Prompted by his new bride, who is concerned she might “catch something” from him, a 53-year-old man self-refers for evaluation of a slightly itchy intergluteal rash. He’s had it for years; it waxes and wanes but never fully resolves.

It has been previously diagnosed as a yeast infection, fungal infection, and even herpes. But none of the respective treatments have helped.

More history-taking reveals a family history of psoriasis (maternal grandmother), but the patient denies other areas of involvement or other skin changes. He also denies having arthritis.

EXAMINATION
A salmon-pink, 7-cm, roughly round dry patch covered by white tenacious scale is located in the upper intergluteal/sacral interface. There is no increased warmth or tenderness on palpation.

A similar process is noted in the periumbilical area (a difficult area for this patient to see, due to his weight). Inspection of his fingernails reveals 3/10 with definite tiny pits.

What is the diagnosis?

DISCUSSION
The urge to call any and every rash occurring near the genitals a yeast infection is universally compelling among primary care providers. It is often so reflexive that even when anti-yeast medications fail, the provider hangs onto the diagnosis. This happens for one simple reason: Their differential is lacking.

This patient has psoriasis, albeit a somewhat unusual form, which demonstrates an important learning point: Psoriasis can present in any number of ways, not just in the standard “extensor surfaces of elbows and knees” distribution. It’s not unusual for psoriasis to zero in on one or two areas. I’ve seen it confined to the groin, the genitals, and the scalp. It can even involve the oral mucosa.

In these somewhat obscure cases, additional findings can be helpful to establish the diagnosis. The two areas of involvement in this case—the upper intergluteal area and the periumbilical region—may not fit the classic “knees and elbows” picture of psoriasis, but they are not atypical for the disease. Add the nail pits, the fixed nature of the problem, and the family history, and you’ve nailed the diagnosis.

Don’t forget that, occasionally, psoriatic arthropathy can precede the appearance of psoriasis, and that the severity of one does not predict the severity of the other.

Finally, in a fair number of cases, the diagnosis of psoriasis must be made by biopsy, which shows characteristic changes such as parakeratosis, epidermal thickening, and fusing of rete ridges. These “psoriasiform” changes seen microscopically must be corroborated by clinical findings, though, since many other papulosquamous diseases can exhibit similar changes.

TAKE-HOME LEARNING POINTS

• Psoriasis is one of the more common dermatoses in this country, which means you will see it with some frequency.
• Psoriasis can affect limited or atypical areas, but corroboration of the diagnosis can be sought in classic areas (nails, scalp, upper intergluteal and periumbilical areas).
• Strive to develop alternative diagnoses for similar rashes—in other words, build your differential for “yeast infection.”

Prompted by his new bride, who is concerned she might “catch something” from him, a 53-year-old man self-refers for evaluation of a slightly itchy intergluteal rash. He’s had it for years; it waxes and wanes but never fully resolves.

It has been previously diagnosed as a yeast infection, fungal infection, and even herpes. But none of the respective treatments have helped.

More history-taking reveals a family history of psoriasis (maternal grandmother), but the patient denies other areas of involvement or other skin changes. He also denies having arthritis.

EXAMINATION
A salmon-pink, 7-cm, roughly round dry patch covered by white tenacious scale is located in the upper intergluteal/sacral interface. There is no increased warmth or tenderness on palpation.

A similar process is noted in the periumbilical area (a difficult area for this patient to see, due to his weight). Inspection of his fingernails reveals 3/10 with definite tiny pits.

What is the diagnosis?

DISCUSSION
The urge to call any and every rash occurring near the genitals a yeast infection is universally compelling among primary care providers. It is often so reflexive that even when anti-yeast medications fail, the provider hangs onto the diagnosis. This happens for one simple reason: Their differential is lacking.

This patient has psoriasis, albeit a somewhat unusual form, which demonstrates an important learning point: Psoriasis can present in any number of ways, not just in the standard “extensor surfaces of elbows and knees” distribution. It’s not unusual for psoriasis to zero in on one or two areas. I’ve seen it confined to the groin, the genitals, and the scalp. It can even involve the oral mucosa.

In these somewhat obscure cases, additional findings can be helpful to establish the diagnosis. The two areas of involvement in this case—the upper intergluteal area and the periumbilical region—may not fit the classic “knees and elbows” picture of psoriasis, but they are not atypical for the disease. Add the nail pits, the fixed nature of the problem, and the family history, and you’ve nailed the diagnosis.

Don’t forget that, occasionally, psoriatic arthropathy can precede the appearance of psoriasis, and that the severity of one does not predict the severity of the other.

Finally, in a fair number of cases, the diagnosis of psoriasis must be made by biopsy, which shows characteristic changes such as parakeratosis, epidermal thickening, and fusing of rete ridges. These “psoriasiform” changes seen microscopically must be corroborated by clinical findings, though, since many other papulosquamous diseases can exhibit similar changes.

TAKE-HOME LEARNING POINTS

• Psoriasis is one of the more common dermatoses in this country, which means you will see it with some frequency.
• Psoriasis can affect limited or atypical areas, but corroboration of the diagnosis can be sought in classic areas (nails, scalp, upper intergluteal and periumbilical areas).
• Strive to develop alternative diagnoses for similar rashes—in other words, build your differential for “yeast infection.”

Prompted by his new bride, who is concerned she might “catch something” from him, a 53-year-old man self-refers for evaluation of a slightly itchy intergluteal rash. He’s had it for years; it waxes and wanes but never fully resolves.

It has been previously diagnosed as a yeast infection, fungal infection, and even herpes. But none of the respective treatments have helped.

More history-taking reveals a family history of psoriasis (maternal grandmother), but the patient denies other areas of involvement or other skin changes. He also denies having arthritis.

EXAMINATION
A salmon-pink, 7-cm, roughly round dry patch covered by white tenacious scale is located in the upper intergluteal/sacral interface. There is no increased warmth or tenderness on palpation.

A similar process is noted in the periumbilical area (a difficult area for this patient to see, due to his weight). Inspection of his fingernails reveals 3/10 with definite tiny pits.

What is the diagnosis?

DISCUSSION
The urge to call any and every rash occurring near the genitals a yeast infection is universally compelling among primary care providers. It is often so reflexive that even when anti-yeast medications fail, the provider hangs onto the diagnosis. This happens for one simple reason: Their differential is lacking.

This patient has psoriasis, albeit a somewhat unusual form, which demonstrates an important learning point: Psoriasis can present in any number of ways, not just in the standard “extensor surfaces of elbows and knees” distribution. It’s not unusual for psoriasis to zero in on one or two areas. I’ve seen it confined to the groin, the genitals, and the scalp. It can even involve the oral mucosa.

In these somewhat obscure cases, additional findings can be helpful to establish the diagnosis. The two areas of involvement in this case—the upper intergluteal area and the periumbilical region—may not fit the classic “knees and elbows” picture of psoriasis, but they are not atypical for the disease. Add the nail pits, the fixed nature of the problem, and the family history, and you’ve nailed the diagnosis.

Don’t forget that, occasionally, psoriatic arthropathy can precede the appearance of psoriasis, and that the severity of one does not predict the severity of the other.

Finally, in a fair number of cases, the diagnosis of psoriasis must be made by biopsy, which shows characteristic changes such as parakeratosis, epidermal thickening, and fusing of rete ridges. These “psoriasiform” changes seen microscopically must be corroborated by clinical findings, though, since many other papulosquamous diseases can exhibit similar changes.

TAKE-HOME LEARNING POINTS

• Psoriasis is one of the more common dermatoses in this country, which means you will see it with some frequency.
• Psoriasis can affect limited or atypical areas, but corroboration of the diagnosis can be sought in classic areas (nails, scalp, upper intergluteal and periumbilical areas).
• Strive to develop alternative diagnoses for similar rashes—in other words, build your differential for “yeast infection.”

In the October 2018 issue of Medscape Business of Medicine, the question was asked, “How can you practice quality medicine if you’re being asked to see patients every 15 minutes or less?”

CherriesJD/Thinkstock

I’m pretty sure the answer is, “you can’t.”

Yet, this is what many doctors are asked to do just to make ends meet. The majority of everyday medicine is, and always will be, a thinking game. It takes time to piece together the clues from a history and exam and decide what tests and/or treatment are the next step.

This ain’t easy. Even the shortest residencies require a combined 7 years of medical school and postgrad training. Experience and learning makes us all faster, but then the number of things that you can handle in 15 minutes is minimal. And that doesn’t even include the time needed to answer patient or family questions (which can be quite a lot) write up or transmit test orders or a prescription, and, inevitably, document the entire encounter in a meaningful way.

I don’t see patients at such a breakneck speed in my office, and yet I still end up doing most of my dictations after (or before) office hours.

In spite of lip service by politicians and administrators to correct the issue, medicine still continues to penalize those services that require thinking. And this task is the center of being a good doctor – and always has been.

Procedures are more lucrative, but imagine how my colleagues in neurosurgery would react if they were given a similar time limit on cases: A new patient has to be on the table every 15-30 minutes, and in that time you have to open, do the surgery, close, meet with family, and document the whole thing. Then get back in the OR (scrub, first) before the next case. Doesn’t matter whether you’re doing a lumbar fusion, glioma resection, or carotid endarterectomy. Those are the time limits. You get 30 minutes for lunch and to return calls. The administrator said so.

And this is where medicine continues to go. Overhead costs keep rising, and, for most docs, the only way they know to keep up is to keep cramming more patients into the day. Nobody wants to practice shoddy, hurried medicine, but neither do they want to lose their jobs to the next hungry graduate or close down a practice they spent years building.

I wish I had an answer. In fact, I think most of us do, but not one that will make patients, administrators, and doctors all happy. So the spiral continues.

And that isn’t good for patients, the people at the center of this job.
 

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

In the October 2018 issue of Medscape Business of Medicine, the question was asked, “How can you practice quality medicine if you’re being asked to see patients every 15 minutes or less?”

CherriesJD/Thinkstock

I’m pretty sure the answer is, “you can’t.”

Yet, this is what many doctors are asked to do just to make ends meet. The majority of everyday medicine is, and always will be, a thinking game. It takes time to piece together the clues from a history and exam and decide what tests and/or treatment are the next step.

This ain’t easy. Even the shortest residencies require a combined 7 years of medical school and postgrad training. Experience and learning makes us all faster, but then the number of things that you can handle in 15 minutes is minimal. And that doesn’t even include the time needed to answer patient or family questions (which can be quite a lot) write up or transmit test orders or a prescription, and, inevitably, document the entire encounter in a meaningful way.

I don’t see patients at such a breakneck speed in my office, and yet I still end up doing most of my dictations after (or before) office hours.

In spite of lip service by politicians and administrators to correct the issue, medicine still continues to penalize those services that require thinking. And this task is the center of being a good doctor – and always has been.

Procedures are more lucrative, but imagine how my colleagues in neurosurgery would react if they were given a similar time limit on cases: A new patient has to be on the table every 15-30 minutes, and in that time you have to open, do the surgery, close, meet with family, and document the whole thing. Then get back in the OR (scrub, first) before the next case. Doesn’t matter whether you’re doing a lumbar fusion, glioma resection, or carotid endarterectomy. Those are the time limits. You get 30 minutes for lunch and to return calls. The administrator said so.

And this is where medicine continues to go. Overhead costs keep rising, and, for most docs, the only way they know to keep up is to keep cramming more patients into the day. Nobody wants to practice shoddy, hurried medicine, but neither do they want to lose their jobs to the next hungry graduate or close down a practice they spent years building.

I wish I had an answer. In fact, I think most of us do, but not one that will make patients, administrators, and doctors all happy. So the spiral continues.

And that isn’t good for patients, the people at the center of this job.
 

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

In the October 2018 issue of Medscape Business of Medicine, the question was asked, “How can you practice quality medicine if you’re being asked to see patients every 15 minutes or less?”

CherriesJD/Thinkstock

I’m pretty sure the answer is, “you can’t.”

Yet, this is what many doctors are asked to do just to make ends meet. The majority of everyday medicine is, and always will be, a thinking game. It takes time to piece together the clues from a history and exam and decide what tests and/or treatment are the next step.

This ain’t easy. Even the shortest residencies require a combined 7 years of medical school and postgrad training. Experience and learning makes us all faster, but then the number of things that you can handle in 15 minutes is minimal. And that doesn’t even include the time needed to answer patient or family questions (which can be quite a lot) write up or transmit test orders or a prescription, and, inevitably, document the entire encounter in a meaningful way.

I don’t see patients at such a breakneck speed in my office, and yet I still end up doing most of my dictations after (or before) office hours.

In spite of lip service by politicians and administrators to correct the issue, medicine still continues to penalize those services that require thinking. And this task is the center of being a good doctor – and always has been.

Procedures are more lucrative, but imagine how my colleagues in neurosurgery would react if they were given a similar time limit on cases: A new patient has to be on the table every 15-30 minutes, and in that time you have to open, do the surgery, close, meet with family, and document the whole thing. Then get back in the OR (scrub, first) before the next case. Doesn’t matter whether you’re doing a lumbar fusion, glioma resection, or carotid endarterectomy. Those are the time limits. You get 30 minutes for lunch and to return calls. The administrator said so.

And this is where medicine continues to go. Overhead costs keep rising, and, for most docs, the only way they know to keep up is to keep cramming more patients into the day. Nobody wants to practice shoddy, hurried medicine, but neither do they want to lose their jobs to the next hungry graduate or close down a practice they spent years building.

I wish I had an answer. In fact, I think most of us do, but not one that will make patients, administrators, and doctors all happy. So the spiral continues.

And that isn’t good for patients, the people at the center of this job.
 

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

About 372,000 people selected a health insurance plan during the first week of Affordable Care Act open enrollment for 2019, according to the Centers for Medicare & Medicaid Services. The first week was short, with only 3 days to select coverage.

For Nov. 1-3, the exact number of plans selected was 371,676, which is about 38% less than last year’s first week, which was 4 days long, so the average number of plans selected per day was down by a little less than 18%, CMS data show.

“The final number of plan selections associated with enrollment activity during a reporting period may change due to plan modifications or cancellations,” CMS officials said, adding that the weekly data release “only reports new plan selections and active plan renewals and does not report the number of consumers who have paid premiums to effectuate their enrollment.”

Open enrollment will continue for another 6 weeks, with Dec. 15 being the final day to enroll for 2019 coverage on the 39 state exchanges that use the HealthCare.gov platform.

[email protected]

About 372,000 people selected a health insurance plan during the first week of Affordable Care Act open enrollment for 2019, according to the Centers for Medicare & Medicaid Services. The first week was short, with only 3 days to select coverage.

For Nov. 1-3, the exact number of plans selected was 371,676, which is about 38% less than last year’s first week, which was 4 days long, so the average number of plans selected per day was down by a little less than 18%, CMS data show.

“The final number of plan selections associated with enrollment activity during a reporting period may change due to plan modifications or cancellations,” CMS officials said, adding that the weekly data release “only reports new plan selections and active plan renewals and does not report the number of consumers who have paid premiums to effectuate their enrollment.”

Open enrollment will continue for another 6 weeks, with Dec. 15 being the final day to enroll for 2019 coverage on the 39 state exchanges that use the HealthCare.gov platform.

[email protected]

About 372,000 people selected a health insurance plan during the first week of Affordable Care Act open enrollment for 2019, according to the Centers for Medicare & Medicaid Services. The first week was short, with only 3 days to select coverage.

For Nov. 1-3, the exact number of plans selected was 371,676, which is about 38% less than last year’s first week, which was 4 days long, so the average number of plans selected per day was down by a little less than 18%, CMS data show.

“The final number of plan selections associated with enrollment activity during a reporting period may change due to plan modifications or cancellations,” CMS officials said, adding that the weekly data release “only reports new plan selections and active plan renewals and does not report the number of consumers who have paid premiums to effectuate their enrollment.”

Open enrollment will continue for another 6 weeks, with Dec. 15 being the final day to enroll for 2019 coverage on the 39 state exchanges that use the HealthCare.gov platform.

[email protected]

Pregnancy does not necessarily increase a woman’s risk for melanoma, nor is it clear that becoming pregnant affects melanoma’s disease course, according to current evidence. This guidance is among several updates added to newly released guidelines for managing patients with primary cutaneous melanoma.

The American Academy of Dermatology, which formed a working group to develop the updated cutaneous melanoma (CM) treatment guidelines, also addressed the burgeoning field of genetic testing for cancer in the guidelines, which were published online on Nov. 1. Although there may be a hereditary component to some melanomas, genetic testing may not be appropriate for all patients, and any formal genetic testing should be carried out only after individualized education and counseling, according to the updates.

However, the guidelines make it clear that all patients whose family history includes melanoma should be counseled about their genetic risk.

As with genetic testing, counseling regarding future pregnancies for women with melanoma, or a history of melanoma, should be personalized and account for individual history and melanoma risk, according to the new guidelines. Since evidence is lacking that pregnancy affects the course of melanoma, physicians caring for pregnant women with melanoma should first look at patient and the disease characteristics. The addition of detailed guidance regarding pregnancy reflects research showing that CM is the most common malignancy seen in pregnancy, amounting to nearly one-third of the malignancies that arise in pregnancy. “Although the incidence of CM is generally higher in men, it is higher in younger women than in men, most notably during women’s reproductive years,” wrote Susan M. Swetter, MD, and her guideline coauthors.

The National Cancer Institute

“Melanoma is the deadliest form of skin cancer, and we hope these guidelines will help dermatologists and other physicians enhance their delivery of life-saving treatment to patients,” Dr. Swetter said in a press release announcing the guideline updates. Dr. Swetter, professor of dermatology and director of the pigmented lesion and melanoma program at Stanford (Calif.) University Medical Center and Cancer Institute, led the working group that developed the guidelines. “In order to provide the best possible resource for practitioners, we reviewed the latest scientific data and addressed certain topics that weren’t covered in the AAD’s previous melanoma guidelines,” she said.

A cornerstone of cutaneous melanoma care remains unchanged in the guidelines: Surgical excision is still the preferred method for treating melanoma. Adjuvant topical therapies or radiation, say the guidelines, can be considered as second-line care, but only in limited situations in which surgery is not feasible. Staged excision techniques, such as Mohs surgery, also may be considered for certain types of melanoma and in certain body areas.

[email protected]

SOURCE: Swetter S. et al. J Am Acad Dermatol. 2011 Nov;65(5):1032-47.

Pregnancy does not necessarily increase a woman’s risk for melanoma, nor is it clear that becoming pregnant affects melanoma’s disease course, according to current evidence. This guidance is among several updates added to newly released guidelines for managing patients with primary cutaneous melanoma.

The American Academy of Dermatology, which formed a working group to develop the updated cutaneous melanoma (CM) treatment guidelines, also addressed the burgeoning field of genetic testing for cancer in the guidelines, which were published online on Nov. 1. Although there may be a hereditary component to some melanomas, genetic testing may not be appropriate for all patients, and any formal genetic testing should be carried out only after individualized education and counseling, according to the updates.

However, the guidelines make it clear that all patients whose family history includes melanoma should be counseled about their genetic risk.

As with genetic testing, counseling regarding future pregnancies for women with melanoma, or a history of melanoma, should be personalized and account for individual history and melanoma risk, according to the new guidelines. Since evidence is lacking that pregnancy affects the course of melanoma, physicians caring for pregnant women with melanoma should first look at patient and the disease characteristics. The addition of detailed guidance regarding pregnancy reflects research showing that CM is the most common malignancy seen in pregnancy, amounting to nearly one-third of the malignancies that arise in pregnancy. “Although the incidence of CM is generally higher in men, it is higher in younger women than in men, most notably during women’s reproductive years,” wrote Susan M. Swetter, MD, and her guideline coauthors.

The National Cancer Institute

“Melanoma is the deadliest form of skin cancer, and we hope these guidelines will help dermatologists and other physicians enhance their delivery of life-saving treatment to patients,” Dr. Swetter said in a press release announcing the guideline updates. Dr. Swetter, professor of dermatology and director of the pigmented lesion and melanoma program at Stanford (Calif.) University Medical Center and Cancer Institute, led the working group that developed the guidelines. “In order to provide the best possible resource for practitioners, we reviewed the latest scientific data and addressed certain topics that weren’t covered in the AAD’s previous melanoma guidelines,” she said.

A cornerstone of cutaneous melanoma care remains unchanged in the guidelines: Surgical excision is still the preferred method for treating melanoma. Adjuvant topical therapies or radiation, say the guidelines, can be considered as second-line care, but only in limited situations in which surgery is not feasible. Staged excision techniques, such as Mohs surgery, also may be considered for certain types of melanoma and in certain body areas.

[email protected]

SOURCE: Swetter S. et al. J Am Acad Dermatol. 2011 Nov;65(5):1032-47.

Pregnancy does not necessarily increase a woman’s risk for melanoma, nor is it clear that becoming pregnant affects melanoma’s disease course, according to current evidence. This guidance is among several updates added to newly released guidelines for managing patients with primary cutaneous melanoma.

The American Academy of Dermatology, which formed a working group to develop the updated cutaneous melanoma (CM) treatment guidelines, also addressed the burgeoning field of genetic testing for cancer in the guidelines, which were published online on Nov. 1. Although there may be a hereditary component to some melanomas, genetic testing may not be appropriate for all patients, and any formal genetic testing should be carried out only after individualized education and counseling, according to the updates.

However, the guidelines make it clear that all patients whose family history includes melanoma should be counseled about their genetic risk.

As with genetic testing, counseling regarding future pregnancies for women with melanoma, or a history of melanoma, should be personalized and account for individual history and melanoma risk, according to the new guidelines. Since evidence is lacking that pregnancy affects the course of melanoma, physicians caring for pregnant women with melanoma should first look at patient and the disease characteristics. The addition of detailed guidance regarding pregnancy reflects research showing that CM is the most common malignancy seen in pregnancy, amounting to nearly one-third of the malignancies that arise in pregnancy. “Although the incidence of CM is generally higher in men, it is higher in younger women than in men, most notably during women’s reproductive years,” wrote Susan M. Swetter, MD, and her guideline coauthors.

The National Cancer Institute

“Melanoma is the deadliest form of skin cancer, and we hope these guidelines will help dermatologists and other physicians enhance their delivery of life-saving treatment to patients,” Dr. Swetter said in a press release announcing the guideline updates. Dr. Swetter, professor of dermatology and director of the pigmented lesion and melanoma program at Stanford (Calif.) University Medical Center and Cancer Institute, led the working group that developed the guidelines. “In order to provide the best possible resource for practitioners, we reviewed the latest scientific data and addressed certain topics that weren’t covered in the AAD’s previous melanoma guidelines,” she said.

A cornerstone of cutaneous melanoma care remains unchanged in the guidelines: Surgical excision is still the preferred method for treating melanoma. Adjuvant topical therapies or radiation, say the guidelines, can be considered as second-line care, but only in limited situations in which surgery is not feasible. Staged excision techniques, such as Mohs surgery, also may be considered for certain types of melanoma and in certain body areas.

[email protected]

SOURCE: Swetter S. et al. J Am Acad Dermatol. 2011 Nov;65(5):1032-47.

DUBROVNIK, CROATIA – New research suggests there is no association between the PTPN22 R620W polymorphism and chronic lymphocytic leukemia (CLL) or autoimmune hematologic disorders in patients from the Republic of Macedonia.

Past studies have shown an association between the PTPN22 R620W variant and both CLL and autoimmune diseases in patients from Northwest Europe. However, a new study of Macedonian patients suggests there is no association between the variant and CLL, autoimmune hemolytic anemia (AIHA), or idiopathic thrombocytopenic purpura (ITP) for patients from Southeast Europe.

Irina Panovska-Stavridis, PhD, of Ss. Cyril and Methodius University in Skopje, Republic of Macedonia, and her colleagues presented this finding at Leukemia and Lymphoma, a meeting jointly sponsored by the University of Texas MD Anderson Cancer Center and the School of Medicine at the University of Zagreb, Croatia.

“A lot of data from the literature suggests [the PTPN22 R620W variant ] has a role in developing multiple immune diseases, but it is validated just in patients from Northwest Europe,” Dr. Panovska-Stavridis noted.

She and her colleagues decided to assess the frequency of the PTPN22 R620W variant (C1858T, rs2476601) in individuals from Southeast Europe, particularly the Republic of Macedonia.

The researchers evaluated 320 patients – 168 with CLL, 66 with AIHA, and 86 with ITP – and 182 age- and sex-matched control subjects with no history of malignant or autoimmune disease.

The team found a similar frequency of the minor T allele and genotype distribution in control subjects and patients. For example, minor T allele was 0.107 in CLL, 0.067 in AIHA, 0.036 in ITP, and 0.05 in controls. Similarly, the frequency of the CC genotype was 0.809 in CLL, 0.166 in AIHA, 0.023 in ITP, and 0.901 in controls.

Dr. Panovska-Stavridis said these results suggest the PTPN22 R620W variant is not a risk factor for the development of CLL, AIHA, or ITP in patients from Southeast Europe.

She also said the results suggest the influence of the variant on lymphocytic homeostasis is affected by certain genetic and environmental factors, and the development of CLL and autoimmune diseases is influenced by race/ethnicity-based variations in the germline composition of the IGHV locus in correlation with environmental factors.

Dr. Panovska-Stavridis did not declare any conflicts of interest.

The Leukemia and Lymphoma meeting is organized by Jonathan Wood & Associates, which is owned by the parent company of this news organization.
 

[email protected]

DUBROVNIK, CROATIA – New research suggests there is no association between the PTPN22 R620W polymorphism and chronic lymphocytic leukemia (CLL) or autoimmune hematologic disorders in patients from the Republic of Macedonia.

Past studies have shown an association between the PTPN22 R620W variant and both CLL and autoimmune diseases in patients from Northwest Europe. However, a new study of Macedonian patients suggests there is no association between the variant and CLL, autoimmune hemolytic anemia (AIHA), or idiopathic thrombocytopenic purpura (ITP) for patients from Southeast Europe.

Irina Panovska-Stavridis, PhD, of Ss. Cyril and Methodius University in Skopje, Republic of Macedonia, and her colleagues presented this finding at Leukemia and Lymphoma, a meeting jointly sponsored by the University of Texas MD Anderson Cancer Center and the School of Medicine at the University of Zagreb, Croatia.

“A lot of data from the literature suggests [the PTPN22 R620W variant ] has a role in developing multiple immune diseases, but it is validated just in patients from Northwest Europe,” Dr. Panovska-Stavridis noted.

She and her colleagues decided to assess the frequency of the PTPN22 R620W variant (C1858T, rs2476601) in individuals from Southeast Europe, particularly the Republic of Macedonia.

The researchers evaluated 320 patients – 168 with CLL, 66 with AIHA, and 86 with ITP – and 182 age- and sex-matched control subjects with no history of malignant or autoimmune disease.

The team found a similar frequency of the minor T allele and genotype distribution in control subjects and patients. For example, minor T allele was 0.107 in CLL, 0.067 in AIHA, 0.036 in ITP, and 0.05 in controls. Similarly, the frequency of the CC genotype was 0.809 in CLL, 0.166 in AIHA, 0.023 in ITP, and 0.901 in controls.

Dr. Panovska-Stavridis said these results suggest the PTPN22 R620W variant is not a risk factor for the development of CLL, AIHA, or ITP in patients from Southeast Europe.

She also said the results suggest the influence of the variant on lymphocytic homeostasis is affected by certain genetic and environmental factors, and the development of CLL and autoimmune diseases is influenced by race/ethnicity-based variations in the germline composition of the IGHV locus in correlation with environmental factors.

Dr. Panovska-Stavridis did not declare any conflicts of interest.

The Leukemia and Lymphoma meeting is organized by Jonathan Wood & Associates, which is owned by the parent company of this news organization.
 

[email protected]

DUBROVNIK, CROATIA – New research suggests there is no association between the PTPN22 R620W polymorphism and chronic lymphocytic leukemia (CLL) or autoimmune hematologic disorders in patients from the Republic of Macedonia.

Past studies have shown an association between the PTPN22 R620W variant and both CLL and autoimmune diseases in patients from Northwest Europe. However, a new study of Macedonian patients suggests there is no association between the variant and CLL, autoimmune hemolytic anemia (AIHA), or idiopathic thrombocytopenic purpura (ITP) for patients from Southeast Europe.

Irina Panovska-Stavridis, PhD, of Ss. Cyril and Methodius University in Skopje, Republic of Macedonia, and her colleagues presented this finding at Leukemia and Lymphoma, a meeting jointly sponsored by the University of Texas MD Anderson Cancer Center and the School of Medicine at the University of Zagreb, Croatia.

“A lot of data from the literature suggests [the PTPN22 R620W variant ] has a role in developing multiple immune diseases, but it is validated just in patients from Northwest Europe,” Dr. Panovska-Stavridis noted.

She and her colleagues decided to assess the frequency of the PTPN22 R620W variant (C1858T, rs2476601) in individuals from Southeast Europe, particularly the Republic of Macedonia.

The researchers evaluated 320 patients – 168 with CLL, 66 with AIHA, and 86 with ITP – and 182 age- and sex-matched control subjects with no history of malignant or autoimmune disease.

The team found a similar frequency of the minor T allele and genotype distribution in control subjects and patients. For example, minor T allele was 0.107 in CLL, 0.067 in AIHA, 0.036 in ITP, and 0.05 in controls. Similarly, the frequency of the CC genotype was 0.809 in CLL, 0.166 in AIHA, 0.023 in ITP, and 0.901 in controls.

Dr. Panovska-Stavridis said these results suggest the PTPN22 R620W variant is not a risk factor for the development of CLL, AIHA, or ITP in patients from Southeast Europe.

She also said the results suggest the influence of the variant on lymphocytic homeostasis is affected by certain genetic and environmental factors, and the development of CLL and autoimmune diseases is influenced by race/ethnicity-based variations in the germline composition of the IGHV locus in correlation with environmental factors.

Dr. Panovska-Stavridis did not declare any conflicts of interest.

The Leukemia and Lymphoma meeting is organized by Jonathan Wood & Associates, which is owned by the parent company of this news organization.
 

[email protected]

Among patients in the ODYSSEY Outcomes trial who’d had an acute coronary syndrome, only 9.5% of the alirocumab group versus 11.1% of the placebo group experienced composite primary endpoint events – death from coronary heart disease, nonfatal MI, fatal or nonfatal ischemic stroke, or unstable angina requiring hospitalization. Furthermore, the incidence of adverse events in both groups was similar, although the alirocumab group experienced more local injection-site reactions.

The ODYSSEY Outcomes primary results were published in the New England Journal of Medicine (2018 Nov 7; doi: 10.1056/NEJMoa1801174).

We covered the story last March, from the American College of Cardiology scientific sessions. Find our coverage at the link below:

https://www.mdedge.com/ecardiologynews/article/160512/acc-conference-coverage/odyssey-outcomes-trial-redefines-secondary.






 

Among patients in the ODYSSEY Outcomes trial who’d had an acute coronary syndrome, only 9.5% of the alirocumab group versus 11.1% of the placebo group experienced composite primary endpoint events – death from coronary heart disease, nonfatal MI, fatal or nonfatal ischemic stroke, or unstable angina requiring hospitalization. Furthermore, the incidence of adverse events in both groups was similar, although the alirocumab group experienced more local injection-site reactions.

The ODYSSEY Outcomes primary results were published in the New England Journal of Medicine (2018 Nov 7; doi: 10.1056/NEJMoa1801174).

We covered the story last March, from the American College of Cardiology scientific sessions. Find our coverage at the link below:

https://www.mdedge.com/ecardiologynews/article/160512/acc-conference-coverage/odyssey-outcomes-trial-redefines-secondary.






 

Among patients in the ODYSSEY Outcomes trial who’d had an acute coronary syndrome, only 9.5% of the alirocumab group versus 11.1% of the placebo group experienced composite primary endpoint events – death from coronary heart disease, nonfatal MI, fatal or nonfatal ischemic stroke, or unstable angina requiring hospitalization. Furthermore, the incidence of adverse events in both groups was similar, although the alirocumab group experienced more local injection-site reactions.

The ODYSSEY Outcomes primary results were published in the New England Journal of Medicine (2018 Nov 7; doi: 10.1056/NEJMoa1801174).

We covered the story last March, from the American College of Cardiology scientific sessions. Find our coverage at the link below:

https://www.mdedge.com/ecardiologynews/article/160512/acc-conference-coverage/odyssey-outcomes-trial-redefines-secondary.






 

A new antibiotic successfully treated uncomplicated urogenital and rectal gonococcal infections, but was not as effective as ceftriaxone in treating pharyngeal infections, according to the results of a randomized, phase 2 study.

Centers for Disease Control and Prevention

About 96% of patients with infection at urogenital sites had microbiologic cure with zoliflodacin, a novel antimicrobial agent that inhibits DNA biosynthesis. The cure rate was 100% for rectal infections, but was just 50%-82% for pharyngeal infections, though few participants in this study had infection at either of those sites.

The study investigators, led by Stephanie N. Taylor, MD, professor of medicine and microbiology at Louisiana State University, New Orleans, wrote that the need for new antimicrobial agents has been underscored by reports of multidrug-resistant Neisseria gonorrhoeae and the possibility of untreatable gonorrhea.

“This phase 2 trial creates equipoise for larger, more definitive studies of zoliflodacin,” Dr. Taylor and her coauthors wrote in the New England Journal of Medicine.

At this point, N. gonorrhoeae has developed resistance to every recommended antibiotic class, including cephalosporins and macrolides, they added.

Zoliflodacin (ETX0914) is an antimicrobial that has received fast-track designation from the Food and Drug Administration specifically for development as an oral treatment for gonococcal infections, the authors noted.

“The mechanism of action of zoliflodacin differs from currently available therapies in that it inhibits microbial biosynthesis by arresting the cleaved covalent gyrase complex and the formation of fused circular DNA required for biosynthesis,” they wrote.

Dr. Taylor and her colleagues studied single 2- and 3-gram doses of zoliflodacin in comparison with 500 mg of intramuscular ceftriaxone in 181 patients with uncomplicated urogenital gonorrhea enrolled in the open-label, randomized, phase 2 study between November 2014 and December 2015.

A total of 141 patients included in the microbiologic intention-to-treat analysis had confirmed positive urethral or cervical cultures. Cures were seen in 55 of 57 infections treated with 2 grams (96%) and 54 of 56 treated with 3 grams (96%) of zoliflodacin, and in 28 of 28 infections (100%) treated with ceftriaxone.

Of 15 confirmed rectal infections, 100% were cured, including 12 treated with zoliflodacin at 2 or 3 grams and 3 treated with ceftriaxone. Of 23 confirmed pharyngeal infections, cures were seen in 4 of 8 (50%) treated with 2 grams of zoliflodacin and 9 of 11 (82%) treated with 3 grams, compared with 4 of 4 cured (100%) with ceftriaxone.

That suggests zoliflodacin was not as effective as ceftriaxone in treating pharyngeal gonorrhea, which is generally considered more difficult to treat than infections at other sites, according to Dr. Taylor and her coauthors.

“Currently, this limitation has not curtailed recommendations for the use of drugs such as spectinomycin or fluoroquinolones for the treatment of gonorrhea,” they wrote.

The study was funded by the National Institutes of Health and Entasis Therapeutics. Dr. Taylor reported grants from the NIH during the study, and other disclosures related to a variety of pharma companies. Her coauthors reported disclosures related to AstraZeneca (parent company of Entasis, which is developing zoliflodacin) and other pharmaceutical companies.

SOURCE: Taylor SN et al. N Engl J Med. 2018 Nov 7; 379:1835-45.

A new antibiotic successfully treated uncomplicated urogenital and rectal gonococcal infections, but was not as effective as ceftriaxone in treating pharyngeal infections, according to the results of a randomized, phase 2 study.

Centers for Disease Control and Prevention

About 96% of patients with infection at urogenital sites had microbiologic cure with zoliflodacin, a novel antimicrobial agent that inhibits DNA biosynthesis. The cure rate was 100% for rectal infections, but was just 50%-82% for pharyngeal infections, though few participants in this study had infection at either of those sites.

The study investigators, led by Stephanie N. Taylor, MD, professor of medicine and microbiology at Louisiana State University, New Orleans, wrote that the need for new antimicrobial agents has been underscored by reports of multidrug-resistant Neisseria gonorrhoeae and the possibility of untreatable gonorrhea.

“This phase 2 trial creates equipoise for larger, more definitive studies of zoliflodacin,” Dr. Taylor and her coauthors wrote in the New England Journal of Medicine.

At this point, N. gonorrhoeae has developed resistance to every recommended antibiotic class, including cephalosporins and macrolides, they added.

Zoliflodacin (ETX0914) is an antimicrobial that has received fast-track designation from the Food and Drug Administration specifically for development as an oral treatment for gonococcal infections, the authors noted.

“The mechanism of action of zoliflodacin differs from currently available therapies in that it inhibits microbial biosynthesis by arresting the cleaved covalent gyrase complex and the formation of fused circular DNA required for biosynthesis,” they wrote.

Dr. Taylor and her colleagues studied single 2- and 3-gram doses of zoliflodacin in comparison with 500 mg of intramuscular ceftriaxone in 181 patients with uncomplicated urogenital gonorrhea enrolled in the open-label, randomized, phase 2 study between November 2014 and December 2015.

A total of 141 patients included in the microbiologic intention-to-treat analysis had confirmed positive urethral or cervical cultures. Cures were seen in 55 of 57 infections treated with 2 grams (96%) and 54 of 56 treated with 3 grams (96%) of zoliflodacin, and in 28 of 28 infections (100%) treated with ceftriaxone.

Of 15 confirmed rectal infections, 100% were cured, including 12 treated with zoliflodacin at 2 or 3 grams and 3 treated with ceftriaxone. Of 23 confirmed pharyngeal infections, cures were seen in 4 of 8 (50%) treated with 2 grams of zoliflodacin and 9 of 11 (82%) treated with 3 grams, compared with 4 of 4 cured (100%) with ceftriaxone.

That suggests zoliflodacin was not as effective as ceftriaxone in treating pharyngeal gonorrhea, which is generally considered more difficult to treat than infections at other sites, according to Dr. Taylor and her coauthors.

“Currently, this limitation has not curtailed recommendations for the use of drugs such as spectinomycin or fluoroquinolones for the treatment of gonorrhea,” they wrote.

The study was funded by the National Institutes of Health and Entasis Therapeutics. Dr. Taylor reported grants from the NIH during the study, and other disclosures related to a variety of pharma companies. Her coauthors reported disclosures related to AstraZeneca (parent company of Entasis, which is developing zoliflodacin) and other pharmaceutical companies.

SOURCE: Taylor SN et al. N Engl J Med. 2018 Nov 7; 379:1835-45.

A new antibiotic successfully treated uncomplicated urogenital and rectal gonococcal infections, but was not as effective as ceftriaxone in treating pharyngeal infections, according to the results of a randomized, phase 2 study.

Centers for Disease Control and Prevention

About 96% of patients with infection at urogenital sites had microbiologic cure with zoliflodacin, a novel antimicrobial agent that inhibits DNA biosynthesis. The cure rate was 100% for rectal infections, but was just 50%-82% for pharyngeal infections, though few participants in this study had infection at either of those sites.

The study investigators, led by Stephanie N. Taylor, MD, professor of medicine and microbiology at Louisiana State University, New Orleans, wrote that the need for new antimicrobial agents has been underscored by reports of multidrug-resistant Neisseria gonorrhoeae and the possibility of untreatable gonorrhea.

“This phase 2 trial creates equipoise for larger, more definitive studies of zoliflodacin,” Dr. Taylor and her coauthors wrote in the New England Journal of Medicine.

At this point, N. gonorrhoeae has developed resistance to every recommended antibiotic class, including cephalosporins and macrolides, they added.

Zoliflodacin (ETX0914) is an antimicrobial that has received fast-track designation from the Food and Drug Administration specifically for development as an oral treatment for gonococcal infections, the authors noted.

“The mechanism of action of zoliflodacin differs from currently available therapies in that it inhibits microbial biosynthesis by arresting the cleaved covalent gyrase complex and the formation of fused circular DNA required for biosynthesis,” they wrote.

Dr. Taylor and her colleagues studied single 2- and 3-gram doses of zoliflodacin in comparison with 500 mg of intramuscular ceftriaxone in 181 patients with uncomplicated urogenital gonorrhea enrolled in the open-label, randomized, phase 2 study between November 2014 and December 2015.

A total of 141 patients included in the microbiologic intention-to-treat analysis had confirmed positive urethral or cervical cultures. Cures were seen in 55 of 57 infections treated with 2 grams (96%) and 54 of 56 treated with 3 grams (96%) of zoliflodacin, and in 28 of 28 infections (100%) treated with ceftriaxone.

Of 15 confirmed rectal infections, 100% were cured, including 12 treated with zoliflodacin at 2 or 3 grams and 3 treated with ceftriaxone. Of 23 confirmed pharyngeal infections, cures were seen in 4 of 8 (50%) treated with 2 grams of zoliflodacin and 9 of 11 (82%) treated with 3 grams, compared with 4 of 4 cured (100%) with ceftriaxone.

That suggests zoliflodacin was not as effective as ceftriaxone in treating pharyngeal gonorrhea, which is generally considered more difficult to treat than infections at other sites, according to Dr. Taylor and her coauthors.

“Currently, this limitation has not curtailed recommendations for the use of drugs such as spectinomycin or fluoroquinolones for the treatment of gonorrhea,” they wrote.

The study was funded by the National Institutes of Health and Entasis Therapeutics. Dr. Taylor reported grants from the NIH during the study, and other disclosures related to a variety of pharma companies. Her coauthors reported disclosures related to AstraZeneca (parent company of Entasis, which is developing zoliflodacin) and other pharmaceutical companies.

SOURCE: Taylor SN et al. N Engl J Med. 2018 Nov 7; 379:1835-45.

Patients with multiple myeloma who did not respond to treatment with lenalidomide and a proteasome inhibitor had a significantly lower risk of progression or death when receiving elotuzumab plus pomalidomide and dexamethasone, compared with pomalidomide and dexamethasone alone (hazard ratio, 0.54; 95% confidence interval, 0.34-0.86; P = .008), according to results of a multicenter, randomized, open-label, phase 2 trial published in the New England Journal of Medicine 2018 Nov 7. doi: 10.1056/NEJMoa1805762.

Study results of ELOQUENT-3 were presented earlier this year at the Annual Congress of the European Hematology Association.

[email protected]

Patients with multiple myeloma who did not respond to treatment with lenalidomide and a proteasome inhibitor had a significantly lower risk of progression or death when receiving elotuzumab plus pomalidomide and dexamethasone, compared with pomalidomide and dexamethasone alone (hazard ratio, 0.54; 95% confidence interval, 0.34-0.86; P = .008), according to results of a multicenter, randomized, open-label, phase 2 trial published in the New England Journal of Medicine 2018 Nov 7. doi: 10.1056/NEJMoa1805762.

Study results of ELOQUENT-3 were presented earlier this year at the Annual Congress of the European Hematology Association.

[email protected]

Patients with multiple myeloma who did not respond to treatment with lenalidomide and a proteasome inhibitor had a significantly lower risk of progression or death when receiving elotuzumab plus pomalidomide and dexamethasone, compared with pomalidomide and dexamethasone alone (hazard ratio, 0.54; 95% confidence interval, 0.34-0.86; P = .008), according to results of a multicenter, randomized, open-label, phase 2 trial published in the New England Journal of Medicine 2018 Nov 7. doi: 10.1056/NEJMoa1805762.

Study results of ELOQUENT-3 were presented earlier this year at the Annual Congress of the European Hematology Association.

[email protected]

A series of three studies in college students showed that some serum markers are associated with concussion but the background level of the markers can vary considerably. There was no association between the markers and history of concussion, and they markers varied significantly by sex and race.

jpbcpa/Getty Images

The work, published in Neurology, suggests that there is hope for finding biomarkers for concussion, but much more work needs to be done.

Serum levels of amyloid beta 42 (Abeta42), total tau, and S100 calcium binding protein B (S100B) were associated with concussion, especially when tests were performed within 4 hours of the injury. However, the varying background levels indicate that these biomarkers are not yet ready for clinical application.

All three studies looked at serum levels of Abeta42, total tau, S100B, ubiquitin carboxyl-terminal hydrolase L1 (UCH-L1), glial fibrillary acidic protein (GFAP), microtubule-associated protein 2 (MAP2), and 2’,3’-cyclic-nucleotide 3’-phosphodiesterase (CNPase).

In the first study, researchers recruited 415 college athletes without a concussion (61% male, 40% white). The researchers took measurements outside of the athletes’ competitive sports season to maximize the odds that the levels would represent a true baseline. The median time between blood draw and the last risk of head impact was 80 days (mean, 98.4 days; interquartile range, 38-204 days).

Males had higher levels of UCH-L1 (Cohen d = 0.75; P less than .001) and S100B (Cohen d = 0.56; P less than .001), while females had higher levels of CNPase (Cohen d = 0.43; P less than .001). White subjects had higher levels of Abeta42 (Cohen d = .28; P = .005) and CNPase (Cohen d = 0.46; P less than .001). Black subjects had higher levels of UCH-L1 (Cohen d = 0.61; P less than .001) and S100 B (Cohen d = 1.1; P less than .001).

The measurements were not particularly reliable, with retests over 6- to 12-month periods yielding varying results such that none of the test/retest cutoff points reached the cutoff for acceptable reliability.

The second study was an observational cohort study of the same 415 subjects. The researchers assessed the self-reported concussion history and the cumulative exposure to collision sports with serum levels of the above biomarkers. The only relationship between a biomarker history and self-reported concussions was higher baseline Abeta42, but that had a small effect size (P = .005). Among football players, there was no association between approximate number of head impacts and any baseline biomarker.

The third study looked at 31 subjects who had experienced a sports-related concussion, 29 of whom had had both a baseline and a postconcussion blood draw, and compared them with nonconcussed, demographically matched athletes.

Of all the biomarkers studied, only levels of S100B rose following a concussion, with 67% of concussed subjects experiencing such a change (P = .003). When the researchers restricted the analysis to subjects who had a blood draw within 4 hours of the concussion, 88% of the tests showed an increase (P = .001). UCH-L1 also rose in 86% of subjects, but this change was not significant after adjustment for multiple comparisons (P greater than .007).

Compared with controls, concussed individuals had significantly higher levels of Abeta42, total tau, S100B, and GFAP. Of the concussed patients, 79.4% had Abeta42 levels higher than the median of controls, 67.6% had higher levels of total tau than the median of controls, and 83.3% had higher levels of S100B. Restriction of analysis to blood drawn within 4 hours of the injury yielded values of 81.3%, 75.0%, and 88.2%, respectively.

When limited to blood draws taken within 4 hours of injury, the researchers found fair diagnostic accuracy for measurements of Abeta42 (area under the curve, 0.75; 95% confidence interval, 0.59-0.91), total tau (AUC, 0.74; 95% CI, 0.58-0.90), and S100B (AUC, 0.75; 95% CI, 0.64-0.85). Abeta42 concentrations higher than 13.7 pg/mL were 75.0% sensitive and 82.4% specific to a sports-related concussion. Total tau concentrations higher than 1.7 pg/mL detected sports-related concussions at 75.0% sensitivity and 66.3% specificity, with acceptable diagnostic accuracy for white subjects (AUC, 0.82, 95% CI, 0.72-0.93). Also for white participants, S100B concentrations higher than 53 pg/mL predicted sports-related concussions with 83.3% sensitivity and 74.6% specificity.

The researchers found no associations between biomarkers and performance on clinical tests or time away from sports.

SOURCE: BM Asken et al. Neurology. 2018. doi: 10.1212/WNL.0000000000006613.

A series of three studies in college students showed that some serum markers are associated with concussion but the background level of the markers can vary considerably. There was no association between the markers and history of concussion, and they markers varied significantly by sex and race.

jpbcpa/Getty Images

The work, published in Neurology, suggests that there is hope for finding biomarkers for concussion, but much more work needs to be done.

Serum levels of amyloid beta 42 (Abeta42), total tau, and S100 calcium binding protein B (S100B) were associated with concussion, especially when tests were performed within 4 hours of the injury. However, the varying background levels indicate that these biomarkers are not yet ready for clinical application.

All three studies looked at serum levels of Abeta42, total tau, S100B, ubiquitin carboxyl-terminal hydrolase L1 (UCH-L1), glial fibrillary acidic protein (GFAP), microtubule-associated protein 2 (MAP2), and 2’,3’-cyclic-nucleotide 3’-phosphodiesterase (CNPase).

In the first study, researchers recruited 415 college athletes without a concussion (61% male, 40% white). The researchers took measurements outside of the athletes’ competitive sports season to maximize the odds that the levels would represent a true baseline. The median time between blood draw and the last risk of head impact was 80 days (mean, 98.4 days; interquartile range, 38-204 days).

Males had higher levels of UCH-L1 (Cohen d = 0.75; P less than .001) and S100B (Cohen d = 0.56; P less than .001), while females had higher levels of CNPase (Cohen d = 0.43; P less than .001). White subjects had higher levels of Abeta42 (Cohen d = .28; P = .005) and CNPase (Cohen d = 0.46; P less than .001). Black subjects had higher levels of UCH-L1 (Cohen d = 0.61; P less than .001) and S100 B (Cohen d = 1.1; P less than .001).

The measurements were not particularly reliable, with retests over 6- to 12-month periods yielding varying results such that none of the test/retest cutoff points reached the cutoff for acceptable reliability.

The second study was an observational cohort study of the same 415 subjects. The researchers assessed the self-reported concussion history and the cumulative exposure to collision sports with serum levels of the above biomarkers. The only relationship between a biomarker history and self-reported concussions was higher baseline Abeta42, but that had a small effect size (P = .005). Among football players, there was no association between approximate number of head impacts and any baseline biomarker.

The third study looked at 31 subjects who had experienced a sports-related concussion, 29 of whom had had both a baseline and a postconcussion blood draw, and compared them with nonconcussed, demographically matched athletes.

Of all the biomarkers studied, only levels of S100B rose following a concussion, with 67% of concussed subjects experiencing such a change (P = .003). When the researchers restricted the analysis to subjects who had a blood draw within 4 hours of the concussion, 88% of the tests showed an increase (P = .001). UCH-L1 also rose in 86% of subjects, but this change was not significant after adjustment for multiple comparisons (P greater than .007).

Compared with controls, concussed individuals had significantly higher levels of Abeta42, total tau, S100B, and GFAP. Of the concussed patients, 79.4% had Abeta42 levels higher than the median of controls, 67.6% had higher levels of total tau than the median of controls, and 83.3% had higher levels of S100B. Restriction of analysis to blood drawn within 4 hours of the injury yielded values of 81.3%, 75.0%, and 88.2%, respectively.

When limited to blood draws taken within 4 hours of injury, the researchers found fair diagnostic accuracy for measurements of Abeta42 (area under the curve, 0.75; 95% confidence interval, 0.59-0.91), total tau (AUC, 0.74; 95% CI, 0.58-0.90), and S100B (AUC, 0.75; 95% CI, 0.64-0.85). Abeta42 concentrations higher than 13.7 pg/mL were 75.0% sensitive and 82.4% specific to a sports-related concussion. Total tau concentrations higher than 1.7 pg/mL detected sports-related concussions at 75.0% sensitivity and 66.3% specificity, with acceptable diagnostic accuracy for white subjects (AUC, 0.82, 95% CI, 0.72-0.93). Also for white participants, S100B concentrations higher than 53 pg/mL predicted sports-related concussions with 83.3% sensitivity and 74.6% specificity.

The researchers found no associations between biomarkers and performance on clinical tests or time away from sports.

SOURCE: BM Asken et al. Neurology. 2018. doi: 10.1212/WNL.0000000000006613.

A series of three studies in college students showed that some serum markers are associated with concussion but the background level of the markers can vary considerably. There was no association between the markers and history of concussion, and they markers varied significantly by sex and race.

jpbcpa/Getty Images

The work, published in Neurology, suggests that there is hope for finding biomarkers for concussion, but much more work needs to be done.

Serum levels of amyloid beta 42 (Abeta42), total tau, and S100 calcium binding protein B (S100B) were associated with concussion, especially when tests were performed within 4 hours of the injury. However, the varying background levels indicate that these biomarkers are not yet ready for clinical application.

All three studies looked at serum levels of Abeta42, total tau, S100B, ubiquitin carboxyl-terminal hydrolase L1 (UCH-L1), glial fibrillary acidic protein (GFAP), microtubule-associated protein 2 (MAP2), and 2’,3’-cyclic-nucleotide 3’-phosphodiesterase (CNPase).

In the first study, researchers recruited 415 college athletes without a concussion (61% male, 40% white). The researchers took measurements outside of the athletes’ competitive sports season to maximize the odds that the levels would represent a true baseline. The median time between blood draw and the last risk of head impact was 80 days (mean, 98.4 days; interquartile range, 38-204 days).

Males had higher levels of UCH-L1 (Cohen d = 0.75; P less than .001) and S100B (Cohen d = 0.56; P less than .001), while females had higher levels of CNPase (Cohen d = 0.43; P less than .001). White subjects had higher levels of Abeta42 (Cohen d = .28; P = .005) and CNPase (Cohen d = 0.46; P less than .001). Black subjects had higher levels of UCH-L1 (Cohen d = 0.61; P less than .001) and S100 B (Cohen d = 1.1; P less than .001).

The measurements were not particularly reliable, with retests over 6- to 12-month periods yielding varying results such that none of the test/retest cutoff points reached the cutoff for acceptable reliability.

The second study was an observational cohort study of the same 415 subjects. The researchers assessed the self-reported concussion history and the cumulative exposure to collision sports with serum levels of the above biomarkers. The only relationship between a biomarker history and self-reported concussions was higher baseline Abeta42, but that had a small effect size (P = .005). Among football players, there was no association between approximate number of head impacts and any baseline biomarker.

The third study looked at 31 subjects who had experienced a sports-related concussion, 29 of whom had had both a baseline and a postconcussion blood draw, and compared them with nonconcussed, demographically matched athletes.

Of all the biomarkers studied, only levels of S100B rose following a concussion, with 67% of concussed subjects experiencing such a change (P = .003). When the researchers restricted the analysis to subjects who had a blood draw within 4 hours of the concussion, 88% of the tests showed an increase (P = .001). UCH-L1 also rose in 86% of subjects, but this change was not significant after adjustment for multiple comparisons (P greater than .007).

Compared with controls, concussed individuals had significantly higher levels of Abeta42, total tau, S100B, and GFAP. Of the concussed patients, 79.4% had Abeta42 levels higher than the median of controls, 67.6% had higher levels of total tau than the median of controls, and 83.3% had higher levels of S100B. Restriction of analysis to blood drawn within 4 hours of the injury yielded values of 81.3%, 75.0%, and 88.2%, respectively.

When limited to blood draws taken within 4 hours of injury, the researchers found fair diagnostic accuracy for measurements of Abeta42 (area under the curve, 0.75; 95% confidence interval, 0.59-0.91), total tau (AUC, 0.74; 95% CI, 0.58-0.90), and S100B (AUC, 0.75; 95% CI, 0.64-0.85). Abeta42 concentrations higher than 13.7 pg/mL were 75.0% sensitive and 82.4% specific to a sports-related concussion. Total tau concentrations higher than 1.7 pg/mL detected sports-related concussions at 75.0% sensitivity and 66.3% specificity, with acceptable diagnostic accuracy for white subjects (AUC, 0.82, 95% CI, 0.72-0.93). Also for white participants, S100B concentrations higher than 53 pg/mL predicted sports-related concussions with 83.3% sensitivity and 74.6% specificity.

The researchers found no associations between biomarkers and performance on clinical tests or time away from sports.

SOURCE: BM Asken et al. Neurology. 2018. doi: 10.1212/WNL.0000000000006613.

In this episode of the MDedge Psychcast, Lorenzo Norris, MD and Petros Levounis, MD, discuss pharmacological and psychosocial options for treating patients with substance abuse disorders including alcohol, opiates, and even the holy grail -- cocaine. And Dr. DK wants you to know that it’s time for sanity.

In this episode of the MDedge Psychcast, Lorenzo Norris, MD and Petros Levounis, MD, discuss pharmacological and psychosocial options for treating patients with substance abuse disorders including alcohol, opiates, and even the holy grail -- cocaine. And Dr. DK wants you to know that it’s time for sanity.

In this episode of the MDedge Psychcast, Lorenzo Norris, MD and Petros Levounis, MD, discuss pharmacological and psychosocial options for treating patients with substance abuse disorders including alcohol, opiates, and even the holy grail -- cocaine. And Dr. DK wants you to know that it’s time for sanity.