Case

A 65-year-old woman presented to the ED with a chief complaint of an animal bite, in Southwest Ohio. The patient reported picking up what she thought to be an injured bird, which in fact turned out to be a chipmunk. When she handled the creature, it jumped up and bit her on the right arm, latching on through the sleeve of her sweater. Her husband struck the chipmunk with a shovel, thus terminating the threat. The patient was brought to the ED by her husband for evaluation, along with the lifeless animal which had been placed in a plastic bag. On examination, the patient had a small superficial abrasion to her right forearm with shallow skin puncture. This was treated with local wound care, including copious irrigation with normal saline and chlorhexidine. Given that she sustained an animal bite wound, she was treated empirically with amoxicillin/clavulanic acid (Augmentin) orally. Her tetanus vaccine was up to date. The critically important question regarding management of the patient was whether she should be treated with post-exposure prophylaxis for rabies after being bitten by the rodent.

Discussion

According to the Centers for Disease Control and Prevention (CDC) website regarding the indications for rabies post-exposure prophylaxis, it was found that small rodents, including chipmunks, have not been known to transmit rabies to humans. While these small animals are rarely infected with rabies, there have been reports of squirrels infected with rabies in the United States.^1,2 Therefore, it is recommended that in all cases of rodent bites, the state or local health department should be contacted prior to making a decision regarding post-exposure prophylaxis.¹ The state health department was contacted and agreed that post-exposure prophylaxis was not indicated; however, they requested the animal be sent to them for testing, which was arranged. An in-depth literature review found a case report in India of a 7-year-old boy who contracted rabies after being bitten by a squirrel. Per this research, small rodents are rarely infected with rabies, with woodchucks being indicated as local vectors. This particular patient received a tetanus vaccine and wound care initially after the squirrel bite, but presented 2 months later with difficulty with oral feeding, fever, and cough. He succumbed to his illness just 4 hours after admission, and rabies was confirmed through a corneal impression smear.³ Birhane et al⁴ reported three human deaths in the United States from rabies during 2015. The deaths included one due to a rabid dog bite while abroad, one due to contact with a bat, and one from a mongoose bite. None of these patients had been treated with post-exposure prophylaxis.⁴

Rabies is an RNA virus in the genus Lyssavirus. Once contracted, the rabies virus initially binds to the nicotinic acetylcholine receptor in muscle, replicates, and ascends along the nerves until it reaches the central nervous system (CNS), then propagates outward via the peripheral nerves. Replication in the CNS occurs in the Negri bodies, which are highly specific for rabies. There are two forms of rabies, a paralytic form and an encephalitic form, with the encephalitic form occurring far more commonly. The encephalitic form presents with hallucinations, and disorientation intermixed with lucid intervals. The paralytic form presents with weakness in the affected limb(s), progressing to quadriparesis and facial weakness, eventually leading to organ failure. The classic hydrophobia that is thought of in connection with rabies is present in only 50% of cases.⁵Transmission occurs from an infected host via bite most commonly, but can occur through exposure to mucous membranes, aerosol transmission, or exposure in a laboratory setting. The rabies virus can be “shed in the saliva concomitantly with, before or after the development of clinical signs.”⁶ Lyssaviruses, such as the rabies virus, do not persist in the environment. Once outside the host, the virus is rapidly inactivated, therefore, fomites do not play a role in transmission.⁶ Rabies hosts vary significantly, and the virus has been found in almost all mammalian orders and on all continents except for Antarctica. The primary reservoir for rabies is the bat, followed by dogs; however, cats, foxes, coyotes, jackals, wolves, mongoose, and raccoons are all vectors of rabies. Animals infected with rabies typically show signs of CNS disturbance. According to Rupprecht,² “the most reliable signs, regardless of species, are acute behavioral changes and unexplained progressive paralysis.” Notably, wild animals infected with rabies “may lose their fear of people, and nocturnal species may be seen wandering about during the daytime.”²According to Rupprecht et al,⁶ “Rodents and lagomorphs, although used heavily as laboratory models, are not important in the epidemiology of the disease [rabies], except in the public-health resources devoted to consultation or prophylaxis after routine contact with these ubiquitous small mammals.”

Case Conclusion

In this case of the chipmunk bite, in accordance with the state health department, rabies prophylaxis was not indicated. It was recommended that the chipmunk be sent off for a necropsy (noting to leave the chipmunk intact and not to behead it). Following shared decision making with the patient and her husband, the chipmunk was sent off for testing with the results to be sent to the patient. She was discharged from the ED with Augmentin, but without rabies post-exposure prophylaxis. According to review of outpatient medical records, the patient was doing well at primary care appointments after the injury.

Case

A 65-year-old woman presented to the ED with a chief complaint of an animal bite, in Southwest Ohio. The patient reported picking up what she thought to be an injured bird, which in fact turned out to be a chipmunk. When she handled the creature, it jumped up and bit her on the right arm, latching on through the sleeve of her sweater. Her husband struck the chipmunk with a shovel, thus terminating the threat. The patient was brought to the ED by her husband for evaluation, along with the lifeless animal which had been placed in a plastic bag. On examination, the patient had a small superficial abrasion to her right forearm with shallow skin puncture. This was treated with local wound care, including copious irrigation with normal saline and chlorhexidine. Given that she sustained an animal bite wound, she was treated empirically with amoxicillin/clavulanic acid (Augmentin) orally. Her tetanus vaccine was up to date. The critically important question regarding management of the patient was whether she should be treated with post-exposure prophylaxis for rabies after being bitten by the rodent.

Discussion

According to the Centers for Disease Control and Prevention (CDC) website regarding the indications for rabies post-exposure prophylaxis, it was found that small rodents, including chipmunks, have not been known to transmit rabies to humans. While these small animals are rarely infected with rabies, there have been reports of squirrels infected with rabies in the United States.^1,2 Therefore, it is recommended that in all cases of rodent bites, the state or local health department should be contacted prior to making a decision regarding post-exposure prophylaxis.¹ The state health department was contacted and agreed that post-exposure prophylaxis was not indicated; however, they requested the animal be sent to them for testing, which was arranged. An in-depth literature review found a case report in India of a 7-year-old boy who contracted rabies after being bitten by a squirrel. Per this research, small rodents are rarely infected with rabies, with woodchucks being indicated as local vectors. This particular patient received a tetanus vaccine and wound care initially after the squirrel bite, but presented 2 months later with difficulty with oral feeding, fever, and cough. He succumbed to his illness just 4 hours after admission, and rabies was confirmed through a corneal impression smear.³ Birhane et al⁴ reported three human deaths in the United States from rabies during 2015. The deaths included one due to a rabid dog bite while abroad, one due to contact with a bat, and one from a mongoose bite. None of these patients had been treated with post-exposure prophylaxis.⁴

Rabies is an RNA virus in the genus Lyssavirus. Once contracted, the rabies virus initially binds to the nicotinic acetylcholine receptor in muscle, replicates, and ascends along the nerves until it reaches the central nervous system (CNS), then propagates outward via the peripheral nerves. Replication in the CNS occurs in the Negri bodies, which are highly specific for rabies. There are two forms of rabies, a paralytic form and an encephalitic form, with the encephalitic form occurring far more commonly. The encephalitic form presents with hallucinations, and disorientation intermixed with lucid intervals. The paralytic form presents with weakness in the affected limb(s), progressing to quadriparesis and facial weakness, eventually leading to organ failure. The classic hydrophobia that is thought of in connection with rabies is present in only 50% of cases.⁵Transmission occurs from an infected host via bite most commonly, but can occur through exposure to mucous membranes, aerosol transmission, or exposure in a laboratory setting. The rabies virus can be “shed in the saliva concomitantly with, before or after the development of clinical signs.”⁶ Lyssaviruses, such as the rabies virus, do not persist in the environment. Once outside the host, the virus is rapidly inactivated, therefore, fomites do not play a role in transmission.⁶ Rabies hosts vary significantly, and the virus has been found in almost all mammalian orders and on all continents except for Antarctica. The primary reservoir for rabies is the bat, followed by dogs; however, cats, foxes, coyotes, jackals, wolves, mongoose, and raccoons are all vectors of rabies. Animals infected with rabies typically show signs of CNS disturbance. According to Rupprecht,² “the most reliable signs, regardless of species, are acute behavioral changes and unexplained progressive paralysis.” Notably, wild animals infected with rabies “may lose their fear of people, and nocturnal species may be seen wandering about during the daytime.”²According to Rupprecht et al,⁶ “Rodents and lagomorphs, although used heavily as laboratory models, are not important in the epidemiology of the disease [rabies], except in the public-health resources devoted to consultation or prophylaxis after routine contact with these ubiquitous small mammals.”

Case Conclusion

In this case of the chipmunk bite, in accordance with the state health department, rabies prophylaxis was not indicated. It was recommended that the chipmunk be sent off for a necropsy (noting to leave the chipmunk intact and not to behead it). Following shared decision making with the patient and her husband, the chipmunk was sent off for testing with the results to be sent to the patient. She was discharged from the ED with Augmentin, but without rabies post-exposure prophylaxis. According to review of outpatient medical records, the patient was doing well at primary care appointments after the injury.

Case

A 65-year-old woman presented to the ED with a chief complaint of an animal bite, in Southwest Ohio. The patient reported picking up what she thought to be an injured bird, which in fact turned out to be a chipmunk. When she handled the creature, it jumped up and bit her on the right arm, latching on through the sleeve of her sweater. Her husband struck the chipmunk with a shovel, thus terminating the threat. The patient was brought to the ED by her husband for evaluation, along with the lifeless animal which had been placed in a plastic bag. On examination, the patient had a small superficial abrasion to her right forearm with shallow skin puncture. This was treated with local wound care, including copious irrigation with normal saline and chlorhexidine. Given that she sustained an animal bite wound, she was treated empirically with amoxicillin/clavulanic acid (Augmentin) orally. Her tetanus vaccine was up to date. The critically important question regarding management of the patient was whether she should be treated with post-exposure prophylaxis for rabies after being bitten by the rodent.

Discussion

According to the Centers for Disease Control and Prevention (CDC) website regarding the indications for rabies post-exposure prophylaxis, it was found that small rodents, including chipmunks, have not been known to transmit rabies to humans. While these small animals are rarely infected with rabies, there have been reports of squirrels infected with rabies in the United States.^1,2 Therefore, it is recommended that in all cases of rodent bites, the state or local health department should be contacted prior to making a decision regarding post-exposure prophylaxis.¹ The state health department was contacted and agreed that post-exposure prophylaxis was not indicated; however, they requested the animal be sent to them for testing, which was arranged. An in-depth literature review found a case report in India of a 7-year-old boy who contracted rabies after being bitten by a squirrel. Per this research, small rodents are rarely infected with rabies, with woodchucks being indicated as local vectors. This particular patient received a tetanus vaccine and wound care initially after the squirrel bite, but presented 2 months later with difficulty with oral feeding, fever, and cough. He succumbed to his illness just 4 hours after admission, and rabies was confirmed through a corneal impression smear.³ Birhane et al⁴ reported three human deaths in the United States from rabies during 2015. The deaths included one due to a rabid dog bite while abroad, one due to contact with a bat, and one from a mongoose bite. None of these patients had been treated with post-exposure prophylaxis.⁴

Rabies is an RNA virus in the genus Lyssavirus. Once contracted, the rabies virus initially binds to the nicotinic acetylcholine receptor in muscle, replicates, and ascends along the nerves until it reaches the central nervous system (CNS), then propagates outward via the peripheral nerves. Replication in the CNS occurs in the Negri bodies, which are highly specific for rabies. There are two forms of rabies, a paralytic form and an encephalitic form, with the encephalitic form occurring far more commonly. The encephalitic form presents with hallucinations, and disorientation intermixed with lucid intervals. The paralytic form presents with weakness in the affected limb(s), progressing to quadriparesis and facial weakness, eventually leading to organ failure. The classic hydrophobia that is thought of in connection with rabies is present in only 50% of cases.⁵Transmission occurs from an infected host via bite most commonly, but can occur through exposure to mucous membranes, aerosol transmission, or exposure in a laboratory setting. The rabies virus can be “shed in the saliva concomitantly with, before or after the development of clinical signs.”⁶ Lyssaviruses, such as the rabies virus, do not persist in the environment. Once outside the host, the virus is rapidly inactivated, therefore, fomites do not play a role in transmission.⁶ Rabies hosts vary significantly, and the virus has been found in almost all mammalian orders and on all continents except for Antarctica. The primary reservoir for rabies is the bat, followed by dogs; however, cats, foxes, coyotes, jackals, wolves, mongoose, and raccoons are all vectors of rabies. Animals infected with rabies typically show signs of CNS disturbance. According to Rupprecht,² “the most reliable signs, regardless of species, are acute behavioral changes and unexplained progressive paralysis.” Notably, wild animals infected with rabies “may lose their fear of people, and nocturnal species may be seen wandering about during the daytime.”²According to Rupprecht et al,⁶ “Rodents and lagomorphs, although used heavily as laboratory models, are not important in the epidemiology of the disease [rabies], except in the public-health resources devoted to consultation or prophylaxis after routine contact with these ubiquitous small mammals.”

Case Conclusion

In this case of the chipmunk bite, in accordance with the state health department, rabies prophylaxis was not indicated. It was recommended that the chipmunk be sent off for a necropsy (noting to leave the chipmunk intact and not to behead it). Following shared decision making with the patient and her husband, the chipmunk was sent off for testing with the results to be sent to the patient. She was discharged from the ED with Augmentin, but without rabies post-exposure prophylaxis. According to review of outpatient medical records, the patient was doing well at primary care appointments after the injury.

A tai chi exercise program was more effective than multimodal exercise or stretching at reducing falls among older adults in a 6-month study of 670 participants aged 70 years and older.

bloodstone/iStockphoto.com

Although exercise can be a safe way to reduce falls in older adults, “few comparative effectiveness data are available, especially for older adults with high fall risk,” wrote Fuzhong Li, PhD, of the Oregon Research Institute in Eugene, and his colleagues.

In a study published in JAMA Internal Medicine, the researchers randomized participants to a tailored tai chi program, Tai Ji Quan: Moving for Better Balance (TJQMBB), multimodal exercise, or a control intervention of basic stretching. Each intervention consisted of a twice-weekly 60-minute session for 24 weeks.

The study population included 670 community-dwelling adults aged 70 years and older at seven urban and suburban cities in Oregon. All participants had fallen within the past year or had impaired mobility that put them at increased fall risk. The average age of the participants was 78 years, 65% were women, and 92% were white.

A total of 152 falls occurred among 85 individuals in the TJQMBB group during the study period, compared with 218 falls among 112 individuals in the multimodal exercise group and 363 falls among 127 individuals in the stretching group. Overall, the tai chi group had a 58% reduced incidence of falls, compared with stretching, and a 31% reduced risk, compared with multimodal exercise.

The tai chi program used in the study included balance and stability training, described by the researchers as “unilateral weight-bearing and weight-shifting movements, trunk and pelvic rotation, ankle sway, and eye-head-hand movements.” The multimodal exercise program included aerobic conditioning, strength, balance, and flexibility activities, and the stretching intervention included stretching, breathing, and relaxation.

The results were limited by several factors, including the use of self-reports, low representation of African American participants, and collection of data from a single state, the researchers noted.

However, the findings support the potential of tai chi programs to reduce the risk of falls in older adults. “With increasing evidence of community adoption and implementation and information from cost-benefit and cost-effectiveness analyses, the intervention program represents a promising approach to low-cost and easily implementable fall prevention programs,” the researchers explained.

The study was supported in part by the National Institute on Aging. Dr. Li reported that he is the founder and owner of a consulting company, Exercise Alternatives, and that a licensing free for TJQMBB is paid directly to that company.

SOURCE: Li F et al. JAMA Intern Med. 2018 Sep 10. doi: 10.1001/jamainternmed.2018.3915.

A tai chi exercise program was more effective than multimodal exercise or stretching at reducing falls among older adults in a 6-month study of 670 participants aged 70 years and older.

bloodstone/iStockphoto.com

Although exercise can be a safe way to reduce falls in older adults, “few comparative effectiveness data are available, especially for older adults with high fall risk,” wrote Fuzhong Li, PhD, of the Oregon Research Institute in Eugene, and his colleagues.

In a study published in JAMA Internal Medicine, the researchers randomized participants to a tailored tai chi program, Tai Ji Quan: Moving for Better Balance (TJQMBB), multimodal exercise, or a control intervention of basic stretching. Each intervention consisted of a twice-weekly 60-minute session for 24 weeks.

The study population included 670 community-dwelling adults aged 70 years and older at seven urban and suburban cities in Oregon. All participants had fallen within the past year or had impaired mobility that put them at increased fall risk. The average age of the participants was 78 years, 65% were women, and 92% were white.

A total of 152 falls occurred among 85 individuals in the TJQMBB group during the study period, compared with 218 falls among 112 individuals in the multimodal exercise group and 363 falls among 127 individuals in the stretching group. Overall, the tai chi group had a 58% reduced incidence of falls, compared with stretching, and a 31% reduced risk, compared with multimodal exercise.

The tai chi program used in the study included balance and stability training, described by the researchers as “unilateral weight-bearing and weight-shifting movements, trunk and pelvic rotation, ankle sway, and eye-head-hand movements.” The multimodal exercise program included aerobic conditioning, strength, balance, and flexibility activities, and the stretching intervention included stretching, breathing, and relaxation.

The results were limited by several factors, including the use of self-reports, low representation of African American participants, and collection of data from a single state, the researchers noted.

However, the findings support the potential of tai chi programs to reduce the risk of falls in older adults. “With increasing evidence of community adoption and implementation and information from cost-benefit and cost-effectiveness analyses, the intervention program represents a promising approach to low-cost and easily implementable fall prevention programs,” the researchers explained.

The study was supported in part by the National Institute on Aging. Dr. Li reported that he is the founder and owner of a consulting company, Exercise Alternatives, and that a licensing free for TJQMBB is paid directly to that company.

SOURCE: Li F et al. JAMA Intern Med. 2018 Sep 10. doi: 10.1001/jamainternmed.2018.3915.

A tai chi exercise program was more effective than multimodal exercise or stretching at reducing falls among older adults in a 6-month study of 670 participants aged 70 years and older.

bloodstone/iStockphoto.com

Although exercise can be a safe way to reduce falls in older adults, “few comparative effectiveness data are available, especially for older adults with high fall risk,” wrote Fuzhong Li, PhD, of the Oregon Research Institute in Eugene, and his colleagues.

In a study published in JAMA Internal Medicine, the researchers randomized participants to a tailored tai chi program, Tai Ji Quan: Moving for Better Balance (TJQMBB), multimodal exercise, or a control intervention of basic stretching. Each intervention consisted of a twice-weekly 60-minute session for 24 weeks.

The study population included 670 community-dwelling adults aged 70 years and older at seven urban and suburban cities in Oregon. All participants had fallen within the past year or had impaired mobility that put them at increased fall risk. The average age of the participants was 78 years, 65% were women, and 92% were white.

A total of 152 falls occurred among 85 individuals in the TJQMBB group during the study period, compared with 218 falls among 112 individuals in the multimodal exercise group and 363 falls among 127 individuals in the stretching group. Overall, the tai chi group had a 58% reduced incidence of falls, compared with stretching, and a 31% reduced risk, compared with multimodal exercise.

The tai chi program used in the study included balance and stability training, described by the researchers as “unilateral weight-bearing and weight-shifting movements, trunk and pelvic rotation, ankle sway, and eye-head-hand movements.” The multimodal exercise program included aerobic conditioning, strength, balance, and flexibility activities, and the stretching intervention included stretching, breathing, and relaxation.

The results were limited by several factors, including the use of self-reports, low representation of African American participants, and collection of data from a single state, the researchers noted.

However, the findings support the potential of tai chi programs to reduce the risk of falls in older adults. “With increasing evidence of community adoption and implementation and information from cost-benefit and cost-effectiveness analyses, the intervention program represents a promising approach to low-cost and easily implementable fall prevention programs,” the researchers explained.

The study was supported in part by the National Institute on Aging. Dr. Li reported that he is the founder and owner of a consulting company, Exercise Alternatives, and that a licensing free for TJQMBB is paid directly to that company.

SOURCE: Li F et al. JAMA Intern Med. 2018 Sep 10. doi: 10.1001/jamainternmed.2018.3915.

Nearly all newborns who received an acellular pertussis-only vaccine at birth showed titers for pertussis and no difference in adverse events, compared with a group receiving only the hepatitis B vaccine, a randomized clinical trial from Australia has found.

copyright Jacopo Werther/Wikimedia Commons/Creative Commons Attribution 2.0

“These results indicate that a birth dose of aP vaccine is immunogenic in newborns and significantly narrows the immunity gap between birth and 14 days after receipt of DTaP at 6 or 8 weeks of age, marking the critical period when infants are most vulnerable to severe pertussis infection,” reported Nicholas Wood, PhD, of the National Centre for Immunisation Research and Surveillance of Vaccine Preventable Diseases in New South Wales, Australia, and his colleagues.

“Administration of the acellular pertussis vaccine at birth has the potential to reduce severe morbidity from Bordetella pertussis infection in the first 3 months of life, especially for infants of mothers who have not received a pertussis vaccine during pregnancy,” the researchers concluded in JAMA Pediatrics.

The researchers enrolled 417 infants from Sydney, Melbourne, Adelaide, and Perth between June 2010 and March 2013 and randomized them to receive either the hepatitis B vaccine alone (n = 205) or the hepatitis B vaccine with a monovalent acellular pertussis vaccine (n = 212) within the first 5 days after birth. The randomization was stratified for mothers’ receipt of the Tdap before pregnancy.

The Centers for Disease Control and Prevention currently recommends all newborns receive the hepatitis B vaccine shortly after birth and that pregnant women receive the Tdap vaccine during each pregnancy. There is not currently a monovalent acellular pertussis vaccine licensed in the United States.

The study infants then received the hexavalent DTaP-Hib-hep B-polio vaccine and the 10-valent pneumococcal conjugate vaccine at 6 weeks, 4 months, and 6 months.

The primary outcome was detectable levels of IgG antibody to pertussis toxin and pertactin at 10 weeks old.

Of the 206 infants receiving the pertussis vaccine at birth, 93% had detectable antibodies to pertussis toxin and pertactin at 10 weeks, compared with 51% of the 193 infants who received only the hepatitis B shot (P less than .001). Geometric mean concentration for pertussis toxin IgG also was four times higher in infants who received the pertussis vaccine at birth.

Adverse events were similar in the two groups both at birth and at 32 weeks, demonstrating that the pertussis birth dose is safe and tolerable.

“More important, in this study, the prevalence of fever after receipt of the birth dose, which can mistakenly be associated with potential sepsis and result in additional investigations in the neonatal period, was similar in both the group that received the aP vaccine at birth and the control group,” the authors reported.

A remaining question is the potential impact of maternal antibodies on protection from pertussis.

“The presence of maternal pertussis antibodies at birth can negatively affect postprimary responses to pertussis, diphtheria, and diphtheria-related CRM197 conjugate vaccines with a variety of infant immunization schedules and vaccines,” the authors noted. “The clinical significance of reductions in pertussis antibody related to maternal interference will require ongoing clinical evaluation, because there are no accepted serologic correlates of protection.”

The research was funded by a Australian National Health and Medical Research Council (NHMRC) grant, and several authors received NHMRC grants. One author also was supported by a Murdoch Children’s Research Institute Career Development Award. GlaxoSmithKline provided the vaccine and conducted the serologic assays. The authors reported having no conflicts of interest.

SOURCE: Wood N et al, JAMA Pediatr. 2018 Sep 10. doi: 10.1001/jamapediatrics.2018.2349.

Nearly all newborns who received an acellular pertussis-only vaccine at birth showed titers for pertussis and no difference in adverse events, compared with a group receiving only the hepatitis B vaccine, a randomized clinical trial from Australia has found.

copyright Jacopo Werther/Wikimedia Commons/Creative Commons Attribution 2.0

“These results indicate that a birth dose of aP vaccine is immunogenic in newborns and significantly narrows the immunity gap between birth and 14 days after receipt of DTaP at 6 or 8 weeks of age, marking the critical period when infants are most vulnerable to severe pertussis infection,” reported Nicholas Wood, PhD, of the National Centre for Immunisation Research and Surveillance of Vaccine Preventable Diseases in New South Wales, Australia, and his colleagues.

“Administration of the acellular pertussis vaccine at birth has the potential to reduce severe morbidity from Bordetella pertussis infection in the first 3 months of life, especially for infants of mothers who have not received a pertussis vaccine during pregnancy,” the researchers concluded in JAMA Pediatrics.

The researchers enrolled 417 infants from Sydney, Melbourne, Adelaide, and Perth between June 2010 and March 2013 and randomized them to receive either the hepatitis B vaccine alone (n = 205) or the hepatitis B vaccine with a monovalent acellular pertussis vaccine (n = 212) within the first 5 days after birth. The randomization was stratified for mothers’ receipt of the Tdap before pregnancy.

The Centers for Disease Control and Prevention currently recommends all newborns receive the hepatitis B vaccine shortly after birth and that pregnant women receive the Tdap vaccine during each pregnancy. There is not currently a monovalent acellular pertussis vaccine licensed in the United States.

The study infants then received the hexavalent DTaP-Hib-hep B-polio vaccine and the 10-valent pneumococcal conjugate vaccine at 6 weeks, 4 months, and 6 months.

The primary outcome was detectable levels of IgG antibody to pertussis toxin and pertactin at 10 weeks old.

Of the 206 infants receiving the pertussis vaccine at birth, 93% had detectable antibodies to pertussis toxin and pertactin at 10 weeks, compared with 51% of the 193 infants who received only the hepatitis B shot (P less than .001). Geometric mean concentration for pertussis toxin IgG also was four times higher in infants who received the pertussis vaccine at birth.

Adverse events were similar in the two groups both at birth and at 32 weeks, demonstrating that the pertussis birth dose is safe and tolerable.

“More important, in this study, the prevalence of fever after receipt of the birth dose, which can mistakenly be associated with potential sepsis and result in additional investigations in the neonatal period, was similar in both the group that received the aP vaccine at birth and the control group,” the authors reported.

A remaining question is the potential impact of maternal antibodies on protection from pertussis.

“The presence of maternal pertussis antibodies at birth can negatively affect postprimary responses to pertussis, diphtheria, and diphtheria-related CRM197 conjugate vaccines with a variety of infant immunization schedules and vaccines,” the authors noted. “The clinical significance of reductions in pertussis antibody related to maternal interference will require ongoing clinical evaluation, because there are no accepted serologic correlates of protection.”

The research was funded by a Australian National Health and Medical Research Council (NHMRC) grant, and several authors received NHMRC grants. One author also was supported by a Murdoch Children’s Research Institute Career Development Award. GlaxoSmithKline provided the vaccine and conducted the serologic assays. The authors reported having no conflicts of interest.

SOURCE: Wood N et al, JAMA Pediatr. 2018 Sep 10. doi: 10.1001/jamapediatrics.2018.2349.

Nearly all newborns who received an acellular pertussis-only vaccine at birth showed titers for pertussis and no difference in adverse events, compared with a group receiving only the hepatitis B vaccine, a randomized clinical trial from Australia has found.

copyright Jacopo Werther/Wikimedia Commons/Creative Commons Attribution 2.0

“These results indicate that a birth dose of aP vaccine is immunogenic in newborns and significantly narrows the immunity gap between birth and 14 days after receipt of DTaP at 6 or 8 weeks of age, marking the critical period when infants are most vulnerable to severe pertussis infection,” reported Nicholas Wood, PhD, of the National Centre for Immunisation Research and Surveillance of Vaccine Preventable Diseases in New South Wales, Australia, and his colleagues.

“Administration of the acellular pertussis vaccine at birth has the potential to reduce severe morbidity from Bordetella pertussis infection in the first 3 months of life, especially for infants of mothers who have not received a pertussis vaccine during pregnancy,” the researchers concluded in JAMA Pediatrics.

The researchers enrolled 417 infants from Sydney, Melbourne, Adelaide, and Perth between June 2010 and March 2013 and randomized them to receive either the hepatitis B vaccine alone (n = 205) or the hepatitis B vaccine with a monovalent acellular pertussis vaccine (n = 212) within the first 5 days after birth. The randomization was stratified for mothers’ receipt of the Tdap before pregnancy.

The Centers for Disease Control and Prevention currently recommends all newborns receive the hepatitis B vaccine shortly after birth and that pregnant women receive the Tdap vaccine during each pregnancy. There is not currently a monovalent acellular pertussis vaccine licensed in the United States.

The study infants then received the hexavalent DTaP-Hib-hep B-polio vaccine and the 10-valent pneumococcal conjugate vaccine at 6 weeks, 4 months, and 6 months.

The primary outcome was detectable levels of IgG antibody to pertussis toxin and pertactin at 10 weeks old.

Of the 206 infants receiving the pertussis vaccine at birth, 93% had detectable antibodies to pertussis toxin and pertactin at 10 weeks, compared with 51% of the 193 infants who received only the hepatitis B shot (P less than .001). Geometric mean concentration for pertussis toxin IgG also was four times higher in infants who received the pertussis vaccine at birth.

Adverse events were similar in the two groups both at birth and at 32 weeks, demonstrating that the pertussis birth dose is safe and tolerable.

“More important, in this study, the prevalence of fever after receipt of the birth dose, which can mistakenly be associated with potential sepsis and result in additional investigations in the neonatal period, was similar in both the group that received the aP vaccine at birth and the control group,” the authors reported.

A remaining question is the potential impact of maternal antibodies on protection from pertussis.

“The presence of maternal pertussis antibodies at birth can negatively affect postprimary responses to pertussis, diphtheria, and diphtheria-related CRM197 conjugate vaccines with a variety of infant immunization schedules and vaccines,” the authors noted. “The clinical significance of reductions in pertussis antibody related to maternal interference will require ongoing clinical evaluation, because there are no accepted serologic correlates of protection.”

The research was funded by a Australian National Health and Medical Research Council (NHMRC) grant, and several authors received NHMRC grants. One author also was supported by a Murdoch Children’s Research Institute Career Development Award. GlaxoSmithKline provided the vaccine and conducted the serologic assays. The authors reported having no conflicts of interest.

SOURCE: Wood N et al, JAMA Pediatr. 2018 Sep 10. doi: 10.1001/jamapediatrics.2018.2349.

A new classification system that incorporates clinical and serologic data may be useful in the classification of idiopathic inflammatory myopathies, results of a recent analysis suggest.

By analyzing the patterns of relationships between 47 variables in this observational, retrospective cohort study, investigators identified 4 clusters of patients that corresponded to known idiopathic inflammatory myopathy subtypes.

Myositis-specific antibodies played a key role in predicting whether a patient belonged in a cluster, according to investigators, who noted that myositis-specific antibodies known to be associated with certain subgroups fell into the corresponding clusters they identified.

“This emphasizes that muscle biopsy may no longer be necessary for diagnosis of idiopathic inflammatory myopathies in patients with [myositis-specific antibodies] and corresponding phenotypes,” said the investigators, led by Kubéraka Mariampillai, PhD, of the Université Pierre et Marie Curie, Institut National de la Santé et de la Recherche Médicale (INSERM), Paris, France.

The study, described in JAMA Neurology, was based on data for 260 patients in the database of the French Myositis Network. The mean age of the patients was 62 years, and 63% were women.

Investigators conducted a multiple correspondence analysis based on 47 selected variables, including age, race, historical and recent diagnoses, dermatologic changes, creatine kinase levels, myositis-specific antibodies, and pathologic characteristics, among others.

Based on that analysis, they identified four subgroups corresponding to known entities: Dermatomyositis, inclusion body myositis, immune-mediated necrotizing myopathy, and antisynthetase syndrome.

Using decisional algorithm trees, investigators found that myositis-specific antibodies “played a key role in estimating connection to a cluster,” while by contrast, the pathologic data were “dispensable,” Dr. Mariampillai and her associates said.

The best tree omitted variables related to muscle biopsy and had a 78% correct estimation looking just at antisynthetase antibodies, dermatomyositis rash, and finger flexor scores of 3 or less, investigators said.

“The classification quality of the tree was appreciated on the basis of all classification criteria, with an overall sensitivity of 77.0% and a specificity of 92.0%,” the investigators said.

Patients with polymyositis were present in the study data, but fell mainly in the clusters corresponding to immune-mediated necrotizing myopathy and antisynthetase syndrome.

“This finding indicates that patients with polymyositis do not represent a subgroup of patients, and use of this term should probably be discontinued,” Dr. Mariampillai and coinvestigators said.

The study was supported by Association Française contre les Myopathies, and by CSL Behring, which partly funded the development of electronic case report forms. Dr. Mariampillai and colleagues reported no conflicts of interest related to this work.

SOURCE: Mariampillai K, et al. JAMA Neurol. 2018 Sep 10. doi: 10.1001/jamaneurol.2018.2598.

A new classification system that incorporates clinical and serologic data may be useful in the classification of idiopathic inflammatory myopathies, results of a recent analysis suggest.

By analyzing the patterns of relationships between 47 variables in this observational, retrospective cohort study, investigators identified 4 clusters of patients that corresponded to known idiopathic inflammatory myopathy subtypes.

Myositis-specific antibodies played a key role in predicting whether a patient belonged in a cluster, according to investigators, who noted that myositis-specific antibodies known to be associated with certain subgroups fell into the corresponding clusters they identified.

“This emphasizes that muscle biopsy may no longer be necessary for diagnosis of idiopathic inflammatory myopathies in patients with [myositis-specific antibodies] and corresponding phenotypes,” said the investigators, led by Kubéraka Mariampillai, PhD, of the Université Pierre et Marie Curie, Institut National de la Santé et de la Recherche Médicale (INSERM), Paris, France.

The study, described in JAMA Neurology, was based on data for 260 patients in the database of the French Myositis Network. The mean age of the patients was 62 years, and 63% were women.

Investigators conducted a multiple correspondence analysis based on 47 selected variables, including age, race, historical and recent diagnoses, dermatologic changes, creatine kinase levels, myositis-specific antibodies, and pathologic characteristics, among others.

Based on that analysis, they identified four subgroups corresponding to known entities: Dermatomyositis, inclusion body myositis, immune-mediated necrotizing myopathy, and antisynthetase syndrome.

Using decisional algorithm trees, investigators found that myositis-specific antibodies “played a key role in estimating connection to a cluster,” while by contrast, the pathologic data were “dispensable,” Dr. Mariampillai and her associates said.

The best tree omitted variables related to muscle biopsy and had a 78% correct estimation looking just at antisynthetase antibodies, dermatomyositis rash, and finger flexor scores of 3 or less, investigators said.

“The classification quality of the tree was appreciated on the basis of all classification criteria, with an overall sensitivity of 77.0% and a specificity of 92.0%,” the investigators said.

Patients with polymyositis were present in the study data, but fell mainly in the clusters corresponding to immune-mediated necrotizing myopathy and antisynthetase syndrome.

“This finding indicates that patients with polymyositis do not represent a subgroup of patients, and use of this term should probably be discontinued,” Dr. Mariampillai and coinvestigators said.

The study was supported by Association Française contre les Myopathies, and by CSL Behring, which partly funded the development of electronic case report forms. Dr. Mariampillai and colleagues reported no conflicts of interest related to this work.

SOURCE: Mariampillai K, et al. JAMA Neurol. 2018 Sep 10. doi: 10.1001/jamaneurol.2018.2598.

A new classification system that incorporates clinical and serologic data may be useful in the classification of idiopathic inflammatory myopathies, results of a recent analysis suggest.

By analyzing the patterns of relationships between 47 variables in this observational, retrospective cohort study, investigators identified 4 clusters of patients that corresponded to known idiopathic inflammatory myopathy subtypes.

Myositis-specific antibodies played a key role in predicting whether a patient belonged in a cluster, according to investigators, who noted that myositis-specific antibodies known to be associated with certain subgroups fell into the corresponding clusters they identified.

“This emphasizes that muscle biopsy may no longer be necessary for diagnosis of idiopathic inflammatory myopathies in patients with [myositis-specific antibodies] and corresponding phenotypes,” said the investigators, led by Kubéraka Mariampillai, PhD, of the Université Pierre et Marie Curie, Institut National de la Santé et de la Recherche Médicale (INSERM), Paris, France.

The study, described in JAMA Neurology, was based on data for 260 patients in the database of the French Myositis Network. The mean age of the patients was 62 years, and 63% were women.

Investigators conducted a multiple correspondence analysis based on 47 selected variables, including age, race, historical and recent diagnoses, dermatologic changes, creatine kinase levels, myositis-specific antibodies, and pathologic characteristics, among others.

Based on that analysis, they identified four subgroups corresponding to known entities: Dermatomyositis, inclusion body myositis, immune-mediated necrotizing myopathy, and antisynthetase syndrome.

Using decisional algorithm trees, investigators found that myositis-specific antibodies “played a key role in estimating connection to a cluster,” while by contrast, the pathologic data were “dispensable,” Dr. Mariampillai and her associates said.

The best tree omitted variables related to muscle biopsy and had a 78% correct estimation looking just at antisynthetase antibodies, dermatomyositis rash, and finger flexor scores of 3 or less, investigators said.

“The classification quality of the tree was appreciated on the basis of all classification criteria, with an overall sensitivity of 77.0% and a specificity of 92.0%,” the investigators said.

Patients with polymyositis were present in the study data, but fell mainly in the clusters corresponding to immune-mediated necrotizing myopathy and antisynthetase syndrome.

“This finding indicates that patients with polymyositis do not represent a subgroup of patients, and use of this term should probably be discontinued,” Dr. Mariampillai and coinvestigators said.

The study was supported by Association Française contre les Myopathies, and by CSL Behring, which partly funded the development of electronic case report forms. Dr. Mariampillai and colleagues reported no conflicts of interest related to this work.

SOURCE: Mariampillai K, et al. JAMA Neurol. 2018 Sep 10. doi: 10.1001/jamaneurol.2018.2598.

Youths with opioid use disorder (OUD) are more likely to remain in care if they receive medications to treat the condition, but very few are receiving them, results of a retrospective cohort study suggest.

Hailshadow/iStock/Getty Images

Prescribing buprenorphine, naltrexone, or methadone soon after an OUD diagnosis in this study was associated with increased retention in care for adolescents and young adults.

However, medications were provided to just 1 in 4 youths overall in the study, and only 1 in 21 adolescents, according to Scott E. Hadland, MD, MPH, MS, of Grayken Center for Addiction and Department of Pediatrics, Boston Medical Center, and coinvestigators.

These findings highlight a crucial need to improve care of youths with opioid use disorder (OUD) and enhance retention in treatment, Dr. Hadland and coauthors said in JAMA Pediatrics.

“As deaths from overdose increase among U.S. youths, it is vital that clinicians, researchers, and policy makers ensure that access to evidence-based OUD medications for young people remains a national priority,” they said. Their study, based on Medicaid enrollment and claims data from 11 states, included 4,837 youths aged 13-22 years with a diagnosis of OUD. The median age at diagnosis was 20 years, and 2,752 of the youths were female.

Timely buprenorphine, naltrexone, or methadone were received by just 34 out of 728 adolescents (4.7%) and 1,105 out of 4,109 young adults (27%). Most received buprenorphine (82%), while 12% got naltrexone and 6% got methadone. Treatment was considered timely if received within 3 months, and most patients received this treatment within 1 month.

Youths who received timely OUD medications were more likely to be retained in addiction treatment, the investigators found. Median retention in care was 67 days for youths who received behavioral health services only, compared with 123 days for those who received buprenorphine, 150 days for naltrexone, and 324 days for methadone.

Youths receiving buprenorphine were 42% less likely to discontinue addiction treatment, compared with those receiving behavioral services only, while those receiving naltrexone were 46% less likely to discontinue, and those receiving methadone were 68% less likely to discontinue.

Similarly, median duration of behavioral health services was longer for youths who received OUD medications versus those who did not, they added.

Retention in care is critical to successful addiction treatment, according to Dr. Hadland and coauthors.“Even when patients do not reduce their substance use, individuals engaged and retained in care can receive harm-reduction services and treatment of comorbid medical and psychiatric conditions.”

The benefit of that approach is affirmed by results of a recent meta-analysis in adults showing that staying in treatment was associated with reduced all-cause mortality and mortality from overdose, they said.

Dr. Hadland and coauthors reported no conflicts of interest related to the study. Researchers were supported by grants from the National Institutes of Health/National Institute on Drug Abuse (NIH/NIDA), a grant from the NIH/Eunice Kennedy Shriver National Institute of Child Health and Human Development, the Thrasher Research Fund Early Career Award, and the Academic Pediatric Association Young Investigator Award.
 

SOURCE: Hadland SE, et al. JAMA Pediatr. 2018 Sep 10. doi:10.1001/jamapediatrics.2018.2143.

Youths with opioid use disorder (OUD) are more likely to remain in care if they receive medications to treat the condition, but very few are receiving them, results of a retrospective cohort study suggest.

Hailshadow/iStock/Getty Images

Prescribing buprenorphine, naltrexone, or methadone soon after an OUD diagnosis in this study was associated with increased retention in care for adolescents and young adults.

However, medications were provided to just 1 in 4 youths overall in the study, and only 1 in 21 adolescents, according to Scott E. Hadland, MD, MPH, MS, of Grayken Center for Addiction and Department of Pediatrics, Boston Medical Center, and coinvestigators.

These findings highlight a crucial need to improve care of youths with opioid use disorder (OUD) and enhance retention in treatment, Dr. Hadland and coauthors said in JAMA Pediatrics.

“As deaths from overdose increase among U.S. youths, it is vital that clinicians, researchers, and policy makers ensure that access to evidence-based OUD medications for young people remains a national priority,” they said. Their study, based on Medicaid enrollment and claims data from 11 states, included 4,837 youths aged 13-22 years with a diagnosis of OUD. The median age at diagnosis was 20 years, and 2,752 of the youths were female.

Timely buprenorphine, naltrexone, or methadone were received by just 34 out of 728 adolescents (4.7%) and 1,105 out of 4,109 young adults (27%). Most received buprenorphine (82%), while 12% got naltrexone and 6% got methadone. Treatment was considered timely if received within 3 months, and most patients received this treatment within 1 month.

Youths who received timely OUD medications were more likely to be retained in addiction treatment, the investigators found. Median retention in care was 67 days for youths who received behavioral health services only, compared with 123 days for those who received buprenorphine, 150 days for naltrexone, and 324 days for methadone.

Youths receiving buprenorphine were 42% less likely to discontinue addiction treatment, compared with those receiving behavioral services only, while those receiving naltrexone were 46% less likely to discontinue, and those receiving methadone were 68% less likely to discontinue.

Similarly, median duration of behavioral health services was longer for youths who received OUD medications versus those who did not, they added.

Retention in care is critical to successful addiction treatment, according to Dr. Hadland and coauthors.“Even when patients do not reduce their substance use, individuals engaged and retained in care can receive harm-reduction services and treatment of comorbid medical and psychiatric conditions.”

The benefit of that approach is affirmed by results of a recent meta-analysis in adults showing that staying in treatment was associated with reduced all-cause mortality and mortality from overdose, they said.

Dr. Hadland and coauthors reported no conflicts of interest related to the study. Researchers were supported by grants from the National Institutes of Health/National Institute on Drug Abuse (NIH/NIDA), a grant from the NIH/Eunice Kennedy Shriver National Institute of Child Health and Human Development, the Thrasher Research Fund Early Career Award, and the Academic Pediatric Association Young Investigator Award.
 

SOURCE: Hadland SE, et al. JAMA Pediatr. 2018 Sep 10. doi:10.1001/jamapediatrics.2018.2143.

Youths with opioid use disorder (OUD) are more likely to remain in care if they receive medications to treat the condition, but very few are receiving them, results of a retrospective cohort study suggest.

Hailshadow/iStock/Getty Images

Prescribing buprenorphine, naltrexone, or methadone soon after an OUD diagnosis in this study was associated with increased retention in care for adolescents and young adults.

However, medications were provided to just 1 in 4 youths overall in the study, and only 1 in 21 adolescents, according to Scott E. Hadland, MD, MPH, MS, of Grayken Center for Addiction and Department of Pediatrics, Boston Medical Center, and coinvestigators.

These findings highlight a crucial need to improve care of youths with opioid use disorder (OUD) and enhance retention in treatment, Dr. Hadland and coauthors said in JAMA Pediatrics.

“As deaths from overdose increase among U.S. youths, it is vital that clinicians, researchers, and policy makers ensure that access to evidence-based OUD medications for young people remains a national priority,” they said. Their study, based on Medicaid enrollment and claims data from 11 states, included 4,837 youths aged 13-22 years with a diagnosis of OUD. The median age at diagnosis was 20 years, and 2,752 of the youths were female.

Timely buprenorphine, naltrexone, or methadone were received by just 34 out of 728 adolescents (4.7%) and 1,105 out of 4,109 young adults (27%). Most received buprenorphine (82%), while 12% got naltrexone and 6% got methadone. Treatment was considered timely if received within 3 months, and most patients received this treatment within 1 month.

Youths who received timely OUD medications were more likely to be retained in addiction treatment, the investigators found. Median retention in care was 67 days for youths who received behavioral health services only, compared with 123 days for those who received buprenorphine, 150 days for naltrexone, and 324 days for methadone.

Youths receiving buprenorphine were 42% less likely to discontinue addiction treatment, compared with those receiving behavioral services only, while those receiving naltrexone were 46% less likely to discontinue, and those receiving methadone were 68% less likely to discontinue.

Similarly, median duration of behavioral health services was longer for youths who received OUD medications versus those who did not, they added.

Retention in care is critical to successful addiction treatment, according to Dr. Hadland and coauthors.“Even when patients do not reduce their substance use, individuals engaged and retained in care can receive harm-reduction services and treatment of comorbid medical and psychiatric conditions.”

The benefit of that approach is affirmed by results of a recent meta-analysis in adults showing that staying in treatment was associated with reduced all-cause mortality and mortality from overdose, they said.

Dr. Hadland and coauthors reported no conflicts of interest related to the study. Researchers were supported by grants from the National Institutes of Health/National Institute on Drug Abuse (NIH/NIDA), a grant from the NIH/Eunice Kennedy Shriver National Institute of Child Health and Human Development, the Thrasher Research Fund Early Career Award, and the Academic Pediatric Association Young Investigator Award.
 

SOURCE: Hadland SE, et al. JAMA Pediatr. 2018 Sep 10. doi:10.1001/jamapediatrics.2018.2143.

ESTES PARK, COLO. – The first-line medications for anxiety disorders are the same ones used for depression – the SSRIs and serotonin and norepinephrine reuptake inhibitors (SNRIs) – but the dosing strategies are quite different, Elizabeth L. Lowdermilk, MD, said at a conference on internal medicine sponsored by the University of Colorado.

MDedge News

“We know that folks with anxiety disorders tend to need the higher doses. They just need to get there a little more slowly,” according to Dr. Lowdermilk, a psychiatrist at the university and medical director of outpatient psychiatry at Denver Health.

“The trick is not what drug you use, it’s what dose you started at. For example, when I start sertraline for depression I start it at 50 mg per day. When I start it for anxiety I start it at 25. I just give it a week or 2 at 25 and then I double it to 50. And then I keep going, titrating over 2-3 months to a high or maximum dose,” she explained.

The rapidity of response to the SSRIs and SNRIs is quite different, too. When patients are started on one of these agents as treatment for depression, they can expect that it will take at least 4-6 weeks and maybe as long as 12 weeks before they experience the full therapeutic effect. Not so when the same drugs are used to treat anxiety disorders.

“The anxiolytic effect seems to be more robust sooner. Really, people start noticing something within the first couple days to a week. And they will keep getting better, which people love,” Dr. Lowdermilk said.

One of the early positive effects of SSRI/SNRI therapy that patients can be advised to be on the lookout for is “the Teflon mind,” she said.

“It’s not that the worried thoughts won’t arise, but they’re going to slide out faster and patients are going to be able to shift their focus back to where they want it to be and move forward,” the psychiatrist explained.

Other positive treatment effects include reductions in irritability, anger, perseverative thoughts, restlessness, and physical tension, along with improved sleep.

How to monitor patient response

The most practical anxiety rating scale for busy primary care physicians with tight office visit scheduling is the seven-item Generalized Anxiety Disorder Assessment, or GAD 7. It can be used repeatedly to follow a patient’s treatment response.

“While technically it is picking up the symptoms of GAD, because there are so many overlapping symptoms in all of the anxiety disorders this is going to give you a sense of whether someone is getting better. It won’t pick up their nightmares if they have PTSD, and it won’t necessarily pick up their checking behaviors if they have obsessive-compulsive disorder – you can ask them quickly about that,” she said.
 

Augmenting an SSRI/SNRI

Be advised: While some patients with an anxiety disorder will experience complete resolution of symptoms on the maximum approved dose of an SSRI/SNRI, such as 200 mg/day of sertraline (Zoloft), lots of patients will have only a partial response. The next move is not to add a second antidepressant, it’s to augment the high-dose antidepressant the patient is already on with something else. Dr. Lowdermilk highlighted the best and worst strategies:

• Hydroxyzine: This drug, approved by the Food and Drug Administration for treatment of panic attacks at 25-50 mg up to four times per day, has sedating side effects that help with sleep issues.

“We use a lot of this,” Dr. Lowdermilk said.

Hydroxyzine (Vistaril) can be dosed on a fixed schedule or as needed. She strongly favors scheduled dosing. “It’s better to use drugs to reduce anxiety tone, then teach skills to cope with anxiety. As needed treatment subtly teaches patients to take a pill if they have breakthrough symptoms.”

• Buspirone: It takes high doses of this medication to get a robust anxiolytic response. Dr. Lowdermilk recommends starting at 5 mg three times daily and increasing the total daily dose by 15 mg every 2 weeks up to a maximum of 60 mg.

“Buspirone isn’t the strongest medication out there, but it can help. I personally don’t stop until I’m at least at 30 mg per day,” she said.

The drug is especially handy as monotherapy in patients with mild to moderate anxiety who can’t tolerate serotonergic medications well. Also, at higher doses buspirone (Buspar) may reduce the sexual side effects of a concomitant serotonergic agent.

• Gabapentin: Dr. Lowdermilk often turns to this drug off label as an SSRI/SNRI augmentation strategy, starting at 100-300 mg three times daily and increasing over the same time frame as for neuropathic pain up to a maximum total daily dose of 3,600 mg. Like hydroxyzine, it helps with sleep.
• Atypical antipsychotics: Reserve these for patients with an inadequate response to maximum-dose SSRI/SNRI. There is some evidence of efficacy for low-dose risperidone (Risperdal) at 1-2 mg/day, quetiapine(Seroquel) at 50-100 mg, and aripiprazole (Abilify) at 2-5 mg. Because of the risks of metabolic side effects and tardive dyskinesia, it’s best to evaluate the drug’s effectiveness after 2-4 weeks and consider stopping if there is no clinical improvement.
• Benzodiazepines: Yes, they are approved for treatment of anxiety disorders. Nevertheless, Dr. Lowdermilk advises against their as routine practice.

“I want to acknowledge that they really do work for anxiety and there are times you might want to consider them. But we are almost never initiating benzodiazepines anymore. We are learning that they cause more problems than not. What I’ve found over the years is short bursts of use are not short. Patients tend to come back and want more,” according to the psychiatrist.

She is not convinced about the claimed link to dementia, but she does believe long-term use of benzodiazepines is associated with memory and balance problems as well as slowed reaction time. If they are going to be used to treat anxiety disorders, it’s best to turn to a longer-acting agent such as clonazepam (Klonopin) or extended-release alprazolam (Xanax XR), which keep the anxiety tone down without producing the euphoria of short-acting benzodiazepines.

• Behavioral therapies: “I really do think that the combination of medication and behavioral therapy is the best approach,” Dr. Lowdermilk said.

Consider referring patients with a problematic anxiety disorder to a behavioral therapist skilled in cognitive behavioral therapy, exposure therapy, response prevention therapy, or eye movement desensitization and reprocessing.

She reported having no financial conflicts regarding her presentation.

[email protected]

ESTES PARK, COLO. – The first-line medications for anxiety disorders are the same ones used for depression – the SSRIs and serotonin and norepinephrine reuptake inhibitors (SNRIs) – but the dosing strategies are quite different, Elizabeth L. Lowdermilk, MD, said at a conference on internal medicine sponsored by the University of Colorado.

MDedge News

“We know that folks with anxiety disorders tend to need the higher doses. They just need to get there a little more slowly,” according to Dr. Lowdermilk, a psychiatrist at the university and medical director of outpatient psychiatry at Denver Health.

“The trick is not what drug you use, it’s what dose you started at. For example, when I start sertraline for depression I start it at 50 mg per day. When I start it for anxiety I start it at 25. I just give it a week or 2 at 25 and then I double it to 50. And then I keep going, titrating over 2-3 months to a high or maximum dose,” she explained.

The rapidity of response to the SSRIs and SNRIs is quite different, too. When patients are started on one of these agents as treatment for depression, they can expect that it will take at least 4-6 weeks and maybe as long as 12 weeks before they experience the full therapeutic effect. Not so when the same drugs are used to treat anxiety disorders.

“The anxiolytic effect seems to be more robust sooner. Really, people start noticing something within the first couple days to a week. And they will keep getting better, which people love,” Dr. Lowdermilk said.

One of the early positive effects of SSRI/SNRI therapy that patients can be advised to be on the lookout for is “the Teflon mind,” she said.

“It’s not that the worried thoughts won’t arise, but they’re going to slide out faster and patients are going to be able to shift their focus back to where they want it to be and move forward,” the psychiatrist explained.

Other positive treatment effects include reductions in irritability, anger, perseverative thoughts, restlessness, and physical tension, along with improved sleep.

How to monitor patient response

The most practical anxiety rating scale for busy primary care physicians with tight office visit scheduling is the seven-item Generalized Anxiety Disorder Assessment, or GAD 7. It can be used repeatedly to follow a patient’s treatment response.

“While technically it is picking up the symptoms of GAD, because there are so many overlapping symptoms in all of the anxiety disorders this is going to give you a sense of whether someone is getting better. It won’t pick up their nightmares if they have PTSD, and it won’t necessarily pick up their checking behaviors if they have obsessive-compulsive disorder – you can ask them quickly about that,” she said.
 

Augmenting an SSRI/SNRI

Be advised: While some patients with an anxiety disorder will experience complete resolution of symptoms on the maximum approved dose of an SSRI/SNRI, such as 200 mg/day of sertraline (Zoloft), lots of patients will have only a partial response. The next move is not to add a second antidepressant, it’s to augment the high-dose antidepressant the patient is already on with something else. Dr. Lowdermilk highlighted the best and worst strategies:

• Hydroxyzine: This drug, approved by the Food and Drug Administration for treatment of panic attacks at 25-50 mg up to four times per day, has sedating side effects that help with sleep issues.

“We use a lot of this,” Dr. Lowdermilk said.

Hydroxyzine (Vistaril) can be dosed on a fixed schedule or as needed. She strongly favors scheduled dosing. “It’s better to use drugs to reduce anxiety tone, then teach skills to cope with anxiety. As needed treatment subtly teaches patients to take a pill if they have breakthrough symptoms.”

• Buspirone: It takes high doses of this medication to get a robust anxiolytic response. Dr. Lowdermilk recommends starting at 5 mg three times daily and increasing the total daily dose by 15 mg every 2 weeks up to a maximum of 60 mg.

“Buspirone isn’t the strongest medication out there, but it can help. I personally don’t stop until I’m at least at 30 mg per day,” she said.

The drug is especially handy as monotherapy in patients with mild to moderate anxiety who can’t tolerate serotonergic medications well. Also, at higher doses buspirone (Buspar) may reduce the sexual side effects of a concomitant serotonergic agent.

• Gabapentin: Dr. Lowdermilk often turns to this drug off label as an SSRI/SNRI augmentation strategy, starting at 100-300 mg three times daily and increasing over the same time frame as for neuropathic pain up to a maximum total daily dose of 3,600 mg. Like hydroxyzine, it helps with sleep.
• Atypical antipsychotics: Reserve these for patients with an inadequate response to maximum-dose SSRI/SNRI. There is some evidence of efficacy for low-dose risperidone (Risperdal) at 1-2 mg/day, quetiapine(Seroquel) at 50-100 mg, and aripiprazole (Abilify) at 2-5 mg. Because of the risks of metabolic side effects and tardive dyskinesia, it’s best to evaluate the drug’s effectiveness after 2-4 weeks and consider stopping if there is no clinical improvement.
• Benzodiazepines: Yes, they are approved for treatment of anxiety disorders. Nevertheless, Dr. Lowdermilk advises against their as routine practice.

“I want to acknowledge that they really do work for anxiety and there are times you might want to consider them. But we are almost never initiating benzodiazepines anymore. We are learning that they cause more problems than not. What I’ve found over the years is short bursts of use are not short. Patients tend to come back and want more,” according to the psychiatrist.

She is not convinced about the claimed link to dementia, but she does believe long-term use of benzodiazepines is associated with memory and balance problems as well as slowed reaction time. If they are going to be used to treat anxiety disorders, it’s best to turn to a longer-acting agent such as clonazepam (Klonopin) or extended-release alprazolam (Xanax XR), which keep the anxiety tone down without producing the euphoria of short-acting benzodiazepines.

• Behavioral therapies: “I really do think that the combination of medication and behavioral therapy is the best approach,” Dr. Lowdermilk said.

Consider referring patients with a problematic anxiety disorder to a behavioral therapist skilled in cognitive behavioral therapy, exposure therapy, response prevention therapy, or eye movement desensitization and reprocessing.

She reported having no financial conflicts regarding her presentation.

[email protected]

ESTES PARK, COLO. – The first-line medications for anxiety disorders are the same ones used for depression – the SSRIs and serotonin and norepinephrine reuptake inhibitors (SNRIs) – but the dosing strategies are quite different, Elizabeth L. Lowdermilk, MD, said at a conference on internal medicine sponsored by the University of Colorado.

MDedge News

“We know that folks with anxiety disorders tend to need the higher doses. They just need to get there a little more slowly,” according to Dr. Lowdermilk, a psychiatrist at the university and medical director of outpatient psychiatry at Denver Health.

“The trick is not what drug you use, it’s what dose you started at. For example, when I start sertraline for depression I start it at 50 mg per day. When I start it for anxiety I start it at 25. I just give it a week or 2 at 25 and then I double it to 50. And then I keep going, titrating over 2-3 months to a high or maximum dose,” she explained.

The rapidity of response to the SSRIs and SNRIs is quite different, too. When patients are started on one of these agents as treatment for depression, they can expect that it will take at least 4-6 weeks and maybe as long as 12 weeks before they experience the full therapeutic effect. Not so when the same drugs are used to treat anxiety disorders.

“The anxiolytic effect seems to be more robust sooner. Really, people start noticing something within the first couple days to a week. And they will keep getting better, which people love,” Dr. Lowdermilk said.

One of the early positive effects of SSRI/SNRI therapy that patients can be advised to be on the lookout for is “the Teflon mind,” she said.

“It’s not that the worried thoughts won’t arise, but they’re going to slide out faster and patients are going to be able to shift their focus back to where they want it to be and move forward,” the psychiatrist explained.

Other positive treatment effects include reductions in irritability, anger, perseverative thoughts, restlessness, and physical tension, along with improved sleep.

How to monitor patient response

The most practical anxiety rating scale for busy primary care physicians with tight office visit scheduling is the seven-item Generalized Anxiety Disorder Assessment, or GAD 7. It can be used repeatedly to follow a patient’s treatment response.

“While technically it is picking up the symptoms of GAD, because there are so many overlapping symptoms in all of the anxiety disorders this is going to give you a sense of whether someone is getting better. It won’t pick up their nightmares if they have PTSD, and it won’t necessarily pick up their checking behaviors if they have obsessive-compulsive disorder – you can ask them quickly about that,” she said.
 

Augmenting an SSRI/SNRI

Be advised: While some patients with an anxiety disorder will experience complete resolution of symptoms on the maximum approved dose of an SSRI/SNRI, such as 200 mg/day of sertraline (Zoloft), lots of patients will have only a partial response. The next move is not to add a second antidepressant, it’s to augment the high-dose antidepressant the patient is already on with something else. Dr. Lowdermilk highlighted the best and worst strategies:

• Hydroxyzine: This drug, approved by the Food and Drug Administration for treatment of panic attacks at 25-50 mg up to four times per day, has sedating side effects that help with sleep issues.

“We use a lot of this,” Dr. Lowdermilk said.

Hydroxyzine (Vistaril) can be dosed on a fixed schedule or as needed. She strongly favors scheduled dosing. “It’s better to use drugs to reduce anxiety tone, then teach skills to cope with anxiety. As needed treatment subtly teaches patients to take a pill if they have breakthrough symptoms.”

• Buspirone: It takes high doses of this medication to get a robust anxiolytic response. Dr. Lowdermilk recommends starting at 5 mg three times daily and increasing the total daily dose by 15 mg every 2 weeks up to a maximum of 60 mg.

“Buspirone isn’t the strongest medication out there, but it can help. I personally don’t stop until I’m at least at 30 mg per day,” she said.

The drug is especially handy as monotherapy in patients with mild to moderate anxiety who can’t tolerate serotonergic medications well. Also, at higher doses buspirone (Buspar) may reduce the sexual side effects of a concomitant serotonergic agent.

• Gabapentin: Dr. Lowdermilk often turns to this drug off label as an SSRI/SNRI augmentation strategy, starting at 100-300 mg three times daily and increasing over the same time frame as for neuropathic pain up to a maximum total daily dose of 3,600 mg. Like hydroxyzine, it helps with sleep.
• Atypical antipsychotics: Reserve these for patients with an inadequate response to maximum-dose SSRI/SNRI. There is some evidence of efficacy for low-dose risperidone (Risperdal) at 1-2 mg/day, quetiapine(Seroquel) at 50-100 mg, and aripiprazole (Abilify) at 2-5 mg. Because of the risks of metabolic side effects and tardive dyskinesia, it’s best to evaluate the drug’s effectiveness after 2-4 weeks and consider stopping if there is no clinical improvement.
• Benzodiazepines: Yes, they are approved for treatment of anxiety disorders. Nevertheless, Dr. Lowdermilk advises against their as routine practice.

“I want to acknowledge that they really do work for anxiety and there are times you might want to consider them. But we are almost never initiating benzodiazepines anymore. We are learning that they cause more problems than not. What I’ve found over the years is short bursts of use are not short. Patients tend to come back and want more,” according to the psychiatrist.

She is not convinced about the claimed link to dementia, but she does believe long-term use of benzodiazepines is associated with memory and balance problems as well as slowed reaction time. If they are going to be used to treat anxiety disorders, it’s best to turn to a longer-acting agent such as clonazepam (Klonopin) or extended-release alprazolam (Xanax XR), which keep the anxiety tone down without producing the euphoria of short-acting benzodiazepines.

• Behavioral therapies: “I really do think that the combination of medication and behavioral therapy is the best approach,” Dr. Lowdermilk said.

Consider referring patients with a problematic anxiety disorder to a behavioral therapist skilled in cognitive behavioral therapy, exposure therapy, response prevention therapy, or eye movement desensitization and reprocessing.

She reported having no financial conflicts regarding her presentation.

[email protected]

Immunization resources

Current recommended adult (anyone over 18 years old) immunization schedule

ACOG Immunization Champions (ACOG members who have demonstrated exceptional progress in increasing immunization rates among adults and pregnant women in their communities through leadership, innovation, collaboration, and educational activities aimed at following ACOG and CDC guidance.)

Summary of Maternal Immunization Recommendations is a provider resource from ACOG and the Centers for Disease Control and Prevention.

Maternal Immunization Toolkit contains materials, including the Vaccines During Pregnancy Poster, to support ObGyns on recommending the influenza vaccine and the Tdap vaccine to all pregnant patients.

Influenza Immunization During Pregnancy Toolkit

Tdap Immunization Toolkit

Immunization resources

Current recommended adult (anyone over 18 years old) immunization schedule

ACOG Immunization Champions (ACOG members who have demonstrated exceptional progress in increasing immunization rates among adults and pregnant women in their communities through leadership, innovation, collaboration, and educational activities aimed at following ACOG and CDC guidance.)

Summary of Maternal Immunization Recommendations is a provider resource from ACOG and the Centers for Disease Control and Prevention.

Maternal Immunization Toolkit contains materials, including the Vaccines During Pregnancy Poster, to support ObGyns on recommending the influenza vaccine and the Tdap vaccine to all pregnant patients.

Influenza Immunization During Pregnancy Toolkit

Tdap Immunization Toolkit

Immunization resources

Current recommended adult (anyone over 18 years old) immunization schedule

ACOG Immunization Champions (ACOG members who have demonstrated exceptional progress in increasing immunization rates among adults and pregnant women in their communities through leadership, innovation, collaboration, and educational activities aimed at following ACOG and CDC guidance.)

Summary of Maternal Immunization Recommendations is a provider resource from ACOG and the Centers for Disease Control and Prevention.

Maternal Immunization Toolkit contains materials, including the Vaccines During Pregnancy Poster, to support ObGyns on recommending the influenza vaccine and the Tdap vaccine to all pregnant patients.

Influenza Immunization During Pregnancy Toolkit

Tdap Immunization Toolkit

Coding. Practice expenses. Supervised Exercise Therapy. The vascular lab. Medicare reimbursement (including MACRA, MIPS, APMs and QPP). All these topics and more are part of a vascular surgeon's life and livelihood. Vascular surgery trainees interested in health policy and advocacy issues related to vascular surgery are encouraged to apply for the SVS Vascular Surgery Trainee Advocacy Travel Scholarship. Submissions are due by Oct. 31. The winner receives $1,500 to defray travel costs to Washington, D.C., to participate in Capitol Hill visits and learn more about SVS' health policy and advocacy activities.

Coding. Practice expenses. Supervised Exercise Therapy. The vascular lab. Medicare reimbursement (including MACRA, MIPS, APMs and QPP). All these topics and more are part of a vascular surgeon's life and livelihood. Vascular surgery trainees interested in health policy and advocacy issues related to vascular surgery are encouraged to apply for the SVS Vascular Surgery Trainee Advocacy Travel Scholarship. Submissions are due by Oct. 31. The winner receives $1,500 to defray travel costs to Washington, D.C., to participate in Capitol Hill visits and learn more about SVS' health policy and advocacy activities.

Coding. Practice expenses. Supervised Exercise Therapy. The vascular lab. Medicare reimbursement (including MACRA, MIPS, APMs and QPP). All these topics and more are part of a vascular surgeon's life and livelihood. Vascular surgery trainees interested in health policy and advocacy issues related to vascular surgery are encouraged to apply for the SVS Vascular Surgery Trainee Advocacy Travel Scholarship. Submissions are due by Oct. 31. The winner receives $1,500 to defray travel costs to Washington, D.C., to participate in Capitol Hill visits and learn more about SVS' health policy and advocacy activities.

It’s Vascular Nurses Week this week, and as part of the celebration, the SVS is inviting Society for Vascular Nursing members to join the SVS as affiliate members. Applicants will receive a 50 percent discount through Dec. 1. Email CVs and the completed membership form to [email protected].

It’s Vascular Nurses Week this week, and as part of the celebration, the SVS is inviting Society for Vascular Nursing members to join the SVS as affiliate members. Applicants will receive a 50 percent discount through Dec. 1. Email CVs and the completed membership form to [email protected].

It’s Vascular Nurses Week this week, and as part of the celebration, the SVS is inviting Society for Vascular Nursing members to join the SVS as affiliate members. Applicants will receive a 50 percent discount through Dec. 1. Email CVs and the completed membership form to [email protected].

BOSTON – The use of an intravascular ultrasound (IVUS)–based scoring system could predict stent failure at 2 years in the treatment of May-Thurner syndrome, according to Steven D. Abramowitz, MD, of the MedStar Washington Hospital Center, Washington, and his colleagues.

Martin Allred/Nationwide Photographers

Dr. Abramowitz presented their research in the Vascular and Endovascular Society (VESS) sessions held at the Vascular Annual Meeting.

“IVUS has become an important adjuvant diagnostic tool in the treatment of deep venous disease, and as such may provide a useful assessment and predictive tool for treatment success in stenting of May-Thurner syndrome,” said Dr. Abramowitz.

In their study, 118 consecutive patients with May-Thurner syndrome underwent IVUS-guided stent placement from April 2009 through May 2015 at two collaborating institutions. Patients had a mean age of 46 years and included 86 (73%) women. At the time of treatment, 45, 30, 25, and 18 patients had Clinical Etiology Anatomy Pathophysiology disease 3, 4, 5, and 6, respectively.

Dr. Abramowitz described how he and his colleagues derived an IVUS-driven scoring system to assess the following categories of May-Thurner syndrome (nonocclusive or occlusive), disease chronicity (nonthrombotic, acute, or chronic), venous disease length (less than 180 mm or greater than 181 mm), venous inflow compliance (presence or absence of respiratory variation), iliocaval confluence disease involvement (present or absent), iliocaval con-fluence stenting obligation (stented or spared), and presence of perivenous collaterals before and after stenting (none or resolved).

Six of the categories were scored with 0 or 1 and one category was scored with 0, 1, or 2. Scores were tabulated for each patient at the time of initial intervention.

All 118 (100%) patients received anticoagulation and 78 (66%) were on an antiplatelet agent. Thirty-eight (32%) developed moderate in-stent stenosis, required thrombolysis, or underwent additional stenting procedures and were considered treatment failures during the observed period.

Eighty patients (68%) required no additional intervention and were considered treatment successes. The mean IVUS score for all patients was 5.22. The mean IVUS score in the treatment failure cohort was 5.64 compared with a score of 4.67 in the treatment success group, a significant difference. Patients with a score above 4 on this 7-point scale had an increased relative risk (1.6) of stent failure at 2 years.

“An IVUS-driven scoring system score of 4 or greater during initial intervention for May-Thurner syndrome predicts failure at 2 years. Additional treatment modalities should be considered at implantation to prevent failure,” said Dr. Abramowitz.

In an interview, Dr. Abramowitz added: “There is an emerging body of research regarding outcomes of deep venous intervention. However, we are still looking to generate clinically relevant data that will help guide interventionists to achieve durable technical success and long-term positive clinical outcomes for our patients.

“At this time, there is very little data to help correlate what physicians see on venography and IVUS during the treatment of May-Thurner Lesions. This data is hopefully the first step in allowing us to guide intra-operative decision making. IVUS is an excellent tool that has been proven by other studies to aid in the diagnosis and management of venous disease. With this data we also hope that it becomes a drive of patient management as well. Ideally, this data will transition into also guiding anticoagulation management, postoperative surveillance strategies and outcomes stratification for patients,” Dr. Abramowitz concluded.

[email protected]

BOSTON – The use of an intravascular ultrasound (IVUS)–based scoring system could predict stent failure at 2 years in the treatment of May-Thurner syndrome, according to Steven D. Abramowitz, MD, of the MedStar Washington Hospital Center, Washington, and his colleagues.

Martin Allred/Nationwide Photographers

Dr. Abramowitz presented their research in the Vascular and Endovascular Society (VESS) sessions held at the Vascular Annual Meeting.

“IVUS has become an important adjuvant diagnostic tool in the treatment of deep venous disease, and as such may provide a useful assessment and predictive tool for treatment success in stenting of May-Thurner syndrome,” said Dr. Abramowitz.

In their study, 118 consecutive patients with May-Thurner syndrome underwent IVUS-guided stent placement from April 2009 through May 2015 at two collaborating institutions. Patients had a mean age of 46 years and included 86 (73%) women. At the time of treatment, 45, 30, 25, and 18 patients had Clinical Etiology Anatomy Pathophysiology disease 3, 4, 5, and 6, respectively.

Dr. Abramowitz described how he and his colleagues derived an IVUS-driven scoring system to assess the following categories of May-Thurner syndrome (nonocclusive or occlusive), disease chronicity (nonthrombotic, acute, or chronic), venous disease length (less than 180 mm or greater than 181 mm), venous inflow compliance (presence or absence of respiratory variation), iliocaval confluence disease involvement (present or absent), iliocaval con-fluence stenting obligation (stented or spared), and presence of perivenous collaterals before and after stenting (none or resolved).

Six of the categories were scored with 0 or 1 and one category was scored with 0, 1, or 2. Scores were tabulated for each patient at the time of initial intervention.

All 118 (100%) patients received anticoagulation and 78 (66%) were on an antiplatelet agent. Thirty-eight (32%) developed moderate in-stent stenosis, required thrombolysis, or underwent additional stenting procedures and were considered treatment failures during the observed period.

Eighty patients (68%) required no additional intervention and were considered treatment successes. The mean IVUS score for all patients was 5.22. The mean IVUS score in the treatment failure cohort was 5.64 compared with a score of 4.67 in the treatment success group, a significant difference. Patients with a score above 4 on this 7-point scale had an increased relative risk (1.6) of stent failure at 2 years.

“An IVUS-driven scoring system score of 4 or greater during initial intervention for May-Thurner syndrome predicts failure at 2 years. Additional treatment modalities should be considered at implantation to prevent failure,” said Dr. Abramowitz.

In an interview, Dr. Abramowitz added: “There is an emerging body of research regarding outcomes of deep venous intervention. However, we are still looking to generate clinically relevant data that will help guide interventionists to achieve durable technical success and long-term positive clinical outcomes for our patients.

“At this time, there is very little data to help correlate what physicians see on venography and IVUS during the treatment of May-Thurner Lesions. This data is hopefully the first step in allowing us to guide intra-operative decision making. IVUS is an excellent tool that has been proven by other studies to aid in the diagnosis and management of venous disease. With this data we also hope that it becomes a drive of patient management as well. Ideally, this data will transition into also guiding anticoagulation management, postoperative surveillance strategies and outcomes stratification for patients,” Dr. Abramowitz concluded.

[email protected]

BOSTON – The use of an intravascular ultrasound (IVUS)–based scoring system could predict stent failure at 2 years in the treatment of May-Thurner syndrome, according to Steven D. Abramowitz, MD, of the MedStar Washington Hospital Center, Washington, and his colleagues.

Martin Allred/Nationwide Photographers

Dr. Abramowitz presented their research in the Vascular and Endovascular Society (VESS) sessions held at the Vascular Annual Meeting.

“IVUS has become an important adjuvant diagnostic tool in the treatment of deep venous disease, and as such may provide a useful assessment and predictive tool for treatment success in stenting of May-Thurner syndrome,” said Dr. Abramowitz.

In their study, 118 consecutive patients with May-Thurner syndrome underwent IVUS-guided stent placement from April 2009 through May 2015 at two collaborating institutions. Patients had a mean age of 46 years and included 86 (73%) women. At the time of treatment, 45, 30, 25, and 18 patients had Clinical Etiology Anatomy Pathophysiology disease 3, 4, 5, and 6, respectively.

Dr. Abramowitz described how he and his colleagues derived an IVUS-driven scoring system to assess the following categories of May-Thurner syndrome (nonocclusive or occlusive), disease chronicity (nonthrombotic, acute, or chronic), venous disease length (less than 180 mm or greater than 181 mm), venous inflow compliance (presence or absence of respiratory variation), iliocaval confluence disease involvement (present or absent), iliocaval con-fluence stenting obligation (stented or spared), and presence of perivenous collaterals before and after stenting (none or resolved).

Six of the categories were scored with 0 or 1 and one category was scored with 0, 1, or 2. Scores were tabulated for each patient at the time of initial intervention.

All 118 (100%) patients received anticoagulation and 78 (66%) were on an antiplatelet agent. Thirty-eight (32%) developed moderate in-stent stenosis, required thrombolysis, or underwent additional stenting procedures and were considered treatment failures during the observed period.

Eighty patients (68%) required no additional intervention and were considered treatment successes. The mean IVUS score for all patients was 5.22. The mean IVUS score in the treatment failure cohort was 5.64 compared with a score of 4.67 in the treatment success group, a significant difference. Patients with a score above 4 on this 7-point scale had an increased relative risk (1.6) of stent failure at 2 years.

“An IVUS-driven scoring system score of 4 or greater during initial intervention for May-Thurner syndrome predicts failure at 2 years. Additional treatment modalities should be considered at implantation to prevent failure,” said Dr. Abramowitz.

In an interview, Dr. Abramowitz added: “There is an emerging body of research regarding outcomes of deep venous intervention. However, we are still looking to generate clinically relevant data that will help guide interventionists to achieve durable technical success and long-term positive clinical outcomes for our patients.

“At this time, there is very little data to help correlate what physicians see on venography and IVUS during the treatment of May-Thurner Lesions. This data is hopefully the first step in allowing us to guide intra-operative decision making. IVUS is an excellent tool that has been proven by other studies to aid in the diagnosis and management of venous disease. With this data we also hope that it becomes a drive of patient management as well. Ideally, this data will transition into also guiding anticoagulation management, postoperative surveillance strategies and outcomes stratification for patients,” Dr. Abramowitz concluded.

[email protected]