to 35%, and the number of people in remission improved, based on Patient Health Questionnaire (PHQ-9) scores, from 20% to 70% – both in less than a year.
Boeing was particularly concerned about depression among its roughly 27,000 Puget Sound–area employees when it entered a contract with the University of Washington (UW) a few years ago for health services. Workers with depression are less likely to show up to work, and when they do, they are more likely to make mistakes and cause safety problems. To ensure that the university addressed the problem, Boeing tied payments to improved depression scores.
It didn’t take UW long to meet the PHQ-9 targets for improvement and remission, meaning a score below 5 points. Boeing also wanted its employees to be screened annually for depression and repeated testing of patients with depression to track how well they were doing. The university increased the number of patients rescreened within 8 weeks of their first PHQ-9 from about 45% to 75% – also in less than a year.
It simply scaled up the approach to meet Boeing’s targets.
“This has been an interesting journey,” said Jürgen Unützer, MD, MPH, who has been key to the efforts. “It’s required quite a bit of work, but it can be done. We’ve made a lot of progress,” he said at the American Psychiatric Association annual meeting.
Key components, besides the primary care provider, include evidence-based treatment, a mental health case manager, a system to track outcomes, and a psychiatrist to consult when patients do not improve. It’s a team approach.
Dr. Unützer and his colleagues have proved that it can work among older adults with depression and, in the end, save money (Am J Manag Care. 2008 Feb;14[2]:95-100). They’ve even published a how-to book, “Integrated Care: Creating Effective Mental and Primary Health Care Teams” (John Wiley & Sons, 2016).
A key challenge with Boeing was making sure that depressed patients returned for follow-up care and repeat PHQ-9s, and that they did not languish on ineffective treatments.
“We explain [to them that] this is not just a one-time thing,” said Dr. Unützer, chair of psychiatry and behavioral sciences at UW. “We [will] keep with them until they are well.”
Patients are enrolled in the patient portal on UW’s Epic records system to facilitate communication. The system sends out follow-up reminders, and sometimes it is used to send PHQ-9s directly to patients.
“We have automated this as much as possible.” When there’s no response, patients often are sent text messages or called by phone to make sure that they are doing OK and taking their medicine, he said.
Chart reviews are used to identify patients who are not improving. “We reach out to primary care and say, ‘We think you could use some help.’ It’s not always ”a comfortable conversation. “A lot of us like to assume our patients are getting better,” Dr. Unützer said.
Overall, “this notion of population-based care – the idea that ... you have a whole bucket of patients out there you might have seen at some point” but are still responsible for – “is a total change for most of us who are practicing clinicians,” he said.
Dr. Unützer did not report any disclosures.
SAN FRANCISCO – Under an accountable care contract with airplane maker Boeing, the University of Washington, Seattle, increased the rate of depression remission from about 10% to 35%, and the number of people in remission improved, based on Patient Health Questionnaire (PHQ-9) scores, from 20% to 70% – both in less than a year.
Boeing was particularly concerned about depression among its roughly 27,000 Puget Sound–area employees when it entered a contract with the University of Washington (UW) a few years ago for health services. Workers with depression are less likely to show up to work, and when they do, they are more likely to make mistakes and cause safety problems. To ensure that the university addressed the problem, Boeing tied payments to improved depression scores.
It didn’t take UW long to meet the PHQ-9 targets for improvement and remission, meaning a score below 5 points. Boeing also wanted its employees to be screened annually for depression and repeated testing of patients with depression to track how well they were doing. The university increased the number of patients rescreened within 8 weeks of their first PHQ-9 from about 45% to 75% – also in less than a year.
It simply scaled up the approach to meet Boeing’s targets.
“This has been an interesting journey,” said Jürgen Unützer, MD, MPH, who has been key to the efforts. “It’s required quite a bit of work, but it can be done. We’ve made a lot of progress,” he said at the American Psychiatric Association annual meeting.
Key components, besides the primary care provider, include evidence-based treatment, a mental health case manager, a system to track outcomes, and a psychiatrist to consult when patients do not improve. It’s a team approach.
Dr. Unützer and his colleagues have proved that it can work among older adults with depression and, in the end, save money (Am J Manag Care. 2008 Feb;14[2]:95-100). They’ve even published a how-to book, “Integrated Care: Creating Effective Mental and Primary Health Care Teams” (John Wiley & Sons, 2016).
A key challenge with Boeing was making sure that depressed patients returned for follow-up care and repeat PHQ-9s, and that they did not languish on ineffective treatments.
“We explain [to them that] this is not just a one-time thing,” said Dr. Unützer, chair of psychiatry and behavioral sciences at UW. “We [will] keep with them until they are well.”
Patients are enrolled in the patient portal on UW’s Epic records system to facilitate communication. The system sends out follow-up reminders, and sometimes it is used to send PHQ-9s directly to patients.
“We have automated this as much as possible.” When there’s no response, patients often are sent text messages or called by phone to make sure that they are doing OK and taking their medicine, he said.
Chart reviews are used to identify patients who are not improving. “We reach out to primary care and say, ‘We think you could use some help.’ It’s not always ”a comfortable conversation. “A lot of us like to assume our patients are getting better,” Dr. Unützer said.
Overall, “this notion of population-based care – the idea that ... you have a whole bucket of patients out there you might have seen at some point” but are still responsible for – “is a total change for most of us who are practicing clinicians,” he said.
Dr. Unützer did not report any disclosures.
REPORTING FROM APA 2019
No Pip/Tazo for patients with ESBL blood stream infections
Background: ESBL-producing gram-negative bacilli are becoming increasingly common. Carbapenems are considered the treatment of choice for these infections, but they may in turn select for carbapenem-resistant gram-negative bacilli.
Study design: Open-label, noninferiority, randomized clinical trial.
Setting: Adult inpatients from nine countries (not including the United States).
Synopsis: Patients with at least one positive blood culture for ESBL E. coli or K. pneumoniae were screened. Of the initial 1,646 patients assessed, only 391 were enrolled (866 met exclusion criteria, 218 patients declined, and 123 treating physicians declined). Patients were randomized within 72 hours of the positive blood culture collection to either piperacillin/tazobactam 4.5 g every 6 hours or meropenem 1 g every 8 hours. Patients were treated from 4 to 14 days, with the total duration of antibiotics left up to the treating physician.
The primary outcome was all-cause mortality at 30 days after randomization. The study was stopped early because of a significant mortality difference between the two groups (12.3% in the piperacillin/tazobactam group versus 3.7% in the meropenem group).
The overall mortality rate was lower than expected. The sickest patients may have been excluded because the treating physician needed to approve enrollment. Because of the necessity for empiric antibiotic therapy, there was substantial crossover in antibiotics between the groups, although this would have biased the study toward noninferiority.
Bottom line: For patients with ESBL E. coli or K. pneumoniae blood stream infections, treatment with piperacillin/tazobactam was inferior to meropenem for 30-day mortality.
Citation: Harris PNA et al. Effect of piperacillin-tazobactam vs meropenem on 30-day mortality for patients with E coli or Klebsiella pneumoniae bloodstream infection and ceftriaxone resistance: A randomized clinical trial. JAMA. 2018;320(10):984-94.
Dr. Gabriel is assistant professor of medicine and director of Preoperative Medicine and Medicine Consult Service in the division of hospital medicine at Mount Sinai Hospital, New York.
Background: ESBL-producing gram-negative bacilli are becoming increasingly common. Carbapenems are considered the treatment of choice for these infections, but they may in turn select for carbapenem-resistant gram-negative bacilli.
Study design: Open-label, noninferiority, randomized clinical trial.
Setting: Adult inpatients from nine countries (not including the United States).
Synopsis: Patients with at least one positive blood culture for ESBL E. coli or K. pneumoniae were screened. Of the initial 1,646 patients assessed, only 391 were enrolled (866 met exclusion criteria, 218 patients declined, and 123 treating physicians declined). Patients were randomized within 72 hours of the positive blood culture collection to either piperacillin/tazobactam 4.5 g every 6 hours or meropenem 1 g every 8 hours. Patients were treated from 4 to 14 days, with the total duration of antibiotics left up to the treating physician.
The primary outcome was all-cause mortality at 30 days after randomization. The study was stopped early because of a significant mortality difference between the two groups (12.3% in the piperacillin/tazobactam group versus 3.7% in the meropenem group).
The overall mortality rate was lower than expected. The sickest patients may have been excluded because the treating physician needed to approve enrollment. Because of the necessity for empiric antibiotic therapy, there was substantial crossover in antibiotics between the groups, although this would have biased the study toward noninferiority.
Bottom line: For patients with ESBL E. coli or K. pneumoniae blood stream infections, treatment with piperacillin/tazobactam was inferior to meropenem for 30-day mortality.
Citation: Harris PNA et al. Effect of piperacillin-tazobactam vs meropenem on 30-day mortality for patients with E coli or Klebsiella pneumoniae bloodstream infection and ceftriaxone resistance: A randomized clinical trial. JAMA. 2018;320(10):984-94.
Dr. Gabriel is assistant professor of medicine and director of Preoperative Medicine and Medicine Consult Service in the division of hospital medicine at Mount Sinai Hospital, New York.
Background: ESBL-producing gram-negative bacilli are becoming increasingly common. Carbapenems are considered the treatment of choice for these infections, but they may in turn select for carbapenem-resistant gram-negative bacilli.
Study design: Open-label, noninferiority, randomized clinical trial.
Setting: Adult inpatients from nine countries (not including the United States).
Synopsis: Patients with at least one positive blood culture for ESBL E. coli or K. pneumoniae were screened. Of the initial 1,646 patients assessed, only 391 were enrolled (866 met exclusion criteria, 218 patients declined, and 123 treating physicians declined). Patients were randomized within 72 hours of the positive blood culture collection to either piperacillin/tazobactam 4.5 g every 6 hours or meropenem 1 g every 8 hours. Patients were treated from 4 to 14 days, with the total duration of antibiotics left up to the treating physician.
The primary outcome was all-cause mortality at 30 days after randomization. The study was stopped early because of a significant mortality difference between the two groups (12.3% in the piperacillin/tazobactam group versus 3.7% in the meropenem group).
The overall mortality rate was lower than expected. The sickest patients may have been excluded because the treating physician needed to approve enrollment. Because of the necessity for empiric antibiotic therapy, there was substantial crossover in antibiotics between the groups, although this would have biased the study toward noninferiority.
Bottom line: For patients with ESBL E. coli or K. pneumoniae blood stream infections, treatment with piperacillin/tazobactam was inferior to meropenem for 30-day mortality.
Citation: Harris PNA et al. Effect of piperacillin-tazobactam vs meropenem on 30-day mortality for patients with E coli or Klebsiella pneumoniae bloodstream infection and ceftriaxone resistance: A randomized clinical trial. JAMA. 2018;320(10):984-94.
Dr. Gabriel is assistant professor of medicine and director of Preoperative Medicine and Medicine Consult Service in the division of hospital medicine at Mount Sinai Hospital, New York.
Antimalarial may be effective, safe for erosive oral lichen planus
MILAN – an investigator reported at the World Congress of Dermatology.
In a small retrospective study, 85% of patients treated with the oral antimalarial agent had marked improvement or full remission, according to Ziyad Khamaysi, MD, a dermatologist at Rambam Health Care Campus, Haifa, Israel. Adverse effects leading to discontinuation occurred in a minority of patients and included elevated kidney function tests, hyperpigmentation, and an abnormal eye exam, he said.
“It may be a useful and convenient alternative treatment either as a monotherapy or where a rapid symptomatic relief during periods of exacerbations is needed,” he said in an oral presentation at the meeting.
A variety of medications have been used for palliation of oral lichen planus, including corticosteroids, cyclosporine, calcineurin inhibitors, retinoids, and biologics, but few have been evaluated in larger series of patients, he pointed out.
In the retrospective, nonrandomized study, 15 women and 6 men with erosive, recalcitrant oral lichen planus were treated with hydroxychloroquine (Plaquenil) at a dose of 200 mg/day, which was increased to 400 mg/day at one month. The mean age of the patients was 55 years.
In one patient, treatment was stopped after a month because of side effects, Dr. Khamaysi said. Among the remaining patients, 5 (25%) had a complete remission, while 12 (60%) had moderate to marked improvement, and 3 (15%) had no improvement, he said. In the patients who did respond, improvement was noted within 2-4 months of treatment initiation, he added. “Hydroxychloroquine kept the disease under control, with either full remission or marked improvement as long as the patients took it.”
Treatment appeared to be more effective in male patients and those under age 65 years, the investigator commented.
These data corroborate the findings of a smaller study evaluating hydroxychloroquine for oral lichen planus, published in 1993, according to Dr. Khamaysi. In that report, 9 of 10 patients had an “excellent” response to treatment, according to the investigator (J Am Acad Dermatol. 1993 Apr;28[4]:609-12).
Of the 10 patients in that study, 6 had erosions at the start of treatment, and 3 of these patients had complete healing with 3-6 months of therapy, and the other 3 had reepithelialization and at least a 50% reduction in lesion size, according to the report.
Dr. Khamaysi had no disclosures relevant to his presentation.
MILAN – an investigator reported at the World Congress of Dermatology.
In a small retrospective study, 85% of patients treated with the oral antimalarial agent had marked improvement or full remission, according to Ziyad Khamaysi, MD, a dermatologist at Rambam Health Care Campus, Haifa, Israel. Adverse effects leading to discontinuation occurred in a minority of patients and included elevated kidney function tests, hyperpigmentation, and an abnormal eye exam, he said.
“It may be a useful and convenient alternative treatment either as a monotherapy or where a rapid symptomatic relief during periods of exacerbations is needed,” he said in an oral presentation at the meeting.
A variety of medications have been used for palliation of oral lichen planus, including corticosteroids, cyclosporine, calcineurin inhibitors, retinoids, and biologics, but few have been evaluated in larger series of patients, he pointed out.
In the retrospective, nonrandomized study, 15 women and 6 men with erosive, recalcitrant oral lichen planus were treated with hydroxychloroquine (Plaquenil) at a dose of 200 mg/day, which was increased to 400 mg/day at one month. The mean age of the patients was 55 years.
In one patient, treatment was stopped after a month because of side effects, Dr. Khamaysi said. Among the remaining patients, 5 (25%) had a complete remission, while 12 (60%) had moderate to marked improvement, and 3 (15%) had no improvement, he said. In the patients who did respond, improvement was noted within 2-4 months of treatment initiation, he added. “Hydroxychloroquine kept the disease under control, with either full remission or marked improvement as long as the patients took it.”
Treatment appeared to be more effective in male patients and those under age 65 years, the investigator commented.
These data corroborate the findings of a smaller study evaluating hydroxychloroquine for oral lichen planus, published in 1993, according to Dr. Khamaysi. In that report, 9 of 10 patients had an “excellent” response to treatment, according to the investigator (J Am Acad Dermatol. 1993 Apr;28[4]:609-12).
Of the 10 patients in that study, 6 had erosions at the start of treatment, and 3 of these patients had complete healing with 3-6 months of therapy, and the other 3 had reepithelialization and at least a 50% reduction in lesion size, according to the report.
Dr. Khamaysi had no disclosures relevant to his presentation.
MILAN – an investigator reported at the World Congress of Dermatology.
In a small retrospective study, 85% of patients treated with the oral antimalarial agent had marked improvement or full remission, according to Ziyad Khamaysi, MD, a dermatologist at Rambam Health Care Campus, Haifa, Israel. Adverse effects leading to discontinuation occurred in a minority of patients and included elevated kidney function tests, hyperpigmentation, and an abnormal eye exam, he said.
“It may be a useful and convenient alternative treatment either as a monotherapy or where a rapid symptomatic relief during periods of exacerbations is needed,” he said in an oral presentation at the meeting.
A variety of medications have been used for palliation of oral lichen planus, including corticosteroids, cyclosporine, calcineurin inhibitors, retinoids, and biologics, but few have been evaluated in larger series of patients, he pointed out.
In the retrospective, nonrandomized study, 15 women and 6 men with erosive, recalcitrant oral lichen planus were treated with hydroxychloroquine (Plaquenil) at a dose of 200 mg/day, which was increased to 400 mg/day at one month. The mean age of the patients was 55 years.
In one patient, treatment was stopped after a month because of side effects, Dr. Khamaysi said. Among the remaining patients, 5 (25%) had a complete remission, while 12 (60%) had moderate to marked improvement, and 3 (15%) had no improvement, he said. In the patients who did respond, improvement was noted within 2-4 months of treatment initiation, he added. “Hydroxychloroquine kept the disease under control, with either full remission or marked improvement as long as the patients took it.”
Treatment appeared to be more effective in male patients and those under age 65 years, the investigator commented.
These data corroborate the findings of a smaller study evaluating hydroxychloroquine for oral lichen planus, published in 1993, according to Dr. Khamaysi. In that report, 9 of 10 patients had an “excellent” response to treatment, according to the investigator (J Am Acad Dermatol. 1993 Apr;28[4]:609-12).
Of the 10 patients in that study, 6 had erosions at the start of treatment, and 3 of these patients had complete healing with 3-6 months of therapy, and the other 3 had reepithelialization and at least a 50% reduction in lesion size, according to the report.
Dr. Khamaysi had no disclosures relevant to his presentation.
REPORTING FROM WCD2019