The Diagnosis: Trichotillomania

A scalp punch biopsy revealed pigmented hair casts, an increase in catagen and telogen follicles, and a lack of perifollicular inflammation (Figure). Based on the clinical and histopathological findings, a diagnosis of trichotillomania (TTM) was established.

Trichotillomania is a hairpulling disorder with notable dermatologic and psychiatric overlap. Although previously considered an impulse control disorder, the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) reclassified it within obsessive-compulsive and related disorders, which also include body dysmorphic disorder and excoriation (skin-picking) disorder. Diagnostic criteria for TTM include the following: the patient must have recurrent pulling out of his/her hair resulting in hair loss despite repeated attempts to stop; underlying medical conditions and other psychiatric diagnoses must be excluded; and the patient must experience distress or impairment in social, occupational, or other areas of functioning from the hairpulling.¹ Trichotillomania mainly occurs in children and young adults, with a lifetime prevalence of approximately 1% to 2%.² The coexistence of a mood or anxiety disorder is common, as seen in our patient.

The diagnosis of TTM requires strong clinical suspicion because patients and their parents/guardians usually deny hairpulling. The main clinical differential diagnosis often is alopecia areata (AA) because both conditions can present as well-defined patches of nonscarring hair loss. Trichoscopy provides an invaluable noninvasive diagnostic tool that can be particularly useful in pediatric patients who may be reluctant to have a scalp biopsy. There are many overlapping trichoscopic findings of TTM and AA, including yellow dots, black dots, broken hairs, coiled hairs, and exclamation mark hairs.³ More specific trichoscopy findings for TTM include flame hairs (wavy proximal hair residue), V-sign (2 shafts within 1 follicle broken at the same length), and tulip hairs (dark, tulip-shaped ends of broken hairs).⁴ Hair breakage of varying lengths and trichoptilosis (split ends) can be better visualized using trichoscopy and support a diagnosis of TTM over AA.

Androgenetic alopecia (female pattern hair loss) presents with gradual thinning around the part line of the frontal and parietal scalp with trichoscopy showing miniaturization of hairs and decreased follicle density. The moth-eaten-like appearance of alopecia due to secondary syphilis may mimic alopecia areata clinically, but serologic testing can confirm the diagnosis of syphilis. Telogen effluvium does not have the trichoscopic features that are seen in TTM and is clinically distinguished by hair shedding and a positive hair pull test.

Biopsy can provide objective yet nonspecific support for the diagnosis, demonstrating trichomalacia, pigmented hair casts, empty follicles, and an increase in catagen hairs with a lack of inflammation. Normal and damaged hair follicles may be seen in close proximity, and hemorrhage may be seen secondary to trauma. Pigmented hair casts are not specific to TTM and are present in other traumatic hair disorders, such as traction alopecia; therefore, clinical correlation is essential for diagnosis.

Habit reversal training is the most effective treatment of TTM and involves 3 major components: awareness training with self-monitoring, stimulus control, and competing response procedures.⁵ Although numerous pharmacotherapies have been reported as effective treatments for TTM, a 2013 Cochrane review of 8 randomized controlled trials concluded that no medication has demonstrated reliable efficacy. Reported therapies included selective serotonin reuptake inhibitors, naltrexone, olanzapine, N-acetylcysteine, and clomipramine.⁶

The Diagnosis: Trichotillomania

A scalp punch biopsy revealed pigmented hair casts, an increase in catagen and telogen follicles, and a lack of perifollicular inflammation (Figure). Based on the clinical and histopathological findings, a diagnosis of trichotillomania (TTM) was established.

Trichotillomania is a hairpulling disorder with notable dermatologic and psychiatric overlap. Although previously considered an impulse control disorder, the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) reclassified it within obsessive-compulsive and related disorders, which also include body dysmorphic disorder and excoriation (skin-picking) disorder. Diagnostic criteria for TTM include the following: the patient must have recurrent pulling out of his/her hair resulting in hair loss despite repeated attempts to stop; underlying medical conditions and other psychiatric diagnoses must be excluded; and the patient must experience distress or impairment in social, occupational, or other areas of functioning from the hairpulling.¹ Trichotillomania mainly occurs in children and young adults, with a lifetime prevalence of approximately 1% to 2%.² The coexistence of a mood or anxiety disorder is common, as seen in our patient.

The diagnosis of TTM requires strong clinical suspicion because patients and their parents/guardians usually deny hairpulling. The main clinical differential diagnosis often is alopecia areata (AA) because both conditions can present as well-defined patches of nonscarring hair loss. Trichoscopy provides an invaluable noninvasive diagnostic tool that can be particularly useful in pediatric patients who may be reluctant to have a scalp biopsy. There are many overlapping trichoscopic findings of TTM and AA, including yellow dots, black dots, broken hairs, coiled hairs, and exclamation mark hairs.³ More specific trichoscopy findings for TTM include flame hairs (wavy proximal hair residue), V-sign (2 shafts within 1 follicle broken at the same length), and tulip hairs (dark, tulip-shaped ends of broken hairs).⁴ Hair breakage of varying lengths and trichoptilosis (split ends) can be better visualized using trichoscopy and support a diagnosis of TTM over AA.

Androgenetic alopecia (female pattern hair loss) presents with gradual thinning around the part line of the frontal and parietal scalp with trichoscopy showing miniaturization of hairs and decreased follicle density. The moth-eaten-like appearance of alopecia due to secondary syphilis may mimic alopecia areata clinically, but serologic testing can confirm the diagnosis of syphilis. Telogen effluvium does not have the trichoscopic features that are seen in TTM and is clinically distinguished by hair shedding and a positive hair pull test.

Biopsy can provide objective yet nonspecific support for the diagnosis, demonstrating trichomalacia, pigmented hair casts, empty follicles, and an increase in catagen hairs with a lack of inflammation. Normal and damaged hair follicles may be seen in close proximity, and hemorrhage may be seen secondary to trauma. Pigmented hair casts are not specific to TTM and are present in other traumatic hair disorders, such as traction alopecia; therefore, clinical correlation is essential for diagnosis.

Habit reversal training is the most effective treatment of TTM and involves 3 major components: awareness training with self-monitoring, stimulus control, and competing response procedures.⁵ Although numerous pharmacotherapies have been reported as effective treatments for TTM, a 2013 Cochrane review of 8 randomized controlled trials concluded that no medication has demonstrated reliable efficacy. Reported therapies included selective serotonin reuptake inhibitors, naltrexone, olanzapine, N-acetylcysteine, and clomipramine.⁶

The Diagnosis: Trichotillomania

A scalp punch biopsy revealed pigmented hair casts, an increase in catagen and telogen follicles, and a lack of perifollicular inflammation (Figure). Based on the clinical and histopathological findings, a diagnosis of trichotillomania (TTM) was established.

Trichotillomania is a hairpulling disorder with notable dermatologic and psychiatric overlap. Although previously considered an impulse control disorder, the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) reclassified it within obsessive-compulsive and related disorders, which also include body dysmorphic disorder and excoriation (skin-picking) disorder. Diagnostic criteria for TTM include the following: the patient must have recurrent pulling out of his/her hair resulting in hair loss despite repeated attempts to stop; underlying medical conditions and other psychiatric diagnoses must be excluded; and the patient must experience distress or impairment in social, occupational, or other areas of functioning from the hairpulling.¹ Trichotillomania mainly occurs in children and young adults, with a lifetime prevalence of approximately 1% to 2%.² The coexistence of a mood or anxiety disorder is common, as seen in our patient.

The diagnosis of TTM requires strong clinical suspicion because patients and their parents/guardians usually deny hairpulling. The main clinical differential diagnosis often is alopecia areata (AA) because both conditions can present as well-defined patches of nonscarring hair loss. Trichoscopy provides an invaluable noninvasive diagnostic tool that can be particularly useful in pediatric patients who may be reluctant to have a scalp biopsy. There are many overlapping trichoscopic findings of TTM and AA, including yellow dots, black dots, broken hairs, coiled hairs, and exclamation mark hairs.³ More specific trichoscopy findings for TTM include flame hairs (wavy proximal hair residue), V-sign (2 shafts within 1 follicle broken at the same length), and tulip hairs (dark, tulip-shaped ends of broken hairs).⁴ Hair breakage of varying lengths and trichoptilosis (split ends) can be better visualized using trichoscopy and support a diagnosis of TTM over AA.

Androgenetic alopecia (female pattern hair loss) presents with gradual thinning around the part line of the frontal and parietal scalp with trichoscopy showing miniaturization of hairs and decreased follicle density. The moth-eaten-like appearance of alopecia due to secondary syphilis may mimic alopecia areata clinically, but serologic testing can confirm the diagnosis of syphilis. Telogen effluvium does not have the trichoscopic features that are seen in TTM and is clinically distinguished by hair shedding and a positive hair pull test.

Biopsy can provide objective yet nonspecific support for the diagnosis, demonstrating trichomalacia, pigmented hair casts, empty follicles, and an increase in catagen hairs with a lack of inflammation. Normal and damaged hair follicles may be seen in close proximity, and hemorrhage may be seen secondary to trauma. Pigmented hair casts are not specific to TTM and are present in other traumatic hair disorders, such as traction alopecia; therefore, clinical correlation is essential for diagnosis.

Habit reversal training is the most effective treatment of TTM and involves 3 major components: awareness training with self-monitoring, stimulus control, and competing response procedures.⁵ Although numerous pharmacotherapies have been reported as effective treatments for TTM, a 2013 Cochrane review of 8 randomized controlled trials concluded that no medication has demonstrated reliable efficacy. Reported therapies included selective serotonin reuptake inhibitors, naltrexone, olanzapine, N-acetylcysteine, and clomipramine.⁶

Introducing the Postcall Podcast. At MDedge, we know that medicine can be a bit of an awakening at every step of your career. So, we launched the Postcall Podcast as a way to share your stories: what you love about medicine and what you love outside of your career. This podcast is meant to be a place for you to find your truth.

In the first episode, Nick Andrews welcomes the Editor-In-Chief of MDedge Psychiatry and the host of the MDedge Psychcast, Dr. Lorenzo Norris.
Apple Podcasts
Google Podcasts

Introducing the Postcall Podcast. At MDedge, we know that medicine can be a bit of an awakening at every step of your career. So, we launched the Postcall Podcast as a way to share your stories: what you love about medicine and what you love outside of your career. This podcast is meant to be a place for you to find your truth.

In the first episode, Nick Andrews welcomes the Editor-In-Chief of MDedge Psychiatry and the host of the MDedge Psychcast, Dr. Lorenzo Norris.
Apple Podcasts
Google Podcasts

Introducing the Postcall Podcast. At MDedge, we know that medicine can be a bit of an awakening at every step of your career. So, we launched the Postcall Podcast as a way to share your stories: what you love about medicine and what you love outside of your career. This podcast is meant to be a place for you to find your truth.

In the first episode, Nick Andrews welcomes the Editor-In-Chief of MDedge Psychiatry and the host of the MDedge Psychcast, Dr. Lorenzo Norris.
Apple Podcasts
Google Podcasts

SAN ANTONIO – For adolescents with asthma, treatment with the biologic agent dupilumab provided benefits that were at least comparable with what was seen in adults, results from a retrospective analysis of a randomized, phase 3 study suggest.

Andrew Bowser/MDedge News

Adolescents had reduced asthma exacerbations in line with what was seen in adults and had improvements in lung function that were at a greater magnitude than adults, according to study coauthor Neil M.H. Graham, MD, of Regeneron Pharmaceuticals, Tarrytown, N.Y.

“We think, overall, it’s a very good treatment response from this drug in this high-risk population, and it is generally well tolerated, as we’ve seen in other studies,” Dr. Graham said in a podium presentation at the annual meeting of the American College of Chest Physicians.

Dr. Graham presented results of an analysis of the 1,902-patient, phase 3 Liberty Asthma QUEST trial, published in May 2018 in the New England Journal of Medicine.

Top-line results of QUEST showed that treatment with dupilumab, a fully human anti–IL-4Ra monoclonal antibody, resulted in significantly lower rates of severe asthma exacerbation, along with improved lung function, in patients aged 12 years and older with moderate to severe asthma.

Now, this retrospective analysis shows that, in adolescents, improvements from baseline to week 12 in forced expiratory volume in 1 second (FEV₁) were significant and at a greater magnitude than in adults, according to Dr. Graham and his coinvestigators.

The improvement over 12 weeks in FEV₁ for adolescents was 0.36 L and 0.27 L, respectively, for the 200- and 300-mg doses of dupilumab (P less than .05 vs. placebo for both), Dr. Graham and his coinvestigators reported. In adults, the improvement was 0.12 L.

The annualized exacerbation rate dropped by 46.4% for those adolescents who received 200 mg dupilumab, though there was no treatment effect versus placebo for dupilumab 300 mg; the investigators said the lack of effect in this retrospective analysis could have been caused by imbalances in prior event rates or the small sample size.

A total of 107 out of 1,902 patients in QUEST were adolescents, and of those, 68 were randomly assigned to dupilumab, according to the report. Injection site reaction was the most common adverse event in adolescents in both dosing groups.

Dr. Graham reported disclosures related to his employment with Regeneron. Study coauthors reported disclosures related to Regeneron, AstraZeneca, Sanofi, Teva Pharmaceutical, GlaxoSmithKline, Boehringer Ingelheim, Merck, Genentech, and others.

SOURCE: Graham NMH et al. CHEST. 2018 Oct. doi: 10.1016/j.chest.2018.08.022.

SAN ANTONIO – For adolescents with asthma, treatment with the biologic agent dupilumab provided benefits that were at least comparable with what was seen in adults, results from a retrospective analysis of a randomized, phase 3 study suggest.

Andrew Bowser/MDedge News

Adolescents had reduced asthma exacerbations in line with what was seen in adults and had improvements in lung function that were at a greater magnitude than adults, according to study coauthor Neil M.H. Graham, MD, of Regeneron Pharmaceuticals, Tarrytown, N.Y.

“We think, overall, it’s a very good treatment response from this drug in this high-risk population, and it is generally well tolerated, as we’ve seen in other studies,” Dr. Graham said in a podium presentation at the annual meeting of the American College of Chest Physicians.

Dr. Graham presented results of an analysis of the 1,902-patient, phase 3 Liberty Asthma QUEST trial, published in May 2018 in the New England Journal of Medicine.

Top-line results of QUEST showed that treatment with dupilumab, a fully human anti–IL-4Ra monoclonal antibody, resulted in significantly lower rates of severe asthma exacerbation, along with improved lung function, in patients aged 12 years and older with moderate to severe asthma.

Now, this retrospective analysis shows that, in adolescents, improvements from baseline to week 12 in forced expiratory volume in 1 second (FEV₁) were significant and at a greater magnitude than in adults, according to Dr. Graham and his coinvestigators.

The improvement over 12 weeks in FEV₁ for adolescents was 0.36 L and 0.27 L, respectively, for the 200- and 300-mg doses of dupilumab (P less than .05 vs. placebo for both), Dr. Graham and his coinvestigators reported. In adults, the improvement was 0.12 L.

The annualized exacerbation rate dropped by 46.4% for those adolescents who received 200 mg dupilumab, though there was no treatment effect versus placebo for dupilumab 300 mg; the investigators said the lack of effect in this retrospective analysis could have been caused by imbalances in prior event rates or the small sample size.

A total of 107 out of 1,902 patients in QUEST were adolescents, and of those, 68 were randomly assigned to dupilumab, according to the report. Injection site reaction was the most common adverse event in adolescents in both dosing groups.

Dr. Graham reported disclosures related to his employment with Regeneron. Study coauthors reported disclosures related to Regeneron, AstraZeneca, Sanofi, Teva Pharmaceutical, GlaxoSmithKline, Boehringer Ingelheim, Merck, Genentech, and others.

SOURCE: Graham NMH et al. CHEST. 2018 Oct. doi: 10.1016/j.chest.2018.08.022.

SAN ANTONIO – For adolescents with asthma, treatment with the biologic agent dupilumab provided benefits that were at least comparable with what was seen in adults, results from a retrospective analysis of a randomized, phase 3 study suggest.

Andrew Bowser/MDedge News

Adolescents had reduced asthma exacerbations in line with what was seen in adults and had improvements in lung function that were at a greater magnitude than adults, according to study coauthor Neil M.H. Graham, MD, of Regeneron Pharmaceuticals, Tarrytown, N.Y.

“We think, overall, it’s a very good treatment response from this drug in this high-risk population, and it is generally well tolerated, as we’ve seen in other studies,” Dr. Graham said in a podium presentation at the annual meeting of the American College of Chest Physicians.

Dr. Graham presented results of an analysis of the 1,902-patient, phase 3 Liberty Asthma QUEST trial, published in May 2018 in the New England Journal of Medicine.

Top-line results of QUEST showed that treatment with dupilumab, a fully human anti–IL-4Ra monoclonal antibody, resulted in significantly lower rates of severe asthma exacerbation, along with improved lung function, in patients aged 12 years and older with moderate to severe asthma.

Now, this retrospective analysis shows that, in adolescents, improvements from baseline to week 12 in forced expiratory volume in 1 second (FEV₁) were significant and at a greater magnitude than in adults, according to Dr. Graham and his coinvestigators.

The improvement over 12 weeks in FEV₁ for adolescents was 0.36 L and 0.27 L, respectively, for the 200- and 300-mg doses of dupilumab (P less than .05 vs. placebo for both), Dr. Graham and his coinvestigators reported. In adults, the improvement was 0.12 L.

The annualized exacerbation rate dropped by 46.4% for those adolescents who received 200 mg dupilumab, though there was no treatment effect versus placebo for dupilumab 300 mg; the investigators said the lack of effect in this retrospective analysis could have been caused by imbalances in prior event rates or the small sample size.

A total of 107 out of 1,902 patients in QUEST were adolescents, and of those, 68 were randomly assigned to dupilumab, according to the report. Injection site reaction was the most common adverse event in adolescents in both dosing groups.

Dr. Graham reported disclosures related to his employment with Regeneron. Study coauthors reported disclosures related to Regeneron, AstraZeneca, Sanofi, Teva Pharmaceutical, GlaxoSmithKline, Boehringer Ingelheim, Merck, Genentech, and others.

SOURCE: Graham NMH et al. CHEST. 2018 Oct. doi: 10.1016/j.chest.2018.08.022.

BARCELONA – A large Swedish national registry study has found no hint of increased cancer risk in bipolar patients on long-term lithium therapy.

Bruce Jancin/MDedge News

“This is a very important null result. There is no increased risk for cancer for bipolar patients on lithium. It’s a bad rumor. It’s important to tell patients we’re very confident this is true. We studied every single type of cancer. We would have seen something here if there was something to see,” Lina Martinsson, MD, PhD, said at the annual congress of the European College of Neuropsychopharmacology.

Using comprehensive registry data on nearly 2.6 million Swedes aged 50-84 years with 4 years of follow-up, including 2,393 patients with bipolar disorder on long-term lithium and 3,049 patients not on lithium, the overall cancer incidence rate was 5.9% in the group on lithium and 6.0% in those not taking the drug. Those rates were not different from the general Swedish population, reported Dr. Martinsson, a senior psychiatrist at the Karolinska Institute in Stockholm.

There was, however, a statistically significant increase in three types of cancer in bipolar patients not on lithium: Such patients had a 72% greater risk of lung cancer and other cancers of the respiratory system than the general population, a 47% increased risk of GI cancers, and a 150% greater risk of endocrine organ cancers.

“The increase in respiratory and digestive organ cancers might depend upon bipolar patients’ tendency for smoking and other types of hard living. We can’t explain the increase in endocrine cancers,” she said.

In contrast, the rates of these types of cancer were no different from the general population in bipolar patients taking lithium, hinting at a possible protective effect of the drug, although this remains speculative, the psychiatrist added.

The question of whether lithium is associated with increased cancer risk has been controversial. In particular, several groups have reported a possible increased risk of renal cancer on the basis of what Dr. Martinsson considers weak evidence. She felt a responsibility to undertake this definitive Swedish national study examining the issue because the cancer speculation arose following her earlier study demonstrating that bipolar patients on lithium had much longer telomeres than those not on the drug, and that the ones who responded well to lithium had longer telomeres than those who did not (Transl Psychiatry. 2013 May 21. doi: 10.1038/tp.2013.37).

“If longer telomere length gives longer life to the wrong cells, it might enhance the risk of cancer,” she noted.

But this theoretical concern did not hold up under close Swedish scrutiny. “Warnings for cancer in patients with long-term lithium treatment are unnecessary and ought to be omitted from the current policies,” Dr. Martinsson said.

She reported no financial conflicts regarding her study, which was funded by the Swedish Research Council.

[email protected]

BARCELONA – A large Swedish national registry study has found no hint of increased cancer risk in bipolar patients on long-term lithium therapy.

Bruce Jancin/MDedge News

“This is a very important null result. There is no increased risk for cancer for bipolar patients on lithium. It’s a bad rumor. It’s important to tell patients we’re very confident this is true. We studied every single type of cancer. We would have seen something here if there was something to see,” Lina Martinsson, MD, PhD, said at the annual congress of the European College of Neuropsychopharmacology.

Using comprehensive registry data on nearly 2.6 million Swedes aged 50-84 years with 4 years of follow-up, including 2,393 patients with bipolar disorder on long-term lithium and 3,049 patients not on lithium, the overall cancer incidence rate was 5.9% in the group on lithium and 6.0% in those not taking the drug. Those rates were not different from the general Swedish population, reported Dr. Martinsson, a senior psychiatrist at the Karolinska Institute in Stockholm.

There was, however, a statistically significant increase in three types of cancer in bipolar patients not on lithium: Such patients had a 72% greater risk of lung cancer and other cancers of the respiratory system than the general population, a 47% increased risk of GI cancers, and a 150% greater risk of endocrine organ cancers.

“The increase in respiratory and digestive organ cancers might depend upon bipolar patients’ tendency for smoking and other types of hard living. We can’t explain the increase in endocrine cancers,” she said.

In contrast, the rates of these types of cancer were no different from the general population in bipolar patients taking lithium, hinting at a possible protective effect of the drug, although this remains speculative, the psychiatrist added.

The question of whether lithium is associated with increased cancer risk has been controversial. In particular, several groups have reported a possible increased risk of renal cancer on the basis of what Dr. Martinsson considers weak evidence. She felt a responsibility to undertake this definitive Swedish national study examining the issue because the cancer speculation arose following her earlier study demonstrating that bipolar patients on lithium had much longer telomeres than those not on the drug, and that the ones who responded well to lithium had longer telomeres than those who did not (Transl Psychiatry. 2013 May 21. doi: 10.1038/tp.2013.37).

“If longer telomere length gives longer life to the wrong cells, it might enhance the risk of cancer,” she noted.

But this theoretical concern did not hold up under close Swedish scrutiny. “Warnings for cancer in patients with long-term lithium treatment are unnecessary and ought to be omitted from the current policies,” Dr. Martinsson said.

She reported no financial conflicts regarding her study, which was funded by the Swedish Research Council.

[email protected]

BARCELONA – A large Swedish national registry study has found no hint of increased cancer risk in bipolar patients on long-term lithium therapy.

Bruce Jancin/MDedge News

“This is a very important null result. There is no increased risk for cancer for bipolar patients on lithium. It’s a bad rumor. It’s important to tell patients we’re very confident this is true. We studied every single type of cancer. We would have seen something here if there was something to see,” Lina Martinsson, MD, PhD, said at the annual congress of the European College of Neuropsychopharmacology.

Using comprehensive registry data on nearly 2.6 million Swedes aged 50-84 years with 4 years of follow-up, including 2,393 patients with bipolar disorder on long-term lithium and 3,049 patients not on lithium, the overall cancer incidence rate was 5.9% in the group on lithium and 6.0% in those not taking the drug. Those rates were not different from the general Swedish population, reported Dr. Martinsson, a senior psychiatrist at the Karolinska Institute in Stockholm.

There was, however, a statistically significant increase in three types of cancer in bipolar patients not on lithium: Such patients had a 72% greater risk of lung cancer and other cancers of the respiratory system than the general population, a 47% increased risk of GI cancers, and a 150% greater risk of endocrine organ cancers.

“The increase in respiratory and digestive organ cancers might depend upon bipolar patients’ tendency for smoking and other types of hard living. We can’t explain the increase in endocrine cancers,” she said.

In contrast, the rates of these types of cancer were no different from the general population in bipolar patients taking lithium, hinting at a possible protective effect of the drug, although this remains speculative, the psychiatrist added.

The question of whether lithium is associated with increased cancer risk has been controversial. In particular, several groups have reported a possible increased risk of renal cancer on the basis of what Dr. Martinsson considers weak evidence. She felt a responsibility to undertake this definitive Swedish national study examining the issue because the cancer speculation arose following her earlier study demonstrating that bipolar patients on lithium had much longer telomeres than those not on the drug, and that the ones who responded well to lithium had longer telomeres than those who did not (Transl Psychiatry. 2013 May 21. doi: 10.1038/tp.2013.37).

“If longer telomere length gives longer life to the wrong cells, it might enhance the risk of cancer,” she noted.

But this theoretical concern did not hold up under close Swedish scrutiny. “Warnings for cancer in patients with long-term lithium treatment are unnecessary and ought to be omitted from the current policies,” Dr. Martinsson said.

She reported no financial conflicts regarding her study, which was funded by the Swedish Research Council.

[email protected]

Results from the GARFIELD-AF study show that patients who are newly diagnosed with atrial fibrillation using a direct action anticoagulant led to benefits that tracked previously seen in randomized trials. Also today, the obesity paradox extends to PE patients, adjuvant flu vaccine reduces hospitalization in the oldest patients, and Tdap vaccination early in the third trimester of pregnancy raises antibodies in newborns.

Check out the MDedge Postcall podcast here:
Apple Podcasts
Google Podcasts


 

Results from the GARFIELD-AF study show that patients who are newly diagnosed with atrial fibrillation using a direct action anticoagulant led to benefits that tracked previously seen in randomized trials. Also today, the obesity paradox extends to PE patients, adjuvant flu vaccine reduces hospitalization in the oldest patients, and Tdap vaccination early in the third trimester of pregnancy raises antibodies in newborns.

Check out the MDedge Postcall podcast here:
Apple Podcasts
Google Podcasts


 

Results from the GARFIELD-AF study show that patients who are newly diagnosed with atrial fibrillation using a direct action anticoagulant led to benefits that tracked previously seen in randomized trials. Also today, the obesity paradox extends to PE patients, adjuvant flu vaccine reduces hospitalization in the oldest patients, and Tdap vaccination early in the third trimester of pregnancy raises antibodies in newborns.

Check out the MDedge Postcall podcast here:
Apple Podcasts
Google Podcasts


 

SAN ANTONIO – The recommended approach to evaluating suspected pulmonary embolism is “greatly underutilized” in the Veterans Health Administration system, Nancy Hsu, MD, said at the annual meeting of the American College of Chest Physicians.

Andrew Bowser/MDedge News

Most Veterans Affairs sites did not require incorporation of a clinical decision rule (CDR) and highly sensitive D-dimer prior to ordering CT pulmonary angiography (CTPA) for suspected pulmonary embolism (PE), according to results of a survey by Dr. Hsu and her coinvestigator, Guy Soo Hoo, MD.

While CTPA has become the imaging modality of choice for evaluating suspected PE, it is overused and potentially avoidable in one-third of cases, said Dr. Hsu, who is with the VA Greater Los Angeles Healthcare System.

“In the 10 years following the advent of CTPA use, there was a 14-fold increase in usage, but there was no change in mortality,” Dr. Hsu said. “This is consistent with overdiagnosis.”

Indiscriminate use of CTPA results in unnecessary and avoidable radiation exposure, contrast-related reactions, and treatment-related bleeding, Dr. Hsu said.

Dr. Hsu and Dr. Soo Hoo surveyed 606 individuals at 18 Veterans Integrated Service Networks (VISNs) and 143 medical centers. A total of 120 fully completed questionnaires were analyzed.

Most respondents (63%) were chiefs, and 80% had 11+ years of experience, Dr. Hsu reported.

Almost all respondents (85%) said CDR with or without D-dimer was not required before ordering a CTPA, survey results show, while only about 7% required both.

“A very small minority of [Veterans Integrated Service Networks], or geographic regions, contained even one hospital that adhered to the guidelines,” Dr. Hsu added.

Though further analysis was limited by sample size, the average CTPA yield for PE appeared to be higher when both components were used in the evaluation, according to Dr. Hsu, who noted an 11.9% yield for CDR plus D-dimer.

Use of CTPA appeared lower at sites with CDR and D-dimer testing, Dr. Hsu added.

These results suggest a need for further research to compare CTPA use and yield in sites that have the algorithm in place, Dr. Hsu told attendees at the meeting.

Adherence to the CDR plus D-dimer diagnostic strategy is “modest at best” despite being a Top 5 Choosing Wisely recommendation in pulmonary medicine, Dr. Hsu told attendees.

The biggest barrier to optimal practice may be the fear of having a patient who “falls through the cracks” based on false-negative CDR and D-dimer data, according to Dr. Hsu.

On the other hand, judicious use of CTPA likely avoids negative sequelae related to radiation, contrast exposure, and treatment-related bleeding, Dr. Hsu said.

“It’s all about balancing risks and benefits,” she said from the podium in a discussion of the study results.

Dr. Hsu and Dr. Soo Hoo disclosed that they had no relationships relevant to their research.

SOURCE: Hsu N et al. CHEST. 2018 Oct. doi: 10.1016/j.chest.2018.08.937

SAN ANTONIO – The recommended approach to evaluating suspected pulmonary embolism is “greatly underutilized” in the Veterans Health Administration system, Nancy Hsu, MD, said at the annual meeting of the American College of Chest Physicians.

Andrew Bowser/MDedge News

Most Veterans Affairs sites did not require incorporation of a clinical decision rule (CDR) and highly sensitive D-dimer prior to ordering CT pulmonary angiography (CTPA) for suspected pulmonary embolism (PE), according to results of a survey by Dr. Hsu and her coinvestigator, Guy Soo Hoo, MD.

While CTPA has become the imaging modality of choice for evaluating suspected PE, it is overused and potentially avoidable in one-third of cases, said Dr. Hsu, who is with the VA Greater Los Angeles Healthcare System.

“In the 10 years following the advent of CTPA use, there was a 14-fold increase in usage, but there was no change in mortality,” Dr. Hsu said. “This is consistent with overdiagnosis.”

Indiscriminate use of CTPA results in unnecessary and avoidable radiation exposure, contrast-related reactions, and treatment-related bleeding, Dr. Hsu said.

Dr. Hsu and Dr. Soo Hoo surveyed 606 individuals at 18 Veterans Integrated Service Networks (VISNs) and 143 medical centers. A total of 120 fully completed questionnaires were analyzed.

Most respondents (63%) were chiefs, and 80% had 11+ years of experience, Dr. Hsu reported.

Almost all respondents (85%) said CDR with or without D-dimer was not required before ordering a CTPA, survey results show, while only about 7% required both.

“A very small minority of [Veterans Integrated Service Networks], or geographic regions, contained even one hospital that adhered to the guidelines,” Dr. Hsu added.

Though further analysis was limited by sample size, the average CTPA yield for PE appeared to be higher when both components were used in the evaluation, according to Dr. Hsu, who noted an 11.9% yield for CDR plus D-dimer.

Use of CTPA appeared lower at sites with CDR and D-dimer testing, Dr. Hsu added.

These results suggest a need for further research to compare CTPA use and yield in sites that have the algorithm in place, Dr. Hsu told attendees at the meeting.

Adherence to the CDR plus D-dimer diagnostic strategy is “modest at best” despite being a Top 5 Choosing Wisely recommendation in pulmonary medicine, Dr. Hsu told attendees.

The biggest barrier to optimal practice may be the fear of having a patient who “falls through the cracks” based on false-negative CDR and D-dimer data, according to Dr. Hsu.

On the other hand, judicious use of CTPA likely avoids negative sequelae related to radiation, contrast exposure, and treatment-related bleeding, Dr. Hsu said.

“It’s all about balancing risks and benefits,” she said from the podium in a discussion of the study results.

Dr. Hsu and Dr. Soo Hoo disclosed that they had no relationships relevant to their research.

SOURCE: Hsu N et al. CHEST. 2018 Oct. doi: 10.1016/j.chest.2018.08.937

SAN ANTONIO – The recommended approach to evaluating suspected pulmonary embolism is “greatly underutilized” in the Veterans Health Administration system, Nancy Hsu, MD, said at the annual meeting of the American College of Chest Physicians.

Andrew Bowser/MDedge News

Most Veterans Affairs sites did not require incorporation of a clinical decision rule (CDR) and highly sensitive D-dimer prior to ordering CT pulmonary angiography (CTPA) for suspected pulmonary embolism (PE), according to results of a survey by Dr. Hsu and her coinvestigator, Guy Soo Hoo, MD.

While CTPA has become the imaging modality of choice for evaluating suspected PE, it is overused and potentially avoidable in one-third of cases, said Dr. Hsu, who is with the VA Greater Los Angeles Healthcare System.

“In the 10 years following the advent of CTPA use, there was a 14-fold increase in usage, but there was no change in mortality,” Dr. Hsu said. “This is consistent with overdiagnosis.”

Indiscriminate use of CTPA results in unnecessary and avoidable radiation exposure, contrast-related reactions, and treatment-related bleeding, Dr. Hsu said.

Dr. Hsu and Dr. Soo Hoo surveyed 606 individuals at 18 Veterans Integrated Service Networks (VISNs) and 143 medical centers. A total of 120 fully completed questionnaires were analyzed.

Most respondents (63%) were chiefs, and 80% had 11+ years of experience, Dr. Hsu reported.

Almost all respondents (85%) said CDR with or without D-dimer was not required before ordering a CTPA, survey results show, while only about 7% required both.

“A very small minority of [Veterans Integrated Service Networks], or geographic regions, contained even one hospital that adhered to the guidelines,” Dr. Hsu added.

Though further analysis was limited by sample size, the average CTPA yield for PE appeared to be higher when both components were used in the evaluation, according to Dr. Hsu, who noted an 11.9% yield for CDR plus D-dimer.

Use of CTPA appeared lower at sites with CDR and D-dimer testing, Dr. Hsu added.

These results suggest a need for further research to compare CTPA use and yield in sites that have the algorithm in place, Dr. Hsu told attendees at the meeting.

Adherence to the CDR plus D-dimer diagnostic strategy is “modest at best” despite being a Top 5 Choosing Wisely recommendation in pulmonary medicine, Dr. Hsu told attendees.

The biggest barrier to optimal practice may be the fear of having a patient who “falls through the cracks” based on false-negative CDR and D-dimer data, according to Dr. Hsu.

On the other hand, judicious use of CTPA likely avoids negative sequelae related to radiation, contrast exposure, and treatment-related bleeding, Dr. Hsu said.

“It’s all about balancing risks and benefits,” she said from the podium in a discussion of the study results.

Dr. Hsu and Dr. Soo Hoo disclosed that they had no relationships relevant to their research.

SOURCE: Hsu N et al. CHEST. 2018 Oct. doi: 10.1016/j.chest.2018.08.937

One-week treatment with amphotericin B deoxycholate (AmBd)– and flucytosine (5FC)–based therapy, followed by fluconazole (FLU) on days 8 through 14, is probably superior to other regimens for treatment of HIV-associated cryptococcal meningitis, according to the authors of a review of the available literature in the Cochrane Database of Systemic Reviews.

CDC/Dr. Leanor Haley

The review is an update of one previous previously published in 2011. The authors found 13 eligible studies that enrolled 2,426 participants and compared 21 interventions. They performed a network meta-analysis using multivariate meta-regression, modeled treatment differences (RR and 95% confidence interval), and determined treatment rankings for 2-week and 10-week mortality outcomes using surface under the cumulative ranking curve, which represents the probability that a treatment will present the best outcome with no uncertainty and was used to develop a hierarchy of treatments for HIV-associated cryptococcal meningitis.

In addition, certainty of the evidence was assessed using the GRADE approach, according to Mark W. Tenforde, MD, of the University of Washington School of Public Health, Seattle, and his colleagues.

They found “reduced 10-week mortality with shortened [AmBd and 5FC] induction therapy, compared to the current gold standard of 2 weeks of AmBd and 5FC, based on moderate-certainty evidence.” They also found no mortality benefit of combination 2 weeks AmBd and FLU, compared with AmBd alone.

“In resource-limited settings, 1-week AmBd- and 5FC-based therapy is probably superior to other regimens for treatment of HIV-associated cryptococcal meningitis,” they wrote. “An all-oral regimen of 2 weeks 5FC and FLU may be an alternative in settings where AmBd is unavailable or intravenous therapy cannot be safely administered.” These results indicated the need to expand access to 5FC in resource-limited settings in which HIV-associated cryptococcal meningitis is most common.

They also reported finding no mortality benefit of 2 weeks of combination AmBd and FLU, compared with AmBd alone.

“Given the absence of data from studies in children, and limited data from high-income countries, our findings provide limited guidance for treatment in these patients and settings,” Dr. Tenforde and his colleagues stated.

The authors reported that they had no relevant conflicts of interest.

[email protected]

SOURCE: Tenforde MW et al. Treatment for HIV-associated cryptococcal meningitis. Cochrane Database Syst Rev. 2018 Jul 25;7:CD005647. doi: 10.1002/14651858.CD005647.

One-week treatment with amphotericin B deoxycholate (AmBd)– and flucytosine (5FC)–based therapy, followed by fluconazole (FLU) on days 8 through 14, is probably superior to other regimens for treatment of HIV-associated cryptococcal meningitis, according to the authors of a review of the available literature in the Cochrane Database of Systemic Reviews.

CDC/Dr. Leanor Haley

The review is an update of one previous previously published in 2011. The authors found 13 eligible studies that enrolled 2,426 participants and compared 21 interventions. They performed a network meta-analysis using multivariate meta-regression, modeled treatment differences (RR and 95% confidence interval), and determined treatment rankings for 2-week and 10-week mortality outcomes using surface under the cumulative ranking curve, which represents the probability that a treatment will present the best outcome with no uncertainty and was used to develop a hierarchy of treatments for HIV-associated cryptococcal meningitis.

In addition, certainty of the evidence was assessed using the GRADE approach, according to Mark W. Tenforde, MD, of the University of Washington School of Public Health, Seattle, and his colleagues.

They found “reduced 10-week mortality with shortened [AmBd and 5FC] induction therapy, compared to the current gold standard of 2 weeks of AmBd and 5FC, based on moderate-certainty evidence.” They also found no mortality benefit of combination 2 weeks AmBd and FLU, compared with AmBd alone.

“In resource-limited settings, 1-week AmBd- and 5FC-based therapy is probably superior to other regimens for treatment of HIV-associated cryptococcal meningitis,” they wrote. “An all-oral regimen of 2 weeks 5FC and FLU may be an alternative in settings where AmBd is unavailable or intravenous therapy cannot be safely administered.” These results indicated the need to expand access to 5FC in resource-limited settings in which HIV-associated cryptococcal meningitis is most common.

They also reported finding no mortality benefit of 2 weeks of combination AmBd and FLU, compared with AmBd alone.

“Given the absence of data from studies in children, and limited data from high-income countries, our findings provide limited guidance for treatment in these patients and settings,” Dr. Tenforde and his colleagues stated.

The authors reported that they had no relevant conflicts of interest.

[email protected]

SOURCE: Tenforde MW et al. Treatment for HIV-associated cryptococcal meningitis. Cochrane Database Syst Rev. 2018 Jul 25;7:CD005647. doi: 10.1002/14651858.CD005647.

One-week treatment with amphotericin B deoxycholate (AmBd)– and flucytosine (5FC)–based therapy, followed by fluconazole (FLU) on days 8 through 14, is probably superior to other regimens for treatment of HIV-associated cryptococcal meningitis, according to the authors of a review of the available literature in the Cochrane Database of Systemic Reviews.

CDC/Dr. Leanor Haley

The review is an update of one previous previously published in 2011. The authors found 13 eligible studies that enrolled 2,426 participants and compared 21 interventions. They performed a network meta-analysis using multivariate meta-regression, modeled treatment differences (RR and 95% confidence interval), and determined treatment rankings for 2-week and 10-week mortality outcomes using surface under the cumulative ranking curve, which represents the probability that a treatment will present the best outcome with no uncertainty and was used to develop a hierarchy of treatments for HIV-associated cryptococcal meningitis.

In addition, certainty of the evidence was assessed using the GRADE approach, according to Mark W. Tenforde, MD, of the University of Washington School of Public Health, Seattle, and his colleagues.

They found “reduced 10-week mortality with shortened [AmBd and 5FC] induction therapy, compared to the current gold standard of 2 weeks of AmBd and 5FC, based on moderate-certainty evidence.” They also found no mortality benefit of combination 2 weeks AmBd and FLU, compared with AmBd alone.

“In resource-limited settings, 1-week AmBd- and 5FC-based therapy is probably superior to other regimens for treatment of HIV-associated cryptococcal meningitis,” they wrote. “An all-oral regimen of 2 weeks 5FC and FLU may be an alternative in settings where AmBd is unavailable or intravenous therapy cannot be safely administered.” These results indicated the need to expand access to 5FC in resource-limited settings in which HIV-associated cryptococcal meningitis is most common.

They also reported finding no mortality benefit of 2 weeks of combination AmBd and FLU, compared with AmBd alone.

“Given the absence of data from studies in children, and limited data from high-income countries, our findings provide limited guidance for treatment in these patients and settings,” Dr. Tenforde and his colleagues stated.

The authors reported that they had no relevant conflicts of interest.

[email protected]

SOURCE: Tenforde MW et al. Treatment for HIV-associated cryptococcal meningitis. Cochrane Database Syst Rev. 2018 Jul 25;7:CD005647. doi: 10.1002/14651858.CD005647.

BERLIN – The optimal time to start disease-modifying treatments for relapsing-remitting multiple sclerosis (RRMS) is within 6 months of disease onset, according to real-world data from the Big Multiple Sclerosis Data Network.

Sara Freeman/MDedge News

Receiving disease-modifying treatments (DMTs) within 6 months of diagnosis was associated with a 28% reduction in the risk of reaching an Expanded Disability Status Scale score of 3.0 or more for the first time at 12 months versus receiving treatment after 6 months (hazard ratio, 0.72; 95% confidence interval, 0.59-0.90; P = .003).

Results were not significant, looking at all the other periods tested at 6-month intervals from 1 year up to 5 years after diagnosis. HRs (95% CIs) comparing a first DMT given at 1 year, 1.5 years, 2 years, 2.5 years, 3 years, 3.5 years, 4 years, 4.5 years, and 5 years were a respective 0.90 (0.78-1.03), 0.89 (0.79-1.01), 0.99 (0.88-1.11), 0.95 (0.85-1.06), 1.01 (0.90-1.12), 0.97 (0.86-1.09), 1.09 (0.96-1.22), 1.11 (0.98-1.25), and 1.06 (0.93-1.20).

“To date, these data represent the largest RRMS cohort with the longest follow-up ever analyzed to determine the long-term effectiveness of the early start of DMTs,” said Pietro Iaffaldano, MD, at the annual congress of the European Committee for Treatment and Research in Multiple Sclerosis.

“This study also provides evidence that data sharing from MS registries and databases is feasible,” noted Dr. Iaffaldano, who is assistant professor of neurology at the University of Bari (Italy). Such an approach can provide enough statistical power to detect the impact of treatment on disability outcomes in the long term, he suggested.

For the study, a cohort of 11,934 patients was obtained by screening more than 149,636 patients from five large registries and databases of MS patients – the Italian MS Registry, the Swedish MS Registry, the Danish MS Registry, OFSEP (Observatoire Français de al Sclérose en Plaques), and MSBase. Patients were included in the current analysis if they had at least 10 years of follow-up, had at least three EDSS evaluations, and at least one DMT prescription.

“It is well known that randomized, controlled trials support the early start of treatment in MS, but open-label extensions of the same trials reported inconsistent results about the long-term benefit on disability accumulation,” Dr. Iaffaldano explained. Further, recent observational studies have suggested that initiating DMTs early might not only delay the accumulation of disability but perhaps also death.

The aim of the research was thus to look at what effect the time interval from disease onset to the first administration of a DMT might have on long-term disability accumulation, as measured by the EDSS, in patients with RRMS.

The population of patients studied was mostly (71%) female, with a median age of 27 years at disease onset. The number of relapses prior to starting a DMT was two and the baseline EDSS was 2.0. In almost all (98.9%) cases, DMT was used as first-line treatment (second line in 1.1% of cases). The median follow-up was 13.2 years and cumulative DMT exposure was 10.5 years.

The work was supported by Biogen International on the basis of a sponsored research agreement with the Big Multiple Sclerosis Data Network. Dr. Iaffaldano has served on scientific advisory boards for and received funding for travel and/or speaker honoraria from Biogen and other companies that market DMTs for MS. Several study authors are employees of Biogen, and other study authors also reported financial ties to Biogen and other pharmaceutical companies.

SOURCE: Iaffaldano P et al. Mult Scler. 2018;24(Suppl 2):71-2, Abstract 204.

BERLIN – The optimal time to start disease-modifying treatments for relapsing-remitting multiple sclerosis (RRMS) is within 6 months of disease onset, according to real-world data from the Big Multiple Sclerosis Data Network.

Sara Freeman/MDedge News

Receiving disease-modifying treatments (DMTs) within 6 months of diagnosis was associated with a 28% reduction in the risk of reaching an Expanded Disability Status Scale score of 3.0 or more for the first time at 12 months versus receiving treatment after 6 months (hazard ratio, 0.72; 95% confidence interval, 0.59-0.90; P = .003).

Results were not significant, looking at all the other periods tested at 6-month intervals from 1 year up to 5 years after diagnosis. HRs (95% CIs) comparing a first DMT given at 1 year, 1.5 years, 2 years, 2.5 years, 3 years, 3.5 years, 4 years, 4.5 years, and 5 years were a respective 0.90 (0.78-1.03), 0.89 (0.79-1.01), 0.99 (0.88-1.11), 0.95 (0.85-1.06), 1.01 (0.90-1.12), 0.97 (0.86-1.09), 1.09 (0.96-1.22), 1.11 (0.98-1.25), and 1.06 (0.93-1.20).

“To date, these data represent the largest RRMS cohort with the longest follow-up ever analyzed to determine the long-term effectiveness of the early start of DMTs,” said Pietro Iaffaldano, MD, at the annual congress of the European Committee for Treatment and Research in Multiple Sclerosis.

“This study also provides evidence that data sharing from MS registries and databases is feasible,” noted Dr. Iaffaldano, who is assistant professor of neurology at the University of Bari (Italy). Such an approach can provide enough statistical power to detect the impact of treatment on disability outcomes in the long term, he suggested.

For the study, a cohort of 11,934 patients was obtained by screening more than 149,636 patients from five large registries and databases of MS patients – the Italian MS Registry, the Swedish MS Registry, the Danish MS Registry, OFSEP (Observatoire Français de al Sclérose en Plaques), and MSBase. Patients were included in the current analysis if they had at least 10 years of follow-up, had at least three EDSS evaluations, and at least one DMT prescription.

“It is well known that randomized, controlled trials support the early start of treatment in MS, but open-label extensions of the same trials reported inconsistent results about the long-term benefit on disability accumulation,” Dr. Iaffaldano explained. Further, recent observational studies have suggested that initiating DMTs early might not only delay the accumulation of disability but perhaps also death.

The aim of the research was thus to look at what effect the time interval from disease onset to the first administration of a DMT might have on long-term disability accumulation, as measured by the EDSS, in patients with RRMS.

The population of patients studied was mostly (71%) female, with a median age of 27 years at disease onset. The number of relapses prior to starting a DMT was two and the baseline EDSS was 2.0. In almost all (98.9%) cases, DMT was used as first-line treatment (second line in 1.1% of cases). The median follow-up was 13.2 years and cumulative DMT exposure was 10.5 years.

The work was supported by Biogen International on the basis of a sponsored research agreement with the Big Multiple Sclerosis Data Network. Dr. Iaffaldano has served on scientific advisory boards for and received funding for travel and/or speaker honoraria from Biogen and other companies that market DMTs for MS. Several study authors are employees of Biogen, and other study authors also reported financial ties to Biogen and other pharmaceutical companies.

SOURCE: Iaffaldano P et al. Mult Scler. 2018;24(Suppl 2):71-2, Abstract 204.

BERLIN – The optimal time to start disease-modifying treatments for relapsing-remitting multiple sclerosis (RRMS) is within 6 months of disease onset, according to real-world data from the Big Multiple Sclerosis Data Network.

Sara Freeman/MDedge News

Receiving disease-modifying treatments (DMTs) within 6 months of diagnosis was associated with a 28% reduction in the risk of reaching an Expanded Disability Status Scale score of 3.0 or more for the first time at 12 months versus receiving treatment after 6 months (hazard ratio, 0.72; 95% confidence interval, 0.59-0.90; P = .003).

Results were not significant, looking at all the other periods tested at 6-month intervals from 1 year up to 5 years after diagnosis. HRs (95% CIs) comparing a first DMT given at 1 year, 1.5 years, 2 years, 2.5 years, 3 years, 3.5 years, 4 years, 4.5 years, and 5 years were a respective 0.90 (0.78-1.03), 0.89 (0.79-1.01), 0.99 (0.88-1.11), 0.95 (0.85-1.06), 1.01 (0.90-1.12), 0.97 (0.86-1.09), 1.09 (0.96-1.22), 1.11 (0.98-1.25), and 1.06 (0.93-1.20).

“To date, these data represent the largest RRMS cohort with the longest follow-up ever analyzed to determine the long-term effectiveness of the early start of DMTs,” said Pietro Iaffaldano, MD, at the annual congress of the European Committee for Treatment and Research in Multiple Sclerosis.

“This study also provides evidence that data sharing from MS registries and databases is feasible,” noted Dr. Iaffaldano, who is assistant professor of neurology at the University of Bari (Italy). Such an approach can provide enough statistical power to detect the impact of treatment on disability outcomes in the long term, he suggested.

For the study, a cohort of 11,934 patients was obtained by screening more than 149,636 patients from five large registries and databases of MS patients – the Italian MS Registry, the Swedish MS Registry, the Danish MS Registry, OFSEP (Observatoire Français de al Sclérose en Plaques), and MSBase. Patients were included in the current analysis if they had at least 10 years of follow-up, had at least three EDSS evaluations, and at least one DMT prescription.

“It is well known that randomized, controlled trials support the early start of treatment in MS, but open-label extensions of the same trials reported inconsistent results about the long-term benefit on disability accumulation,” Dr. Iaffaldano explained. Further, recent observational studies have suggested that initiating DMTs early might not only delay the accumulation of disability but perhaps also death.

The aim of the research was thus to look at what effect the time interval from disease onset to the first administration of a DMT might have on long-term disability accumulation, as measured by the EDSS, in patients with RRMS.

The population of patients studied was mostly (71%) female, with a median age of 27 years at disease onset. The number of relapses prior to starting a DMT was two and the baseline EDSS was 2.0. In almost all (98.9%) cases, DMT was used as first-line treatment (second line in 1.1% of cases). The median follow-up was 13.2 years and cumulative DMT exposure was 10.5 years.

The work was supported by Biogen International on the basis of a sponsored research agreement with the Big Multiple Sclerosis Data Network. Dr. Iaffaldano has served on scientific advisory boards for and received funding for travel and/or speaker honoraria from Biogen and other companies that market DMTs for MS. Several study authors are employees of Biogen, and other study authors also reported financial ties to Biogen and other pharmaceutical companies.

SOURCE: Iaffaldano P et al. Mult Scler. 2018;24(Suppl 2):71-2, Abstract 204.

The HIV pandemic among sex workers remains underaddressed and underresourced, with “glaring gaps” in comprehensive measures of HIV prevalence and incidence, and in prevention and treatment, according to the results of an updated literature review published in the Lancet.

Wikimedia Commons/msmornington

Kate Shannon, PhD, director of the gender and sexual health initiative at the University of British Columbia, Vancouver, and her colleagues updated a 2013 literature search for the Lancet series on HIV and sex workers to include reports and manuscripts published from Jan. 1, 2006, to Sept. 6, 2017.

They found that “female, male, and transgender sex workers continue to have disproportionately high burdens of HIV infection in low-income, middle-income, and high-income countries in 2018.” In particular, 4 years after their previous Lancet series on HIV and sex workers, this updated analysis showed that the global HIV burden among female sex workers was still similar to the previously determined 11.8% and “unacceptably high” at 10.4%, (95% confidence interval, 9.5-11.5).

Although there has been some improvement in the assessment of HIV in transgender women since the previous analysis, according to Dr. Shannon and her colleagues, small sample sizes and conflation of transgender women and men who have sex with men (MSM) continue to limit the volume of transgender-specific HIV data, particularly in Africa.

Access to HIV prevention and treatment also remains a considerable problem for sex workers, according to the authors. In particular, “qualitative data in sub-Saharan Africa suggest that profound structural barriers of stigma and discrimination impede progress in the HIV care continuum,” with studies confirming that “successful HIV treatment trajectories are impeded by violence and displacement” because of policing, they wrote.

They pointed out that things may well become worse, with evidence-based progress on full decriminalization grounded in health and human rights – which was a key recommendation in their earlier Lancet Series – having stalled in all but South Africa. In fact, they reported that several countries had even rolled back rights further for sex workers.

“HIV prevention and treatment tools are available but, without comprehensive HIV epidemiology, a lack of denominators and failure to address structural determinants (including decriminalisation of sex work) means that progress in achieving health and rights for all sex workers will fall short,” the researchers concluded.

The authors reported that they had no competing interests.

[email protected]

SOURCE: Shannon K et al. Lancet. 2018 Aug 25;392:698-710.

The HIV pandemic among sex workers remains underaddressed and underresourced, with “glaring gaps” in comprehensive measures of HIV prevalence and incidence, and in prevention and treatment, according to the results of an updated literature review published in the Lancet.

Wikimedia Commons/msmornington

Kate Shannon, PhD, director of the gender and sexual health initiative at the University of British Columbia, Vancouver, and her colleagues updated a 2013 literature search for the Lancet series on HIV and sex workers to include reports and manuscripts published from Jan. 1, 2006, to Sept. 6, 2017.

They found that “female, male, and transgender sex workers continue to have disproportionately high burdens of HIV infection in low-income, middle-income, and high-income countries in 2018.” In particular, 4 years after their previous Lancet series on HIV and sex workers, this updated analysis showed that the global HIV burden among female sex workers was still similar to the previously determined 11.8% and “unacceptably high” at 10.4%, (95% confidence interval, 9.5-11.5).

Although there has been some improvement in the assessment of HIV in transgender women since the previous analysis, according to Dr. Shannon and her colleagues, small sample sizes and conflation of transgender women and men who have sex with men (MSM) continue to limit the volume of transgender-specific HIV data, particularly in Africa.

Access to HIV prevention and treatment also remains a considerable problem for sex workers, according to the authors. In particular, “qualitative data in sub-Saharan Africa suggest that profound structural barriers of stigma and discrimination impede progress in the HIV care continuum,” with studies confirming that “successful HIV treatment trajectories are impeded by violence and displacement” because of policing, they wrote.

They pointed out that things may well become worse, with evidence-based progress on full decriminalization grounded in health and human rights – which was a key recommendation in their earlier Lancet Series – having stalled in all but South Africa. In fact, they reported that several countries had even rolled back rights further for sex workers.

“HIV prevention and treatment tools are available but, without comprehensive HIV epidemiology, a lack of denominators and failure to address structural determinants (including decriminalisation of sex work) means that progress in achieving health and rights for all sex workers will fall short,” the researchers concluded.

The authors reported that they had no competing interests.

[email protected]

SOURCE: Shannon K et al. Lancet. 2018 Aug 25;392:698-710.

The HIV pandemic among sex workers remains underaddressed and underresourced, with “glaring gaps” in comprehensive measures of HIV prevalence and incidence, and in prevention and treatment, according to the results of an updated literature review published in the Lancet.

Wikimedia Commons/msmornington

Kate Shannon, PhD, director of the gender and sexual health initiative at the University of British Columbia, Vancouver, and her colleagues updated a 2013 literature search for the Lancet series on HIV and sex workers to include reports and manuscripts published from Jan. 1, 2006, to Sept. 6, 2017.

They found that “female, male, and transgender sex workers continue to have disproportionately high burdens of HIV infection in low-income, middle-income, and high-income countries in 2018.” In particular, 4 years after their previous Lancet series on HIV and sex workers, this updated analysis showed that the global HIV burden among female sex workers was still similar to the previously determined 11.8% and “unacceptably high” at 10.4%, (95% confidence interval, 9.5-11.5).

Although there has been some improvement in the assessment of HIV in transgender women since the previous analysis, according to Dr. Shannon and her colleagues, small sample sizes and conflation of transgender women and men who have sex with men (MSM) continue to limit the volume of transgender-specific HIV data, particularly in Africa.

Access to HIV prevention and treatment also remains a considerable problem for sex workers, according to the authors. In particular, “qualitative data in sub-Saharan Africa suggest that profound structural barriers of stigma and discrimination impede progress in the HIV care continuum,” with studies confirming that “successful HIV treatment trajectories are impeded by violence and displacement” because of policing, they wrote.

They pointed out that things may well become worse, with evidence-based progress on full decriminalization grounded in health and human rights – which was a key recommendation in their earlier Lancet Series – having stalled in all but South Africa. In fact, they reported that several countries had even rolled back rights further for sex workers.

“HIV prevention and treatment tools are available but, without comprehensive HIV epidemiology, a lack of denominators and failure to address structural determinants (including decriminalisation of sex work) means that progress in achieving health and rights for all sex workers will fall short,” the researchers concluded.

The authors reported that they had no competing interests.

[email protected]

SOURCE: Shannon K et al. Lancet. 2018 Aug 25;392:698-710.

Introducing the Postcall Podcast from MDedge. At MDedge, we know that medicine can be a bit of an awakening at every step of your career. So, we launched the Postcall Podcast as a way to share your stories: what you love about medicine and what you love outside of your career. This podcast is meant to be a place for you to find your truth.

In the first edition, MDedge producer and host Nick Andrews sits down with Lorenzo Norris, MD. Dr. Norris is the host of the MDedge Psychcast as well as the editor-in-chief of MDedge Psychiatry and Dean at the George Washington University School of Medicine and Health Sciences.

Subscribe to the Postcall Podcast:
Apple Podcasts
Google Podcasts

Introducing the Postcall Podcast from MDedge. At MDedge, we know that medicine can be a bit of an awakening at every step of your career. So, we launched the Postcall Podcast as a way to share your stories: what you love about medicine and what you love outside of your career. This podcast is meant to be a place for you to find your truth.

In the first edition, MDedge producer and host Nick Andrews sits down with Lorenzo Norris, MD. Dr. Norris is the host of the MDedge Psychcast as well as the editor-in-chief of MDedge Psychiatry and Dean at the George Washington University School of Medicine and Health Sciences.

Subscribe to the Postcall Podcast:
Apple Podcasts
Google Podcasts

Introducing the Postcall Podcast from MDedge. At MDedge, we know that medicine can be a bit of an awakening at every step of your career. So, we launched the Postcall Podcast as a way to share your stories: what you love about medicine and what you love outside of your career. This podcast is meant to be a place for you to find your truth.

In the first edition, MDedge producer and host Nick Andrews sits down with Lorenzo Norris, MD. Dr. Norris is the host of the MDedge Psychcast as well as the editor-in-chief of MDedge Psychiatry and Dean at the George Washington University School of Medicine and Health Sciences.

Subscribe to the Postcall Podcast:
Apple Podcasts
Google Podcasts