The Venous Venous Venous @VEITHsymposium program has become a popular staple of the meeting. With a mixture of didactic sessions and workshops, the Venous Venous Venous program, which will be held on Thursday, Friday, and Saturday, will cover the full gamut of venous disorders and their treatments, surgical, endovascular, and medical.

The didactic Program J (Sessions 63-67) on Superficial Venous Disease will be held on Thursday morning and early afternoon and will detail the latest developments in venous clinical examinations and imaging, superficial vein strategies and techniques, thermal and non-thermal ablation, and there will be a special session on venous societal issues and governance. Moderated by Elna M. Masuda, MD, and Marc A. Passman, MD, this special session will feature discussions of the Centers for Medicare & Medicaid policy update on venous ablation, dealing with MACRA, the RUC, and the reevaluation of phlebectomy, and more.

The didactic Program N (Sessions 88-92) on Deep Venous Disease will be all day Friday and will cover pelvic venous disorders, femoro-iliocaval interventions, deep vein reflux, wounds, and endovascular and open solutions for inferior vena cava disorders, and more.

iStock/Thinkstock

The Venous Venous Venous @VEITHsymposium program has become a popular staple of the meeting. With a mixture of didactic sessions and workshops, the Venous Venous Venous program, which will be held on Thursday, Friday, and Saturday, will cover the full gamut of venous disorders and their treatments, surgical, endovascular, and medical.

The didactic Program J (Sessions 63-67) on Superficial Venous Disease will be held on Thursday morning and early afternoon and will detail the latest developments in venous clinical examinations and imaging, superficial vein strategies and techniques, thermal and non-thermal ablation, and there will be a special session on venous societal issues and governance. Moderated by Elna M. Masuda, MD, and Marc A. Passman, MD, this special session will feature discussions of the Centers for Medicare & Medicaid policy update on venous ablation, dealing with MACRA, the RUC, and the reevaluation of phlebectomy, and more.

The didactic Program N (Sessions 88-92) on Deep Venous Disease will be all day Friday and will cover pelvic venous disorders, femoro-iliocaval interventions, deep vein reflux, wounds, and endovascular and open solutions for inferior vena cava disorders, and more.

iStock/Thinkstock

The Venous Venous Venous @VEITHsymposium program has become a popular staple of the meeting. With a mixture of didactic sessions and workshops, the Venous Venous Venous program, which will be held on Thursday, Friday, and Saturday, will cover the full gamut of venous disorders and their treatments, surgical, endovascular, and medical.

The didactic Program J (Sessions 63-67) on Superficial Venous Disease will be held on Thursday morning and early afternoon and will detail the latest developments in venous clinical examinations and imaging, superficial vein strategies and techniques, thermal and non-thermal ablation, and there will be a special session on venous societal issues and governance. Moderated by Elna M. Masuda, MD, and Marc A. Passman, MD, this special session will feature discussions of the Centers for Medicare & Medicaid policy update on venous ablation, dealing with MACRA, the RUC, and the reevaluation of phlebectomy, and more.

The didactic Program N (Sessions 88-92) on Deep Venous Disease will be all day Friday and will cover pelvic venous disorders, femoro-iliocaval interventions, deep vein reflux, wounds, and endovascular and open solutions for inferior vena cava disorders, and more.

iStock/Thinkstock

A hallmark of the VEITHsymposium has always been its focus on the results of recent and ongoing clinical trials, and this year is no exception. These trials will be presented by experts in their various fields who will discuss how the results will affect your daily practice.

A plethora of such clinical trials take center stage throughout the week and Tuesday alone has its fair share of highlighted studies.

For example, Tuesday morning, Jan D. Blankensteijn, MD, will discuss how and why the late results of the Dutch Randomised Endovascular Aneurysm Management (DREAM) and the Standard Open Surgery Versus Endovascular Repair of Abdominal Aortic Aneurysm (OVER) randomized controlled trials did not show the same late survival benefit for open repair as for EVAR and will address the issue of whether EVAR should be the treatment of choice for all anatomically suitable AAA patients.

Intracranial treatments for stroke will be a key interest of three trial presentations: Colin P. Derdeyn, MD, will present new findings from the Stenting vs. Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis (SAMMPRIS) randomized controlled trial comparing intracranial stenting to best medical treatments, highlighting the high incidence of in-stent restenosis causing strokes that were observed. Alejandro M. Spiotta, MD, will discuss how the COMPASS Trial: a Direct Aspiration First Pass Technique (COMPASS) shows that new aspiration systems are equivalent to stentrievers for removing intracranial clots to treat acute strokes, and address when they appear to be actually better. In addition, L. Nelson Hopkins, MD, will present an update on the value of intracranial clot removal for acute strokes, highlighting the question of when a longer window after symptom onset (up to 24 hours) is acceptable, as seen in recent trials such as the Clinical Mismatch in the Triage of Wake Up and Late Presenting Strokes Undergoing Neurointervention With Trevo (DAWN) and Tenecteplase versus Alteplase before Thrombectomy for Ischemic Stroke (EXTEND-IA TNK) studies.

Switching gears later in the day, the 1-year results of the Bare Metal Stent Versus Paclitaxel Eluting Stent in the Setting of Primary Stenting of Intermediate Length Femoropopliteal Lesions (BATTLE) multicenter randomized controlled trial, will be presented by Yann Gouëffic, MD, PhD.

Be sure to catch up with these trial results and others on Tuesday and the host of trials to be presented and discussed throughout the week at the 2018 VEITHsymposium.

A hallmark of the VEITHsymposium has always been its focus on the results of recent and ongoing clinical trials, and this year is no exception. These trials will be presented by experts in their various fields who will discuss how the results will affect your daily practice.

A plethora of such clinical trials take center stage throughout the week and Tuesday alone has its fair share of highlighted studies.

For example, Tuesday morning, Jan D. Blankensteijn, MD, will discuss how and why the late results of the Dutch Randomised Endovascular Aneurysm Management (DREAM) and the Standard Open Surgery Versus Endovascular Repair of Abdominal Aortic Aneurysm (OVER) randomized controlled trials did not show the same late survival benefit for open repair as for EVAR and will address the issue of whether EVAR should be the treatment of choice for all anatomically suitable AAA patients.

Intracranial treatments for stroke will be a key interest of three trial presentations: Colin P. Derdeyn, MD, will present new findings from the Stenting vs. Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis (SAMMPRIS) randomized controlled trial comparing intracranial stenting to best medical treatments, highlighting the high incidence of in-stent restenosis causing strokes that were observed. Alejandro M. Spiotta, MD, will discuss how the COMPASS Trial: a Direct Aspiration First Pass Technique (COMPASS) shows that new aspiration systems are equivalent to stentrievers for removing intracranial clots to treat acute strokes, and address when they appear to be actually better. In addition, L. Nelson Hopkins, MD, will present an update on the value of intracranial clot removal for acute strokes, highlighting the question of when a longer window after symptom onset (up to 24 hours) is acceptable, as seen in recent trials such as the Clinical Mismatch in the Triage of Wake Up and Late Presenting Strokes Undergoing Neurointervention With Trevo (DAWN) and Tenecteplase versus Alteplase before Thrombectomy for Ischemic Stroke (EXTEND-IA TNK) studies.

Switching gears later in the day, the 1-year results of the Bare Metal Stent Versus Paclitaxel Eluting Stent in the Setting of Primary Stenting of Intermediate Length Femoropopliteal Lesions (BATTLE) multicenter randomized controlled trial, will be presented by Yann Gouëffic, MD, PhD.

Be sure to catch up with these trial results and others on Tuesday and the host of trials to be presented and discussed throughout the week at the 2018 VEITHsymposium.

A hallmark of the VEITHsymposium has always been its focus on the results of recent and ongoing clinical trials, and this year is no exception. These trials will be presented by experts in their various fields who will discuss how the results will affect your daily practice.

A plethora of such clinical trials take center stage throughout the week and Tuesday alone has its fair share of highlighted studies.

For example, Tuesday morning, Jan D. Blankensteijn, MD, will discuss how and why the late results of the Dutch Randomised Endovascular Aneurysm Management (DREAM) and the Standard Open Surgery Versus Endovascular Repair of Abdominal Aortic Aneurysm (OVER) randomized controlled trials did not show the same late survival benefit for open repair as for EVAR and will address the issue of whether EVAR should be the treatment of choice for all anatomically suitable AAA patients.

Intracranial treatments for stroke will be a key interest of three trial presentations: Colin P. Derdeyn, MD, will present new findings from the Stenting vs. Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis (SAMMPRIS) randomized controlled trial comparing intracranial stenting to best medical treatments, highlighting the high incidence of in-stent restenosis causing strokes that were observed. Alejandro M. Spiotta, MD, will discuss how the COMPASS Trial: a Direct Aspiration First Pass Technique (COMPASS) shows that new aspiration systems are equivalent to stentrievers for removing intracranial clots to treat acute strokes, and address when they appear to be actually better. In addition, L. Nelson Hopkins, MD, will present an update on the value of intracranial clot removal for acute strokes, highlighting the question of when a longer window after symptom onset (up to 24 hours) is acceptable, as seen in recent trials such as the Clinical Mismatch in the Triage of Wake Up and Late Presenting Strokes Undergoing Neurointervention With Trevo (DAWN) and Tenecteplase versus Alteplase before Thrombectomy for Ischemic Stroke (EXTEND-IA TNK) studies.

Switching gears later in the day, the 1-year results of the Bare Metal Stent Versus Paclitaxel Eluting Stent in the Setting of Primary Stenting of Intermediate Length Femoropopliteal Lesions (BATTLE) multicenter randomized controlled trial, will be presented by Yann Gouëffic, MD, PhD.

Be sure to catch up with these trial results and others on Tuesday and the host of trials to be presented and discussed throughout the week at the 2018 VEITHsymposium.

The prevalence of cigarette smoking among adults was down to 14% in 2017, the lowest level recorded since monitoring began in 1965, according to the Centers for Disease Control and Prevention.

“This new all-time low in cigarette smoking among U.S. adults is a tremendous public health accomplishment, and it demonstrates the importance of continued proven strategies to reduce smoking,” CDC Director Robert Redfield said in a written statement.

In 2017, 19.3% of adults aged 18 years and older – approximately 47.4 million Americans – reported current use of some type of tobacco product, and current use of combustible tobacco was 16.7%, Teresa W. Wang, PhD, of the CDC’s National Center for Chronic Disease Prevention and Health Promotion, Atlanta, and her associates reported in the Morbidity and Mortality Weekly Report. Current use was defined as use every day or some days, with an added requirement of at least 100 cigarettes in a lifetime added for cigarette smokers.

Data from the National Health Interview Survey showed that from 2016 to 2017, current use declined for any tobacco product, any combustible tobacco product, cigarettes, smokeless tobacco, and the combination of two or more tobacco products. The most common combination in 2017 was cigarettes and e-cigarettes, which was reported by 30.1% of the 9 million adults who used more than one product, Dr. Wang and her associates said.

Prevalence of current tobacco use was higher among men than women (24.8% vs. 14.2%), and adults aged 25-44 years (22.5%) had the highest level by age, followed by those aged 45-64 years (21.3%), 18-24 years (18.3%), and 65 years or older (11%). Use by race/ethnicity was highest among American Indian/Alaska Natives (29.8%), with the Midwest putting up the highest prevalence by region at 23.5%, they said.

“Although cigarette smoking among U.S. adults has declined considerably, tobacco products have evolved in recent years to include various combustible, noncombustible, and electronic products,” Dr. Wang and her associates wrote. “Implementation of evidence-based tobacco control interventions that address the diversity of tobacco products used by U.S. adults, in coordination with regulation of tobacco product manufacturing, marketing, and sales, can reduce tobacco-related disease and death in the United States.”

[email protected]

SOURCE: Wang TW et al. MMWR. 2018 Nov 9;67[44]:1225-32.

The prevalence of cigarette smoking among adults was down to 14% in 2017, the lowest level recorded since monitoring began in 1965, according to the Centers for Disease Control and Prevention.

“This new all-time low in cigarette smoking among U.S. adults is a tremendous public health accomplishment, and it demonstrates the importance of continued proven strategies to reduce smoking,” CDC Director Robert Redfield said in a written statement.

In 2017, 19.3% of adults aged 18 years and older – approximately 47.4 million Americans – reported current use of some type of tobacco product, and current use of combustible tobacco was 16.7%, Teresa W. Wang, PhD, of the CDC’s National Center for Chronic Disease Prevention and Health Promotion, Atlanta, and her associates reported in the Morbidity and Mortality Weekly Report. Current use was defined as use every day or some days, with an added requirement of at least 100 cigarettes in a lifetime added for cigarette smokers.

Data from the National Health Interview Survey showed that from 2016 to 2017, current use declined for any tobacco product, any combustible tobacco product, cigarettes, smokeless tobacco, and the combination of two or more tobacco products. The most common combination in 2017 was cigarettes and e-cigarettes, which was reported by 30.1% of the 9 million adults who used more than one product, Dr. Wang and her associates said.

Prevalence of current tobacco use was higher among men than women (24.8% vs. 14.2%), and adults aged 25-44 years (22.5%) had the highest level by age, followed by those aged 45-64 years (21.3%), 18-24 years (18.3%), and 65 years or older (11%). Use by race/ethnicity was highest among American Indian/Alaska Natives (29.8%), with the Midwest putting up the highest prevalence by region at 23.5%, they said.

“Although cigarette smoking among U.S. adults has declined considerably, tobacco products have evolved in recent years to include various combustible, noncombustible, and electronic products,” Dr. Wang and her associates wrote. “Implementation of evidence-based tobacco control interventions that address the diversity of tobacco products used by U.S. adults, in coordination with regulation of tobacco product manufacturing, marketing, and sales, can reduce tobacco-related disease and death in the United States.”

[email protected]

SOURCE: Wang TW et al. MMWR. 2018 Nov 9;67[44]:1225-32.

The prevalence of cigarette smoking among adults was down to 14% in 2017, the lowest level recorded since monitoring began in 1965, according to the Centers for Disease Control and Prevention.

“This new all-time low in cigarette smoking among U.S. adults is a tremendous public health accomplishment, and it demonstrates the importance of continued proven strategies to reduce smoking,” CDC Director Robert Redfield said in a written statement.

In 2017, 19.3% of adults aged 18 years and older – approximately 47.4 million Americans – reported current use of some type of tobacco product, and current use of combustible tobacco was 16.7%, Teresa W. Wang, PhD, of the CDC’s National Center for Chronic Disease Prevention and Health Promotion, Atlanta, and her associates reported in the Morbidity and Mortality Weekly Report. Current use was defined as use every day or some days, with an added requirement of at least 100 cigarettes in a lifetime added for cigarette smokers.

Data from the National Health Interview Survey showed that from 2016 to 2017, current use declined for any tobacco product, any combustible tobacco product, cigarettes, smokeless tobacco, and the combination of two or more tobacco products. The most common combination in 2017 was cigarettes and e-cigarettes, which was reported by 30.1% of the 9 million adults who used more than one product, Dr. Wang and her associates said.

Prevalence of current tobacco use was higher among men than women (24.8% vs. 14.2%), and adults aged 25-44 years (22.5%) had the highest level by age, followed by those aged 45-64 years (21.3%), 18-24 years (18.3%), and 65 years or older (11%). Use by race/ethnicity was highest among American Indian/Alaska Natives (29.8%), with the Midwest putting up the highest prevalence by region at 23.5%, they said.

“Although cigarette smoking among U.S. adults has declined considerably, tobacco products have evolved in recent years to include various combustible, noncombustible, and electronic products,” Dr. Wang and her associates wrote. “Implementation of evidence-based tobacco control interventions that address the diversity of tobacco products used by U.S. adults, in coordination with regulation of tobacco product manufacturing, marketing, and sales, can reduce tobacco-related disease and death in the United States.”

[email protected]

SOURCE: Wang TW et al. MMWR. 2018 Nov 9;67[44]:1225-32.

AUSTIN, TEX. – While the media relentlessly reports on every mass shooting that occurs, the public hears less often about the shootings that never happened – because people were paying attention and taking action, according to James L. Knoll, IV, MD, director of forensic psychiatry at the State University of New York, Syracuse.

“We’ve learned a lot about risk factors [for mass shootings], we’ve learned a lot about associations and correlations, and it’s gotten us so far,” Dr. Knoll told attendees at the annual meeting of the American Academy of Psychiatry and the Law. “I want to invite you to look at this from the angle of those shootings that were able to be prevented or disrupted.” (Dr. Knoll said he used the term “disrupted” because it’s impossible to ever know for certain that a shooting was thwarted.)

It is difficult to track mass homicides that would have occurred but were disrupted, but one study Dr. Knoll cited combed through news reports and identified 57 interrupted mass homicides (Aggress Viol Behav. 2016 Sep-Oct;30:88-93). Most of those (77%) had been interrupted by family and friends or the general public reporting suspicious behavior.

It was while Dr. Knoll was leading the threat assessment subcommittee of the Syracuse School Safety Task Force that a potential school shooting threat arose.

A 22-year-old Chinese international student named Xiaofeng “Lincoln” Zhan walked into AJ’s Archery/The Gun Shop on March 12, asking to buy an AR-15. The AR-15 is the semiautomatic weapon of choice for most mass shooters.

Mr. Zhan should have been barred from purchasing a gun because he was an international student on a temporary visa. Under U.S. code, it is “unlawful for any person to sell or otherwise dispose of any firearm or ammunition to any person knowing or having reasonable cause to believe that such person” is an alien who is “illegally or unlawfully in the United States” or “ has been admitted to the United States under a nonimmigrant visa.”

But the second provision was subject to certain exceptions, the first of which was that the person had been “admitted to the United States for lawful hunting or supporting purposes“ or was “in possession of a hunting license or permit lawfully issued in the United States.”

Mr. Zhan had a hunting license. He had taken a hunter safety course on March 11, the day before he entered the gun shop, and then bought a hunting license.

But the gun shop owner was not so easily persuaded. Mr. Zhan asked about “high-capacity shotguns” and said he belonged to a shooting club, yet he did not appear familiar with firearms. The gun shop owner was also skeptical because it didn’t make sense to use a high-capacity shotgun for hunting, and Mr. Zhan had just gotten his hunting license and didn’t know how to use the gun. Further, Mr. Zhan claimed that Syracuse University offered a class on how to use the gun – but the gun store owner knew that the university did not offer such a class.

The gun shop owner’s first thought was not that Mr. Zhan was a potential mass shooter but that he was a “secret shopper,” which Dr. Knoll defined as an undercover law enforcement officer who attempts to buy guns in a manner that should arouse suspicion in the store owner.

Ultimately, Zhan’s behavior was concerning and he made the owner feel uncomfortable. The owner captured Mr. Zhan’s information on U.S. ATF form 4473 and recorded his license plate. Then the gun shop owner contacted the Madison County Sheriff’s Office with the information.

The police opened an investigation that established that Mr. Zhan was a student enrolled at Syracuse University, which was on spring break at the time. The Syracuse Police Department arranged a joint meeting between the Onondaga County district attorney, Syracuse University Department of Public Safety, Onondaga County Sheriff’s Office, and the FBI to present their findings, including the fact that local high schools were planning walk-outs that might be potential targets.

Further investigation revealed that Mr. Zhan had been a student at Northeastern University in Boston in 2015, where he had asked a teacher how to get guns. The teacher emailed his supervisor, but the university police found no concerns.

Meanwhile, the police obtained a subpoena to get Mr. Zhan’s mental health records from Syracuse University. Mr. Zhan had sought psychiatric care at two facilities, Northeastern University in 2015 and Syracuse University in 2018. His mental health records revealed alcohol abuse, depression, suicidal thinking, anger problems, feelings of isolation and withdrawal, and his feeling that he might lose control or act violently, said Dr. Knoll, who is also professor of psychiatry at the university.

On March 13, the day after he had attempted to buy the gun, Syracuse University’s mental health services were contacted and briefed on Mr. Zhan. They filled out the paperwork for New York’s SAFE Act, which prevents people from buying a gun if a mental health professional makes the reasonable judgment that the individual might harm themselves or someone else.

The police investigation continued and found that Mr. Zhan had previously tried to buy an AR-15 at a Dick’s Sporting Goods store. He was denied because the SAFE Act prevents their sale.

Mr. Zhan, meanwhile, had gone to Mexico for the break and was due to return March 19. While he was away, an alarm allegedly went off in his apartment on March 16, leading the landlord to check on the apartment since he remembered previous police inquiries. He knocked on the door but there was no answer, so the landlord entered to do a safety check. He found ammunition and other concerning supplies.

The same day the landlord was checking Mr. Zhan’s apartment, students traveling with him in Mexico emailed Syracuse University about concerning behavior they observed in him. This behavior included signs of severe depression, verbalizing extremely negative thoughts, discussing suicide, drinking heavily, and making cuts to his forearms with the knife he possessed.

They also shared screenshots of messages they had seen him post in a social media group about feeling compelled to buy a gun and bulletproof vest and practice shooting.

Three days later, the police obtained a search warrant for Mr. Zhan’s apartment and vehicle. They found in his apartment high-powered optics, scopes, ammunition, targets from shooting ranges, receipts from shooting ranges, and similar equipment.

Ultimately, authorities revoked Mr. Zhan’s visa, enabling them to detain him at the airport when he returned from Mexico and deport him back to China.

After Mr. Zhan had returned to China, further investigation uncovered a series of texts between Mr. Zhan and his girlfriend in which he openly talks about wanting to shoot people.

“So, what went right here instead of what went wrong?” Dr. Knoll rhetorically asked. A lot of things: leakage of Mr. Zhan’s plans; fellow students seeing and reporting his electronic messages and concerning behaviors; the gun store owner’s skepticism and contact with the police; the landlord’s check on Mr. Zhan’s apartment; and the cooperation among local police, school authorities, and the school’s mental health services.

“There was also good communication among the threat assessment teams and law enforcement and the collaboration across disciplines,” Dr. Knoll said. Mass shootings have now “taken on more of a sociocultural phenomenon,” and “sociocultural problems require sociocultural solutions. I like these laws focusing on behaviors, not psychiatric diagnoses.”

He then reviewed potential interventions that might help identify or interfere with a planned incident or intent to commit one, including increased attention paid to suspicious behavior, third-party reporting of a potential shooter’s intent, and suicide prevention programs.

Dr. Knoll shared recent FBI research on 63 active shooters between 2000 and 2013 showing that the majority (77%) had been planning their attack for at least 1 week. Further, 46% have been preparing for 1 week before. The majority of those likely shooters also obtained their guns legally.

Although a quarter of those in the FBI study had some mental health diagnosis – predominantly depression or anxiety – the agency uncovered no significant correlation between mental illness and becoming a shooter.

The study concluded that,“absent specific evidence, careful consideration should be given to social and contextual factors that might interact with any mental health issue before concluding that an active shooting was ‘caused’ by a mental illness. In short, declarations that all active shooters must simply be mentally ill are misleading and unhelpful.”

Dr. Knoll reported no conflicts of interest.

AUSTIN, TEX. – While the media relentlessly reports on every mass shooting that occurs, the public hears less often about the shootings that never happened – because people were paying attention and taking action, according to James L. Knoll, IV, MD, director of forensic psychiatry at the State University of New York, Syracuse.

“We’ve learned a lot about risk factors [for mass shootings], we’ve learned a lot about associations and correlations, and it’s gotten us so far,” Dr. Knoll told attendees at the annual meeting of the American Academy of Psychiatry and the Law. “I want to invite you to look at this from the angle of those shootings that were able to be prevented or disrupted.” (Dr. Knoll said he used the term “disrupted” because it’s impossible to ever know for certain that a shooting was thwarted.)

It is difficult to track mass homicides that would have occurred but were disrupted, but one study Dr. Knoll cited combed through news reports and identified 57 interrupted mass homicides (Aggress Viol Behav. 2016 Sep-Oct;30:88-93). Most of those (77%) had been interrupted by family and friends or the general public reporting suspicious behavior.

It was while Dr. Knoll was leading the threat assessment subcommittee of the Syracuse School Safety Task Force that a potential school shooting threat arose.

A 22-year-old Chinese international student named Xiaofeng “Lincoln” Zhan walked into AJ’s Archery/The Gun Shop on March 12, asking to buy an AR-15. The AR-15 is the semiautomatic weapon of choice for most mass shooters.

Mr. Zhan should have been barred from purchasing a gun because he was an international student on a temporary visa. Under U.S. code, it is “unlawful for any person to sell or otherwise dispose of any firearm or ammunition to any person knowing or having reasonable cause to believe that such person” is an alien who is “illegally or unlawfully in the United States” or “ has been admitted to the United States under a nonimmigrant visa.”

But the second provision was subject to certain exceptions, the first of which was that the person had been “admitted to the United States for lawful hunting or supporting purposes“ or was “in possession of a hunting license or permit lawfully issued in the United States.”

Mr. Zhan had a hunting license. He had taken a hunter safety course on March 11, the day before he entered the gun shop, and then bought a hunting license.

But the gun shop owner was not so easily persuaded. Mr. Zhan asked about “high-capacity shotguns” and said he belonged to a shooting club, yet he did not appear familiar with firearms. The gun shop owner was also skeptical because it didn’t make sense to use a high-capacity shotgun for hunting, and Mr. Zhan had just gotten his hunting license and didn’t know how to use the gun. Further, Mr. Zhan claimed that Syracuse University offered a class on how to use the gun – but the gun store owner knew that the university did not offer such a class.

The gun shop owner’s first thought was not that Mr. Zhan was a potential mass shooter but that he was a “secret shopper,” which Dr. Knoll defined as an undercover law enforcement officer who attempts to buy guns in a manner that should arouse suspicion in the store owner.

Ultimately, Zhan’s behavior was concerning and he made the owner feel uncomfortable. The owner captured Mr. Zhan’s information on U.S. ATF form 4473 and recorded his license plate. Then the gun shop owner contacted the Madison County Sheriff’s Office with the information.

The police opened an investigation that established that Mr. Zhan was a student enrolled at Syracuse University, which was on spring break at the time. The Syracuse Police Department arranged a joint meeting between the Onondaga County district attorney, Syracuse University Department of Public Safety, Onondaga County Sheriff’s Office, and the FBI to present their findings, including the fact that local high schools were planning walk-outs that might be potential targets.

Further investigation revealed that Mr. Zhan had been a student at Northeastern University in Boston in 2015, where he had asked a teacher how to get guns. The teacher emailed his supervisor, but the university police found no concerns.

Meanwhile, the police obtained a subpoena to get Mr. Zhan’s mental health records from Syracuse University. Mr. Zhan had sought psychiatric care at two facilities, Northeastern University in 2015 and Syracuse University in 2018. His mental health records revealed alcohol abuse, depression, suicidal thinking, anger problems, feelings of isolation and withdrawal, and his feeling that he might lose control or act violently, said Dr. Knoll, who is also professor of psychiatry at the university.

On March 13, the day after he had attempted to buy the gun, Syracuse University’s mental health services were contacted and briefed on Mr. Zhan. They filled out the paperwork for New York’s SAFE Act, which prevents people from buying a gun if a mental health professional makes the reasonable judgment that the individual might harm themselves or someone else.

The police investigation continued and found that Mr. Zhan had previously tried to buy an AR-15 at a Dick’s Sporting Goods store. He was denied because the SAFE Act prevents their sale.

Mr. Zhan, meanwhile, had gone to Mexico for the break and was due to return March 19. While he was away, an alarm allegedly went off in his apartment on March 16, leading the landlord to check on the apartment since he remembered previous police inquiries. He knocked on the door but there was no answer, so the landlord entered to do a safety check. He found ammunition and other concerning supplies.

The same day the landlord was checking Mr. Zhan’s apartment, students traveling with him in Mexico emailed Syracuse University about concerning behavior they observed in him. This behavior included signs of severe depression, verbalizing extremely negative thoughts, discussing suicide, drinking heavily, and making cuts to his forearms with the knife he possessed.

They also shared screenshots of messages they had seen him post in a social media group about feeling compelled to buy a gun and bulletproof vest and practice shooting.

Three days later, the police obtained a search warrant for Mr. Zhan’s apartment and vehicle. They found in his apartment high-powered optics, scopes, ammunition, targets from shooting ranges, receipts from shooting ranges, and similar equipment.

Ultimately, authorities revoked Mr. Zhan’s visa, enabling them to detain him at the airport when he returned from Mexico and deport him back to China.

After Mr. Zhan had returned to China, further investigation uncovered a series of texts between Mr. Zhan and his girlfriend in which he openly talks about wanting to shoot people.

“So, what went right here instead of what went wrong?” Dr. Knoll rhetorically asked. A lot of things: leakage of Mr. Zhan’s plans; fellow students seeing and reporting his electronic messages and concerning behaviors; the gun store owner’s skepticism and contact with the police; the landlord’s check on Mr. Zhan’s apartment; and the cooperation among local police, school authorities, and the school’s mental health services.

“There was also good communication among the threat assessment teams and law enforcement and the collaboration across disciplines,” Dr. Knoll said. Mass shootings have now “taken on more of a sociocultural phenomenon,” and “sociocultural problems require sociocultural solutions. I like these laws focusing on behaviors, not psychiatric diagnoses.”

He then reviewed potential interventions that might help identify or interfere with a planned incident or intent to commit one, including increased attention paid to suspicious behavior, third-party reporting of a potential shooter’s intent, and suicide prevention programs.

Dr. Knoll shared recent FBI research on 63 active shooters between 2000 and 2013 showing that the majority (77%) had been planning their attack for at least 1 week. Further, 46% have been preparing for 1 week before. The majority of those likely shooters also obtained their guns legally.

Although a quarter of those in the FBI study had some mental health diagnosis – predominantly depression or anxiety – the agency uncovered no significant correlation between mental illness and becoming a shooter.

The study concluded that,“absent specific evidence, careful consideration should be given to social and contextual factors that might interact with any mental health issue before concluding that an active shooting was ‘caused’ by a mental illness. In short, declarations that all active shooters must simply be mentally ill are misleading and unhelpful.”

Dr. Knoll reported no conflicts of interest.

AUSTIN, TEX. – While the media relentlessly reports on every mass shooting that occurs, the public hears less often about the shootings that never happened – because people were paying attention and taking action, according to James L. Knoll, IV, MD, director of forensic psychiatry at the State University of New York, Syracuse.

“We’ve learned a lot about risk factors [for mass shootings], we’ve learned a lot about associations and correlations, and it’s gotten us so far,” Dr. Knoll told attendees at the annual meeting of the American Academy of Psychiatry and the Law. “I want to invite you to look at this from the angle of those shootings that were able to be prevented or disrupted.” (Dr. Knoll said he used the term “disrupted” because it’s impossible to ever know for certain that a shooting was thwarted.)

It is difficult to track mass homicides that would have occurred but were disrupted, but one study Dr. Knoll cited combed through news reports and identified 57 interrupted mass homicides (Aggress Viol Behav. 2016 Sep-Oct;30:88-93). Most of those (77%) had been interrupted by family and friends or the general public reporting suspicious behavior.

It was while Dr. Knoll was leading the threat assessment subcommittee of the Syracuse School Safety Task Force that a potential school shooting threat arose.

A 22-year-old Chinese international student named Xiaofeng “Lincoln” Zhan walked into AJ’s Archery/The Gun Shop on March 12, asking to buy an AR-15. The AR-15 is the semiautomatic weapon of choice for most mass shooters.

Mr. Zhan should have been barred from purchasing a gun because he was an international student on a temporary visa. Under U.S. code, it is “unlawful for any person to sell or otherwise dispose of any firearm or ammunition to any person knowing or having reasonable cause to believe that such person” is an alien who is “illegally or unlawfully in the United States” or “ has been admitted to the United States under a nonimmigrant visa.”

But the second provision was subject to certain exceptions, the first of which was that the person had been “admitted to the United States for lawful hunting or supporting purposes“ or was “in possession of a hunting license or permit lawfully issued in the United States.”

Mr. Zhan had a hunting license. He had taken a hunter safety course on March 11, the day before he entered the gun shop, and then bought a hunting license.

But the gun shop owner was not so easily persuaded. Mr. Zhan asked about “high-capacity shotguns” and said he belonged to a shooting club, yet he did not appear familiar with firearms. The gun shop owner was also skeptical because it didn’t make sense to use a high-capacity shotgun for hunting, and Mr. Zhan had just gotten his hunting license and didn’t know how to use the gun. Further, Mr. Zhan claimed that Syracuse University offered a class on how to use the gun – but the gun store owner knew that the university did not offer such a class.

The gun shop owner’s first thought was not that Mr. Zhan was a potential mass shooter but that he was a “secret shopper,” which Dr. Knoll defined as an undercover law enforcement officer who attempts to buy guns in a manner that should arouse suspicion in the store owner.

Ultimately, Zhan’s behavior was concerning and he made the owner feel uncomfortable. The owner captured Mr. Zhan’s information on U.S. ATF form 4473 and recorded his license plate. Then the gun shop owner contacted the Madison County Sheriff’s Office with the information.

The police opened an investigation that established that Mr. Zhan was a student enrolled at Syracuse University, which was on spring break at the time. The Syracuse Police Department arranged a joint meeting between the Onondaga County district attorney, Syracuse University Department of Public Safety, Onondaga County Sheriff’s Office, and the FBI to present their findings, including the fact that local high schools were planning walk-outs that might be potential targets.

Further investigation revealed that Mr. Zhan had been a student at Northeastern University in Boston in 2015, where he had asked a teacher how to get guns. The teacher emailed his supervisor, but the university police found no concerns.

Meanwhile, the police obtained a subpoena to get Mr. Zhan’s mental health records from Syracuse University. Mr. Zhan had sought psychiatric care at two facilities, Northeastern University in 2015 and Syracuse University in 2018. His mental health records revealed alcohol abuse, depression, suicidal thinking, anger problems, feelings of isolation and withdrawal, and his feeling that he might lose control or act violently, said Dr. Knoll, who is also professor of psychiatry at the university.

On March 13, the day after he had attempted to buy the gun, Syracuse University’s mental health services were contacted and briefed on Mr. Zhan. They filled out the paperwork for New York’s SAFE Act, which prevents people from buying a gun if a mental health professional makes the reasonable judgment that the individual might harm themselves or someone else.

The police investigation continued and found that Mr. Zhan had previously tried to buy an AR-15 at a Dick’s Sporting Goods store. He was denied because the SAFE Act prevents their sale.

Mr. Zhan, meanwhile, had gone to Mexico for the break and was due to return March 19. While he was away, an alarm allegedly went off in his apartment on March 16, leading the landlord to check on the apartment since he remembered previous police inquiries. He knocked on the door but there was no answer, so the landlord entered to do a safety check. He found ammunition and other concerning supplies.

The same day the landlord was checking Mr. Zhan’s apartment, students traveling with him in Mexico emailed Syracuse University about concerning behavior they observed in him. This behavior included signs of severe depression, verbalizing extremely negative thoughts, discussing suicide, drinking heavily, and making cuts to his forearms with the knife he possessed.

They also shared screenshots of messages they had seen him post in a social media group about feeling compelled to buy a gun and bulletproof vest and practice shooting.

Three days later, the police obtained a search warrant for Mr. Zhan’s apartment and vehicle. They found in his apartment high-powered optics, scopes, ammunition, targets from shooting ranges, receipts from shooting ranges, and similar equipment.

Ultimately, authorities revoked Mr. Zhan’s visa, enabling them to detain him at the airport when he returned from Mexico and deport him back to China.

After Mr. Zhan had returned to China, further investigation uncovered a series of texts between Mr. Zhan and his girlfriend in which he openly talks about wanting to shoot people.

“So, what went right here instead of what went wrong?” Dr. Knoll rhetorically asked. A lot of things: leakage of Mr. Zhan’s plans; fellow students seeing and reporting his electronic messages and concerning behaviors; the gun store owner’s skepticism and contact with the police; the landlord’s check on Mr. Zhan’s apartment; and the cooperation among local police, school authorities, and the school’s mental health services.

“There was also good communication among the threat assessment teams and law enforcement and the collaboration across disciplines,” Dr. Knoll said. Mass shootings have now “taken on more of a sociocultural phenomenon,” and “sociocultural problems require sociocultural solutions. I like these laws focusing on behaviors, not psychiatric diagnoses.”

He then reviewed potential interventions that might help identify or interfere with a planned incident or intent to commit one, including increased attention paid to suspicious behavior, third-party reporting of a potential shooter’s intent, and suicide prevention programs.

Dr. Knoll shared recent FBI research on 63 active shooters between 2000 and 2013 showing that the majority (77%) had been planning their attack for at least 1 week. Further, 46% have been preparing for 1 week before. The majority of those likely shooters also obtained their guns legally.

Although a quarter of those in the FBI study had some mental health diagnosis – predominantly depression or anxiety – the agency uncovered no significant correlation between mental illness and becoming a shooter.

The study concluded that,“absent specific evidence, careful consideration should be given to social and contextual factors that might interact with any mental health issue before concluding that an active shooting was ‘caused’ by a mental illness. In short, declarations that all active shooters must simply be mentally ill are misleading and unhelpful.”

Dr. Knoll reported no conflicts of interest.

ORLANDO – Consider point-of-care testing and treat potentially infected partners when diagnosing and treating adolescents for STIs, Diane M. Straub, MD, MPH, said at the annual meeting of the American Academy of Pediatrics.

In addition, adolescents are sometimes reluctant to disclose their full sexual history to their health care provider, which can complicate diagnosis and treatment, noted Dr. Straub, professor of pediatrics at the University of South Florida, Tampa. “That sometimes takes a few questions,” but can be achieved by asking the same questions in different ways and emphasizing the clinical importance of testing.

According to the 2017 Youth Risk Behavior Surveillance survey, 40% of adolescents reported ever having sexual intercourse, with 20% of 9th-grade, 36% of 10th-grade, 47% of 11th-grade, and 57% of 12th-grade students reporting they had sexual intercourse. By gender, 41% of adolescent males and 38% of adolescent females reported ever having sexual intercourse; by race, 39% of white, 41% of Hispanic, and 46% of black participants reported any sexual activity. Overall, 10% of adolescents said they had four or more partners, 3% said they had intercourse before age 13 years, 54% used a condom the last time they had intercourse, and 7% said they were raped.

CDC

The rate of STIs in the United States is rising. There has been a sharp increase in the number of combined diagnoses of gonorrhea, syphilis, and chlamydia, with an increase from 1.8 million in 2013 to 2.3 million cases in 2017, according to the Centers for Disease Control and Prevention. During that same time period, gonorrhea increased 67% from 333,004 to 555,608 cases, syphilis (primary and secondary) rose 76% from 17,375 to 30,644 cases, and chlamydia increased 22% to 1.7 million cases.

According to a 2013 CDC infographic shown by Dr. Straub, young people in the United States aged 15-24 years old represent 27% of the total sexually active population but account for 50% of new STI cases each year. Persons in this population account for 70% of gonorrhea cases, 63% of chlamydia cases, 49% of human papillomavirus (HPV) cases, 45% of genital herpes cases, and 20% of syphilis cases.

CDC

All sexually active females aged 25 years or younger should be screened for chlamydia and gonorrhea, as well as “at-risk” young men who have sex with men (YMSM), Dr. Straub said. All adolescent males and females aged over 13 years should be offered HIV screening, and HIV screening should be discussed “at least once.” And depending on how at risk each subpopulation is, health care providers should be have that conversation and offer screening multiple times.

Women who have sex with women (WSW) are a diverse population and should be treated based on their individual sexual identities, behaviors, and practices. “Most self-identified WSWs report having sex with men, so therefore adolescent WSWs and females with both male and female sex partners might be at increased risk for STIs, such as syphillis, chlamydia, and HPV as well as HIV, so you may want to adjust your screening accordingly,” she said.

Pregnant women, if at risk, should be screened for HIV, syphilis, hepatitis B, gonorrhea, and chlamydia.

CDC/Dr. E. Arum; Dr. N. Jacobs

YMSM should have annual screenings for syphilis and HIV, screenings for chlamydia and gonorrhea by infection site; also consider herpes simplex virus serology and anal cytology in these patients, Dr. Straub said. They also should be screened for hepatitis B surface antigen, vaccinated for hepatitis A, hepatitis B and, if using drugs, screened* for hepatitis C virus.

Dr. Straub recommended licensed health care professionals who may treat minor patients review their state’s laws on minors and their legal ability to consent to treatment of STIs without the involvement of their parent or guardian, including disclosure of positive results and in the case of HIV care.

In places where index insured are allowed to find out about any services a beneficiary receives on their insurance, “this is a little problematic, because in some states, this is in direct conflict with the explanation of benefits requirement,” she said. “There are certain ways to get around that, but it’s really important for you to know what the statutes are where you’re practicing and where the breaches of confidentiality [are].”

Expedited partner therapy, or treating one or multiple partners of patients with an STI, is recommended for certain patients and infections, such as male partners of female patients with chlamydia and gonorrhea. While this is recommended less for YMSM because of a higher rate of concurrent infection, “if you have a young person who has partners who are unlikely to have access to care and get treated, it’s recommended you give that treatment to your index patient and to then treat their partners,” Dr. Straub said.

A recent and frequently updated resource on STI treatment can be found at the CDC website.

Dr. Straub reported no relevant conflicts of interest.

*This article was updated 1/11/19.

ORLANDO – Consider point-of-care testing and treat potentially infected partners when diagnosing and treating adolescents for STIs, Diane M. Straub, MD, MPH, said at the annual meeting of the American Academy of Pediatrics.

In addition, adolescents are sometimes reluctant to disclose their full sexual history to their health care provider, which can complicate diagnosis and treatment, noted Dr. Straub, professor of pediatrics at the University of South Florida, Tampa. “That sometimes takes a few questions,” but can be achieved by asking the same questions in different ways and emphasizing the clinical importance of testing.

According to the 2017 Youth Risk Behavior Surveillance survey, 40% of adolescents reported ever having sexual intercourse, with 20% of 9th-grade, 36% of 10th-grade, 47% of 11th-grade, and 57% of 12th-grade students reporting they had sexual intercourse. By gender, 41% of adolescent males and 38% of adolescent females reported ever having sexual intercourse; by race, 39% of white, 41% of Hispanic, and 46% of black participants reported any sexual activity. Overall, 10% of adolescents said they had four or more partners, 3% said they had intercourse before age 13 years, 54% used a condom the last time they had intercourse, and 7% said they were raped.

CDC

The rate of STIs in the United States is rising. There has been a sharp increase in the number of combined diagnoses of gonorrhea, syphilis, and chlamydia, with an increase from 1.8 million in 2013 to 2.3 million cases in 2017, according to the Centers for Disease Control and Prevention. During that same time period, gonorrhea increased 67% from 333,004 to 555,608 cases, syphilis (primary and secondary) rose 76% from 17,375 to 30,644 cases, and chlamydia increased 22% to 1.7 million cases.

According to a 2013 CDC infographic shown by Dr. Straub, young people in the United States aged 15-24 years old represent 27% of the total sexually active population but account for 50% of new STI cases each year. Persons in this population account for 70% of gonorrhea cases, 63% of chlamydia cases, 49% of human papillomavirus (HPV) cases, 45% of genital herpes cases, and 20% of syphilis cases.

CDC

All sexually active females aged 25 years or younger should be screened for chlamydia and gonorrhea, as well as “at-risk” young men who have sex with men (YMSM), Dr. Straub said. All adolescent males and females aged over 13 years should be offered HIV screening, and HIV screening should be discussed “at least once.” And depending on how at risk each subpopulation is, health care providers should be have that conversation and offer screening multiple times.

Women who have sex with women (WSW) are a diverse population and should be treated based on their individual sexual identities, behaviors, and practices. “Most self-identified WSWs report having sex with men, so therefore adolescent WSWs and females with both male and female sex partners might be at increased risk for STIs, such as syphillis, chlamydia, and HPV as well as HIV, so you may want to adjust your screening accordingly,” she said.

Pregnant women, if at risk, should be screened for HIV, syphilis, hepatitis B, gonorrhea, and chlamydia.

CDC/Dr. E. Arum; Dr. N. Jacobs

YMSM should have annual screenings for syphilis and HIV, screenings for chlamydia and gonorrhea by infection site; also consider herpes simplex virus serology and anal cytology in these patients, Dr. Straub said. They also should be screened for hepatitis B surface antigen, vaccinated for hepatitis A, hepatitis B and, if using drugs, screened* for hepatitis C virus.

Dr. Straub recommended licensed health care professionals who may treat minor patients review their state’s laws on minors and their legal ability to consent to treatment of STIs without the involvement of their parent or guardian, including disclosure of positive results and in the case of HIV care.

In places where index insured are allowed to find out about any services a beneficiary receives on their insurance, “this is a little problematic, because in some states, this is in direct conflict with the explanation of benefits requirement,” she said. “There are certain ways to get around that, but it’s really important for you to know what the statutes are where you’re practicing and where the breaches of confidentiality [are].”

Expedited partner therapy, or treating one or multiple partners of patients with an STI, is recommended for certain patients and infections, such as male partners of female patients with chlamydia and gonorrhea. While this is recommended less for YMSM because of a higher rate of concurrent infection, “if you have a young person who has partners who are unlikely to have access to care and get treated, it’s recommended you give that treatment to your index patient and to then treat their partners,” Dr. Straub said.

A recent and frequently updated resource on STI treatment can be found at the CDC website.

Dr. Straub reported no relevant conflicts of interest.

*This article was updated 1/11/19.

ORLANDO – Consider point-of-care testing and treat potentially infected partners when diagnosing and treating adolescents for STIs, Diane M. Straub, MD, MPH, said at the annual meeting of the American Academy of Pediatrics.

In addition, adolescents are sometimes reluctant to disclose their full sexual history to their health care provider, which can complicate diagnosis and treatment, noted Dr. Straub, professor of pediatrics at the University of South Florida, Tampa. “That sometimes takes a few questions,” but can be achieved by asking the same questions in different ways and emphasizing the clinical importance of testing.

According to the 2017 Youth Risk Behavior Surveillance survey, 40% of adolescents reported ever having sexual intercourse, with 20% of 9th-grade, 36% of 10th-grade, 47% of 11th-grade, and 57% of 12th-grade students reporting they had sexual intercourse. By gender, 41% of adolescent males and 38% of adolescent females reported ever having sexual intercourse; by race, 39% of white, 41% of Hispanic, and 46% of black participants reported any sexual activity. Overall, 10% of adolescents said they had four or more partners, 3% said they had intercourse before age 13 years, 54% used a condom the last time they had intercourse, and 7% said they were raped.

CDC

The rate of STIs in the United States is rising. There has been a sharp increase in the number of combined diagnoses of gonorrhea, syphilis, and chlamydia, with an increase from 1.8 million in 2013 to 2.3 million cases in 2017, according to the Centers for Disease Control and Prevention. During that same time period, gonorrhea increased 67% from 333,004 to 555,608 cases, syphilis (primary and secondary) rose 76% from 17,375 to 30,644 cases, and chlamydia increased 22% to 1.7 million cases.

According to a 2013 CDC infographic shown by Dr. Straub, young people in the United States aged 15-24 years old represent 27% of the total sexually active population but account for 50% of new STI cases each year. Persons in this population account for 70% of gonorrhea cases, 63% of chlamydia cases, 49% of human papillomavirus (HPV) cases, 45% of genital herpes cases, and 20% of syphilis cases.

CDC

All sexually active females aged 25 years or younger should be screened for chlamydia and gonorrhea, as well as “at-risk” young men who have sex with men (YMSM), Dr. Straub said. All adolescent males and females aged over 13 years should be offered HIV screening, and HIV screening should be discussed “at least once.” And depending on how at risk each subpopulation is, health care providers should be have that conversation and offer screening multiple times.

Women who have sex with women (WSW) are a diverse population and should be treated based on their individual sexual identities, behaviors, and practices. “Most self-identified WSWs report having sex with men, so therefore adolescent WSWs and females with both male and female sex partners might be at increased risk for STIs, such as syphillis, chlamydia, and HPV as well as HIV, so you may want to adjust your screening accordingly,” she said.

Pregnant women, if at risk, should be screened for HIV, syphilis, hepatitis B, gonorrhea, and chlamydia.

CDC/Dr. E. Arum; Dr. N. Jacobs

YMSM should have annual screenings for syphilis and HIV, screenings for chlamydia and gonorrhea by infection site; also consider herpes simplex virus serology and anal cytology in these patients, Dr. Straub said. They also should be screened for hepatitis B surface antigen, vaccinated for hepatitis A, hepatitis B and, if using drugs, screened* for hepatitis C virus.

Dr. Straub recommended licensed health care professionals who may treat minor patients review their state’s laws on minors and their legal ability to consent to treatment of STIs without the involvement of their parent or guardian, including disclosure of positive results and in the case of HIV care.

In places where index insured are allowed to find out about any services a beneficiary receives on their insurance, “this is a little problematic, because in some states, this is in direct conflict with the explanation of benefits requirement,” she said. “There are certain ways to get around that, but it’s really important for you to know what the statutes are where you’re practicing and where the breaches of confidentiality [are].”

Expedited partner therapy, or treating one or multiple partners of patients with an STI, is recommended for certain patients and infections, such as male partners of female patients with chlamydia and gonorrhea. While this is recommended less for YMSM because of a higher rate of concurrent infection, “if you have a young person who has partners who are unlikely to have access to care and get treated, it’s recommended you give that treatment to your index patient and to then treat their partners,” Dr. Straub said.

A recent and frequently updated resource on STI treatment can be found at the CDC website.

Dr. Straub reported no relevant conflicts of interest.

*This article was updated 1/11/19.

BETHESDA, MD. – Obtaining an extended red cell antigen profile before a patient’s first transfusion can help improve outcomes and avoid complications in highly transfused patients, according to one researcher.

“We strongly feel that you should get an extended red cell type on the first encounter” for patients facing long-term transfusion support, Connie Westhoff, PhD, of the New York Blood Center, said at Sickle Cell in Focus, a conference held by the National Institutes of Health. “This can be a one-time test. It doesn’t have to be repeated.”

She also stressed the importance of ensuring that this information travels with patients, who may be seen at various hospitals. “One of the challenges here is making this part of the patient’s electronic medical record.”

Alloimmunization has been a major concern for chronically transfused patients, so there’s a real advantage to knowing a patient’s extended red cell antigen profile before the patient develops alloantibodies following transfusion, Dr. Westhoff said. Hemolytic transfusion reactions can sometimes destroy patients’ own RBCs in addition to the transfused RBCs. Having the patient’s profile to identify the potential cause of the incompatibility and guide transfusion support in an emergency can be lifesaving.

The implementation of genotyping by DNA-based methods has brought down the cost of this screening, making it no longer a barrier in care.


Dr. Westhoff cited a study she and her colleagues published on a study typing patients who have sickle cell disease (Transfusion. 2015 Jun;55[6 Pt 2]:1388-93). In that paper, they found that DNA-based RBC typing provided improved accuracy and expanded information on RBC antigens, compared with hemagglutination methods. This led to its implementation as the primary method for extended RBC typing for patients with sickle cell disease at the Children’s Hospital of Philadelphia.

About 65%-70% of antibodies drop to levels that are not detectable by routine assays, further demonstrating the need for DNA-based methods. The drugs used to dampen the immune response in many of these patients may also hinder or impact detection of antibodies that remain at levels that continue to cause in vivo hemolysis, Dr. Westhoff said in an interview.

For patients with sickle cell disease in many Western countries, antigen matching for CEK, at a minimum, is routine. The United States is now moving in this direction.

“Modern transfusion practice is moving to knowing what antigens the patient is at risk to become immunized against. ... What antigens does the patient lack and what antibodies could the patient make,” Dr. Westhoff said in an interview. “It’s a major advantage in your transfusion service to expedite work-ups and patient care by having that extended antigen profile.”

Dr. Westhoff reported no relevant financial disclosures.

BETHESDA, MD. – Obtaining an extended red cell antigen profile before a patient’s first transfusion can help improve outcomes and avoid complications in highly transfused patients, according to one researcher.

“We strongly feel that you should get an extended red cell type on the first encounter” for patients facing long-term transfusion support, Connie Westhoff, PhD, of the New York Blood Center, said at Sickle Cell in Focus, a conference held by the National Institutes of Health. “This can be a one-time test. It doesn’t have to be repeated.”

She also stressed the importance of ensuring that this information travels with patients, who may be seen at various hospitals. “One of the challenges here is making this part of the patient’s electronic medical record.”

Alloimmunization has been a major concern for chronically transfused patients, so there’s a real advantage to knowing a patient’s extended red cell antigen profile before the patient develops alloantibodies following transfusion, Dr. Westhoff said. Hemolytic transfusion reactions can sometimes destroy patients’ own RBCs in addition to the transfused RBCs. Having the patient’s profile to identify the potential cause of the incompatibility and guide transfusion support in an emergency can be lifesaving.

The implementation of genotyping by DNA-based methods has brought down the cost of this screening, making it no longer a barrier in care.


Dr. Westhoff cited a study she and her colleagues published on a study typing patients who have sickle cell disease (Transfusion. 2015 Jun;55[6 Pt 2]:1388-93). In that paper, they found that DNA-based RBC typing provided improved accuracy and expanded information on RBC antigens, compared with hemagglutination methods. This led to its implementation as the primary method for extended RBC typing for patients with sickle cell disease at the Children’s Hospital of Philadelphia.

About 65%-70% of antibodies drop to levels that are not detectable by routine assays, further demonstrating the need for DNA-based methods. The drugs used to dampen the immune response in many of these patients may also hinder or impact detection of antibodies that remain at levels that continue to cause in vivo hemolysis, Dr. Westhoff said in an interview.

For patients with sickle cell disease in many Western countries, antigen matching for CEK, at a minimum, is routine. The United States is now moving in this direction.

“Modern transfusion practice is moving to knowing what antigens the patient is at risk to become immunized against. ... What antigens does the patient lack and what antibodies could the patient make,” Dr. Westhoff said in an interview. “It’s a major advantage in your transfusion service to expedite work-ups and patient care by having that extended antigen profile.”

Dr. Westhoff reported no relevant financial disclosures.

BETHESDA, MD. – Obtaining an extended red cell antigen profile before a patient’s first transfusion can help improve outcomes and avoid complications in highly transfused patients, according to one researcher.

“We strongly feel that you should get an extended red cell type on the first encounter” for patients facing long-term transfusion support, Connie Westhoff, PhD, of the New York Blood Center, said at Sickle Cell in Focus, a conference held by the National Institutes of Health. “This can be a one-time test. It doesn’t have to be repeated.”

She also stressed the importance of ensuring that this information travels with patients, who may be seen at various hospitals. “One of the challenges here is making this part of the patient’s electronic medical record.”

Alloimmunization has been a major concern for chronically transfused patients, so there’s a real advantage to knowing a patient’s extended red cell antigen profile before the patient develops alloantibodies following transfusion, Dr. Westhoff said. Hemolytic transfusion reactions can sometimes destroy patients’ own RBCs in addition to the transfused RBCs. Having the patient’s profile to identify the potential cause of the incompatibility and guide transfusion support in an emergency can be lifesaving.

The implementation of genotyping by DNA-based methods has brought down the cost of this screening, making it no longer a barrier in care.


Dr. Westhoff cited a study she and her colleagues published on a study typing patients who have sickle cell disease (Transfusion. 2015 Jun;55[6 Pt 2]:1388-93). In that paper, they found that DNA-based RBC typing provided improved accuracy and expanded information on RBC antigens, compared with hemagglutination methods. This led to its implementation as the primary method for extended RBC typing for patients with sickle cell disease at the Children’s Hospital of Philadelphia.

About 65%-70% of antibodies drop to levels that are not detectable by routine assays, further demonstrating the need for DNA-based methods. The drugs used to dampen the immune response in many of these patients may also hinder or impact detection of antibodies that remain at levels that continue to cause in vivo hemolysis, Dr. Westhoff said in an interview.

For patients with sickle cell disease in many Western countries, antigen matching for CEK, at a minimum, is routine. The United States is now moving in this direction.

“Modern transfusion practice is moving to knowing what antigens the patient is at risk to become immunized against. ... What antigens does the patient lack and what antibodies could the patient make,” Dr. Westhoff said in an interview. “It’s a major advantage in your transfusion service to expedite work-ups and patient care by having that extended antigen profile.”

Dr. Westhoff reported no relevant financial disclosures.

SAN DIEGO – Dipeptidyl peptidase–4 (DPP-4) inhibitors appear to delay the progression of chronic kidney disease (CKD) in patients with type 2 diabetes mellitus (T2DM), a new study has found. Researchers also found that all-cause long-term mortality dropped by an astonishing 78% in patients who took the drugs for an average of more than 3 years.

While the reasons for the impressive mortality results are a mystery, “these medications could have a beneficial effect on the kidneys, and it begins to show after 3 years,” said lead author Mariana Garcia-Touza, MD, of the Kansas City (Missouri) Department of Veterans Affairs Medical Center, in an interview. She presented the results at the meeting, sponsored by the American Society of Nephrology.

DPP-4 inhibitor drugs have been available for more than a decade in the United States. The medications, which include sitagliptin (Januvia) and linagliptin (Tradjenta), are used to treat patients with T2DM who are inadequately controlled by first-line treatments.

The drugs have critics. As UpToDate notes, they’re expensive and their effect on glucose levels is “modest.” In addition, UpToDate says, “some of the DPP-4 inhibitors have been associated with an increased risk of heart failure resulting in hospitalization.”

The authors of the new study sought to understand whether the drugs affect kidney function. As Dr. Garcia-Touza noted, metformin, which is processed in part by the kidneys, is considered harmful to certain patients with kidney disease. However, DPP-4 inhibitors are cleared through the liver. In fact, research has suggested the drugs may actually benefit the liver (Med Sci Monit. 2014 Sep 17;20:1662-7).

For the new study, researchers retrospectively analyzed 20,424 patients with T2DM in the VA system who took DPP-4 inhibitors (average age, 68 years) and compared them with a matched group of 52,118 patients with T2DM who didn’t take the drugs, tracking all patients for a mean of over 3 years.

T2DM control improved slightly in the DPP-4 group but remained worse than the non–DPP-4 group. However, “a significant reduction in progression of CKD was seen” in the DPP-4 group, she said.

The number of patients with creatinine levels above 1.5 mg/dL, 3 mg/dL, and 6 mg/dL was reduced by 7%, 41%, and 47%, respectively, in the DPP-4 group, compared with the other group (P less than .01). And the time to end-stage renal disease (creatinine above 6 mg/dL) was delayed by 144 days in the DPP-4 group (P less than .01).

All-cause mortality also fell by 78% in the DPP-4 group (P less than .0001). “Despite having worse glucose control [than the non–DPP-4 group], these patients have better overall mortality,” Dr. Garcia-Touza said.

The drugs may reduce the burden on the kidneys by decreasing inflammation, she said.

Could DPP-4 drugs be beneficial to patients with CKD even if they don’t have T2DM? Dr. Garcia-Touza wasn’t sure. However, she had a theory about why these kidney benefits didn’t show up in previous research. “My impression is that they didn’t go far enough [in time]. That was the main difference.”

Going forward, Dr. Garcia-Touza said her team plans to study the effects of the drugs on retinopathy and diabetic neuropathy.

The study was funded by the Midwest Biomedical Research Foundation and the VA. The study authors reported no relevant disclosures.
 

SOURCE: Garcia-Tourza M et al. Kidney Week 2018, Abstract TH-OR035.

SAN DIEGO – Dipeptidyl peptidase–4 (DPP-4) inhibitors appear to delay the progression of chronic kidney disease (CKD) in patients with type 2 diabetes mellitus (T2DM), a new study has found. Researchers also found that all-cause long-term mortality dropped by an astonishing 78% in patients who took the drugs for an average of more than 3 years.

While the reasons for the impressive mortality results are a mystery, “these medications could have a beneficial effect on the kidneys, and it begins to show after 3 years,” said lead author Mariana Garcia-Touza, MD, of the Kansas City (Missouri) Department of Veterans Affairs Medical Center, in an interview. She presented the results at the meeting, sponsored by the American Society of Nephrology.

DPP-4 inhibitor drugs have been available for more than a decade in the United States. The medications, which include sitagliptin (Januvia) and linagliptin (Tradjenta), are used to treat patients with T2DM who are inadequately controlled by first-line treatments.

The drugs have critics. As UpToDate notes, they’re expensive and their effect on glucose levels is “modest.” In addition, UpToDate says, “some of the DPP-4 inhibitors have been associated with an increased risk of heart failure resulting in hospitalization.”

The authors of the new study sought to understand whether the drugs affect kidney function. As Dr. Garcia-Touza noted, metformin, which is processed in part by the kidneys, is considered harmful to certain patients with kidney disease. However, DPP-4 inhibitors are cleared through the liver. In fact, research has suggested the drugs may actually benefit the liver (Med Sci Monit. 2014 Sep 17;20:1662-7).

For the new study, researchers retrospectively analyzed 20,424 patients with T2DM in the VA system who took DPP-4 inhibitors (average age, 68 years) and compared them with a matched group of 52,118 patients with T2DM who didn’t take the drugs, tracking all patients for a mean of over 3 years.

T2DM control improved slightly in the DPP-4 group but remained worse than the non–DPP-4 group. However, “a significant reduction in progression of CKD was seen” in the DPP-4 group, she said.

The number of patients with creatinine levels above 1.5 mg/dL, 3 mg/dL, and 6 mg/dL was reduced by 7%, 41%, and 47%, respectively, in the DPP-4 group, compared with the other group (P less than .01). And the time to end-stage renal disease (creatinine above 6 mg/dL) was delayed by 144 days in the DPP-4 group (P less than .01).

All-cause mortality also fell by 78% in the DPP-4 group (P less than .0001). “Despite having worse glucose control [than the non–DPP-4 group], these patients have better overall mortality,” Dr. Garcia-Touza said.

The drugs may reduce the burden on the kidneys by decreasing inflammation, she said.

Could DPP-4 drugs be beneficial to patients with CKD even if they don’t have T2DM? Dr. Garcia-Touza wasn’t sure. However, she had a theory about why these kidney benefits didn’t show up in previous research. “My impression is that they didn’t go far enough [in time]. That was the main difference.”

Going forward, Dr. Garcia-Touza said her team plans to study the effects of the drugs on retinopathy and diabetic neuropathy.

The study was funded by the Midwest Biomedical Research Foundation and the VA. The study authors reported no relevant disclosures.
 

SOURCE: Garcia-Tourza M et al. Kidney Week 2018, Abstract TH-OR035.

SAN DIEGO – Dipeptidyl peptidase–4 (DPP-4) inhibitors appear to delay the progression of chronic kidney disease (CKD) in patients with type 2 diabetes mellitus (T2DM), a new study has found. Researchers also found that all-cause long-term mortality dropped by an astonishing 78% in patients who took the drugs for an average of more than 3 years.

While the reasons for the impressive mortality results are a mystery, “these medications could have a beneficial effect on the kidneys, and it begins to show after 3 years,” said lead author Mariana Garcia-Touza, MD, of the Kansas City (Missouri) Department of Veterans Affairs Medical Center, in an interview. She presented the results at the meeting, sponsored by the American Society of Nephrology.

DPP-4 inhibitor drugs have been available for more than a decade in the United States. The medications, which include sitagliptin (Januvia) and linagliptin (Tradjenta), are used to treat patients with T2DM who are inadequately controlled by first-line treatments.

The drugs have critics. As UpToDate notes, they’re expensive and their effect on glucose levels is “modest.” In addition, UpToDate says, “some of the DPP-4 inhibitors have been associated with an increased risk of heart failure resulting in hospitalization.”

The authors of the new study sought to understand whether the drugs affect kidney function. As Dr. Garcia-Touza noted, metformin, which is processed in part by the kidneys, is considered harmful to certain patients with kidney disease. However, DPP-4 inhibitors are cleared through the liver. In fact, research has suggested the drugs may actually benefit the liver (Med Sci Monit. 2014 Sep 17;20:1662-7).

For the new study, researchers retrospectively analyzed 20,424 patients with T2DM in the VA system who took DPP-4 inhibitors (average age, 68 years) and compared them with a matched group of 52,118 patients with T2DM who didn’t take the drugs, tracking all patients for a mean of over 3 years.

T2DM control improved slightly in the DPP-4 group but remained worse than the non–DPP-4 group. However, “a significant reduction in progression of CKD was seen” in the DPP-4 group, she said.

The number of patients with creatinine levels above 1.5 mg/dL, 3 mg/dL, and 6 mg/dL was reduced by 7%, 41%, and 47%, respectively, in the DPP-4 group, compared with the other group (P less than .01). And the time to end-stage renal disease (creatinine above 6 mg/dL) was delayed by 144 days in the DPP-4 group (P less than .01).

All-cause mortality also fell by 78% in the DPP-4 group (P less than .0001). “Despite having worse glucose control [than the non–DPP-4 group], these patients have better overall mortality,” Dr. Garcia-Touza said.

The drugs may reduce the burden on the kidneys by decreasing inflammation, she said.

Could DPP-4 drugs be beneficial to patients with CKD even if they don’t have T2DM? Dr. Garcia-Touza wasn’t sure. However, she had a theory about why these kidney benefits didn’t show up in previous research. “My impression is that they didn’t go far enough [in time]. That was the main difference.”

Going forward, Dr. Garcia-Touza said her team plans to study the effects of the drugs on retinopathy and diabetic neuropathy.

The study was funded by the Midwest Biomedical Research Foundation and the VA. The study authors reported no relevant disclosures.
 

SOURCE: Garcia-Tourza M et al. Kidney Week 2018, Abstract TH-OR035.

The Diagnosis: Acute Generalized Exanthematous Pustulosis

Histopathology demonstrated spongiosis with subcorneal pustules and an overlying basket-weave pattern stratum corneum. There was mild papillary dermal edema with scattered dermal neutrophils and rare eosinophils (Figure). The patient's clinical presentation and histopathology were consistent with acute generalized exanthematous pustulosis (AGEP). The inciting agent in this case was the contrast medium iopamidol. The patient was treated with a short course of prednisone, triamcinolone cream, diphenhydramine, and acetaminophen. Within 1 week the pustules and erythema had resolved.

Acute generalized exanthematous pustulosis is an uncommon T cell-mediated cutaneous reaction characterized by widespread progressive erythema with numerous nonfollicular pinpoint pustules. The patient usually is well appearing; however, he/she often will have concurrent fever and facial edema. Mucous membranes rarely are involved. Laboratory results typically are notable only for leukocytosis with neutrophilia.

The pustular eruption typically occurs within 1 to 2 days after exposure to an inciting agent¹; however, this latent period can range from 1 hour to nearly 4 weeks in some studies.² Systemic medications are the cause in approximately 90% of cases, with antibiotics being the most common category. Frequently implicated medications include β-lactams, macrolides, quinolones, sulfonamides, proton pump inhibitors, hydroxychloroquine, terbinafine, nonsteroidal anti-inflammatory drugs, diltiazem, ketoconazole, and fluconazole. Acute generalized exanthematous pustulosis also has been rarely reported following contact with mercury, viral and bacterial infections, and spider bites.³

Iodinated contrast agents have long been known to cause immediate and delayed adverse cutaneous reactions. However, one consensus study indicated that these reactions occur in only 0.05% to 0.10% of patients.⁴ Although rare, iodinated contrast media (eg, iopamidol, iohexol, ioversol, iodixanol, iomeprol, iobitridol, iopromide) have been reported as a cause of AGEP. A PubMed search of articles indexed for MEDLINE using the terms acute generalized exanthematous pustulosis, contrast, iodine, and iodinated revealed 10 adult cases reported in 6 articles in the English-language literature.^1,5-9 The most recent articles focus on methods to identify the causative agent. If the etiology of the reaction is unclear, patch or intradermal testing can help to confirm the causative agent. These tests also can help determine similar agents to which the patient may cross-react.^4,5

It can be difficult to differentiate AGEP from other cutaneous drug reactions and other nonfollicular pustular conditions. Drug-induced hypersensitivity syndrome typically presents with facial edema and a morbilliform rash. Although it can present with pustules, the latent period is longer (2-6 weeks), and there frequently are signs of multiorgan involvement including hepatic dysfunction, eosinophilia, atypical lymphocytosis, and lymphadenopathy. Patients with generalized pustular psoriasis often have a history of plaque psoriasis; the pustules are more concentrated in flexural sites; the eruption is gradual in onset; and histologically there tends to be features of psoriasis including parakeratosis, Munro microabscesses, and dilated blood vessels.¹⁰ Subcorneal pustular dermatosis also is more concentrated in flexural sites and frequently has an annular or serpiginous configuration. The onset also is gradual, and it follows a more chronic course than AGEP. Exfoliative erythroderma presents with widespread erythema and superficial desquamating scale. It often occurs in association with systemic symptoms and can be the result of a drug reaction or underlying inflammatory dermatosis such as psoriasis, mycosis fungoides, or pityriasis rubra pilaris.

Acute generalized exanthematous pustulosis usually resolves spontaneously within 2 weeks and is associated with a superficial desquamation as it clears. Appropriate treatment includes discontinuing the offending agent; monitoring for systemic involvement; and treating the patient's symptoms with antihistamines, analgesics, topical steroids, and emollients. In more severe or persistent cases, treatment with systemic steroids and tumor necrosis factor α inhibitors has been attempted, though their efficacy remains unclear. We report a case of iopamidol-induced AGEP that highlights the importance of eliciting a history of contrast exposure from a patient with suspected AGEP.

The Diagnosis: Acute Generalized Exanthematous Pustulosis

Histopathology demonstrated spongiosis with subcorneal pustules and an overlying basket-weave pattern stratum corneum. There was mild papillary dermal edema with scattered dermal neutrophils and rare eosinophils (Figure). The patient's clinical presentation and histopathology were consistent with acute generalized exanthematous pustulosis (AGEP). The inciting agent in this case was the contrast medium iopamidol. The patient was treated with a short course of prednisone, triamcinolone cream, diphenhydramine, and acetaminophen. Within 1 week the pustules and erythema had resolved.

Acute generalized exanthematous pustulosis is an uncommon T cell-mediated cutaneous reaction characterized by widespread progressive erythema with numerous nonfollicular pinpoint pustules. The patient usually is well appearing; however, he/she often will have concurrent fever and facial edema. Mucous membranes rarely are involved. Laboratory results typically are notable only for leukocytosis with neutrophilia.

The pustular eruption typically occurs within 1 to 2 days after exposure to an inciting agent¹; however, this latent period can range from 1 hour to nearly 4 weeks in some studies.² Systemic medications are the cause in approximately 90% of cases, with antibiotics being the most common category. Frequently implicated medications include β-lactams, macrolides, quinolones, sulfonamides, proton pump inhibitors, hydroxychloroquine, terbinafine, nonsteroidal anti-inflammatory drugs, diltiazem, ketoconazole, and fluconazole. Acute generalized exanthematous pustulosis also has been rarely reported following contact with mercury, viral and bacterial infections, and spider bites.³

Iodinated contrast agents have long been known to cause immediate and delayed adverse cutaneous reactions. However, one consensus study indicated that these reactions occur in only 0.05% to 0.10% of patients.⁴ Although rare, iodinated contrast media (eg, iopamidol, iohexol, ioversol, iodixanol, iomeprol, iobitridol, iopromide) have been reported as a cause of AGEP. A PubMed search of articles indexed for MEDLINE using the terms acute generalized exanthematous pustulosis, contrast, iodine, and iodinated revealed 10 adult cases reported in 6 articles in the English-language literature.^1,5-9 The most recent articles focus on methods to identify the causative agent. If the etiology of the reaction is unclear, patch or intradermal testing can help to confirm the causative agent. These tests also can help determine similar agents to which the patient may cross-react.^4,5

It can be difficult to differentiate AGEP from other cutaneous drug reactions and other nonfollicular pustular conditions. Drug-induced hypersensitivity syndrome typically presents with facial edema and a morbilliform rash. Although it can present with pustules, the latent period is longer (2-6 weeks), and there frequently are signs of multiorgan involvement including hepatic dysfunction, eosinophilia, atypical lymphocytosis, and lymphadenopathy. Patients with generalized pustular psoriasis often have a history of plaque psoriasis; the pustules are more concentrated in flexural sites; the eruption is gradual in onset; and histologically there tends to be features of psoriasis including parakeratosis, Munro microabscesses, and dilated blood vessels.¹⁰ Subcorneal pustular dermatosis also is more concentrated in flexural sites and frequently has an annular or serpiginous configuration. The onset also is gradual, and it follows a more chronic course than AGEP. Exfoliative erythroderma presents with widespread erythema and superficial desquamating scale. It often occurs in association with systemic symptoms and can be the result of a drug reaction or underlying inflammatory dermatosis such as psoriasis, mycosis fungoides, or pityriasis rubra pilaris.

Acute generalized exanthematous pustulosis usually resolves spontaneously within 2 weeks and is associated with a superficial desquamation as it clears. Appropriate treatment includes discontinuing the offending agent; monitoring for systemic involvement; and treating the patient's symptoms with antihistamines, analgesics, topical steroids, and emollients. In more severe or persistent cases, treatment with systemic steroids and tumor necrosis factor α inhibitors has been attempted, though their efficacy remains unclear. We report a case of iopamidol-induced AGEP that highlights the importance of eliciting a history of contrast exposure from a patient with suspected AGEP.

The Diagnosis: Acute Generalized Exanthematous Pustulosis

Histopathology demonstrated spongiosis with subcorneal pustules and an overlying basket-weave pattern stratum corneum. There was mild papillary dermal edema with scattered dermal neutrophils and rare eosinophils (Figure). The patient's clinical presentation and histopathology were consistent with acute generalized exanthematous pustulosis (AGEP). The inciting agent in this case was the contrast medium iopamidol. The patient was treated with a short course of prednisone, triamcinolone cream, diphenhydramine, and acetaminophen. Within 1 week the pustules and erythema had resolved.

Acute generalized exanthematous pustulosis is an uncommon T cell-mediated cutaneous reaction characterized by widespread progressive erythema with numerous nonfollicular pinpoint pustules. The patient usually is well appearing; however, he/she often will have concurrent fever and facial edema. Mucous membranes rarely are involved. Laboratory results typically are notable only for leukocytosis with neutrophilia.

The pustular eruption typically occurs within 1 to 2 days after exposure to an inciting agent¹; however, this latent period can range from 1 hour to nearly 4 weeks in some studies.² Systemic medications are the cause in approximately 90% of cases, with antibiotics being the most common category. Frequently implicated medications include β-lactams, macrolides, quinolones, sulfonamides, proton pump inhibitors, hydroxychloroquine, terbinafine, nonsteroidal anti-inflammatory drugs, diltiazem, ketoconazole, and fluconazole. Acute generalized exanthematous pustulosis also has been rarely reported following contact with mercury, viral and bacterial infections, and spider bites.³

Iodinated contrast agents have long been known to cause immediate and delayed adverse cutaneous reactions. However, one consensus study indicated that these reactions occur in only 0.05% to 0.10% of patients.⁴ Although rare, iodinated contrast media (eg, iopamidol, iohexol, ioversol, iodixanol, iomeprol, iobitridol, iopromide) have been reported as a cause of AGEP. A PubMed search of articles indexed for MEDLINE using the terms acute generalized exanthematous pustulosis, contrast, iodine, and iodinated revealed 10 adult cases reported in 6 articles in the English-language literature.^1,5-9 The most recent articles focus on methods to identify the causative agent. If the etiology of the reaction is unclear, patch or intradermal testing can help to confirm the causative agent. These tests also can help determine similar agents to which the patient may cross-react.^4,5

It can be difficult to differentiate AGEP from other cutaneous drug reactions and other nonfollicular pustular conditions. Drug-induced hypersensitivity syndrome typically presents with facial edema and a morbilliform rash. Although it can present with pustules, the latent period is longer (2-6 weeks), and there frequently are signs of multiorgan involvement including hepatic dysfunction, eosinophilia, atypical lymphocytosis, and lymphadenopathy. Patients with generalized pustular psoriasis often have a history of plaque psoriasis; the pustules are more concentrated in flexural sites; the eruption is gradual in onset; and histologically there tends to be features of psoriasis including parakeratosis, Munro microabscesses, and dilated blood vessels.¹⁰ Subcorneal pustular dermatosis also is more concentrated in flexural sites and frequently has an annular or serpiginous configuration. The onset also is gradual, and it follows a more chronic course than AGEP. Exfoliative erythroderma presents with widespread erythema and superficial desquamating scale. It often occurs in association with systemic symptoms and can be the result of a drug reaction or underlying inflammatory dermatosis such as psoriasis, mycosis fungoides, or pityriasis rubra pilaris.

Acute generalized exanthematous pustulosis usually resolves spontaneously within 2 weeks and is associated with a superficial desquamation as it clears. Appropriate treatment includes discontinuing the offending agent; monitoring for systemic involvement; and treating the patient's symptoms with antihistamines, analgesics, topical steroids, and emollients. In more severe or persistent cases, treatment with systemic steroids and tumor necrosis factor α inhibitors has been attempted, though their efficacy remains unclear. We report a case of iopamidol-induced AGEP that highlights the importance of eliciting a history of contrast exposure from a patient with suspected AGEP.

Allowed costs for patients with blood cancer averaged almost $157,000 in the year after diagnosis, with costs for acute leukemia almost tripling that amount, according to a new report from the Leukemia & Lymphoma Society (LLS).

Total allowed cost – the average amount paid by the insurer and patient combined – for acute leukemia was more than $463,000 for the 12 months after initial diagnosis. Averages for the other four cancers included in the analysis came in at $214,000 for multiple myeloma, $134,000 for bone marrow disorders, $131,000 for lymphoma, and $89,000 for chronic leukemia, the LLS said.

The cost figures are drawn from claims data for 2,332 patients diagnosed in 2014.

Differences in out-of-pocket (OOP) costs were smaller, with the average for all patients at almost $3,900 in the year after diagnosis and acute leukemia coming in the highest at $5,100. Over time, however, OOP costs for multiple myeloma patients became the highest, totaling $9,100 for the 3 years after diagnosis, compared with $8,800 for acute leukemia and an average of less than $7,800 for the other blood cancers, the LLS said in the report, which was prepared by the actuarial firm Milliman.

OOP costs also varied by the type of plan. Patients in high-deductible plans averaged nearly $5,400 for the first year after diagnosis, compared with $3,300 for those with traditional insurance, the LLS noted. For acute leukemia, the OOP costs of high-deductible plans were more than twice as high as those of traditional plans.

The study was based on data for adults aged 18-64 years from the Truven Health MarketScan commercial claims databases for the years from 2013 to 2016. The LLS received support for the study from Pfizer, Genentech, and Amgen.
 

[email protected]

Allowed costs for patients with blood cancer averaged almost $157,000 in the year after diagnosis, with costs for acute leukemia almost tripling that amount, according to a new report from the Leukemia & Lymphoma Society (LLS).

Total allowed cost – the average amount paid by the insurer and patient combined – for acute leukemia was more than $463,000 for the 12 months after initial diagnosis. Averages for the other four cancers included in the analysis came in at $214,000 for multiple myeloma, $134,000 for bone marrow disorders, $131,000 for lymphoma, and $89,000 for chronic leukemia, the LLS said.

The cost figures are drawn from claims data for 2,332 patients diagnosed in 2014.

Differences in out-of-pocket (OOP) costs were smaller, with the average for all patients at almost $3,900 in the year after diagnosis and acute leukemia coming in the highest at $5,100. Over time, however, OOP costs for multiple myeloma patients became the highest, totaling $9,100 for the 3 years after diagnosis, compared with $8,800 for acute leukemia and an average of less than $7,800 for the other blood cancers, the LLS said in the report, which was prepared by the actuarial firm Milliman.

OOP costs also varied by the type of plan. Patients in high-deductible plans averaged nearly $5,400 for the first year after diagnosis, compared with $3,300 for those with traditional insurance, the LLS noted. For acute leukemia, the OOP costs of high-deductible plans were more than twice as high as those of traditional plans.

The study was based on data for adults aged 18-64 years from the Truven Health MarketScan commercial claims databases for the years from 2013 to 2016. The LLS received support for the study from Pfizer, Genentech, and Amgen.
 

[email protected]

Allowed costs for patients with blood cancer averaged almost $157,000 in the year after diagnosis, with costs for acute leukemia almost tripling that amount, according to a new report from the Leukemia & Lymphoma Society (LLS).

Total allowed cost – the average amount paid by the insurer and patient combined – for acute leukemia was more than $463,000 for the 12 months after initial diagnosis. Averages for the other four cancers included in the analysis came in at $214,000 for multiple myeloma, $134,000 for bone marrow disorders, $131,000 for lymphoma, and $89,000 for chronic leukemia, the LLS said.

The cost figures are drawn from claims data for 2,332 patients diagnosed in 2014.

Differences in out-of-pocket (OOP) costs were smaller, with the average for all patients at almost $3,900 in the year after diagnosis and acute leukemia coming in the highest at $5,100. Over time, however, OOP costs for multiple myeloma patients became the highest, totaling $9,100 for the 3 years after diagnosis, compared with $8,800 for acute leukemia and an average of less than $7,800 for the other blood cancers, the LLS said in the report, which was prepared by the actuarial firm Milliman.

OOP costs also varied by the type of plan. Patients in high-deductible plans averaged nearly $5,400 for the first year after diagnosis, compared with $3,300 for those with traditional insurance, the LLS noted. For acute leukemia, the OOP costs of high-deductible plans were more than twice as high as those of traditional plans.

The study was based on data for adults aged 18-64 years from the Truven Health MarketScan commercial claims databases for the years from 2013 to 2016. The LLS received support for the study from Pfizer, Genentech, and Amgen.
 

[email protected]