Mr. M, age 55, presents to his primary care physician (PCP) with hematochezia. Mr. M states that for the past week, he has noticed blood upon wiping after a bowel movement and is worried that he might have cancer.

Mr. M has a 10-year history of opioid use disorder as diagnosed by his psychiatrist. He is presently maintained on long-acting injectable naltrexone, 380 mg IM every 4 weeks, and has not used opioids for the past 1.5 years. Mr. M is also taking simvastatin, 40 mg, for dyslipidemia, lisinopril, 5 mg, for hypertension, and cetirizine, 5 mg as needed, for seasonal allergies.

A standard workup including a physical examination and laboratory tests are performed. Mr. M’s PCP would like for him to undergo a colonoscopy to investigate the etiology of the bleeding. In consultation with both the PCP and psychiatrist, the gastroenterologist determines that the colonoscopy can be performed within 48 hours with no changes to Mr. M’s medication regimen. The gastroenterologist utilizes a nonopioid, ketorolac, 30 mg IV, for pain management during the procedure. Diverticula were identified in the lower gastrointestinal tract and are treated endoscopically. Mr. M is successfully withdrawn from sedation with no adverse events or pain and continues to be in opioid remission.

Naltrexone competitively antagonizes opioid receptors with the highest affinity for the µ-opioid receptor. It is approved for treatment of alcohol and opioid dependence following opioid detoxification.¹ Its competitive inhibition at the µ-opioid receptor results in the inhibition of exogenous opioid effects. The medication is available as an orally administered tablet as well as a long-acting injection administered intramuscularly (Table 1¹). The long-acting injection can be useful in patients who have difficulty with adherence, because good adherence to naltrexone is required to maximize efficacy.

Due to its ability to block opioid analgesic effects, naltrexone presents a unique challenge for patients taking it who need to undergo procedures that require pain control. Pharmacologic regimens used during procedures often contain a sedative agent, such as propofol, and an opioid for analgesia. Alternative strategies are needed for patients taking naltrexone who require an opioid analgesic agent for procedures such as colonoscopies.

One strategy could be to withhold naltrexone before the procedure to ensure that the medication will not compete with the opioid agent to relieve pain. This strategy depends on the urgency of the procedure, the formulation of naltrexone being used, and patient-specific factors that may increase the risk for adverse events. For a non-urgent, elective procedure, it may be acceptable to hold oral naltrexone approximately 72 hours before the procedure. However, this is likely not a favorable approach for patients who may be at high risk for relapse or for patients who are receiving the long-acting formulation. Additionally, the use of an opioid agent intra- or post-operatively for pain may increase the risk of relapse. The use of opioids for such procedures may also be more difficult in a patient with a history of opioid abuse or dependence because he or she may have developed tolerance to opioids. Conversely, if a patient has been treated with naltrexone for an extended period, a lack of tolerance may increase the risk of respiratory depression with opioid administration due to upregulation of the opioid receptor.²

Continue to: Nonopioid analgesic agents

For a patient receiving naltrexone who needs to undergo a procedure, a multi­disciplinary consultation between the patient’s psychiatrist and other clinicians is key for providing a regimen that is safe and effective. A nonopioid analgesic agent may be considered to avoid the problematic interactions possible in these patients (Table 2^3-5). Nonopioid regimens can be utilized alone or in combination, and may include the following^3-5:

Ketamine is a non-competitive antagonist at the N-methyl-d-aspartate receptor that can provide sedation and analgesia with a rapid onset and short duration of action. However, analgesics should still be used for patients undergoing procedures that might cause visceral pain. Ketamine is contraindicated for patients with uncontrolled hypertension.

Dexmedetomidine is an alpha-2 agonist that can provide sedative and analgesic effects. It can cause procedural hypotension and bradycardia, so caution is advised in patients with cardiac disease and hepatic and/or renal insufficiencies.

Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen or ketorolac, inhibit cyclooxygenase enzymes and can be considered in analgesic regimens. However, for most surgical procedures, the increased risk of bleeding due to platelet inhibition is a concern.

Continue to: Acetaminophen

Acetaminophen. Although its full mechanism of action has not been discovered, acetaminophen may also act on the cyclooxygenase pathway to produce analgesia. Compared with the oral formulation, IV acetaminophen is more expensive but may offer certain advantages, including faster plasma peak levels and lower production of acetaminophen’s toxic metabolite, N-acetyl-p-benzoquinone imine. Nonetheless, hepatotoxicity and overdose remain a concern.

The use of nonopioid analgesics during elective procedures that require pain control will allow continued use of an opioid antagonist such as naltrexone, while minimizing the risk for withdrawal or relapse. Their use must be evaluated on a case-by-case basis to ensure maximum safety and efficacy for each patient from both a medical and psychiatric standpoint. Overall, with the proper expertise and consultation, nonopioid pain regimens represent a reasonable alternative to opiates for patients who take naltrexone.

Related Resources

• American Society of Anesthesiologists. Standards guidelines and related resources. https://www.asahq.org/quality-and-practice-management/standards-guidelines-and-related-resources-search.
• American Society of Addiction Medicine. Clinical resources. https://www.asam.org/resources/guidelines-and-consensus-documents.

Drug Brand Names

Acetaminophen • Tylenol
Cetirizine • Zyrtec
Dexmedetomidine • Precedex
Ibuprofen • Caldolor (IV), Motrin (oral)
Ketamine • Ketalar
Ketorolac • Toradol
Lisinopril • Prinivil, Zestril
Naltrexone • ReVia, Vivitrol
Propofol • Diprivan
Simvastatin • Juvisync, Simcor

Mr. M, age 55, presents to his primary care physician (PCP) with hematochezia. Mr. M states that for the past week, he has noticed blood upon wiping after a bowel movement and is worried that he might have cancer.

Mr. M has a 10-year history of opioid use disorder as diagnosed by his psychiatrist. He is presently maintained on long-acting injectable naltrexone, 380 mg IM every 4 weeks, and has not used opioids for the past 1.5 years. Mr. M is also taking simvastatin, 40 mg, for dyslipidemia, lisinopril, 5 mg, for hypertension, and cetirizine, 5 mg as needed, for seasonal allergies.

A standard workup including a physical examination and laboratory tests are performed. Mr. M’s PCP would like for him to undergo a colonoscopy to investigate the etiology of the bleeding. In consultation with both the PCP and psychiatrist, the gastroenterologist determines that the colonoscopy can be performed within 48 hours with no changes to Mr. M’s medication regimen. The gastroenterologist utilizes a nonopioid, ketorolac, 30 mg IV, for pain management during the procedure. Diverticula were identified in the lower gastrointestinal tract and are treated endoscopically. Mr. M is successfully withdrawn from sedation with no adverse events or pain and continues to be in opioid remission.

Naltrexone competitively antagonizes opioid receptors with the highest affinity for the µ-opioid receptor. It is approved for treatment of alcohol and opioid dependence following opioid detoxification.¹ Its competitive inhibition at the µ-opioid receptor results in the inhibition of exogenous opioid effects. The medication is available as an orally administered tablet as well as a long-acting injection administered intramuscularly (Table 1¹). The long-acting injection can be useful in patients who have difficulty with adherence, because good adherence to naltrexone is required to maximize efficacy.

Due to its ability to block opioid analgesic effects, naltrexone presents a unique challenge for patients taking it who need to undergo procedures that require pain control. Pharmacologic regimens used during procedures often contain a sedative agent, such as propofol, and an opioid for analgesia. Alternative strategies are needed for patients taking naltrexone who require an opioid analgesic agent for procedures such as colonoscopies.

One strategy could be to withhold naltrexone before the procedure to ensure that the medication will not compete with the opioid agent to relieve pain. This strategy depends on the urgency of the procedure, the formulation of naltrexone being used, and patient-specific factors that may increase the risk for adverse events. For a non-urgent, elective procedure, it may be acceptable to hold oral naltrexone approximately 72 hours before the procedure. However, this is likely not a favorable approach for patients who may be at high risk for relapse or for patients who are receiving the long-acting formulation. Additionally, the use of an opioid agent intra- or post-operatively for pain may increase the risk of relapse. The use of opioids for such procedures may also be more difficult in a patient with a history of opioid abuse or dependence because he or she may have developed tolerance to opioids. Conversely, if a patient has been treated with naltrexone for an extended period, a lack of tolerance may increase the risk of respiratory depression with opioid administration due to upregulation of the opioid receptor.²

Continue to: Nonopioid analgesic agents

For a patient receiving naltrexone who needs to undergo a procedure, a multi­disciplinary consultation between the patient’s psychiatrist and other clinicians is key for providing a regimen that is safe and effective. A nonopioid analgesic agent may be considered to avoid the problematic interactions possible in these patients (Table 2^3-5). Nonopioid regimens can be utilized alone or in combination, and may include the following^3-5:

Ketamine is a non-competitive antagonist at the N-methyl-d-aspartate receptor that can provide sedation and analgesia with a rapid onset and short duration of action. However, analgesics should still be used for patients undergoing procedures that might cause visceral pain. Ketamine is contraindicated for patients with uncontrolled hypertension.

Dexmedetomidine is an alpha-2 agonist that can provide sedative and analgesic effects. It can cause procedural hypotension and bradycardia, so caution is advised in patients with cardiac disease and hepatic and/or renal insufficiencies.

Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen or ketorolac, inhibit cyclooxygenase enzymes and can be considered in analgesic regimens. However, for most surgical procedures, the increased risk of bleeding due to platelet inhibition is a concern.

Continue to: Acetaminophen

Acetaminophen. Although its full mechanism of action has not been discovered, acetaminophen may also act on the cyclooxygenase pathway to produce analgesia. Compared with the oral formulation, IV acetaminophen is more expensive but may offer certain advantages, including faster plasma peak levels and lower production of acetaminophen’s toxic metabolite, N-acetyl-p-benzoquinone imine. Nonetheless, hepatotoxicity and overdose remain a concern.

The use of nonopioid analgesics during elective procedures that require pain control will allow continued use of an opioid antagonist such as naltrexone, while minimizing the risk for withdrawal or relapse. Their use must be evaluated on a case-by-case basis to ensure maximum safety and efficacy for each patient from both a medical and psychiatric standpoint. Overall, with the proper expertise and consultation, nonopioid pain regimens represent a reasonable alternative to opiates for patients who take naltrexone.

Related Resources

• American Society of Anesthesiologists. Standards guidelines and related resources. https://www.asahq.org/quality-and-practice-management/standards-guidelines-and-related-resources-search.
• American Society of Addiction Medicine. Clinical resources. https://www.asam.org/resources/guidelines-and-consensus-documents.

Drug Brand Names

Acetaminophen • Tylenol
Cetirizine • Zyrtec
Dexmedetomidine • Precedex
Ibuprofen • Caldolor (IV), Motrin (oral)
Ketamine • Ketalar
Ketorolac • Toradol
Lisinopril • Prinivil, Zestril
Naltrexone • ReVia, Vivitrol
Propofol • Diprivan
Simvastatin • Juvisync, Simcor

Mr. M, age 55, presents to his primary care physician (PCP) with hematochezia. Mr. M states that for the past week, he has noticed blood upon wiping after a bowel movement and is worried that he might have cancer.

Mr. M has a 10-year history of opioid use disorder as diagnosed by his psychiatrist. He is presently maintained on long-acting injectable naltrexone, 380 mg IM every 4 weeks, and has not used opioids for the past 1.5 years. Mr. M is also taking simvastatin, 40 mg, for dyslipidemia, lisinopril, 5 mg, for hypertension, and cetirizine, 5 mg as needed, for seasonal allergies.

A standard workup including a physical examination and laboratory tests are performed. Mr. M’s PCP would like for him to undergo a colonoscopy to investigate the etiology of the bleeding. In consultation with both the PCP and psychiatrist, the gastroenterologist determines that the colonoscopy can be performed within 48 hours with no changes to Mr. M’s medication regimen. The gastroenterologist utilizes a nonopioid, ketorolac, 30 mg IV, for pain management during the procedure. Diverticula were identified in the lower gastrointestinal tract and are treated endoscopically. Mr. M is successfully withdrawn from sedation with no adverse events or pain and continues to be in opioid remission.

Naltrexone competitively antagonizes opioid receptors with the highest affinity for the µ-opioid receptor. It is approved for treatment of alcohol and opioid dependence following opioid detoxification.¹ Its competitive inhibition at the µ-opioid receptor results in the inhibition of exogenous opioid effects. The medication is available as an orally administered tablet as well as a long-acting injection administered intramuscularly (Table 1¹). The long-acting injection can be useful in patients who have difficulty with adherence, because good adherence to naltrexone is required to maximize efficacy.

Due to its ability to block opioid analgesic effects, naltrexone presents a unique challenge for patients taking it who need to undergo procedures that require pain control. Pharmacologic regimens used during procedures often contain a sedative agent, such as propofol, and an opioid for analgesia. Alternative strategies are needed for patients taking naltrexone who require an opioid analgesic agent for procedures such as colonoscopies.

One strategy could be to withhold naltrexone before the procedure to ensure that the medication will not compete with the opioid agent to relieve pain. This strategy depends on the urgency of the procedure, the formulation of naltrexone being used, and patient-specific factors that may increase the risk for adverse events. For a non-urgent, elective procedure, it may be acceptable to hold oral naltrexone approximately 72 hours before the procedure. However, this is likely not a favorable approach for patients who may be at high risk for relapse or for patients who are receiving the long-acting formulation. Additionally, the use of an opioid agent intra- or post-operatively for pain may increase the risk of relapse. The use of opioids for such procedures may also be more difficult in a patient with a history of opioid abuse or dependence because he or she may have developed tolerance to opioids. Conversely, if a patient has been treated with naltrexone for an extended period, a lack of tolerance may increase the risk of respiratory depression with opioid administration due to upregulation of the opioid receptor.²

Continue to: Nonopioid analgesic agents

For a patient receiving naltrexone who needs to undergo a procedure, a multi­disciplinary consultation between the patient’s psychiatrist and other clinicians is key for providing a regimen that is safe and effective. A nonopioid analgesic agent may be considered to avoid the problematic interactions possible in these patients (Table 2^3-5). Nonopioid regimens can be utilized alone or in combination, and may include the following^3-5:

Ketamine is a non-competitive antagonist at the N-methyl-d-aspartate receptor that can provide sedation and analgesia with a rapid onset and short duration of action. However, analgesics should still be used for patients undergoing procedures that might cause visceral pain. Ketamine is contraindicated for patients with uncontrolled hypertension.

Dexmedetomidine is an alpha-2 agonist that can provide sedative and analgesic effects. It can cause procedural hypotension and bradycardia, so caution is advised in patients with cardiac disease and hepatic and/or renal insufficiencies.

Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen or ketorolac, inhibit cyclooxygenase enzymes and can be considered in analgesic regimens. However, for most surgical procedures, the increased risk of bleeding due to platelet inhibition is a concern.

Continue to: Acetaminophen

Acetaminophen. Although its full mechanism of action has not been discovered, acetaminophen may also act on the cyclooxygenase pathway to produce analgesia. Compared with the oral formulation, IV acetaminophen is more expensive but may offer certain advantages, including faster plasma peak levels and lower production of acetaminophen’s toxic metabolite, N-acetyl-p-benzoquinone imine. Nonetheless, hepatotoxicity and overdose remain a concern.

The use of nonopioid analgesics during elective procedures that require pain control will allow continued use of an opioid antagonist such as naltrexone, while minimizing the risk for withdrawal or relapse. Their use must be evaluated on a case-by-case basis to ensure maximum safety and efficacy for each patient from both a medical and psychiatric standpoint. Overall, with the proper expertise and consultation, nonopioid pain regimens represent a reasonable alternative to opiates for patients who take naltrexone.

Related Resources

• American Society of Anesthesiologists. Standards guidelines and related resources. https://www.asahq.org/quality-and-practice-management/standards-guidelines-and-related-resources-search.
• American Society of Addiction Medicine. Clinical resources. https://www.asam.org/resources/guidelines-and-consensus-documents.

Drug Brand Names

Acetaminophen • Tylenol
Cetirizine • Zyrtec
Dexmedetomidine • Precedex
Ibuprofen • Caldolor (IV), Motrin (oral)
Ketamine • Ketalar
Ketorolac • Toradol
Lisinopril • Prinivil, Zestril
Naltrexone • ReVia, Vivitrol
Propofol • Diprivan
Simvastatin • Juvisync, Simcor

Anticoagulation thresholds based on CHA₂DS₂-VASc risk score varied from population to population, researchers reported in the Annals of Internal Medicine.

After accounting for differing rates of stroke in published studies, the benefit of warfarin anticoagulation varied nearly fourfold, said Sachin J. Shah, MD, of the University of California San Francisco and his associates. They called for guidelines that “better reflect the uncertainty in current thresholds of stroke risk score for recommending anticoagulation.”

Oral anticoagulation markedly reduces risk of ischemic stroke in patients with atrial fibrillation but increases the risk of major bleeding, including intracranial hemorrhage, which often is fatal. Therefore, when deciding whether to recommend oral anticoagulation, physicians must estimate clinical net benefit by quantifying the difference between reduction in stroke risk and increase in major bleeding risk, weighted by the severity of each outcome.

Guidelines on nonvalvular atrial fibrillation from the European Society of Cardiology and joint guidelines from the American Heart Association, American College of Cardiology, and Heart Rhythm Society (AHA/ACC/HRS) recommend oral anticoagulation when CHA₂DS₂-VASc (congestive heart failure, hypertension, age, diabetes, stroke, and vascular disease) risk score is 2 or greater. These guidelines implicitly assume that a particular CHA₂DS₂-VASc score denotes the same amount of risk across populations, even though a recent meta-analysis found otherwise, as the researchers noted.

To further test this assumption, they applied an existing Markov model to data from more than 33,000 members of the ATRIA-CVRN cohort. All patients had nonvalvular atrial fibrillation, were members of Kaiser Permanente Northern California, and were diagnosed during 1996-1997. About 81% had a CHA₂DS₂-VASc score of at least 2. For each patient, the researchers produced four estimates of the net clinical benefit of oral anticoagulation based on ischemic stroke rates from ATRIA, the Swedish AF cohort study, the SPORTIF study, and the Danish National Patient Registry.

Optimal anticoagulation thresholds were a CHA₂DS₂-VASc score of 3 or more using stroke rates from ATRIA, 2 or more based on Swedish AF rates, 1 or more based on SPORTIF rates, and 0 or more using rates from the Danish National Patient Registry. Oral anticoagulation thresholds were lower but still varied widely after accounting for the lower rates of intracranial hemorrhage associated with non–vitamin K antagonist therapy.

Therefore, current guidelines based on CHA₂DS₂-VASc score may need revising “in favor of more accurate, individualized assessments of risk for both ischemic stroke and major bleeding,” the investigators wrote. “Until such time, guidelines should better reflect the uncertainty of the current approach in which a patient’s CHA₂DS₂-VASc score is used as the primary basis for recommending oral anticoagulation.”

The study had no primary funding source. Dr. Shah reported having no conflicts of interest. Three coinvestigators disclosed research support from relevant pharmaceutical or device companies.

SOURCE: Shah SJ et al. Ann Intern Med. 2018 Sep 25. doi: 10.7326/M17-2762  

Anticoagulation thresholds based on CHA₂DS₂-VASc risk score varied from population to population, researchers reported in the Annals of Internal Medicine.

After accounting for differing rates of stroke in published studies, the benefit of warfarin anticoagulation varied nearly fourfold, said Sachin J. Shah, MD, of the University of California San Francisco and his associates. They called for guidelines that “better reflect the uncertainty in current thresholds of stroke risk score for recommending anticoagulation.”

Oral anticoagulation markedly reduces risk of ischemic stroke in patients with atrial fibrillation but increases the risk of major bleeding, including intracranial hemorrhage, which often is fatal. Therefore, when deciding whether to recommend oral anticoagulation, physicians must estimate clinical net benefit by quantifying the difference between reduction in stroke risk and increase in major bleeding risk, weighted by the severity of each outcome.

Guidelines on nonvalvular atrial fibrillation from the European Society of Cardiology and joint guidelines from the American Heart Association, American College of Cardiology, and Heart Rhythm Society (AHA/ACC/HRS) recommend oral anticoagulation when CHA₂DS₂-VASc (congestive heart failure, hypertension, age, diabetes, stroke, and vascular disease) risk score is 2 or greater. These guidelines implicitly assume that a particular CHA₂DS₂-VASc score denotes the same amount of risk across populations, even though a recent meta-analysis found otherwise, as the researchers noted.

To further test this assumption, they applied an existing Markov model to data from more than 33,000 members of the ATRIA-CVRN cohort. All patients had nonvalvular atrial fibrillation, were members of Kaiser Permanente Northern California, and were diagnosed during 1996-1997. About 81% had a CHA₂DS₂-VASc score of at least 2. For each patient, the researchers produced four estimates of the net clinical benefit of oral anticoagulation based on ischemic stroke rates from ATRIA, the Swedish AF cohort study, the SPORTIF study, and the Danish National Patient Registry.

Optimal anticoagulation thresholds were a CHA₂DS₂-VASc score of 3 or more using stroke rates from ATRIA, 2 or more based on Swedish AF rates, 1 or more based on SPORTIF rates, and 0 or more using rates from the Danish National Patient Registry. Oral anticoagulation thresholds were lower but still varied widely after accounting for the lower rates of intracranial hemorrhage associated with non–vitamin K antagonist therapy.

Therefore, current guidelines based on CHA₂DS₂-VASc score may need revising “in favor of more accurate, individualized assessments of risk for both ischemic stroke and major bleeding,” the investigators wrote. “Until such time, guidelines should better reflect the uncertainty of the current approach in which a patient’s CHA₂DS₂-VASc score is used as the primary basis for recommending oral anticoagulation.”

The study had no primary funding source. Dr. Shah reported having no conflicts of interest. Three coinvestigators disclosed research support from relevant pharmaceutical or device companies.

SOURCE: Shah SJ et al. Ann Intern Med. 2018 Sep 25. doi: 10.7326/M17-2762  

Anticoagulation thresholds based on CHA₂DS₂-VASc risk score varied from population to population, researchers reported in the Annals of Internal Medicine.

After accounting for differing rates of stroke in published studies, the benefit of warfarin anticoagulation varied nearly fourfold, said Sachin J. Shah, MD, of the University of California San Francisco and his associates. They called for guidelines that “better reflect the uncertainty in current thresholds of stroke risk score for recommending anticoagulation.”

Oral anticoagulation markedly reduces risk of ischemic stroke in patients with atrial fibrillation but increases the risk of major bleeding, including intracranial hemorrhage, which often is fatal. Therefore, when deciding whether to recommend oral anticoagulation, physicians must estimate clinical net benefit by quantifying the difference between reduction in stroke risk and increase in major bleeding risk, weighted by the severity of each outcome.

Guidelines on nonvalvular atrial fibrillation from the European Society of Cardiology and joint guidelines from the American Heart Association, American College of Cardiology, and Heart Rhythm Society (AHA/ACC/HRS) recommend oral anticoagulation when CHA₂DS₂-VASc (congestive heart failure, hypertension, age, diabetes, stroke, and vascular disease) risk score is 2 or greater. These guidelines implicitly assume that a particular CHA₂DS₂-VASc score denotes the same amount of risk across populations, even though a recent meta-analysis found otherwise, as the researchers noted.

To further test this assumption, they applied an existing Markov model to data from more than 33,000 members of the ATRIA-CVRN cohort. All patients had nonvalvular atrial fibrillation, were members of Kaiser Permanente Northern California, and were diagnosed during 1996-1997. About 81% had a CHA₂DS₂-VASc score of at least 2. For each patient, the researchers produced four estimates of the net clinical benefit of oral anticoagulation based on ischemic stroke rates from ATRIA, the Swedish AF cohort study, the SPORTIF study, and the Danish National Patient Registry.

Optimal anticoagulation thresholds were a CHA₂DS₂-VASc score of 3 or more using stroke rates from ATRIA, 2 or more based on Swedish AF rates, 1 or more based on SPORTIF rates, and 0 or more using rates from the Danish National Patient Registry. Oral anticoagulation thresholds were lower but still varied widely after accounting for the lower rates of intracranial hemorrhage associated with non–vitamin K antagonist therapy.

Therefore, current guidelines based on CHA₂DS₂-VASc score may need revising “in favor of more accurate, individualized assessments of risk for both ischemic stroke and major bleeding,” the investigators wrote. “Until such time, guidelines should better reflect the uncertainty of the current approach in which a patient’s CHA₂DS₂-VASc score is used as the primary basis for recommending oral anticoagulation.”

The study had no primary funding source. Dr. Shah reported having no conflicts of interest. Three coinvestigators disclosed research support from relevant pharmaceutical or device companies.

SOURCE: Shah SJ et al. Ann Intern Med. 2018 Sep 25. doi: 10.7326/M17-2762  

A combination of low-dose isotretinoin and nonablative fractional laser (NAFL) was a safe and effective treatment for moderate to severe acne and also improved acne scars in a small Chinese study, investigators reported.

In the randomized, split-face, controlled study of 18 adult Asian patients with moderate to severe acne, low-dose isotretinoin alone effectively controlled papule and pustule acne lesions, whereas NAFL had the additional effect of reducing the number of comedones and improving boxcar atrophic scars, reported Weihui Zeng, MD, and associates from the department of dermatology at the Second Affiliated Hospital of Xi’an Jiaotong University, Shanxi, China.

The authors noted that many patients seen at their clinic cannot tolerate a 20 mg/day dose of isotretinoin because of severe mucocutaneous side effects and that treatment with nonablative lasers, which – in contrast to ablative lasers – use infrared radiation to penetrate the skin deeply and thereby selectively heat dermal tissue while sparing the epidermis, could be a treatment option for these patients.

Therefore, they set out to investigate a treatment plan combining 1,550-nm NAFL with low-dose isotretinoin (10 mg/day) in the 18 patients (mean age, 24 years; skin types II-IV) attending their outpatient dermatology clinic. Three laser treatments were administered at monthly intervals to one side of the face, with the other side of the face serving as a control. Each patient was on low-dose isotretinoin for 30-45 days before laser treatment. A revised Leeds acne-grading system was used.

At follow-up after the third treatment – 3 months after the first laser treatment – both sides of the face showed significant recovery in all participants, but there was greater improvement on the laser-treated side. The mean Leeds acne-grading scores decreased from 10.6 at baseline to 5.8 on the control side of the face, and from 10.4 at baseline to 3.5 on the laser-treated side. The changes in scores differed significantly between sides (P less than .05), and the number of comedones decreased more on the laser-treated side of the face than it did the control side.

Significant improvements were also seen with superficial scars (P less than .05) and deep boxcar atrophic scars (P less than .01) on the laser-treated sides of patients’ faces, compared with the control sides, but significant improvements were not seen with the number of papules and nodules or with icepick or rolling scars.

Patients reported discomfort after NAFL treatment, including pain (100%), sensation of heat (100%), erythema (94.5%), and edema (88.9%), which resolved spontaneously within 24 hours.

Most of the patients (n = 12; 66.7%) were satisfied after the last treatment, two (11.1%) were “very satisfied,” and four (22.2%) were neutral; none were dissatisfied.

“Low-dose isotretinoin effectively controlled papule and pustule acne lesions, whereas use of 1,550-nm Er:glass NAFL may significantly reduce the number of comedones and improve boxcar atrophic scars,” the authors wrote.

They authors reported no significant interest with commercial supporters.

SOURCE: Xia J et al. Dermatol Surg. 2018 Sep;44(9):1201-8.

A combination of low-dose isotretinoin and nonablative fractional laser (NAFL) was a safe and effective treatment for moderate to severe acne and also improved acne scars in a small Chinese study, investigators reported.

In the randomized, split-face, controlled study of 18 adult Asian patients with moderate to severe acne, low-dose isotretinoin alone effectively controlled papule and pustule acne lesions, whereas NAFL had the additional effect of reducing the number of comedones and improving boxcar atrophic scars, reported Weihui Zeng, MD, and associates from the department of dermatology at the Second Affiliated Hospital of Xi’an Jiaotong University, Shanxi, China.

The authors noted that many patients seen at their clinic cannot tolerate a 20 mg/day dose of isotretinoin because of severe mucocutaneous side effects and that treatment with nonablative lasers, which – in contrast to ablative lasers – use infrared radiation to penetrate the skin deeply and thereby selectively heat dermal tissue while sparing the epidermis, could be a treatment option for these patients.

Therefore, they set out to investigate a treatment plan combining 1,550-nm NAFL with low-dose isotretinoin (10 mg/day) in the 18 patients (mean age, 24 years; skin types II-IV) attending their outpatient dermatology clinic. Three laser treatments were administered at monthly intervals to one side of the face, with the other side of the face serving as a control. Each patient was on low-dose isotretinoin for 30-45 days before laser treatment. A revised Leeds acne-grading system was used.

At follow-up after the third treatment – 3 months after the first laser treatment – both sides of the face showed significant recovery in all participants, but there was greater improvement on the laser-treated side. The mean Leeds acne-grading scores decreased from 10.6 at baseline to 5.8 on the control side of the face, and from 10.4 at baseline to 3.5 on the laser-treated side. The changes in scores differed significantly between sides (P less than .05), and the number of comedones decreased more on the laser-treated side of the face than it did the control side.

Significant improvements were also seen with superficial scars (P less than .05) and deep boxcar atrophic scars (P less than .01) on the laser-treated sides of patients’ faces, compared with the control sides, but significant improvements were not seen with the number of papules and nodules or with icepick or rolling scars.

Patients reported discomfort after NAFL treatment, including pain (100%), sensation of heat (100%), erythema (94.5%), and edema (88.9%), which resolved spontaneously within 24 hours.

Most of the patients (n = 12; 66.7%) were satisfied after the last treatment, two (11.1%) were “very satisfied,” and four (22.2%) were neutral; none were dissatisfied.

“Low-dose isotretinoin effectively controlled papule and pustule acne lesions, whereas use of 1,550-nm Er:glass NAFL may significantly reduce the number of comedones and improve boxcar atrophic scars,” the authors wrote.

They authors reported no significant interest with commercial supporters.

SOURCE: Xia J et al. Dermatol Surg. 2018 Sep;44(9):1201-8.

A combination of low-dose isotretinoin and nonablative fractional laser (NAFL) was a safe and effective treatment for moderate to severe acne and also improved acne scars in a small Chinese study, investigators reported.

In the randomized, split-face, controlled study of 18 adult Asian patients with moderate to severe acne, low-dose isotretinoin alone effectively controlled papule and pustule acne lesions, whereas NAFL had the additional effect of reducing the number of comedones and improving boxcar atrophic scars, reported Weihui Zeng, MD, and associates from the department of dermatology at the Second Affiliated Hospital of Xi’an Jiaotong University, Shanxi, China.

The authors noted that many patients seen at their clinic cannot tolerate a 20 mg/day dose of isotretinoin because of severe mucocutaneous side effects and that treatment with nonablative lasers, which – in contrast to ablative lasers – use infrared radiation to penetrate the skin deeply and thereby selectively heat dermal tissue while sparing the epidermis, could be a treatment option for these patients.

Therefore, they set out to investigate a treatment plan combining 1,550-nm NAFL with low-dose isotretinoin (10 mg/day) in the 18 patients (mean age, 24 years; skin types II-IV) attending their outpatient dermatology clinic. Three laser treatments were administered at monthly intervals to one side of the face, with the other side of the face serving as a control. Each patient was on low-dose isotretinoin for 30-45 days before laser treatment. A revised Leeds acne-grading system was used.

At follow-up after the third treatment – 3 months after the first laser treatment – both sides of the face showed significant recovery in all participants, but there was greater improvement on the laser-treated side. The mean Leeds acne-grading scores decreased from 10.6 at baseline to 5.8 on the control side of the face, and from 10.4 at baseline to 3.5 on the laser-treated side. The changes in scores differed significantly between sides (P less than .05), and the number of comedones decreased more on the laser-treated side of the face than it did the control side.

Significant improvements were also seen with superficial scars (P less than .05) and deep boxcar atrophic scars (P less than .01) on the laser-treated sides of patients’ faces, compared with the control sides, but significant improvements were not seen with the number of papules and nodules or with icepick or rolling scars.

Patients reported discomfort after NAFL treatment, including pain (100%), sensation of heat (100%), erythema (94.5%), and edema (88.9%), which resolved spontaneously within 24 hours.

Most of the patients (n = 12; 66.7%) were satisfied after the last treatment, two (11.1%) were “very satisfied,” and four (22.2%) were neutral; none were dissatisfied.

“Low-dose isotretinoin effectively controlled papule and pustule acne lesions, whereas use of 1,550-nm Er:glass NAFL may significantly reduce the number of comedones and improve boxcar atrophic scars,” the authors wrote.

They authors reported no significant interest with commercial supporters.

SOURCE: Xia J et al. Dermatol Surg. 2018 Sep;44(9):1201-8.

At the visit, the girl’s skin scrapings were analyzed under the microscope with potassium hydroxide (KOH) and no fungal elements were seen. A culture from one of the lesions was positive for methicillin-sensitive Staphylococcus aureus.

She was diagnosed with bullous impetigo (BI).

Impetigo is the most common superficial skin infection and can present as a nonbullous (most common) and bullous (least common) form.¹ Nonbullous impetigo is usually caused the Staphylococcus aureus or Streptococcus pyogenes and tends to occur at sites of prior trauma like insect bites, scratches, atopic dermatitis, or varicella. On the other hand, bullous impetigo is caused by the local production of exfoliative toxins (ETA or ETB) by phage group II of Staphylococcus aureus. The exfoliative toxin binds to desmoglin-1, one of the desmosomal proteins of the skin, causing acantholysis at the level of the granular layer and blister formation. Different from nonbullous impetigo, bullous impetigo tends to occur in normal, undamaged skin. Lesions are more common in neonates and young infants but children also can be affected.

The characteristic lesions in bullous impetigo are small blisters that enlarge to 1-cm to 5-cm bullae that easily rupture, leaving an erythematous plaque with a collarette of scale or “double ring scale,” with minimal crust and mild erythema. They commonly occur on the face, trunk, buttocks, and intertriginous areas. The lesions heal within 4-6 weeks, leaving no scarring. Associated systemic symptoms are rare but some patients can present with weakness, fever, and diarrhea. The toxin can disseminate and cause staphylococcal scalded skin syndrome in neonates or older patients with renal failure or immunodeficiency.

The transmission of Staphylococcus aureus can occur from colonized or infected family members, children in contact sports, as well as contact with animals such as dogs, cattle, and poultry.² Transmission from a pet rabbit also has been reported. In our patient, transmission from her pet hamster could have occurred as the areas on the body where there were lesions were areas where she was holding and cuddling her new pet.

The differential diagnosis of the type of lesions our patient presented with includes tinea corporis, and bullous tinea, which also can be transmitted by animals such as kittens. A KOH analysis ruled out this diagnosis. Tinea skin lesions tend to be more scaly than bullous impetigo lesions, which are more inflamed and crusted. Bullous arthropod reactions should be considered in the differential diagnosis as well. Bullous bite reaction lesions present with tense bullae, as they are subepidermal in nature and are pruritic. Subacute cutaneous lupus lesions present as annular scaly plaques with an erythematous border and central clearing usually in sun exposed areas similar to the distribution of our patient. Severe contact dermatitis reactions also can blister and form similar lesions as seen in our patient but with the difference that our patient didn’t complain of pruritus, which is a characteristic feature of allergic contact dermatitis. In neonates or young infants with bullous lesions other conditions such as herpes simplex infection, epidermolysis bullosa, bullous pemphigoid, linear IgA bullous dermatosis, bullous mastocytosis, and bullous erythema multiforme should be considered in the differential diagnosis.

First line treatment for impetigo consists of the use of topical application of mupirocin (Bactroban) 2% ointment, retapamulin (Altabax) 1% ointment, or fusidic acid 2% cream. A Cochrane review compared systemic versus topical treatment for impetigo concluding that topical treatment with either mupirocin or retapamulin is equally if not more effective than oral antibiotics.³ Ozenoxacin (Xepi), a new nonfluorinated topical quinolone has recently been Food and Drug Administration approved for the treatment of localized impetigo in patients 2 months of age and older.⁴ When there is treatment failure with topical antibiotics, widespread disease, or systemic symptoms, oral antimicrobials should be consider, such as beta-lactamase–resistant penicillin, first-generation cephalosporins, or clindamycin. The use of bleach baths and general hygiene measures for 4 months can reduce the risks of recurrence in 20% of the patients as noted by a study by Kaplan et al.⁵

Our patient was treated with oral cephalexin for 7 days as well as topical mupirocin with fast resolution of the lesions. Sadly, the parents gave her hamster pet away.

Dr. Matiz is a pediatric dermatologist at Southern California Permanente Medical Group, San Diego. Email her at [email protected]

References

1. Am Fam Physician. 2014 Aug 15;90(4):229-35.

2. Zentralbl Bakteriol Mikrobiol Hyg A. 1987 Jun;265(1-2):218-26.

3. Cochrane Database Syst Rev. 2012 Jan 18;1:CD003261.

4. Ann Pharmacother. 2018 Jun 1:1060028018786510.

5. Clin Infect Dis. 2014 Mar;58(5):679-82.

At the visit, the girl’s skin scrapings were analyzed under the microscope with potassium hydroxide (KOH) and no fungal elements were seen. A culture from one of the lesions was positive for methicillin-sensitive Staphylococcus aureus.

She was diagnosed with bullous impetigo (BI).

Impetigo is the most common superficial skin infection and can present as a nonbullous (most common) and bullous (least common) form.¹ Nonbullous impetigo is usually caused the Staphylococcus aureus or Streptococcus pyogenes and tends to occur at sites of prior trauma like insect bites, scratches, atopic dermatitis, or varicella. On the other hand, bullous impetigo is caused by the local production of exfoliative toxins (ETA or ETB) by phage group II of Staphylococcus aureus. The exfoliative toxin binds to desmoglin-1, one of the desmosomal proteins of the skin, causing acantholysis at the level of the granular layer and blister formation. Different from nonbullous impetigo, bullous impetigo tends to occur in normal, undamaged skin. Lesions are more common in neonates and young infants but children also can be affected.

The characteristic lesions in bullous impetigo are small blisters that enlarge to 1-cm to 5-cm bullae that easily rupture, leaving an erythematous plaque with a collarette of scale or “double ring scale,” with minimal crust and mild erythema. They commonly occur on the face, trunk, buttocks, and intertriginous areas. The lesions heal within 4-6 weeks, leaving no scarring. Associated systemic symptoms are rare but some patients can present with weakness, fever, and diarrhea. The toxin can disseminate and cause staphylococcal scalded skin syndrome in neonates or older patients with renal failure or immunodeficiency.

The transmission of Staphylococcus aureus can occur from colonized or infected family members, children in contact sports, as well as contact with animals such as dogs, cattle, and poultry.² Transmission from a pet rabbit also has been reported. In our patient, transmission from her pet hamster could have occurred as the areas on the body where there were lesions were areas where she was holding and cuddling her new pet.

The differential diagnosis of the type of lesions our patient presented with includes tinea corporis, and bullous tinea, which also can be transmitted by animals such as kittens. A KOH analysis ruled out this diagnosis. Tinea skin lesions tend to be more scaly than bullous impetigo lesions, which are more inflamed and crusted. Bullous arthropod reactions should be considered in the differential diagnosis as well. Bullous bite reaction lesions present with tense bullae, as they are subepidermal in nature and are pruritic. Subacute cutaneous lupus lesions present as annular scaly plaques with an erythematous border and central clearing usually in sun exposed areas similar to the distribution of our patient. Severe contact dermatitis reactions also can blister and form similar lesions as seen in our patient but with the difference that our patient didn’t complain of pruritus, which is a characteristic feature of allergic contact dermatitis. In neonates or young infants with bullous lesions other conditions such as herpes simplex infection, epidermolysis bullosa, bullous pemphigoid, linear IgA bullous dermatosis, bullous mastocytosis, and bullous erythema multiforme should be considered in the differential diagnosis.

First line treatment for impetigo consists of the use of topical application of mupirocin (Bactroban) 2% ointment, retapamulin (Altabax) 1% ointment, or fusidic acid 2% cream. A Cochrane review compared systemic versus topical treatment for impetigo concluding that topical treatment with either mupirocin or retapamulin is equally if not more effective than oral antibiotics.³ Ozenoxacin (Xepi), a new nonfluorinated topical quinolone has recently been Food and Drug Administration approved for the treatment of localized impetigo in patients 2 months of age and older.⁴ When there is treatment failure with topical antibiotics, widespread disease, or systemic symptoms, oral antimicrobials should be consider, such as beta-lactamase–resistant penicillin, first-generation cephalosporins, or clindamycin. The use of bleach baths and general hygiene measures for 4 months can reduce the risks of recurrence in 20% of the patients as noted by a study by Kaplan et al.⁵

Our patient was treated with oral cephalexin for 7 days as well as topical mupirocin with fast resolution of the lesions. Sadly, the parents gave her hamster pet away.

Dr. Matiz is a pediatric dermatologist at Southern California Permanente Medical Group, San Diego. Email her at [email protected]

References

1. Am Fam Physician. 2014 Aug 15;90(4):229-35.

2. Zentralbl Bakteriol Mikrobiol Hyg A. 1987 Jun;265(1-2):218-26.

3. Cochrane Database Syst Rev. 2012 Jan 18;1:CD003261.

4. Ann Pharmacother. 2018 Jun 1:1060028018786510.

5. Clin Infect Dis. 2014 Mar;58(5):679-82.

At the visit, the girl’s skin scrapings were analyzed under the microscope with potassium hydroxide (KOH) and no fungal elements were seen. A culture from one of the lesions was positive for methicillin-sensitive Staphylococcus aureus.

She was diagnosed with bullous impetigo (BI).

Impetigo is the most common superficial skin infection and can present as a nonbullous (most common) and bullous (least common) form.¹ Nonbullous impetigo is usually caused the Staphylococcus aureus or Streptococcus pyogenes and tends to occur at sites of prior trauma like insect bites, scratches, atopic dermatitis, or varicella. On the other hand, bullous impetigo is caused by the local production of exfoliative toxins (ETA or ETB) by phage group II of Staphylococcus aureus. The exfoliative toxin binds to desmoglin-1, one of the desmosomal proteins of the skin, causing acantholysis at the level of the granular layer and blister formation. Different from nonbullous impetigo, bullous impetigo tends to occur in normal, undamaged skin. Lesions are more common in neonates and young infants but children also can be affected.

The characteristic lesions in bullous impetigo are small blisters that enlarge to 1-cm to 5-cm bullae that easily rupture, leaving an erythematous plaque with a collarette of scale or “double ring scale,” with minimal crust and mild erythema. They commonly occur on the face, trunk, buttocks, and intertriginous areas. The lesions heal within 4-6 weeks, leaving no scarring. Associated systemic symptoms are rare but some patients can present with weakness, fever, and diarrhea. The toxin can disseminate and cause staphylococcal scalded skin syndrome in neonates or older patients with renal failure or immunodeficiency.

The transmission of Staphylococcus aureus can occur from colonized or infected family members, children in contact sports, as well as contact with animals such as dogs, cattle, and poultry.² Transmission from a pet rabbit also has been reported. In our patient, transmission from her pet hamster could have occurred as the areas on the body where there were lesions were areas where she was holding and cuddling her new pet.

The differential diagnosis of the type of lesions our patient presented with includes tinea corporis, and bullous tinea, which also can be transmitted by animals such as kittens. A KOH analysis ruled out this diagnosis. Tinea skin lesions tend to be more scaly than bullous impetigo lesions, which are more inflamed and crusted. Bullous arthropod reactions should be considered in the differential diagnosis as well. Bullous bite reaction lesions present with tense bullae, as they are subepidermal in nature and are pruritic. Subacute cutaneous lupus lesions present as annular scaly plaques with an erythematous border and central clearing usually in sun exposed areas similar to the distribution of our patient. Severe contact dermatitis reactions also can blister and form similar lesions as seen in our patient but with the difference that our patient didn’t complain of pruritus, which is a characteristic feature of allergic contact dermatitis. In neonates or young infants with bullous lesions other conditions such as herpes simplex infection, epidermolysis bullosa, bullous pemphigoid, linear IgA bullous dermatosis, bullous mastocytosis, and bullous erythema multiforme should be considered in the differential diagnosis.

First line treatment for impetigo consists of the use of topical application of mupirocin (Bactroban) 2% ointment, retapamulin (Altabax) 1% ointment, or fusidic acid 2% cream. A Cochrane review compared systemic versus topical treatment for impetigo concluding that topical treatment with either mupirocin or retapamulin is equally if not more effective than oral antibiotics.³ Ozenoxacin (Xepi), a new nonfluorinated topical quinolone has recently been Food and Drug Administration approved for the treatment of localized impetigo in patients 2 months of age and older.⁴ When there is treatment failure with topical antibiotics, widespread disease, or systemic symptoms, oral antimicrobials should be consider, such as beta-lactamase–resistant penicillin, first-generation cephalosporins, or clindamycin. The use of bleach baths and general hygiene measures for 4 months can reduce the risks of recurrence in 20% of the patients as noted by a study by Kaplan et al.⁵

Our patient was treated with oral cephalexin for 7 days as well as topical mupirocin with fast resolution of the lesions. Sadly, the parents gave her hamster pet away.

Dr. Matiz is a pediatric dermatologist at Southern California Permanente Medical Group, San Diego. Email her at [email protected]

References

1. Am Fam Physician. 2014 Aug 15;90(4):229-35.

2. Zentralbl Bakteriol Mikrobiol Hyg A. 1987 Jun;265(1-2):218-26.

3. Cochrane Database Syst Rev. 2012 Jan 18;1:CD003261.

4. Ann Pharmacother. 2018 Jun 1:1060028018786510.

5. Clin Infect Dis. 2014 Mar;58(5):679-82.

Teva Pharmaceutical Industries Ltd. announced that the FDA approved Ajovy (fremanezumab-vfrm) injection for the preventive treatment of migraine in adults. Ajovy, a humanized monoclonal antibody that binds to the calcitonin gene-related peptide (CGRP) ligand and blocks its binding to the receptor, is the first and only anti-CGRP treatment for the prevention of migraine with quarterly (675 mg) and monthly (225 mg) dosing options.

“Migraine is a disabling neurological disease that affects more than 36 million people in the United States,” said Stephen Silberstein, MD, Director of the Jefferson Headache Center at Thomas Jefferson University Hospital in Philadelphia, and lead investigator of the Phase III clinical trial program for Ajovy. “About 40% of people living with migraine may be appropriate candidates for preventive treatment, yet the majority of them are untreated. I am pleased to have another treatment option that may allow my patients to experience fewer monthly migraine days.”

Ajovy was evaluated in two Phase III, placebo-controlled clinical trials that enrolled patients with disabling migraine and was studied as both a stand-alone preventive treatment and in combination with oral preventive treatments. In these trials, patients experienced a reduction in monthly migraine days during a 12-week period. The most common adverse reactions (≥ 5% and greater than placebo) were injection site reactions.

Teva Pharmaceutical Industries Ltd. announced that the FDA approved Ajovy (fremanezumab-vfrm) injection for the preventive treatment of migraine in adults. Ajovy, a humanized monoclonal antibody that binds to the calcitonin gene-related peptide (CGRP) ligand and blocks its binding to the receptor, is the first and only anti-CGRP treatment for the prevention of migraine with quarterly (675 mg) and monthly (225 mg) dosing options.

“Migraine is a disabling neurological disease that affects more than 36 million people in the United States,” said Stephen Silberstein, MD, Director of the Jefferson Headache Center at Thomas Jefferson University Hospital in Philadelphia, and lead investigator of the Phase III clinical trial program for Ajovy. “About 40% of people living with migraine may be appropriate candidates for preventive treatment, yet the majority of them are untreated. I am pleased to have another treatment option that may allow my patients to experience fewer monthly migraine days.”

Ajovy was evaluated in two Phase III, placebo-controlled clinical trials that enrolled patients with disabling migraine and was studied as both a stand-alone preventive treatment and in combination with oral preventive treatments. In these trials, patients experienced a reduction in monthly migraine days during a 12-week period. The most common adverse reactions (≥ 5% and greater than placebo) were injection site reactions.

Teva Pharmaceutical Industries Ltd. announced that the FDA approved Ajovy (fremanezumab-vfrm) injection for the preventive treatment of migraine in adults. Ajovy, a humanized monoclonal antibody that binds to the calcitonin gene-related peptide (CGRP) ligand and blocks its binding to the receptor, is the first and only anti-CGRP treatment for the prevention of migraine with quarterly (675 mg) and monthly (225 mg) dosing options.

“Migraine is a disabling neurological disease that affects more than 36 million people in the United States,” said Stephen Silberstein, MD, Director of the Jefferson Headache Center at Thomas Jefferson University Hospital in Philadelphia, and lead investigator of the Phase III clinical trial program for Ajovy. “About 40% of people living with migraine may be appropriate candidates for preventive treatment, yet the majority of them are untreated. I am pleased to have another treatment option that may allow my patients to experience fewer monthly migraine days.”

Ajovy was evaluated in two Phase III, placebo-controlled clinical trials that enrolled patients with disabling migraine and was studied as both a stand-alone preventive treatment and in combination with oral preventive treatments. In these trials, patients experienced a reduction in monthly migraine days during a 12-week period. The most common adverse reactions (≥ 5% and greater than placebo) were injection site reactions.

TORONTO – Computed tomography screening among asymptomatic men at high risk for lung cancer reduced lung cancer deaths by a highly statistically significant 26% at 10 years and appeared to reduce lung cancer mortality risk even more in women in the population-based, NELSON trial.

Sharon Worcester/MDedge News

The findings from this large controlled trial encompassing more than 27,000 CT scans in 15,792 individuals support those from the National Lung Screening Trials (NLST), published in 2011, and should “inform and direct future CT screening programs worldwide,” according to Harry de Koning, MD, who presented the findings at the World Conference on Lung Cancer.

Participants were randomized to CT screening at baseline, 1, 3, and 5.5 years after randomization, or to a control group that received usual care. Overall 157 lung cancer deaths occurred in the screening arm vs. 250 in the control arm. Detection rates varied between 0.8% and 1.1% across screenings (0.9% overall), and the positive predictive value of screening was 41%, Dr. de Koning of Erasmus Medical Center, Rotterdam, the Netherlands, said at the meeting sponsored by the International Association for the Study of Lung Cancer.

Notably, 69% of the 243 lung cancers detected by screening were detected at stage 1A or 1B, compared with 10%-12% being detected at stage 4 in about 50% of control patients and based on registry data in the Netherlands.

“There’s huge importance of this early detection in the screening arm,” Dr. de Koning said.

Additionally, an analysis of a subset of those with lung cancer showed a significant threefold increase in surgical treatment among the screened patients vs. those in the control arm who developed lung cancer (67.7% vs. 24.5%), he said.

CT screening reduced the risk of death from lung cancer by 9% to 41% in men over the course of the study, with an overall reduction of 26% at 10 years, and in a smaller subset of women, the rate-ratio of dying from lung cancer varied from 0.39 to 0.61 at different years of follow-up, he said, noting that this suggests a “significant and even larger reduction” in women.

Study participants were individuals aged 50-74 years in the Netherlands and Leuven, Belgium, who were considered at high risk for lung cancer based on responses to a general questionnaire. Participants’ records were linked with national registries with 100% coverage regarding cancer diagnosis and date and cause of death, and medical records for deceased lung cancer patients were reviewed by a blinded expert panel through 2013, and for the remaining study years cause of death as reported by Statistics Netherlands was used. Compliance among those randomized to the screening group was 86%, Dr. de Koning said.

“These findings show that CT screenings are an effective way to assess lung nodules in people at high risk for lung cancer, often leading to detection of suspicious nodules and subsequent surgical intervention at relatively low rates and with few false positives, and can positively increase the chances of cure in this devastating disease,” Dr. de Koning said in a press statement. “It is the second-largest trial in the world, with an even more favorable outcome than the first trial, the NLST, showed. These results should be used to inform and direct future CT screening in the world.”

During a press briefing, in response to a question about whether lung cancer screening should be offered more widely, he said that yes, countries – including the United States – should take note that “now two large-scale trials show large benefit.”

Dr. de Koning reported having no disclosures.

[email protected]

TORONTO – Computed tomography screening among asymptomatic men at high risk for lung cancer reduced lung cancer deaths by a highly statistically significant 26% at 10 years and appeared to reduce lung cancer mortality risk even more in women in the population-based, NELSON trial.

Sharon Worcester/MDedge News

The findings from this large controlled trial encompassing more than 27,000 CT scans in 15,792 individuals support those from the National Lung Screening Trials (NLST), published in 2011, and should “inform and direct future CT screening programs worldwide,” according to Harry de Koning, MD, who presented the findings at the World Conference on Lung Cancer.

Participants were randomized to CT screening at baseline, 1, 3, and 5.5 years after randomization, or to a control group that received usual care. Overall 157 lung cancer deaths occurred in the screening arm vs. 250 in the control arm. Detection rates varied between 0.8% and 1.1% across screenings (0.9% overall), and the positive predictive value of screening was 41%, Dr. de Koning of Erasmus Medical Center, Rotterdam, the Netherlands, said at the meeting sponsored by the International Association for the Study of Lung Cancer.

Notably, 69% of the 243 lung cancers detected by screening were detected at stage 1A or 1B, compared with 10%-12% being detected at stage 4 in about 50% of control patients and based on registry data in the Netherlands.

“There’s huge importance of this early detection in the screening arm,” Dr. de Koning said.

Additionally, an analysis of a subset of those with lung cancer showed a significant threefold increase in surgical treatment among the screened patients vs. those in the control arm who developed lung cancer (67.7% vs. 24.5%), he said.

CT screening reduced the risk of death from lung cancer by 9% to 41% in men over the course of the study, with an overall reduction of 26% at 10 years, and in a smaller subset of women, the rate-ratio of dying from lung cancer varied from 0.39 to 0.61 at different years of follow-up, he said, noting that this suggests a “significant and even larger reduction” in women.

Study participants were individuals aged 50-74 years in the Netherlands and Leuven, Belgium, who were considered at high risk for lung cancer based on responses to a general questionnaire. Participants’ records were linked with national registries with 100% coverage regarding cancer diagnosis and date and cause of death, and medical records for deceased lung cancer patients were reviewed by a blinded expert panel through 2013, and for the remaining study years cause of death as reported by Statistics Netherlands was used. Compliance among those randomized to the screening group was 86%, Dr. de Koning said.

“These findings show that CT screenings are an effective way to assess lung nodules in people at high risk for lung cancer, often leading to detection of suspicious nodules and subsequent surgical intervention at relatively low rates and with few false positives, and can positively increase the chances of cure in this devastating disease,” Dr. de Koning said in a press statement. “It is the second-largest trial in the world, with an even more favorable outcome than the first trial, the NLST, showed. These results should be used to inform and direct future CT screening in the world.”

During a press briefing, in response to a question about whether lung cancer screening should be offered more widely, he said that yes, countries – including the United States – should take note that “now two large-scale trials show large benefit.”

Dr. de Koning reported having no disclosures.

[email protected]

TORONTO – Computed tomography screening among asymptomatic men at high risk for lung cancer reduced lung cancer deaths by a highly statistically significant 26% at 10 years and appeared to reduce lung cancer mortality risk even more in women in the population-based, NELSON trial.

Sharon Worcester/MDedge News

The findings from this large controlled trial encompassing more than 27,000 CT scans in 15,792 individuals support those from the National Lung Screening Trials (NLST), published in 2011, and should “inform and direct future CT screening programs worldwide,” according to Harry de Koning, MD, who presented the findings at the World Conference on Lung Cancer.

Participants were randomized to CT screening at baseline, 1, 3, and 5.5 years after randomization, or to a control group that received usual care. Overall 157 lung cancer deaths occurred in the screening arm vs. 250 in the control arm. Detection rates varied between 0.8% and 1.1% across screenings (0.9% overall), and the positive predictive value of screening was 41%, Dr. de Koning of Erasmus Medical Center, Rotterdam, the Netherlands, said at the meeting sponsored by the International Association for the Study of Lung Cancer.

Notably, 69% of the 243 lung cancers detected by screening were detected at stage 1A or 1B, compared with 10%-12% being detected at stage 4 in about 50% of control patients and based on registry data in the Netherlands.

“There’s huge importance of this early detection in the screening arm,” Dr. de Koning said.

Additionally, an analysis of a subset of those with lung cancer showed a significant threefold increase in surgical treatment among the screened patients vs. those in the control arm who developed lung cancer (67.7% vs. 24.5%), he said.

CT screening reduced the risk of death from lung cancer by 9% to 41% in men over the course of the study, with an overall reduction of 26% at 10 years, and in a smaller subset of women, the rate-ratio of dying from lung cancer varied from 0.39 to 0.61 at different years of follow-up, he said, noting that this suggests a “significant and even larger reduction” in women.

Study participants were individuals aged 50-74 years in the Netherlands and Leuven, Belgium, who were considered at high risk for lung cancer based on responses to a general questionnaire. Participants’ records were linked with national registries with 100% coverage regarding cancer diagnosis and date and cause of death, and medical records for deceased lung cancer patients were reviewed by a blinded expert panel through 2013, and for the remaining study years cause of death as reported by Statistics Netherlands was used. Compliance among those randomized to the screening group was 86%, Dr. de Koning said.

“These findings show that CT screenings are an effective way to assess lung nodules in people at high risk for lung cancer, often leading to detection of suspicious nodules and subsequent surgical intervention at relatively low rates and with few false positives, and can positively increase the chances of cure in this devastating disease,” Dr. de Koning said in a press statement. “It is the second-largest trial in the world, with an even more favorable outcome than the first trial, the NLST, showed. These results should be used to inform and direct future CT screening in the world.”

During a press briefing, in response to a question about whether lung cancer screening should be offered more widely, he said that yes, countries – including the United States – should take note that “now two large-scale trials show large benefit.”

Dr. de Koning reported having no disclosures.

[email protected]

AstraZeneca announced top-line results of its phase III DECLARE-TIMI 58 cardiovascular outcomes trial for dapagliflozin (Farxiga). The 5-year international trial evaluated the cardiovascular outcomes of dapagliflozin compared with placebo in more than 17,000 adults with type 2 diabetes at high cardiovascular risk or established disease.

DECLARE met its primary safety endpoint of noninferiority for major adverse cardiovascular events for dabigatran the company said. Specifically, it achieved a statistically significant reduction in the composite endpoint of hospitalization for heart failure or cardiovascular death.

Dapagliflozin, approved in 2014, is a sodium-glucose  cotransporter  2  (SGLT2)  inhibitor  indicated as  an  adjunct  to  diet  and  exercise  to  improve  glycemic  control  in  adults  with type 2 diabetes.

Full results of DECLARE will be presented on November 10 at the American Heart Association annual meeting, according to the AstraZeneca release.

AstraZeneca announced top-line results of its phase III DECLARE-TIMI 58 cardiovascular outcomes trial for dapagliflozin (Farxiga). The 5-year international trial evaluated the cardiovascular outcomes of dapagliflozin compared with placebo in more than 17,000 adults with type 2 diabetes at high cardiovascular risk or established disease.

DECLARE met its primary safety endpoint of noninferiority for major adverse cardiovascular events for dabigatran the company said. Specifically, it achieved a statistically significant reduction in the composite endpoint of hospitalization for heart failure or cardiovascular death.

Dapagliflozin, approved in 2014, is a sodium-glucose  cotransporter  2  (SGLT2)  inhibitor  indicated as  an  adjunct  to  diet  and  exercise  to  improve  glycemic  control  in  adults  with type 2 diabetes.

Full results of DECLARE will be presented on November 10 at the American Heart Association annual meeting, according to the AstraZeneca release.

AstraZeneca announced top-line results of its phase III DECLARE-TIMI 58 cardiovascular outcomes trial for dapagliflozin (Farxiga). The 5-year international trial evaluated the cardiovascular outcomes of dapagliflozin compared with placebo in more than 17,000 adults with type 2 diabetes at high cardiovascular risk or established disease.

DECLARE met its primary safety endpoint of noninferiority for major adverse cardiovascular events for dabigatran the company said. Specifically, it achieved a statistically significant reduction in the composite endpoint of hospitalization for heart failure or cardiovascular death.

Dapagliflozin, approved in 2014, is a sodium-glucose  cotransporter  2  (SGLT2)  inhibitor  indicated as  an  adjunct  to  diet  and  exercise  to  improve  glycemic  control  in  adults  with type 2 diabetes.

Full results of DECLARE will be presented on November 10 at the American Heart Association annual meeting, according to the AstraZeneca release.

NEW YORK – Although optimal sequencing strategies in chronic lymphocytic leukemia are still unclear, real-world data suggest an alternate kinase inhibitor or venetoclax is the best approach for a patient who has received ibrutinib or idelalisib, according to John N. Allan, MD, of Cornell University, New York.

©Ed Uthman/Flickr

“I think for the most part, there’s enough evidence,” Dr. Allan said at the annual congress on Hematologic Malignancies held by the National Comprehensive Cancer Network.

“If you had one to two lines of therapy, it still favors the novel agents rather than the chemotherapy arms in all these studies,” said Dr. Allan, referring to some of the pivotal trials supporting approval of novel agents in chronic lymphocytic leukemia (CLL). “The earlier we get to these drugs, I believe, the better.”

While venetoclax after ibrutinib is supported by multiple studies, “vice versa is unknown, but there’s seemingly no reason to think it wouldn’t work – different mechanisms of actions, different pathways,” Dr. Allan said.

What is clear, he added, is that retreating those patients with chemoimmunotherapy is not optimal.

In support of that, he cited a multicenter retrospective analysis, which is believed to be the largest real-world experience to date of novel agents in CLL looking at post–kinase inhibitor salvage strategies (Ann Oncol. 2017 May 1;28[5]:1050-6).

Using an alternate kinase inhibitor or venetoclax resulted in superior progression-free survival versus chemoimmunotherapy at the time of initial kinase inhibitor failure in that study, which looked at treatment strategies and outcomes for 683 patients.

Ibrutinib appeared to be superior to idelalisib as a first kinase inhibitor, with significantly better progression-free survival in both frontline and relapsed/refractory settings, and in both complex karyotype and del17p patients, according to the report. Additionally, the response rate to venetoclax seemed superior to that of idelalisib in patients who discontinued ibrutinib because of progression or toxicity.

All of that supports the need for trials to test various sequencing strategies and establish clear treatment algorithms, according to Dr. Allan. “Optimal sequencing is unknown, but real-world data gives us some idea.”

For relapsed/refractory patients, ibrutinib, idelalisib, and venetoclax all have lengthened responses, improved survival, and are approved by the Food and Drug Administration, he added, noting that the toxicity profiles vary and must be understood when dosing and prescribing these agents.

More novel treatments are on the way. On Sept. 24, just days after Dr. Allan’s NCCN presentation, the FDA granted approval to duvelisib for adults with relapsed or refractory CLL or small lymphocytic lymphoma following two or more previous lines of therapy.

Dr. Allan reported financial disclosures related to AbbVie, Acerta Pharma, Genentech, Pharmacyclics, Sunesis Pharmaceuticals, and Verastem Oncology.

NEW YORK – Although optimal sequencing strategies in chronic lymphocytic leukemia are still unclear, real-world data suggest an alternate kinase inhibitor or venetoclax is the best approach for a patient who has received ibrutinib or idelalisib, according to John N. Allan, MD, of Cornell University, New York.

©Ed Uthman/Flickr

“I think for the most part, there’s enough evidence,” Dr. Allan said at the annual congress on Hematologic Malignancies held by the National Comprehensive Cancer Network.

“If you had one to two lines of therapy, it still favors the novel agents rather than the chemotherapy arms in all these studies,” said Dr. Allan, referring to some of the pivotal trials supporting approval of novel agents in chronic lymphocytic leukemia (CLL). “The earlier we get to these drugs, I believe, the better.”

While venetoclax after ibrutinib is supported by multiple studies, “vice versa is unknown, but there’s seemingly no reason to think it wouldn’t work – different mechanisms of actions, different pathways,” Dr. Allan said.

What is clear, he added, is that retreating those patients with chemoimmunotherapy is not optimal.

In support of that, he cited a multicenter retrospective analysis, which is believed to be the largest real-world experience to date of novel agents in CLL looking at post–kinase inhibitor salvage strategies (Ann Oncol. 2017 May 1;28[5]:1050-6).

Using an alternate kinase inhibitor or venetoclax resulted in superior progression-free survival versus chemoimmunotherapy at the time of initial kinase inhibitor failure in that study, which looked at treatment strategies and outcomes for 683 patients.

Ibrutinib appeared to be superior to idelalisib as a first kinase inhibitor, with significantly better progression-free survival in both frontline and relapsed/refractory settings, and in both complex karyotype and del17p patients, according to the report. Additionally, the response rate to venetoclax seemed superior to that of idelalisib in patients who discontinued ibrutinib because of progression or toxicity.

All of that supports the need for trials to test various sequencing strategies and establish clear treatment algorithms, according to Dr. Allan. “Optimal sequencing is unknown, but real-world data gives us some idea.”

For relapsed/refractory patients, ibrutinib, idelalisib, and venetoclax all have lengthened responses, improved survival, and are approved by the Food and Drug Administration, he added, noting that the toxicity profiles vary and must be understood when dosing and prescribing these agents.

More novel treatments are on the way. On Sept. 24, just days after Dr. Allan’s NCCN presentation, the FDA granted approval to duvelisib for adults with relapsed or refractory CLL or small lymphocytic lymphoma following two or more previous lines of therapy.

Dr. Allan reported financial disclosures related to AbbVie, Acerta Pharma, Genentech, Pharmacyclics, Sunesis Pharmaceuticals, and Verastem Oncology.

NEW YORK – Although optimal sequencing strategies in chronic lymphocytic leukemia are still unclear, real-world data suggest an alternate kinase inhibitor or venetoclax is the best approach for a patient who has received ibrutinib or idelalisib, according to John N. Allan, MD, of Cornell University, New York.

©Ed Uthman/Flickr

“I think for the most part, there’s enough evidence,” Dr. Allan said at the annual congress on Hematologic Malignancies held by the National Comprehensive Cancer Network.

“If you had one to two lines of therapy, it still favors the novel agents rather than the chemotherapy arms in all these studies,” said Dr. Allan, referring to some of the pivotal trials supporting approval of novel agents in chronic lymphocytic leukemia (CLL). “The earlier we get to these drugs, I believe, the better.”

While venetoclax after ibrutinib is supported by multiple studies, “vice versa is unknown, but there’s seemingly no reason to think it wouldn’t work – different mechanisms of actions, different pathways,” Dr. Allan said.

What is clear, he added, is that retreating those patients with chemoimmunotherapy is not optimal.

In support of that, he cited a multicenter retrospective analysis, which is believed to be the largest real-world experience to date of novel agents in CLL looking at post–kinase inhibitor salvage strategies (Ann Oncol. 2017 May 1;28[5]:1050-6).

Using an alternate kinase inhibitor or venetoclax resulted in superior progression-free survival versus chemoimmunotherapy at the time of initial kinase inhibitor failure in that study, which looked at treatment strategies and outcomes for 683 patients.

Ibrutinib appeared to be superior to idelalisib as a first kinase inhibitor, with significantly better progression-free survival in both frontline and relapsed/refractory settings, and in both complex karyotype and del17p patients, according to the report. Additionally, the response rate to venetoclax seemed superior to that of idelalisib in patients who discontinued ibrutinib because of progression or toxicity.

All of that supports the need for trials to test various sequencing strategies and establish clear treatment algorithms, according to Dr. Allan. “Optimal sequencing is unknown, but real-world data gives us some idea.”

For relapsed/refractory patients, ibrutinib, idelalisib, and venetoclax all have lengthened responses, improved survival, and are approved by the Food and Drug Administration, he added, noting that the toxicity profiles vary and must be understood when dosing and prescribing these agents.

More novel treatments are on the way. On Sept. 24, just days after Dr. Allan’s NCCN presentation, the FDA granted approval to duvelisib for adults with relapsed or refractory CLL or small lymphocytic lymphoma following two or more previous lines of therapy.

Dr. Allan reported financial disclosures related to AbbVie, Acerta Pharma, Genentech, Pharmacyclics, Sunesis Pharmaceuticals, and Verastem Oncology.

IDWeek 2018 includes the annual meeting of the Pediatric Infectious Diseases Society, which is celebrating its 40th anniversary as a society this year.

Paul Spearman, MD, the PIDS president, specifically highlighted some of the special 40th anniversary events: The Stanley A. Plotkin Lectureship in Vaccinology will be held on Friday, Oct. 5. “This is an annual highlight for PIDS in honor of Stanley Plotkin, the founder of PIDS and [an] inspiration to all of us. We are delighted to have Gary Marshall as the speaker this year giving a talk entitled “Vaccine Hesitancy, History and Human Nature,” Dr. Spearman wrote in an article posted on the PIDS website.

He noted that the PIDS anniversary special celebration, dinner, and lecture in honor of the contributions of George McCracken and John Nelson also will be held Oct. 5.

Throughout the meeting, the latest data and practices for the treatment of infants and children will be featured. Although pediatric issues will be discussed in many sessions, there are a number of events specifically dedicated to pediatric cases.

Of particular interest, on Wednesday morning, Oral Abstract Session 31 will focus on “Infant Viral Infections.” Talks will include “Role of Maternal Antibodies in Protection Against Postnatal Cytomegalovirus Acquisition,” by Frances Saccoccio, MD, PhD, and “Effect of Nasopharyngeal Pneumococcal Carriage on RSV and hMPV Illness Severity in Infants in Nepal,” by Alastair Murray.

On Thursday morning, the symposium “Hot Topics in Pediatric Infectious Diseases” will feature talks by experts in the field detailing this year’s important clinical advances and discoveries that have the potential to impact clinical care.

The Thursday afternoon poster session “Pediatric Antimicrobial and Diagnostic Stewardship” will focus on topics such as “Variation in Antibiotic Use Among Neonates Hospitalized in United States Academically Affiliated Centers,” which will be presented by Prachi Singh, DO, and “Alternative Antibiotic Prescribing for Community Acquired Pneumonia (CAP) in Pediatric Patients in Relation to Allergy Status,” to be presented by Ankita Desai, MD.

There also will be a poster session that afternoon focused on “Maternal-Child Infections” that will feature “Risk Factors for Congenital Infection in the United States: Analysis of the Kids’ Inpatient Database (KID),” by Angela F. Veesenmeyer, MD, and “The Effect of Prenatal Screening for Chlamydia trachomatis (CT) on Chlamydial Conjunctivitis in Infants,” by Natalie Banniettis, MD.

Later that same day, “Mano-a-Mano III,” an interactive session on “Controversies in Pediatric ID,” will focus on the tuberculin skin test vs. the interferon-gamma release assay (IGRA) for TB identification, the use of vancomycin therapy for meningitis, and the value of respiratory viral panel testing.

As part of the program committee, Marsha S. Anderson, MD, FIDSA, from the University of Colorado School of Medicine, serves as this year’s IDWeek chair, for the PIDS portion of the meeting, and Roberta L. DeBiasi, MD, of the Children’s National Health System serves as vice chair.

IDWeek 2018 includes the annual meeting of the Pediatric Infectious Diseases Society, which is celebrating its 40th anniversary as a society this year.

Paul Spearman, MD, the PIDS president, specifically highlighted some of the special 40th anniversary events: The Stanley A. Plotkin Lectureship in Vaccinology will be held on Friday, Oct. 5. “This is an annual highlight for PIDS in honor of Stanley Plotkin, the founder of PIDS and [an] inspiration to all of us. We are delighted to have Gary Marshall as the speaker this year giving a talk entitled “Vaccine Hesitancy, History and Human Nature,” Dr. Spearman wrote in an article posted on the PIDS website.

He noted that the PIDS anniversary special celebration, dinner, and lecture in honor of the contributions of George McCracken and John Nelson also will be held Oct. 5.

Throughout the meeting, the latest data and practices for the treatment of infants and children will be featured. Although pediatric issues will be discussed in many sessions, there are a number of events specifically dedicated to pediatric cases.

Of particular interest, on Wednesday morning, Oral Abstract Session 31 will focus on “Infant Viral Infections.” Talks will include “Role of Maternal Antibodies in Protection Against Postnatal Cytomegalovirus Acquisition,” by Frances Saccoccio, MD, PhD, and “Effect of Nasopharyngeal Pneumococcal Carriage on RSV and hMPV Illness Severity in Infants in Nepal,” by Alastair Murray.

On Thursday morning, the symposium “Hot Topics in Pediatric Infectious Diseases” will feature talks by experts in the field detailing this year’s important clinical advances and discoveries that have the potential to impact clinical care.

The Thursday afternoon poster session “Pediatric Antimicrobial and Diagnostic Stewardship” will focus on topics such as “Variation in Antibiotic Use Among Neonates Hospitalized in United States Academically Affiliated Centers,” which will be presented by Prachi Singh, DO, and “Alternative Antibiotic Prescribing for Community Acquired Pneumonia (CAP) in Pediatric Patients in Relation to Allergy Status,” to be presented by Ankita Desai, MD.

There also will be a poster session that afternoon focused on “Maternal-Child Infections” that will feature “Risk Factors for Congenital Infection in the United States: Analysis of the Kids’ Inpatient Database (KID),” by Angela F. Veesenmeyer, MD, and “The Effect of Prenatal Screening for Chlamydia trachomatis (CT) on Chlamydial Conjunctivitis in Infants,” by Natalie Banniettis, MD.

Later that same day, “Mano-a-Mano III,” an interactive session on “Controversies in Pediatric ID,” will focus on the tuberculin skin test vs. the interferon-gamma release assay (IGRA) for TB identification, the use of vancomycin therapy for meningitis, and the value of respiratory viral panel testing.

As part of the program committee, Marsha S. Anderson, MD, FIDSA, from the University of Colorado School of Medicine, serves as this year’s IDWeek chair, for the PIDS portion of the meeting, and Roberta L. DeBiasi, MD, of the Children’s National Health System serves as vice chair.

IDWeek 2018 includes the annual meeting of the Pediatric Infectious Diseases Society, which is celebrating its 40th anniversary as a society this year.

Paul Spearman, MD, the PIDS president, specifically highlighted some of the special 40th anniversary events: The Stanley A. Plotkin Lectureship in Vaccinology will be held on Friday, Oct. 5. “This is an annual highlight for PIDS in honor of Stanley Plotkin, the founder of PIDS and [an] inspiration to all of us. We are delighted to have Gary Marshall as the speaker this year giving a talk entitled “Vaccine Hesitancy, History and Human Nature,” Dr. Spearman wrote in an article posted on the PIDS website.

He noted that the PIDS anniversary special celebration, dinner, and lecture in honor of the contributions of George McCracken and John Nelson also will be held Oct. 5.

Throughout the meeting, the latest data and practices for the treatment of infants and children will be featured. Although pediatric issues will be discussed in many sessions, there are a number of events specifically dedicated to pediatric cases.

Of particular interest, on Wednesday morning, Oral Abstract Session 31 will focus on “Infant Viral Infections.” Talks will include “Role of Maternal Antibodies in Protection Against Postnatal Cytomegalovirus Acquisition,” by Frances Saccoccio, MD, PhD, and “Effect of Nasopharyngeal Pneumococcal Carriage on RSV and hMPV Illness Severity in Infants in Nepal,” by Alastair Murray.

On Thursday morning, the symposium “Hot Topics in Pediatric Infectious Diseases” will feature talks by experts in the field detailing this year’s important clinical advances and discoveries that have the potential to impact clinical care.

The Thursday afternoon poster session “Pediatric Antimicrobial and Diagnostic Stewardship” will focus on topics such as “Variation in Antibiotic Use Among Neonates Hospitalized in United States Academically Affiliated Centers,” which will be presented by Prachi Singh, DO, and “Alternative Antibiotic Prescribing for Community Acquired Pneumonia (CAP) in Pediatric Patients in Relation to Allergy Status,” to be presented by Ankita Desai, MD.

There also will be a poster session that afternoon focused on “Maternal-Child Infections” that will feature “Risk Factors for Congenital Infection in the United States: Analysis of the Kids’ Inpatient Database (KID),” by Angela F. Veesenmeyer, MD, and “The Effect of Prenatal Screening for Chlamydia trachomatis (CT) on Chlamydial Conjunctivitis in Infants,” by Natalie Banniettis, MD.

Later that same day, “Mano-a-Mano III,” an interactive session on “Controversies in Pediatric ID,” will focus on the tuberculin skin test vs. the interferon-gamma release assay (IGRA) for TB identification, the use of vancomycin therapy for meningitis, and the value of respiratory viral panel testing.

As part of the program committee, Marsha S. Anderson, MD, FIDSA, from the University of Colorado School of Medicine, serves as this year’s IDWeek chair, for the PIDS portion of the meeting, and Roberta L. DeBiasi, MD, of the Children’s National Health System serves as vice chair.

More than 500 VA hematologists, oncologists, pharmacists, nurses, social workers, and cancer registrars came to the 14th annual Association of VA Hematology/Oncology meeting held outside of Chicago, September 28 through September 30. Mark Klein, MD, succeeded Rusty Crawford, BPharm, as president and William Wachsman, MD, PhD, was named president-elect.

A key focus of the meeting was health care disparities and providing cancer care to underserved populations. An entire track of the meeting was devoted to patients with serious mental illness (SMI), including discussions of the risk of suicide Also a focus was the challenge of providing optimal treatments for patients who may not be adherent because they do not have access to support networks or steady housing.

According to Jessica B. Geller, PhD, MS, and Jessica L. Brand, PhD, a patient with a SMI diagnosis should not preclude considering aggressive treatment but requires a close level of care. Cancer care of patients with SMI requires close collaboration with mental health and pharmacy providers to manage these complex patients. According to Elizabeth Holyman, PsyD, care providers should give serious attention to complaints despite difficult behavior, treat pain, use active listening and provide interpersonal supports, and assume people with SMI have similar needs to the non-SMI.

For both patients with SMI and the entire veteran population, a cancer diagnosis can raise the risk of suicide, explained Catherine Rotolo, LISW-S. Suicidal ideation occurs in nearly 9% of people with cancer, most frequently in the first 3 months after diagnosis, and remains a significant cause of mortality for cancer patients. For patients with cancer, the rate of suicide—already elevated for veterans—is twice that of the baseline rate.

In a keynote address, Lisa Margolies, executive director of the LGBT Cancer Network, cautioned care providers not only to provide a welcoming environment, but also  avoid making any assumptions about sexual behavior. “Do ask, we want to tell,” she told attendees, “Make it a part of your regular questions.” According to Margolies, there are more than 1 million LGBT veterans; they use the VA at higher rates, and the best estimate is that there are about 150,000 transgender veterans. According to Margolies, many do not tell their health care providers about their identity; 24% of lesbian, gay, bisexual, and transgender (LGBT) adults withheld information about sexual practices; 9.4% of men who identified as straight had sex with another man within the previous year. In another survey, more than 77% of lesbians had at least 1 sexual experience with a man—8% in the previous year. Margolies’ key point: avoid assumptions about a patient’s identity and simply take a comprehensive medical history so that you better understand the individual in front of you.

Another track of sessions focused on the challenges women face receiving care in the VA. Many female veterans, especially survivors of military sexual trauma (MST), are not comfortable going to the VA for care or being around groups of male veterans. Col (ret) Mona Pearl Treyball, PhD, RN, pointed out that up to 70% of women veterans experienced MST; most never reported it. That point was reinforced by Chad Hamilton, MD, who noted that among veteran women “Significantly higher proportion of users, compared to nonusers reported avoiding VA because of past sexual trauma (19% of users vs 8% of nonusers).

Yeun-hee Anna Park reported on the High Risk Breast Cancer Screening Program, a 10-site pilot project to assess breast cancer risk. The quality improvement program sought to enhance screening for high-risk breast cancer and increase use of chemoprevention and genetic counseling in accordance with national guidelines. In the pilot, women veterans were at increased risk of breast cancer compared with that of the general population (46% vs 13%, respectively), based on a high rate of prior breast biopsies or positive family history. Moreover, posttraumatic stress disorder rates were nearly 3 times the national average. In the program, use of chemoprevention was nearly 2 times the national average.

Female patients undergoing treatment for cancer also face distinct risks related to fertility, bone health, and vasomotor symptoms of menopause. According to Tyler Fenton, PharmD, some cancer treatment approaches involving chemotherapy, radiation, and/or surgery carry a risk of ovarian failure and the accompanying symptoms of premature menopause. Dr. Fenton noted, that menopausal symptoms such as hot flashes are reported to occur in as many as 73% of breast cancer survivors, and 42% of female patients with cancer of reproductive age may develop premature ovarian failure as a result of their chemotherapy.

More than 500 VA hematologists, oncologists, pharmacists, nurses, social workers, and cancer registrars came to the 14th annual Association of VA Hematology/Oncology meeting held outside of Chicago, September 28 through September 30. Mark Klein, MD, succeeded Rusty Crawford, BPharm, as president and William Wachsman, MD, PhD, was named president-elect.

A key focus of the meeting was health care disparities and providing cancer care to underserved populations. An entire track of the meeting was devoted to patients with serious mental illness (SMI), including discussions of the risk of suicide Also a focus was the challenge of providing optimal treatments for patients who may not be adherent because they do not have access to support networks or steady housing.

According to Jessica B. Geller, PhD, MS, and Jessica L. Brand, PhD, a patient with a SMI diagnosis should not preclude considering aggressive treatment but requires a close level of care. Cancer care of patients with SMI requires close collaboration with mental health and pharmacy providers to manage these complex patients. According to Elizabeth Holyman, PsyD, care providers should give serious attention to complaints despite difficult behavior, treat pain, use active listening and provide interpersonal supports, and assume people with SMI have similar needs to the non-SMI.

For both patients with SMI and the entire veteran population, a cancer diagnosis can raise the risk of suicide, explained Catherine Rotolo, LISW-S. Suicidal ideation occurs in nearly 9% of people with cancer, most frequently in the first 3 months after diagnosis, and remains a significant cause of mortality for cancer patients. For patients with cancer, the rate of suicide—already elevated for veterans—is twice that of the baseline rate.

In a keynote address, Lisa Margolies, executive director of the LGBT Cancer Network, cautioned care providers not only to provide a welcoming environment, but also  avoid making any assumptions about sexual behavior. “Do ask, we want to tell,” she told attendees, “Make it a part of your regular questions.” According to Margolies, there are more than 1 million LGBT veterans; they use the VA at higher rates, and the best estimate is that there are about 150,000 transgender veterans. According to Margolies, many do not tell their health care providers about their identity; 24% of lesbian, gay, bisexual, and transgender (LGBT) adults withheld information about sexual practices; 9.4% of men who identified as straight had sex with another man within the previous year. In another survey, more than 77% of lesbians had at least 1 sexual experience with a man—8% in the previous year. Margolies’ key point: avoid assumptions about a patient’s identity and simply take a comprehensive medical history so that you better understand the individual in front of you.

Another track of sessions focused on the challenges women face receiving care in the VA. Many female veterans, especially survivors of military sexual trauma (MST), are not comfortable going to the VA for care or being around groups of male veterans. Col (ret) Mona Pearl Treyball, PhD, RN, pointed out that up to 70% of women veterans experienced MST; most never reported it. That point was reinforced by Chad Hamilton, MD, who noted that among veteran women “Significantly higher proportion of users, compared to nonusers reported avoiding VA because of past sexual trauma (19% of users vs 8% of nonusers).

Yeun-hee Anna Park reported on the High Risk Breast Cancer Screening Program, a 10-site pilot project to assess breast cancer risk. The quality improvement program sought to enhance screening for high-risk breast cancer and increase use of chemoprevention and genetic counseling in accordance with national guidelines. In the pilot, women veterans were at increased risk of breast cancer compared with that of the general population (46% vs 13%, respectively), based on a high rate of prior breast biopsies or positive family history. Moreover, posttraumatic stress disorder rates were nearly 3 times the national average. In the program, use of chemoprevention was nearly 2 times the national average.

Female patients undergoing treatment for cancer also face distinct risks related to fertility, bone health, and vasomotor symptoms of menopause. According to Tyler Fenton, PharmD, some cancer treatment approaches involving chemotherapy, radiation, and/or surgery carry a risk of ovarian failure and the accompanying symptoms of premature menopause. Dr. Fenton noted, that menopausal symptoms such as hot flashes are reported to occur in as many as 73% of breast cancer survivors, and 42% of female patients with cancer of reproductive age may develop premature ovarian failure as a result of their chemotherapy.

More than 500 VA hematologists, oncologists, pharmacists, nurses, social workers, and cancer registrars came to the 14th annual Association of VA Hematology/Oncology meeting held outside of Chicago, September 28 through September 30. Mark Klein, MD, succeeded Rusty Crawford, BPharm, as president and William Wachsman, MD, PhD, was named president-elect.

A key focus of the meeting was health care disparities and providing cancer care to underserved populations. An entire track of the meeting was devoted to patients with serious mental illness (SMI), including discussions of the risk of suicide Also a focus was the challenge of providing optimal treatments for patients who may not be adherent because they do not have access to support networks or steady housing.

According to Jessica B. Geller, PhD, MS, and Jessica L. Brand, PhD, a patient with a SMI diagnosis should not preclude considering aggressive treatment but requires a close level of care. Cancer care of patients with SMI requires close collaboration with mental health and pharmacy providers to manage these complex patients. According to Elizabeth Holyman, PsyD, care providers should give serious attention to complaints despite difficult behavior, treat pain, use active listening and provide interpersonal supports, and assume people with SMI have similar needs to the non-SMI.

For both patients with SMI and the entire veteran population, a cancer diagnosis can raise the risk of suicide, explained Catherine Rotolo, LISW-S. Suicidal ideation occurs in nearly 9% of people with cancer, most frequently in the first 3 months after diagnosis, and remains a significant cause of mortality for cancer patients. For patients with cancer, the rate of suicide—already elevated for veterans—is twice that of the baseline rate.

In a keynote address, Lisa Margolies, executive director of the LGBT Cancer Network, cautioned care providers not only to provide a welcoming environment, but also  avoid making any assumptions about sexual behavior. “Do ask, we want to tell,” she told attendees, “Make it a part of your regular questions.” According to Margolies, there are more than 1 million LGBT veterans; they use the VA at higher rates, and the best estimate is that there are about 150,000 transgender veterans. According to Margolies, many do not tell their health care providers about their identity; 24% of lesbian, gay, bisexual, and transgender (LGBT) adults withheld information about sexual practices; 9.4% of men who identified as straight had sex with another man within the previous year. In another survey, more than 77% of lesbians had at least 1 sexual experience with a man—8% in the previous year. Margolies’ key point: avoid assumptions about a patient’s identity and simply take a comprehensive medical history so that you better understand the individual in front of you.

Another track of sessions focused on the challenges women face receiving care in the VA. Many female veterans, especially survivors of military sexual trauma (MST), are not comfortable going to the VA for care or being around groups of male veterans. Col (ret) Mona Pearl Treyball, PhD, RN, pointed out that up to 70% of women veterans experienced MST; most never reported it. That point was reinforced by Chad Hamilton, MD, who noted that among veteran women “Significantly higher proportion of users, compared to nonusers reported avoiding VA because of past sexual trauma (19% of users vs 8% of nonusers).

Yeun-hee Anna Park reported on the High Risk Breast Cancer Screening Program, a 10-site pilot project to assess breast cancer risk. The quality improvement program sought to enhance screening for high-risk breast cancer and increase use of chemoprevention and genetic counseling in accordance with national guidelines. In the pilot, women veterans were at increased risk of breast cancer compared with that of the general population (46% vs 13%, respectively), based on a high rate of prior breast biopsies or positive family history. Moreover, posttraumatic stress disorder rates were nearly 3 times the national average. In the program, use of chemoprevention was nearly 2 times the national average.

Female patients undergoing treatment for cancer also face distinct risks related to fertility, bone health, and vasomotor symptoms of menopause. According to Tyler Fenton, PharmD, some cancer treatment approaches involving chemotherapy, radiation, and/or surgery carry a risk of ovarian failure and the accompanying symptoms of premature menopause. Dr. Fenton noted, that menopausal symptoms such as hot flashes are reported to occur in as many as 73% of breast cancer survivors, and 42% of female patients with cancer of reproductive age may develop premature ovarian failure as a result of their chemotherapy.