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Mohammed Sanjak, PhD
Is adjuvant chemo warranted in stage I ovarian clear cell carcinoma?
In patients with stage I ovarian clear cell carcinoma, the use of adjuvant chemotherapy was associated with superior overall survival (OS), according to results of a large, retrospective cohort study.
The finding, published in Gynecologic Oncology, provides further evidence that adjuvant chemotherapy may provide a survival advantage for patients with this relatively common epithelial ovarian cancer subtype.
However, not all data to date point toward a benefit of adjuvant chemotherapy. “Its utility has yet to be established, especially for patients with stage IA disease,” wrote Dimitrios Nasioudis, MD, and his coauthors in the department of obstetrics and gynecology, Hospital of the University of Pennsylvania, Philadelphia.
In one recent large population-based study, chemotherapy was not associated with superior OS in patients with stage I disease, whereas two smaller retrospective studies suggested that chemotherapy may improve progression-free survival in that setting, noted Dr. Nasioudis and his colleagues.
Their study included data on 2,325 patients in the National Cancer Data Base diagnosed with stage I ovarian clear cell carcinoma between 2004 and 2014. That is the largest cohort of patients with stage I ovarian clear cell carcinoma with adequate staging reported to date in the medical literature, the investigators noted.
The rate of OS at 5 years was 89.2% for patients receiving adjuvant chemotherapy, versus 82.6% for those who did not (P less than .001). Furthermore, adjuvant chemotherapy was associated with improved OS after the researchers controlled for medical comorbidities, age, race, disease substage, and hospital type (hazard ratio, 0.59; 95% confidence interval, 0.45-0.78).
When the researchers looked at disease substage, women with stage IA or IB disease had superior OS with chemotherapy versus no chemotherapy, while in women with stage IC disease, there was a trend toward better OS with chemotherapy that did not reach statistical significance.
“The administration of adjuvant chemotherapy was associated with a survival benefit, even for those with stage IA disease,” the researchers wrote.
Ovarian clear cell carcinoma is the third most common subtype of epithelial ovarian carcinoma, accounting for up to 25% of new diagnoses, they said. Current U.S. and European clinical practice guidelines recommend adjuvant chemotherapy for all women with stage I disease because of a high risk of relapse associated with this subtype.
Observation could be acceptable for patients with surgical stage IA disease, in light of excellent survival rates, the Gynecologic Cancer Intergroup has suggested.
While the present study suggests a survival benefit associated with chemotherapy in stage I ovarian clear cell carcinoma, the investigators had no information on morbidity, cost, or quality-of-life impacts associated with treatment, which limit the findings.
“International collaboration, such as the creation of ovarian clear cell carcinoma registry, is greatly needed to further elucidate the optimal management of those patients,” they wrote.
Dr. Nasioudis and his coauthors had no conflicts of interest to report.
SOURCE: Nasioudis D et al. Gynecol Oncol. 2018 May 8. doi: 10.1016/j.ygyno.2018.04.567.
In patients with stage I ovarian clear cell carcinoma, the use of adjuvant chemotherapy was associated with superior overall survival (OS), according to results of a large, retrospective cohort study.
The finding, published in Gynecologic Oncology, provides further evidence that adjuvant chemotherapy may provide a survival advantage for patients with this relatively common epithelial ovarian cancer subtype.
However, not all data to date point toward a benefit of adjuvant chemotherapy. “Its utility has yet to be established, especially for patients with stage IA disease,” wrote Dimitrios Nasioudis, MD, and his coauthors in the department of obstetrics and gynecology, Hospital of the University of Pennsylvania, Philadelphia.
In one recent large population-based study, chemotherapy was not associated with superior OS in patients with stage I disease, whereas two smaller retrospective studies suggested that chemotherapy may improve progression-free survival in that setting, noted Dr. Nasioudis and his colleagues.
Their study included data on 2,325 patients in the National Cancer Data Base diagnosed with stage I ovarian clear cell carcinoma between 2004 and 2014. That is the largest cohort of patients with stage I ovarian clear cell carcinoma with adequate staging reported to date in the medical literature, the investigators noted.
The rate of OS at 5 years was 89.2% for patients receiving adjuvant chemotherapy, versus 82.6% for those who did not (P less than .001). Furthermore, adjuvant chemotherapy was associated with improved OS after the researchers controlled for medical comorbidities, age, race, disease substage, and hospital type (hazard ratio, 0.59; 95% confidence interval, 0.45-0.78).
When the researchers looked at disease substage, women with stage IA or IB disease had superior OS with chemotherapy versus no chemotherapy, while in women with stage IC disease, there was a trend toward better OS with chemotherapy that did not reach statistical significance.
“The administration of adjuvant chemotherapy was associated with a survival benefit, even for those with stage IA disease,” the researchers wrote.
Ovarian clear cell carcinoma is the third most common subtype of epithelial ovarian carcinoma, accounting for up to 25% of new diagnoses, they said. Current U.S. and European clinical practice guidelines recommend adjuvant chemotherapy for all women with stage I disease because of a high risk of relapse associated with this subtype.
Observation could be acceptable for patients with surgical stage IA disease, in light of excellent survival rates, the Gynecologic Cancer Intergroup has suggested.
While the present study suggests a survival benefit associated with chemotherapy in stage I ovarian clear cell carcinoma, the investigators had no information on morbidity, cost, or quality-of-life impacts associated with treatment, which limit the findings.
“International collaboration, such as the creation of ovarian clear cell carcinoma registry, is greatly needed to further elucidate the optimal management of those patients,” they wrote.
Dr. Nasioudis and his coauthors had no conflicts of interest to report.
SOURCE: Nasioudis D et al. Gynecol Oncol. 2018 May 8. doi: 10.1016/j.ygyno.2018.04.567.
In patients with stage I ovarian clear cell carcinoma, the use of adjuvant chemotherapy was associated with superior overall survival (OS), according to results of a large, retrospective cohort study.
The finding, published in Gynecologic Oncology, provides further evidence that adjuvant chemotherapy may provide a survival advantage for patients with this relatively common epithelial ovarian cancer subtype.
However, not all data to date point toward a benefit of adjuvant chemotherapy. “Its utility has yet to be established, especially for patients with stage IA disease,” wrote Dimitrios Nasioudis, MD, and his coauthors in the department of obstetrics and gynecology, Hospital of the University of Pennsylvania, Philadelphia.
In one recent large population-based study, chemotherapy was not associated with superior OS in patients with stage I disease, whereas two smaller retrospective studies suggested that chemotherapy may improve progression-free survival in that setting, noted Dr. Nasioudis and his colleagues.
Their study included data on 2,325 patients in the National Cancer Data Base diagnosed with stage I ovarian clear cell carcinoma between 2004 and 2014. That is the largest cohort of patients with stage I ovarian clear cell carcinoma with adequate staging reported to date in the medical literature, the investigators noted.
The rate of OS at 5 years was 89.2% for patients receiving adjuvant chemotherapy, versus 82.6% for those who did not (P less than .001). Furthermore, adjuvant chemotherapy was associated with improved OS after the researchers controlled for medical comorbidities, age, race, disease substage, and hospital type (hazard ratio, 0.59; 95% confidence interval, 0.45-0.78).
When the researchers looked at disease substage, women with stage IA or IB disease had superior OS with chemotherapy versus no chemotherapy, while in women with stage IC disease, there was a trend toward better OS with chemotherapy that did not reach statistical significance.
“The administration of adjuvant chemotherapy was associated with a survival benefit, even for those with stage IA disease,” the researchers wrote.
Ovarian clear cell carcinoma is the third most common subtype of epithelial ovarian carcinoma, accounting for up to 25% of new diagnoses, they said. Current U.S. and European clinical practice guidelines recommend adjuvant chemotherapy for all women with stage I disease because of a high risk of relapse associated with this subtype.
Observation could be acceptable for patients with surgical stage IA disease, in light of excellent survival rates, the Gynecologic Cancer Intergroup has suggested.
While the present study suggests a survival benefit associated with chemotherapy in stage I ovarian clear cell carcinoma, the investigators had no information on morbidity, cost, or quality-of-life impacts associated with treatment, which limit the findings.
“International collaboration, such as the creation of ovarian clear cell carcinoma registry, is greatly needed to further elucidate the optimal management of those patients,” they wrote.
Dr. Nasioudis and his coauthors had no conflicts of interest to report.
SOURCE: Nasioudis D et al. Gynecol Oncol. 2018 May 8. doi: 10.1016/j.ygyno.2018.04.567.
FROM GYNECOLOGIC ONCOLOGY
Key clinical point: Adjuvant chemotherapy was associated with improved survival in patients with stage I OCCC.
Major finding: Five-year overall survival was 89.2% for patients receiving adjuvant chemotherapy versus 82.6% for those who did not (P less than .001).
Study details: A retrospective cohort study of 2,325 patients with stage I ovarian clear cell carcinoma diagnosed between 2004 and 2014.
Disclosures: The authors had no conflicts of interest to report.
Source: Nasioudis D et al. Gynecol Oncol. 2018 May 8. doi: 10.1016/j.ygyno.2018.04.567.
ESBL-resistant bacteria spread in hospital despite strict contact precautions
MADRID – even when staff employed an active surveillance screening protocol to identify every carrier at admission.
The failure of precautions may have root in two thorny issues, said Friederike Maechler, MD, who presented the data at the the European Society of Clinical Microbiology and Infectious Diseases annual congress.
“Adherence to strict contact isolation and hand hygiene is never 100% in a real-life scenario,” said Dr. Maechler, of Charite University Hospital, Berlin. Also, she said, contact isolation can only be effective in a ward if all, or at least most, of the ESBL-E carriers are identified. “Even with an extensive surveillance screening program established, many carriers remained unknown to the health care staff.”
The 25-month study, dubbed R-Gnosis, was conducted in 20 Western European hospitals in Madrid, Berlin, Utrecht, and Geneva. It compared 12 months of contact precaution with standard precaution infection control strategies in medical and surgical non-ICUs.
The entire study hinged on a strict protocol to identify as many ESBL-E carriers as possible. This was done by screening upon admission to the unit, screening once per week during the hospital stay, and screening on discharge. Each patient underwent deep rectal swabs that were cultured on agar and screened for resistance.
The crossover design trial randomized each unit to either contact precautions or standard precautions for 12 months, followed by a 1-month washout period, after which they began the other protocol.
In all, 50,870 patients were entered into the study. By the end, Dr. Maechler had data on 11,367 patients with full screening and follow-up.
Standard precautions did not require a private bedroom, with gloves, gowns, and apron needed for direct contact to body fluids or wounds only, and consistent hand hygiene. Contact precautions required a private bedroom and strict hand hygiene, with gloves, gowns, and aprons used for any patient contact. Study staff monitored compliance with these procedures monthly.
The primary outcome was the ESBL-E acquisition rate per 1,000 patient days. This was defined as a new ESBL-E detection after the patient had a prior negative screen. Dr. Maechler noted that by epidemiological definition, acquisition does not necessarily imply cross-transmission from other patients.
Adherence to the study protocols was good, she said. Adherence to both contact and standard precautions was about 85%, while adherence to hand hygiene was less at around 62%.
Admission ESBL-E screenings revealed that about 12% of the study population was colonized with the strain at admission. The proportion was nearly identical in the contact and standard precaution groups (11.6%, 12.2%).
The incidence density of ward-acquired ESBL-E per 1,000 patient-days at risk was 4.6 in both intervention periods, regardless of the type of precaution taken. Contact precautions appeared to be slightly less effective for Escherichia coli (3.6 per 1,000 patient-days in contact precautions vs. 3.5 in standard), compared with Klebsiella pneumoniae (1.8 vs. 2.2).
A multivariate analysis controlled for screening compliance, colonization pressure, and length of stay, study site, and season of year. It showed that strict contact precautions did not reduce the risk of ward-acquired ESBL-E carriage.
Dr. Maechler had no financial disclosures. The R-Gnosis study was funded by the European Community’s Seventh Framework Programme.
SOURCE: Maechler F et al. ECCMID 2018, Oral Abstract O1130.
MADRID – even when staff employed an active surveillance screening protocol to identify every carrier at admission.
The failure of precautions may have root in two thorny issues, said Friederike Maechler, MD, who presented the data at the the European Society of Clinical Microbiology and Infectious Diseases annual congress.
“Adherence to strict contact isolation and hand hygiene is never 100% in a real-life scenario,” said Dr. Maechler, of Charite University Hospital, Berlin. Also, she said, contact isolation can only be effective in a ward if all, or at least most, of the ESBL-E carriers are identified. “Even with an extensive surveillance screening program established, many carriers remained unknown to the health care staff.”
The 25-month study, dubbed R-Gnosis, was conducted in 20 Western European hospitals in Madrid, Berlin, Utrecht, and Geneva. It compared 12 months of contact precaution with standard precaution infection control strategies in medical and surgical non-ICUs.
The entire study hinged on a strict protocol to identify as many ESBL-E carriers as possible. This was done by screening upon admission to the unit, screening once per week during the hospital stay, and screening on discharge. Each patient underwent deep rectal swabs that were cultured on agar and screened for resistance.
The crossover design trial randomized each unit to either contact precautions or standard precautions for 12 months, followed by a 1-month washout period, after which they began the other protocol.
In all, 50,870 patients were entered into the study. By the end, Dr. Maechler had data on 11,367 patients with full screening and follow-up.
Standard precautions did not require a private bedroom, with gloves, gowns, and apron needed for direct contact to body fluids or wounds only, and consistent hand hygiene. Contact precautions required a private bedroom and strict hand hygiene, with gloves, gowns, and aprons used for any patient contact. Study staff monitored compliance with these procedures monthly.
The primary outcome was the ESBL-E acquisition rate per 1,000 patient days. This was defined as a new ESBL-E detection after the patient had a prior negative screen. Dr. Maechler noted that by epidemiological definition, acquisition does not necessarily imply cross-transmission from other patients.
Adherence to the study protocols was good, she said. Adherence to both contact and standard precautions was about 85%, while adherence to hand hygiene was less at around 62%.
Admission ESBL-E screenings revealed that about 12% of the study population was colonized with the strain at admission. The proportion was nearly identical in the contact and standard precaution groups (11.6%, 12.2%).
The incidence density of ward-acquired ESBL-E per 1,000 patient-days at risk was 4.6 in both intervention periods, regardless of the type of precaution taken. Contact precautions appeared to be slightly less effective for Escherichia coli (3.6 per 1,000 patient-days in contact precautions vs. 3.5 in standard), compared with Klebsiella pneumoniae (1.8 vs. 2.2).
A multivariate analysis controlled for screening compliance, colonization pressure, and length of stay, study site, and season of year. It showed that strict contact precautions did not reduce the risk of ward-acquired ESBL-E carriage.
Dr. Maechler had no financial disclosures. The R-Gnosis study was funded by the European Community’s Seventh Framework Programme.
SOURCE: Maechler F et al. ECCMID 2018, Oral Abstract O1130.
MADRID – even when staff employed an active surveillance screening protocol to identify every carrier at admission.
The failure of precautions may have root in two thorny issues, said Friederike Maechler, MD, who presented the data at the the European Society of Clinical Microbiology and Infectious Diseases annual congress.
“Adherence to strict contact isolation and hand hygiene is never 100% in a real-life scenario,” said Dr. Maechler, of Charite University Hospital, Berlin. Also, she said, contact isolation can only be effective in a ward if all, or at least most, of the ESBL-E carriers are identified. “Even with an extensive surveillance screening program established, many carriers remained unknown to the health care staff.”
The 25-month study, dubbed R-Gnosis, was conducted in 20 Western European hospitals in Madrid, Berlin, Utrecht, and Geneva. It compared 12 months of contact precaution with standard precaution infection control strategies in medical and surgical non-ICUs.
The entire study hinged on a strict protocol to identify as many ESBL-E carriers as possible. This was done by screening upon admission to the unit, screening once per week during the hospital stay, and screening on discharge. Each patient underwent deep rectal swabs that were cultured on agar and screened for resistance.
The crossover design trial randomized each unit to either contact precautions or standard precautions for 12 months, followed by a 1-month washout period, after which they began the other protocol.
In all, 50,870 patients were entered into the study. By the end, Dr. Maechler had data on 11,367 patients with full screening and follow-up.
Standard precautions did not require a private bedroom, with gloves, gowns, and apron needed for direct contact to body fluids or wounds only, and consistent hand hygiene. Contact precautions required a private bedroom and strict hand hygiene, with gloves, gowns, and aprons used for any patient contact. Study staff monitored compliance with these procedures monthly.
The primary outcome was the ESBL-E acquisition rate per 1,000 patient days. This was defined as a new ESBL-E detection after the patient had a prior negative screen. Dr. Maechler noted that by epidemiological definition, acquisition does not necessarily imply cross-transmission from other patients.
Adherence to the study protocols was good, she said. Adherence to both contact and standard precautions was about 85%, while adherence to hand hygiene was less at around 62%.
Admission ESBL-E screenings revealed that about 12% of the study population was colonized with the strain at admission. The proportion was nearly identical in the contact and standard precaution groups (11.6%, 12.2%).
The incidence density of ward-acquired ESBL-E per 1,000 patient-days at risk was 4.6 in both intervention periods, regardless of the type of precaution taken. Contact precautions appeared to be slightly less effective for Escherichia coli (3.6 per 1,000 patient-days in contact precautions vs. 3.5 in standard), compared with Klebsiella pneumoniae (1.8 vs. 2.2).
A multivariate analysis controlled for screening compliance, colonization pressure, and length of stay, study site, and season of year. It showed that strict contact precautions did not reduce the risk of ward-acquired ESBL-E carriage.
Dr. Maechler had no financial disclosures. The R-Gnosis study was funded by the European Community’s Seventh Framework Programme.
SOURCE: Maechler F et al. ECCMID 2018, Oral Abstract O1130.
REPORTING FROM ECCMID 2018
Key clinical point: A protocol of strict contact precautions and hand hygiene was no better than standard contact precautions at preventing the spread of extended-spectrum, beta-lactamase–resistant Enterobacteriaceae.
Major finding: The incidence density of ward-acquired ESBL-E per 1,000 patient-days at risk was 4.6, regardless of precaution.
Study details: The 25-month crossover trial comprised more than 11,000 patients.
Disclosures: Dr. Maechler had no financial disclosures. The R-Gnosis study was funded by the European Community’s Seventh Framework Programme.
Source: Maechler F et al. ECCMID 2018, Oral Abstract O1130.
Multiple analgesia options for kids with acute pain
TORONTO – according to Naveen Poonai, MD, FRCPC.
“Too many times, nonpharmacologic therapies are relegated to the very last paragraph of recommendations or to the very bottom of a URL,” he said at the Pediatric Academic Societies meeting. “Nonpharmacologic therapies are things that our grandparents told us to do: common sense things that can be done at triage. They don’t require memorization of dosing, and most importantly, they don’t have side effects.”
When analgesia is indicated, clinicians can choose from a variety of agents in the postcodeine era. Dr. Poonai said that musculoskeletal injuries constitute 10-20% of pediatric emergency department visits, yet fewer than 60% of children receive adequate analgesia. “That’s what’s really important for patient and caregiver satisfaction,” he said.
Mounting evidence supports the use of ibuprofen as a go-to agent for mild to moderate pain in patients with musculoskeletal injuries, including results from a randomized, controlled multicenter trial of 500 youth (Canadian J Emerg Med. 2016:18:S29). “We know that ibuprofen is superior to acetaminophen or codeine and that it’s as good or better than oral opioids and with fewer side effects,” Dr. Poonai said, adding that it provides a 25 mm visual analog score (VAS) reduction in pain at 60 minutes. Another study that compared ibuprofen with codeine for acute pediatric arm fracture pain found that ibuprofen was associated with improved functioning and was at least as effective as acetaminophen plus codeine (Ann Emerg Med. 2009 Oct;54[4]:553-60).
A number of oral opioids have gained favor for use in children who present with acute pain. However, in a randomized trial, Dr. Poonai and his associates found no significant difference in analgesic efficacy between orally administered morphine and ibuprofen for the management of postfracture pain in 134 children (CMAJ. 2014 Dec 9;186[18]:1358-63). Oral morphine was also associated with more side effects. At the same time, tramadol and hydromorphone have not been well studied in children with musculoskeletal pain. “Currently, the use of hydromorphone is limited to children with sickle cell disease, but the use is branching out,” he said. “Oxycodone and oral morphine pose the greatest risk of side effects. The bottom line here is that opioids should be added to ibuprofen and acetaminophen rather than replacing them for mild to moderate pain.”
In 2014, a study from the Cochrane Database of Systematic Reviews concluded that intranasal fentanyl can be effective for the management of moderate to severe pain in children. A dose of 1.0-1.5 mcg/kg is associated with a 40-mm pain reduction in VAS at 10 minutes. “The benefits are that it is not an invasive approach, it’s been rigorously studied, and it is equivalent to IV morphine for moderate to severe pain,” said Dr. Poonai, who was not part of the Cochrane review. “It lasts about 60 minutes, with minimal side effects.”
A separate analysis found that intranasal fentanyl and ketamine were associated with similar pain reduction in children with moderate to severe pain from limb injury (Ann Emerg Med. 2015 Mar;65[3]:248-54.e1). Ketamine was associated with more minor adverse events. An intranasal dose of 1 mg/kg can cause a 40- to 45-mm reduction in VAS at 30 minutes.
Dr. Poonai went on to discuss treatment options for abdominal pain, noting that fewer than two-thirds of children with suspected appendicitis receive analgesia. “If they are receiving it, it’s often not until after the ultrasound is performed,” he said. “There is a still a reluctance toward providing opioid analgesia for a child with suspected appendicitis for fear of masking a diagnosis or leading to complications.” A systematic review led by Dr. Poonai found that the use of opioids in undifferentiated acute abdominal pain in children is associated with no difference in pain scores and an increased risk of mild side effects (Acad Emerg Med. 2014 21[11]:1183-92). However, there was no increased risk of perforation or abscess. “We found that single-dose IV opioids were actually beneficial,” he said.
Dr. Poonai characterized most of the current evidence on IV morphine for suspected appendicitis as being of low to moderate quality, “but they are generally favorable for the indication,” he said. “It is titratable to effect, and triage-initiated protocols improve timing and consistency of analgesia.” He reported having no financial disclosures.
TORONTO – according to Naveen Poonai, MD, FRCPC.
“Too many times, nonpharmacologic therapies are relegated to the very last paragraph of recommendations or to the very bottom of a URL,” he said at the Pediatric Academic Societies meeting. “Nonpharmacologic therapies are things that our grandparents told us to do: common sense things that can be done at triage. They don’t require memorization of dosing, and most importantly, they don’t have side effects.”
When analgesia is indicated, clinicians can choose from a variety of agents in the postcodeine era. Dr. Poonai said that musculoskeletal injuries constitute 10-20% of pediatric emergency department visits, yet fewer than 60% of children receive adequate analgesia. “That’s what’s really important for patient and caregiver satisfaction,” he said.
Mounting evidence supports the use of ibuprofen as a go-to agent for mild to moderate pain in patients with musculoskeletal injuries, including results from a randomized, controlled multicenter trial of 500 youth (Canadian J Emerg Med. 2016:18:S29). “We know that ibuprofen is superior to acetaminophen or codeine and that it’s as good or better than oral opioids and with fewer side effects,” Dr. Poonai said, adding that it provides a 25 mm visual analog score (VAS) reduction in pain at 60 minutes. Another study that compared ibuprofen with codeine for acute pediatric arm fracture pain found that ibuprofen was associated with improved functioning and was at least as effective as acetaminophen plus codeine (Ann Emerg Med. 2009 Oct;54[4]:553-60).
A number of oral opioids have gained favor for use in children who present with acute pain. However, in a randomized trial, Dr. Poonai and his associates found no significant difference in analgesic efficacy between orally administered morphine and ibuprofen for the management of postfracture pain in 134 children (CMAJ. 2014 Dec 9;186[18]:1358-63). Oral morphine was also associated with more side effects. At the same time, tramadol and hydromorphone have not been well studied in children with musculoskeletal pain. “Currently, the use of hydromorphone is limited to children with sickle cell disease, but the use is branching out,” he said. “Oxycodone and oral morphine pose the greatest risk of side effects. The bottom line here is that opioids should be added to ibuprofen and acetaminophen rather than replacing them for mild to moderate pain.”
In 2014, a study from the Cochrane Database of Systematic Reviews concluded that intranasal fentanyl can be effective for the management of moderate to severe pain in children. A dose of 1.0-1.5 mcg/kg is associated with a 40-mm pain reduction in VAS at 10 minutes. “The benefits are that it is not an invasive approach, it’s been rigorously studied, and it is equivalent to IV morphine for moderate to severe pain,” said Dr. Poonai, who was not part of the Cochrane review. “It lasts about 60 minutes, with minimal side effects.”
A separate analysis found that intranasal fentanyl and ketamine were associated with similar pain reduction in children with moderate to severe pain from limb injury (Ann Emerg Med. 2015 Mar;65[3]:248-54.e1). Ketamine was associated with more minor adverse events. An intranasal dose of 1 mg/kg can cause a 40- to 45-mm reduction in VAS at 30 minutes.
Dr. Poonai went on to discuss treatment options for abdominal pain, noting that fewer than two-thirds of children with suspected appendicitis receive analgesia. “If they are receiving it, it’s often not until after the ultrasound is performed,” he said. “There is a still a reluctance toward providing opioid analgesia for a child with suspected appendicitis for fear of masking a diagnosis or leading to complications.” A systematic review led by Dr. Poonai found that the use of opioids in undifferentiated acute abdominal pain in children is associated with no difference in pain scores and an increased risk of mild side effects (Acad Emerg Med. 2014 21[11]:1183-92). However, there was no increased risk of perforation or abscess. “We found that single-dose IV opioids were actually beneficial,” he said.
Dr. Poonai characterized most of the current evidence on IV morphine for suspected appendicitis as being of low to moderate quality, “but they are generally favorable for the indication,” he said. “It is titratable to effect, and triage-initiated protocols improve timing and consistency of analgesia.” He reported having no financial disclosures.
TORONTO – according to Naveen Poonai, MD, FRCPC.
“Too many times, nonpharmacologic therapies are relegated to the very last paragraph of recommendations or to the very bottom of a URL,” he said at the Pediatric Academic Societies meeting. “Nonpharmacologic therapies are things that our grandparents told us to do: common sense things that can be done at triage. They don’t require memorization of dosing, and most importantly, they don’t have side effects.”
When analgesia is indicated, clinicians can choose from a variety of agents in the postcodeine era. Dr. Poonai said that musculoskeletal injuries constitute 10-20% of pediatric emergency department visits, yet fewer than 60% of children receive adequate analgesia. “That’s what’s really important for patient and caregiver satisfaction,” he said.
Mounting evidence supports the use of ibuprofen as a go-to agent for mild to moderate pain in patients with musculoskeletal injuries, including results from a randomized, controlled multicenter trial of 500 youth (Canadian J Emerg Med. 2016:18:S29). “We know that ibuprofen is superior to acetaminophen or codeine and that it’s as good or better than oral opioids and with fewer side effects,” Dr. Poonai said, adding that it provides a 25 mm visual analog score (VAS) reduction in pain at 60 minutes. Another study that compared ibuprofen with codeine for acute pediatric arm fracture pain found that ibuprofen was associated with improved functioning and was at least as effective as acetaminophen plus codeine (Ann Emerg Med. 2009 Oct;54[4]:553-60).
A number of oral opioids have gained favor for use in children who present with acute pain. However, in a randomized trial, Dr. Poonai and his associates found no significant difference in analgesic efficacy between orally administered morphine and ibuprofen for the management of postfracture pain in 134 children (CMAJ. 2014 Dec 9;186[18]:1358-63). Oral morphine was also associated with more side effects. At the same time, tramadol and hydromorphone have not been well studied in children with musculoskeletal pain. “Currently, the use of hydromorphone is limited to children with sickle cell disease, but the use is branching out,” he said. “Oxycodone and oral morphine pose the greatest risk of side effects. The bottom line here is that opioids should be added to ibuprofen and acetaminophen rather than replacing them for mild to moderate pain.”
In 2014, a study from the Cochrane Database of Systematic Reviews concluded that intranasal fentanyl can be effective for the management of moderate to severe pain in children. A dose of 1.0-1.5 mcg/kg is associated with a 40-mm pain reduction in VAS at 10 minutes. “The benefits are that it is not an invasive approach, it’s been rigorously studied, and it is equivalent to IV morphine for moderate to severe pain,” said Dr. Poonai, who was not part of the Cochrane review. “It lasts about 60 minutes, with minimal side effects.”
A separate analysis found that intranasal fentanyl and ketamine were associated with similar pain reduction in children with moderate to severe pain from limb injury (Ann Emerg Med. 2015 Mar;65[3]:248-54.e1). Ketamine was associated with more minor adverse events. An intranasal dose of 1 mg/kg can cause a 40- to 45-mm reduction in VAS at 30 minutes.
Dr. Poonai went on to discuss treatment options for abdominal pain, noting that fewer than two-thirds of children with suspected appendicitis receive analgesia. “If they are receiving it, it’s often not until after the ultrasound is performed,” he said. “There is a still a reluctance toward providing opioid analgesia for a child with suspected appendicitis for fear of masking a diagnosis or leading to complications.” A systematic review led by Dr. Poonai found that the use of opioids in undifferentiated acute abdominal pain in children is associated with no difference in pain scores and an increased risk of mild side effects (Acad Emerg Med. 2014 21[11]:1183-92). However, there was no increased risk of perforation or abscess. “We found that single-dose IV opioids were actually beneficial,” he said.
Dr. Poonai characterized most of the current evidence on IV morphine for suspected appendicitis as being of low to moderate quality, “but they are generally favorable for the indication,” he said. “It is titratable to effect, and triage-initiated protocols improve timing and consistency of analgesia.” He reported having no financial disclosures.
EXPERT ANALYSIS FROM PAS 2018
TissueGene-C effects on knee OA seen at 3 years
LIVERPOOL, ENGLAND – TissueGene-C continues to show promise as a potential disease-modifying osteoarthritis drug, according to the long-term follow-up data of a phase 3 trial.
Within 2-3 years of receiving a single injection of the novel cell-gene therapy, patients with moderate knee OA were still experiencing significant improvement in the coprimary endpoints of knee symptoms, function, sports activity, and knee pain versus baseline values.
Differences in International Knee Documentation Committee (IKDC) scores from baseline to 2 and 3 years were a respective 15.3 and 14.8 points (both P less than .05 vs. baseline). Pain, assessed on a visual analog scale, was also significantly improved from baseline to 2 and 3 years (score changes –23.5 and –23.3; P less than .05 vs. baseline).
There were also significant improvements in the secondary endpoint of pain, stiffness, and physical function measured by the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), with changes in scores of –19.8 and –17.4 versus baseline at 2 and 3 years, respectively (both P less than .05 vs. baseline).
“INVOISSA-K [TissueGene-C] is the first-in-class cell and gene therapy for the treatment of knee OA,” Dr. Lee reminded delegates at the congress, which is sponsored by the Osteoarthritis Research Society International. The novel treatment was made by collecting chondrocytes from a subject with polydactyl hands and then culturing these to create two subpopulations of cells, one with allogenic chondrocytes and the other with genetically modified chondrocytes that overexpress transforming growth factor-beta1. These subpopulations are then mixed in the ratio of 3:1 and delivered in a single intra-articular injection.
Dr. Lee, who is the president and chief executive officer of Kolon TissueGene, Rockville, Md., reported new findings of a phase 3 trial conducted exclusively in Korea at 12 study centers, the results of which were first presented at OARSI 2016.
At that time only the 12-month primary endpoint data were available, which showed that TissueGene-C improved IKDC scores from baseline by a significantly greater amount than a saline placebo, with changes in scores of 15.1 and 5 points, respectively, versus baseline values. Improvements in IKDC scores were seen as early as 3 months but only became significantly better than placebo at 6 months.
Similarly, visual analog scale pain scores had improved from baseline as early as 3 months but were only significantly different from placebo at 6 months (–23.4 change from baseline for TissueGene-C vs. –14.6 for placebo) and out to 12 months (–24.5 vs. –10.3). WOMAC scores with TissueGene-C were only significantly different from placebo at 12 months (–13.5 vs. –6.2 from baseline, respectively).
The 12-month OMERACT-OARSI responder rate was 84% for TissueGene-C and 45% for placebo. The most common adverse events seen with TissueGene-C were related to the injection site, with peripheral edema (9%), arthralgia (8%), joint swelling (6%), and injection-site pain (5%) reported.
A total of 163 patients were recruited into the study, all had Kellgren-Lawrence grade 3 knee OA, which was also graded as 3 or 4 on the International Cartilage Regeneration & Joint Preservation Society scale. Major lesions had be 6 cm2 or smaller. Active treatment was given to 78 patients, and 81 received placebo. The primary assessment period was at 12 months, but patients continued to be followed out to 5 years.
At OARSI 2018, Dr. Lee presented the findings of 12-month structural modification analyses for the first time. These showed that while the osteophyte score on MRI was not significantly different from baseline in the active-treatment arm, there was a significantly increased osteophyte score and total cartilage defect in the placebo-treated patients versus baseline values.
Subchondral bone changes at 12 months showed a trend for less bone area change with TissueGene-C than placebo and a trend for increased cartilage thickness. Greater reductions in serum CTX-1 and urine CTX-II were seen with active treatment than placebo, relative to screening values.
X-ray evaluation of joint-space narrowing showed that nonprogression was more likely in patients treated with TissueGene-C than with placebo (77% vs. 57%), although this was not significant. In addition, fewer patients treated with TissueGene-C than placebo who needed a total knee replacement at 2 years (0% and 7.5%) and at 3 years (2% and 14%).
TissueGene-C “has great potential” for being the first disease-modifying osteoarthritis drug to get to market, Dr. Lee suggested.
The clinical development program for TissueGene-C is further advanced in Korea than in the United States, where a phase 3 trial is about to start recruitment soon.
“We started our clinical trials in 2005 in Korea and in the U.S. simultaneously,” Dr. Lee said, noting that a biologics license application submitted in Korea in 2016 had been accepted by the Ministry of Food and Drug Safety on July 12, 2017, while only phase 1 and 2 trials have been completed in the United States
The study was funded by Kolon Life Science and TissueGene. Dr. Lee is an employee of TissueGene.
SOURCE: Lee B et al. Osteoarthritis Cartilage. 2018 Apr;26(1):S43-4.
LIVERPOOL, ENGLAND – TissueGene-C continues to show promise as a potential disease-modifying osteoarthritis drug, according to the long-term follow-up data of a phase 3 trial.
Within 2-3 years of receiving a single injection of the novel cell-gene therapy, patients with moderate knee OA were still experiencing significant improvement in the coprimary endpoints of knee symptoms, function, sports activity, and knee pain versus baseline values.
Differences in International Knee Documentation Committee (IKDC) scores from baseline to 2 and 3 years were a respective 15.3 and 14.8 points (both P less than .05 vs. baseline). Pain, assessed on a visual analog scale, was also significantly improved from baseline to 2 and 3 years (score changes –23.5 and –23.3; P less than .05 vs. baseline).
There were also significant improvements in the secondary endpoint of pain, stiffness, and physical function measured by the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), with changes in scores of –19.8 and –17.4 versus baseline at 2 and 3 years, respectively (both P less than .05 vs. baseline).
“INVOISSA-K [TissueGene-C] is the first-in-class cell and gene therapy for the treatment of knee OA,” Dr. Lee reminded delegates at the congress, which is sponsored by the Osteoarthritis Research Society International. The novel treatment was made by collecting chondrocytes from a subject with polydactyl hands and then culturing these to create two subpopulations of cells, one with allogenic chondrocytes and the other with genetically modified chondrocytes that overexpress transforming growth factor-beta1. These subpopulations are then mixed in the ratio of 3:1 and delivered in a single intra-articular injection.
Dr. Lee, who is the president and chief executive officer of Kolon TissueGene, Rockville, Md., reported new findings of a phase 3 trial conducted exclusively in Korea at 12 study centers, the results of which were first presented at OARSI 2016.
At that time only the 12-month primary endpoint data were available, which showed that TissueGene-C improved IKDC scores from baseline by a significantly greater amount than a saline placebo, with changes in scores of 15.1 and 5 points, respectively, versus baseline values. Improvements in IKDC scores were seen as early as 3 months but only became significantly better than placebo at 6 months.
Similarly, visual analog scale pain scores had improved from baseline as early as 3 months but were only significantly different from placebo at 6 months (–23.4 change from baseline for TissueGene-C vs. –14.6 for placebo) and out to 12 months (–24.5 vs. –10.3). WOMAC scores with TissueGene-C were only significantly different from placebo at 12 months (–13.5 vs. –6.2 from baseline, respectively).
The 12-month OMERACT-OARSI responder rate was 84% for TissueGene-C and 45% for placebo. The most common adverse events seen with TissueGene-C were related to the injection site, with peripheral edema (9%), arthralgia (8%), joint swelling (6%), and injection-site pain (5%) reported.
A total of 163 patients were recruited into the study, all had Kellgren-Lawrence grade 3 knee OA, which was also graded as 3 or 4 on the International Cartilage Regeneration & Joint Preservation Society scale. Major lesions had be 6 cm2 or smaller. Active treatment was given to 78 patients, and 81 received placebo. The primary assessment period was at 12 months, but patients continued to be followed out to 5 years.
At OARSI 2018, Dr. Lee presented the findings of 12-month structural modification analyses for the first time. These showed that while the osteophyte score on MRI was not significantly different from baseline in the active-treatment arm, there was a significantly increased osteophyte score and total cartilage defect in the placebo-treated patients versus baseline values.
Subchondral bone changes at 12 months showed a trend for less bone area change with TissueGene-C than placebo and a trend for increased cartilage thickness. Greater reductions in serum CTX-1 and urine CTX-II were seen with active treatment than placebo, relative to screening values.
X-ray evaluation of joint-space narrowing showed that nonprogression was more likely in patients treated with TissueGene-C than with placebo (77% vs. 57%), although this was not significant. In addition, fewer patients treated with TissueGene-C than placebo who needed a total knee replacement at 2 years (0% and 7.5%) and at 3 years (2% and 14%).
TissueGene-C “has great potential” for being the first disease-modifying osteoarthritis drug to get to market, Dr. Lee suggested.
The clinical development program for TissueGene-C is further advanced in Korea than in the United States, where a phase 3 trial is about to start recruitment soon.
“We started our clinical trials in 2005 in Korea and in the U.S. simultaneously,” Dr. Lee said, noting that a biologics license application submitted in Korea in 2016 had been accepted by the Ministry of Food and Drug Safety on July 12, 2017, while only phase 1 and 2 trials have been completed in the United States
The study was funded by Kolon Life Science and TissueGene. Dr. Lee is an employee of TissueGene.
SOURCE: Lee B et al. Osteoarthritis Cartilage. 2018 Apr;26(1):S43-4.
LIVERPOOL, ENGLAND – TissueGene-C continues to show promise as a potential disease-modifying osteoarthritis drug, according to the long-term follow-up data of a phase 3 trial.
Within 2-3 years of receiving a single injection of the novel cell-gene therapy, patients with moderate knee OA were still experiencing significant improvement in the coprimary endpoints of knee symptoms, function, sports activity, and knee pain versus baseline values.
Differences in International Knee Documentation Committee (IKDC) scores from baseline to 2 and 3 years were a respective 15.3 and 14.8 points (both P less than .05 vs. baseline). Pain, assessed on a visual analog scale, was also significantly improved from baseline to 2 and 3 years (score changes –23.5 and –23.3; P less than .05 vs. baseline).
There were also significant improvements in the secondary endpoint of pain, stiffness, and physical function measured by the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), with changes in scores of –19.8 and –17.4 versus baseline at 2 and 3 years, respectively (both P less than .05 vs. baseline).
“INVOISSA-K [TissueGene-C] is the first-in-class cell and gene therapy for the treatment of knee OA,” Dr. Lee reminded delegates at the congress, which is sponsored by the Osteoarthritis Research Society International. The novel treatment was made by collecting chondrocytes from a subject with polydactyl hands and then culturing these to create two subpopulations of cells, one with allogenic chondrocytes and the other with genetically modified chondrocytes that overexpress transforming growth factor-beta1. These subpopulations are then mixed in the ratio of 3:1 and delivered in a single intra-articular injection.
Dr. Lee, who is the president and chief executive officer of Kolon TissueGene, Rockville, Md., reported new findings of a phase 3 trial conducted exclusively in Korea at 12 study centers, the results of which were first presented at OARSI 2016.
At that time only the 12-month primary endpoint data were available, which showed that TissueGene-C improved IKDC scores from baseline by a significantly greater amount than a saline placebo, with changes in scores of 15.1 and 5 points, respectively, versus baseline values. Improvements in IKDC scores were seen as early as 3 months but only became significantly better than placebo at 6 months.
Similarly, visual analog scale pain scores had improved from baseline as early as 3 months but were only significantly different from placebo at 6 months (–23.4 change from baseline for TissueGene-C vs. –14.6 for placebo) and out to 12 months (–24.5 vs. –10.3). WOMAC scores with TissueGene-C were only significantly different from placebo at 12 months (–13.5 vs. –6.2 from baseline, respectively).
The 12-month OMERACT-OARSI responder rate was 84% for TissueGene-C and 45% for placebo. The most common adverse events seen with TissueGene-C were related to the injection site, with peripheral edema (9%), arthralgia (8%), joint swelling (6%), and injection-site pain (5%) reported.
A total of 163 patients were recruited into the study, all had Kellgren-Lawrence grade 3 knee OA, which was also graded as 3 or 4 on the International Cartilage Regeneration & Joint Preservation Society scale. Major lesions had be 6 cm2 or smaller. Active treatment was given to 78 patients, and 81 received placebo. The primary assessment period was at 12 months, but patients continued to be followed out to 5 years.
At OARSI 2018, Dr. Lee presented the findings of 12-month structural modification analyses for the first time. These showed that while the osteophyte score on MRI was not significantly different from baseline in the active-treatment arm, there was a significantly increased osteophyte score and total cartilage defect in the placebo-treated patients versus baseline values.
Subchondral bone changes at 12 months showed a trend for less bone area change with TissueGene-C than placebo and a trend for increased cartilage thickness. Greater reductions in serum CTX-1 and urine CTX-II were seen with active treatment than placebo, relative to screening values.
X-ray evaluation of joint-space narrowing showed that nonprogression was more likely in patients treated with TissueGene-C than with placebo (77% vs. 57%), although this was not significant. In addition, fewer patients treated with TissueGene-C than placebo who needed a total knee replacement at 2 years (0% and 7.5%) and at 3 years (2% and 14%).
TissueGene-C “has great potential” for being the first disease-modifying osteoarthritis drug to get to market, Dr. Lee suggested.
The clinical development program for TissueGene-C is further advanced in Korea than in the United States, where a phase 3 trial is about to start recruitment soon.
“We started our clinical trials in 2005 in Korea and in the U.S. simultaneously,” Dr. Lee said, noting that a biologics license application submitted in Korea in 2016 had been accepted by the Ministry of Food and Drug Safety on July 12, 2017, while only phase 1 and 2 trials have been completed in the United States
The study was funded by Kolon Life Science and TissueGene. Dr. Lee is an employee of TissueGene.
SOURCE: Lee B et al. Osteoarthritis Cartilage. 2018 Apr;26(1):S43-4.
REPORTING FROM OARSI 2018
Key clinical point: A single intra-articular injection of TissueGene C produced significant and long-term relief of knee osteoarthritis.
Major finding: Changes in baseline International Knee Documentation Committee and visual analog scale pain scores from baseline to 2 and 3 years were 15.3 and 14.8 points (P less than .05), and –23.5 and –23.3 (P less than .05), respectively.
Study details: A multicenter, phase 3, randomized, double-blind, placebo-controlled trial of 163 patients with knee osteoarthritis.
Disclosures: The study was funded by Kolon Life Science and TissueGene. Dr. Lee is an employee of TissueGene.
Source: Lee B et al. Osteoarthritis Cartilage. 2018 Apr;26(1):S43-4.
Fewer preterm deliveries, and perinatal mortality down
Fewer infants are being delivered early, and there has been a decline in neonatal mortality, according to a retrospective cohort study of more than 34 million singleton live births.
Researchers presented the results of a study in the May 14 online edition of JAMA Pediatrics that attempted to quantify changes in gestational age distribution and gestational age–specific perinatal mortality in the United States between 2007 and 2015.
However the proportion of births at a gestational age of 39-40 weeks increased from 54.5% to 60.2% in that same time period.
“The decreasing proportion of births at gestational ages of 34-36 and 37-38 weeks may be associated with changes in the timing of elective delivery, with hospital policies and quality initiatives effectively reducing unindicated deliveries before 39 completed weeks of gestation,” wrote Cande V. Ananth, PhD, of Columbia University, New York, and coauthors.
“Increased use of low-dose aspirin in women with ischemic placental disease may additionally have resulted in decreased need for indicated delivery before 39 weeks.”
At the same time, perinatal mortality rates decreased overall, from 9 per 1,000 births in 2007 to 8.6 per 1,000 births in 2015, but increased significantly in gestational ages 32-33 weeks (7%), 34-36 weeks (15%), and 37-38 weeks (23%) over that period. There was also a significant 31% increase in perinatal mortality at gestational age 42-44 weeks, but decreases at 20-27 weeks and 39-40 weeks.
Stillbirth rates also increased for gestational ages of 20-27 weeks, 28-31 weeks, 32-33 weeks, 34-36 weeks, 37-38 weeks, and 42-44 weeks.
Commenting on the changes in perinatal and neonatal mortality rates at gestational ages of 34-36 weeks and 37-38 weeks, the authors suggested this may have been the result of recommendations to postpone elective deliveries until 39 weeks.
“A possible reason for the increased mortality at a gestational age of 37-38 weeks could be that physicians may be more likely to defer to 39 weeks for delivery for women at moderately increased risk for adverse perinatal outcomes,” they wrote.
“We found that the decrease in neonatal mortality rates from 2007 to 2015 in the United States was largely associated with changes in the underlying gestational age distribution and less associated with changes in gestational age–specific mortality.”
The researchers reported that they had no conflicts of interest.
SOURCE: Ananth C et al. JAMA Pediatrics. 2018 May 14. doi: 10.1001/jamapediatrics.2018.0249.
Fewer infants are being delivered early, and there has been a decline in neonatal mortality, according to a retrospective cohort study of more than 34 million singleton live births.
Researchers presented the results of a study in the May 14 online edition of JAMA Pediatrics that attempted to quantify changes in gestational age distribution and gestational age–specific perinatal mortality in the United States between 2007 and 2015.
However the proportion of births at a gestational age of 39-40 weeks increased from 54.5% to 60.2% in that same time period.
“The decreasing proportion of births at gestational ages of 34-36 and 37-38 weeks may be associated with changes in the timing of elective delivery, with hospital policies and quality initiatives effectively reducing unindicated deliveries before 39 completed weeks of gestation,” wrote Cande V. Ananth, PhD, of Columbia University, New York, and coauthors.
“Increased use of low-dose aspirin in women with ischemic placental disease may additionally have resulted in decreased need for indicated delivery before 39 weeks.”
At the same time, perinatal mortality rates decreased overall, from 9 per 1,000 births in 2007 to 8.6 per 1,000 births in 2015, but increased significantly in gestational ages 32-33 weeks (7%), 34-36 weeks (15%), and 37-38 weeks (23%) over that period. There was also a significant 31% increase in perinatal mortality at gestational age 42-44 weeks, but decreases at 20-27 weeks and 39-40 weeks.
Stillbirth rates also increased for gestational ages of 20-27 weeks, 28-31 weeks, 32-33 weeks, 34-36 weeks, 37-38 weeks, and 42-44 weeks.
Commenting on the changes in perinatal and neonatal mortality rates at gestational ages of 34-36 weeks and 37-38 weeks, the authors suggested this may have been the result of recommendations to postpone elective deliveries until 39 weeks.
“A possible reason for the increased mortality at a gestational age of 37-38 weeks could be that physicians may be more likely to defer to 39 weeks for delivery for women at moderately increased risk for adverse perinatal outcomes,” they wrote.
“We found that the decrease in neonatal mortality rates from 2007 to 2015 in the United States was largely associated with changes in the underlying gestational age distribution and less associated with changes in gestational age–specific mortality.”
The researchers reported that they had no conflicts of interest.
SOURCE: Ananth C et al. JAMA Pediatrics. 2018 May 14. doi: 10.1001/jamapediatrics.2018.0249.
Fewer infants are being delivered early, and there has been a decline in neonatal mortality, according to a retrospective cohort study of more than 34 million singleton live births.
Researchers presented the results of a study in the May 14 online edition of JAMA Pediatrics that attempted to quantify changes in gestational age distribution and gestational age–specific perinatal mortality in the United States between 2007 and 2015.
However the proportion of births at a gestational age of 39-40 weeks increased from 54.5% to 60.2% in that same time period.
“The decreasing proportion of births at gestational ages of 34-36 and 37-38 weeks may be associated with changes in the timing of elective delivery, with hospital policies and quality initiatives effectively reducing unindicated deliveries before 39 completed weeks of gestation,” wrote Cande V. Ananth, PhD, of Columbia University, New York, and coauthors.
“Increased use of low-dose aspirin in women with ischemic placental disease may additionally have resulted in decreased need for indicated delivery before 39 weeks.”
At the same time, perinatal mortality rates decreased overall, from 9 per 1,000 births in 2007 to 8.6 per 1,000 births in 2015, but increased significantly in gestational ages 32-33 weeks (7%), 34-36 weeks (15%), and 37-38 weeks (23%) over that period. There was also a significant 31% increase in perinatal mortality at gestational age 42-44 weeks, but decreases at 20-27 weeks and 39-40 weeks.
Stillbirth rates also increased for gestational ages of 20-27 weeks, 28-31 weeks, 32-33 weeks, 34-36 weeks, 37-38 weeks, and 42-44 weeks.
Commenting on the changes in perinatal and neonatal mortality rates at gestational ages of 34-36 weeks and 37-38 weeks, the authors suggested this may have been the result of recommendations to postpone elective deliveries until 39 weeks.
“A possible reason for the increased mortality at a gestational age of 37-38 weeks could be that physicians may be more likely to defer to 39 weeks for delivery for women at moderately increased risk for adverse perinatal outcomes,” they wrote.
“We found that the decrease in neonatal mortality rates from 2007 to 2015 in the United States was largely associated with changes in the underlying gestational age distribution and less associated with changes in gestational age–specific mortality.”
The researchers reported that they had no conflicts of interest.
SOURCE: Ananth C et al. JAMA Pediatrics. 2018 May 14. doi: 10.1001/jamapediatrics.2018.0249.
FROM JAMA PEDIATRICS
Key clinical point: Preterm births and perinatal mortality decreased from 2007 to 2015.
Major finding: The proportion of births at 39-40 weeks increased from 54.5% to 60.2% between 2007 and 2015.
Study details: A retrospective cohort study of nearly 35 million singleton births.
Disclosures: The researchers reported that they had no conflicts of interest.
Source: Ananth C et al. JAMA Pediatrics. 2018 May 14. doi: 10.1001/jamapediatrics.2018.0249.
Marketing perks increased opioid prescriptions
, according to a study published in JAMA Internal Medicine.
With 40% of opioid-related deaths still coming from prescription opioids, understanding how marketing influences prescriber habits could lead to the creation of specific policies to lower the number of prescription drugs exchanging hands and save lives.
Dr. Hadland and his colleagues conducted a comparative analysis of opioid prescriptions from 2014 and 2015, retrieved from the Medicare Part D Opioid Prescriber Summary File and cross referenced that information with all recorded transactions from companies to physicians in 2014 from the Open Payments database.
In 2015, a total of 369,139 physicians were recorded prescribing opioids to Medicare patients. About 25,767 (7%) received a combined total of 105,368 “nonresearch opioid-related payments” with a sum total of $9,071,976 in 2014.
While Medicare opioid claims went down in 2015, physicians who received these payments, on average, prescribed 9.3% more opioids than those who did not, according to investigators.
INSYS Therapeutics, Teva Pharmaceuticals USA, and Janssen Pharmaceuticals were the three highest-paying companies, contributing $4.5 million, $869,155, and $854,251, respectively.
Payments included speaking fees ($6.2 million), meals ($1.8 million), travel ($730,824), consulting fees ($290,395), and education ($79,660). Investigators estimated that, with each meal a physician received, there was an associated 0.7% increase in opioid claims.
Dr. Hadland and fellow investigators do acknowledge the possibility of reverse causality, with physicians who already prescribe more opioids being more likely to receive industry payments.
Dr. Hadland and his team report no relevant financial disclosures.
SOURCE: S Hadland et al. JAMA Intern Med. 2018 May 14. doi: 10.1001/jamainternmed.2018.1999.
, according to a study published in JAMA Internal Medicine.
With 40% of opioid-related deaths still coming from prescription opioids, understanding how marketing influences prescriber habits could lead to the creation of specific policies to lower the number of prescription drugs exchanging hands and save lives.
Dr. Hadland and his colleagues conducted a comparative analysis of opioid prescriptions from 2014 and 2015, retrieved from the Medicare Part D Opioid Prescriber Summary File and cross referenced that information with all recorded transactions from companies to physicians in 2014 from the Open Payments database.
In 2015, a total of 369,139 physicians were recorded prescribing opioids to Medicare patients. About 25,767 (7%) received a combined total of 105,368 “nonresearch opioid-related payments” with a sum total of $9,071,976 in 2014.
While Medicare opioid claims went down in 2015, physicians who received these payments, on average, prescribed 9.3% more opioids than those who did not, according to investigators.
INSYS Therapeutics, Teva Pharmaceuticals USA, and Janssen Pharmaceuticals were the three highest-paying companies, contributing $4.5 million, $869,155, and $854,251, respectively.
Payments included speaking fees ($6.2 million), meals ($1.8 million), travel ($730,824), consulting fees ($290,395), and education ($79,660). Investigators estimated that, with each meal a physician received, there was an associated 0.7% increase in opioid claims.
Dr. Hadland and fellow investigators do acknowledge the possibility of reverse causality, with physicians who already prescribe more opioids being more likely to receive industry payments.
Dr. Hadland and his team report no relevant financial disclosures.
SOURCE: S Hadland et al. JAMA Intern Med. 2018 May 14. doi: 10.1001/jamainternmed.2018.1999.
, according to a study published in JAMA Internal Medicine.
With 40% of opioid-related deaths still coming from prescription opioids, understanding how marketing influences prescriber habits could lead to the creation of specific policies to lower the number of prescription drugs exchanging hands and save lives.
Dr. Hadland and his colleagues conducted a comparative analysis of opioid prescriptions from 2014 and 2015, retrieved from the Medicare Part D Opioid Prescriber Summary File and cross referenced that information with all recorded transactions from companies to physicians in 2014 from the Open Payments database.
In 2015, a total of 369,139 physicians were recorded prescribing opioids to Medicare patients. About 25,767 (7%) received a combined total of 105,368 “nonresearch opioid-related payments” with a sum total of $9,071,976 in 2014.
While Medicare opioid claims went down in 2015, physicians who received these payments, on average, prescribed 9.3% more opioids than those who did not, according to investigators.
INSYS Therapeutics, Teva Pharmaceuticals USA, and Janssen Pharmaceuticals were the three highest-paying companies, contributing $4.5 million, $869,155, and $854,251, respectively.
Payments included speaking fees ($6.2 million), meals ($1.8 million), travel ($730,824), consulting fees ($290,395), and education ($79,660). Investigators estimated that, with each meal a physician received, there was an associated 0.7% increase in opioid claims.
Dr. Hadland and fellow investigators do acknowledge the possibility of reverse causality, with physicians who already prescribe more opioids being more likely to receive industry payments.
Dr. Hadland and his team report no relevant financial disclosures.
SOURCE: S Hadland et al. JAMA Intern Med. 2018 May 14. doi: 10.1001/jamainternmed.2018.1999.
FROM JAMA INTERNAL MEDICINE
Key clinical point: Doctors who received nonresearch payments on average had a higher number of opioid prescriptions than those who did not.
Major finding: Receiving a nonresearch payment from a pharmaceutical company was associated with about 9.3% more opioid claims.
Study details: Record analysis of 369,139 physicians collected from the Open Payments database and the Medicare Part D Opioid Prescriber Summary File for the years 2014 and 2015.
Disclosures: Dr. Hadland and his team report no relevant financial disclosures.
Source: S Hadland et al. JAMA Intern Med. 2018 May 14. doi: 10.1001/jamainternmed.2018.1999.
MDedge Daily News: Many moms with postpartum depression go untreated
Progressive Widespread Telangiectasias
The Diagnosis: Cutaneous Collagenous Vasculopathy
Histopathologic examination revealed ectatic blood vessels lined with unremarkable endothelial cells and thickened, hyalinized vessel walls scattered within the papillary dermis (Figure 1). The epidermis was unremarkable. There was minimal associated inflammation and no extravasation of erythrocytes. The hyalinized material was weakly positive on periodic acid-Schiff staining (Figure 2) and negative on Congo red staining, which supported of a diagnosis of cutaneous collagenous vasculopathy (CCV).
The patient previously had been given a suspected diagnosis of generalized essential telangiectasia by an outside dermatologist several years prior to the current presentation, as CCV had yet to be recognized as its own entity and therefore few cases had been described in the literature. She had a known history of obesity, hypertension, hyperlipidemia, and type 2 diabetes mellitus, which are associated with the condition. Multiple specialists concluded that the disease was too extensive for laser treatment. A review of PubMed articles indexed for MEDLINE yielded no established treatment options.
Cutaneous collagenous vasculopathy is a rare acquired microangiopathy involving the small vessels of the skin. Its clinical presentation is indistinguishable from that of generalized essential telangiectasia (GET). Patients generally present with asymptomatic, widespread, blanching, symmetric telangiectasias that classically begin on the legs and steadily progress upward with classic sparing of the face (Figure 3). Whereas GET has been reported to involve the oral and conjunctival mucosa, mucosal involvement is not typically observed in CCV and is considered to be a distinguishing factor between the 2 conditions.1,2 However, our patient reported oral symptoms, and oral erosions were seen on multiple physical examinations; therefore, ours is a rare case of mucosal involvement in conjunction with CCV. Given this finding, it is possible that more cases of CCV with mucosal involvement may exist but have been clinically misdiagnosed as GET.
First described by Salama and Rosenthal3 in 2000, CCV remains a rarely reported entity, with approximately 33 reported cases in the worldwide literature.2,4-7 The condition typically arises in adults with an equal predilection for males and females.2 The true incidence of CCV is unknown and likely is underreported given its close similarities to GET, which often is diagnosed clinically. The unique histopathologic finding of superficial ectatic vascular spaces with eosinophilic hyalinized vessel walls in CCV is key to distinguishing these similar entities, and even this finding can be subtle and is easily overlooked. Inflammation is sparse to absent. Deposited material is positive on periodic acid-Schiff and cytokeratin IV staining (representing reduplicated basement membrane-type collagen) and is diastase resistant. Smooth muscle actin staining is diminished or absent. Ultrastructural examination reveals reduplicated, laminated basement membrane; Luse bodies (abnormally long, widely spaced collagen fibers); and a decrease in or loss of pericytes. Of note, Luse bodies are nonspecific and their absence does not exclude a diagnosis of CCV.1
The etiology of CCV is unclear, and multiple pathogenetic mechanisms have been proposed. Ultimately, this entity is thought to arise from repeated endothelial cell damage, although the trigger for the endothelial cell injury is not completely understood. Diabetes mellitus sometimes is associated with microangiopathy and may be a confounding but not causative factor in some cases.1 Some investigators believe CCV is caused by a genetic defect that alters collagen production in the small vessels of the skin.5 Others have hypothesized that it is a secondary manifestation of an underlying disease or is associated with a medication; however, no disease or drug has been convincingly implicated in CCV.8
Cutaneous collagenous vasculopathy is limited to the skin, with no known reports of systemic involvement in the literature.7 There are no recommended laboratory studies to aid in diagnosis.1 It is critical to exclude hereditary hemorrhagic telangiectasia (HHT), as these patients can have life-threatening systemic involvement. Patients with CCV generally have no history of a bleeding diathesis, patients with HHT classically report recurrent epistaxis and gastrointestinal bleeding.7 A family history of HHT also is helpful for diagnosis, as the condition is autosomal dominant.1 Neither HHT or telangiectasia macularis eruptiva perstans, which also can be included in the differential diagnosis, demonstrate vessel wall hyalinization.
Treatment options for CCV are limited. Basso et al6 reported notable improvement in a patient with CCV treated with a combined 595-nm pulsed dye laser and 1064-nm Nd:YAG laser and optimized pulsed light. In one patient, treatment with a 585-nm pulsed dye laser produced a blanching response, suggesting that this may be a potential treatment option.7 Treatment with sclerotherapy has been ineffective.2
It is critical for both dermatologists and dermatopathologists to recognize and report this newly described entity, as the unique finding of vessel wall hyalinization in CCV may be indicative of a certain pathogenetic mechanism and effective treatment avenue that has yet to be established due to the relatively few number of reports that currently exist in the literature.
- Burdick LM, Lohser S, Somach SC, et al. Cutaneous collagenous vasculopathy: a rare cutaneous microangiopathy. J Cutan Pathol. 2012;39:741-746.
- Brady BG, Ortleb M, Boyd AS, et al. Cutaneous collagenous vasculopathy. J Clin Aesthet Dermatol. 2015;8:49-52.
- Salama S, Rosenthal D. Cutaneous collagenous vasculopathy with generalized telangiectasia: an immunohistochemical and structural study. J Cutan Pathol. 2000;27:40-48.
- Toda-Brito H, Resende C, Catorze G, et al. Cutaneous collagenous vasculopathy: a rare cause of generalised cutaneous telangiectasia. BMJ Case Rep. 2015. doi: 10.1136/bcr-2015-210635.
- Ma DL, Vano-Galvan S. Images in clinical medicine: cutaneous collagenous vasculopathy. N Engl J Med. 2015;373:E14.
- Basso D, Ribero S, Blazek C, et al. Cutaneous collagenous vasculopathy: a rare form of microangiopathy successfully treated with a combination of multiplex laser and optimized pulsed light with a review of the literature. Dermatology. 2016;232:107-111.
- Moteqi SI, Yasuda M, Yamanaka M, et al. Cutaneous collagenous vasculopathy: report of first Japanese case and review of the literature. Australas J Dermatol. 2017;58:145-149.
- González Fernández D, Gómez Bernal S, Vivanco Allende B, et al. Cutaneous collagenous vasculopathy: description of two new cases in elderly women and review of the literature. Dermatology. 2012;225:1-8.
The Diagnosis: Cutaneous Collagenous Vasculopathy
Histopathologic examination revealed ectatic blood vessels lined with unremarkable endothelial cells and thickened, hyalinized vessel walls scattered within the papillary dermis (Figure 1). The epidermis was unremarkable. There was minimal associated inflammation and no extravasation of erythrocytes. The hyalinized material was weakly positive on periodic acid-Schiff staining (Figure 2) and negative on Congo red staining, which supported of a diagnosis of cutaneous collagenous vasculopathy (CCV).
The patient previously had been given a suspected diagnosis of generalized essential telangiectasia by an outside dermatologist several years prior to the current presentation, as CCV had yet to be recognized as its own entity and therefore few cases had been described in the literature. She had a known history of obesity, hypertension, hyperlipidemia, and type 2 diabetes mellitus, which are associated with the condition. Multiple specialists concluded that the disease was too extensive for laser treatment. A review of PubMed articles indexed for MEDLINE yielded no established treatment options.
Cutaneous collagenous vasculopathy is a rare acquired microangiopathy involving the small vessels of the skin. Its clinical presentation is indistinguishable from that of generalized essential telangiectasia (GET). Patients generally present with asymptomatic, widespread, blanching, symmetric telangiectasias that classically begin on the legs and steadily progress upward with classic sparing of the face (Figure 3). Whereas GET has been reported to involve the oral and conjunctival mucosa, mucosal involvement is not typically observed in CCV and is considered to be a distinguishing factor between the 2 conditions.1,2 However, our patient reported oral symptoms, and oral erosions were seen on multiple physical examinations; therefore, ours is a rare case of mucosal involvement in conjunction with CCV. Given this finding, it is possible that more cases of CCV with mucosal involvement may exist but have been clinically misdiagnosed as GET.
First described by Salama and Rosenthal3 in 2000, CCV remains a rarely reported entity, with approximately 33 reported cases in the worldwide literature.2,4-7 The condition typically arises in adults with an equal predilection for males and females.2 The true incidence of CCV is unknown and likely is underreported given its close similarities to GET, which often is diagnosed clinically. The unique histopathologic finding of superficial ectatic vascular spaces with eosinophilic hyalinized vessel walls in CCV is key to distinguishing these similar entities, and even this finding can be subtle and is easily overlooked. Inflammation is sparse to absent. Deposited material is positive on periodic acid-Schiff and cytokeratin IV staining (representing reduplicated basement membrane-type collagen) and is diastase resistant. Smooth muscle actin staining is diminished or absent. Ultrastructural examination reveals reduplicated, laminated basement membrane; Luse bodies (abnormally long, widely spaced collagen fibers); and a decrease in or loss of pericytes. Of note, Luse bodies are nonspecific and their absence does not exclude a diagnosis of CCV.1
The etiology of CCV is unclear, and multiple pathogenetic mechanisms have been proposed. Ultimately, this entity is thought to arise from repeated endothelial cell damage, although the trigger for the endothelial cell injury is not completely understood. Diabetes mellitus sometimes is associated with microangiopathy and may be a confounding but not causative factor in some cases.1 Some investigators believe CCV is caused by a genetic defect that alters collagen production in the small vessels of the skin.5 Others have hypothesized that it is a secondary manifestation of an underlying disease or is associated with a medication; however, no disease or drug has been convincingly implicated in CCV.8
Cutaneous collagenous vasculopathy is limited to the skin, with no known reports of systemic involvement in the literature.7 There are no recommended laboratory studies to aid in diagnosis.1 It is critical to exclude hereditary hemorrhagic telangiectasia (HHT), as these patients can have life-threatening systemic involvement. Patients with CCV generally have no history of a bleeding diathesis, patients with HHT classically report recurrent epistaxis and gastrointestinal bleeding.7 A family history of HHT also is helpful for diagnosis, as the condition is autosomal dominant.1 Neither HHT or telangiectasia macularis eruptiva perstans, which also can be included in the differential diagnosis, demonstrate vessel wall hyalinization.
Treatment options for CCV are limited. Basso et al6 reported notable improvement in a patient with CCV treated with a combined 595-nm pulsed dye laser and 1064-nm Nd:YAG laser and optimized pulsed light. In one patient, treatment with a 585-nm pulsed dye laser produced a blanching response, suggesting that this may be a potential treatment option.7 Treatment with sclerotherapy has been ineffective.2
It is critical for both dermatologists and dermatopathologists to recognize and report this newly described entity, as the unique finding of vessel wall hyalinization in CCV may be indicative of a certain pathogenetic mechanism and effective treatment avenue that has yet to be established due to the relatively few number of reports that currently exist in the literature.
The Diagnosis: Cutaneous Collagenous Vasculopathy
Histopathologic examination revealed ectatic blood vessels lined with unremarkable endothelial cells and thickened, hyalinized vessel walls scattered within the papillary dermis (Figure 1). The epidermis was unremarkable. There was minimal associated inflammation and no extravasation of erythrocytes. The hyalinized material was weakly positive on periodic acid-Schiff staining (Figure 2) and negative on Congo red staining, which supported of a diagnosis of cutaneous collagenous vasculopathy (CCV).
The patient previously had been given a suspected diagnosis of generalized essential telangiectasia by an outside dermatologist several years prior to the current presentation, as CCV had yet to be recognized as its own entity and therefore few cases had been described in the literature. She had a known history of obesity, hypertension, hyperlipidemia, and type 2 diabetes mellitus, which are associated with the condition. Multiple specialists concluded that the disease was too extensive for laser treatment. A review of PubMed articles indexed for MEDLINE yielded no established treatment options.
Cutaneous collagenous vasculopathy is a rare acquired microangiopathy involving the small vessels of the skin. Its clinical presentation is indistinguishable from that of generalized essential telangiectasia (GET). Patients generally present with asymptomatic, widespread, blanching, symmetric telangiectasias that classically begin on the legs and steadily progress upward with classic sparing of the face (Figure 3). Whereas GET has been reported to involve the oral and conjunctival mucosa, mucosal involvement is not typically observed in CCV and is considered to be a distinguishing factor between the 2 conditions.1,2 However, our patient reported oral symptoms, and oral erosions were seen on multiple physical examinations; therefore, ours is a rare case of mucosal involvement in conjunction with CCV. Given this finding, it is possible that more cases of CCV with mucosal involvement may exist but have been clinically misdiagnosed as GET.
First described by Salama and Rosenthal3 in 2000, CCV remains a rarely reported entity, with approximately 33 reported cases in the worldwide literature.2,4-7 The condition typically arises in adults with an equal predilection for males and females.2 The true incidence of CCV is unknown and likely is underreported given its close similarities to GET, which often is diagnosed clinically. The unique histopathologic finding of superficial ectatic vascular spaces with eosinophilic hyalinized vessel walls in CCV is key to distinguishing these similar entities, and even this finding can be subtle and is easily overlooked. Inflammation is sparse to absent. Deposited material is positive on periodic acid-Schiff and cytokeratin IV staining (representing reduplicated basement membrane-type collagen) and is diastase resistant. Smooth muscle actin staining is diminished or absent. Ultrastructural examination reveals reduplicated, laminated basement membrane; Luse bodies (abnormally long, widely spaced collagen fibers); and a decrease in or loss of pericytes. Of note, Luse bodies are nonspecific and their absence does not exclude a diagnosis of CCV.1
The etiology of CCV is unclear, and multiple pathogenetic mechanisms have been proposed. Ultimately, this entity is thought to arise from repeated endothelial cell damage, although the trigger for the endothelial cell injury is not completely understood. Diabetes mellitus sometimes is associated with microangiopathy and may be a confounding but not causative factor in some cases.1 Some investigators believe CCV is caused by a genetic defect that alters collagen production in the small vessels of the skin.5 Others have hypothesized that it is a secondary manifestation of an underlying disease or is associated with a medication; however, no disease or drug has been convincingly implicated in CCV.8
Cutaneous collagenous vasculopathy is limited to the skin, with no known reports of systemic involvement in the literature.7 There are no recommended laboratory studies to aid in diagnosis.1 It is critical to exclude hereditary hemorrhagic telangiectasia (HHT), as these patients can have life-threatening systemic involvement. Patients with CCV generally have no history of a bleeding diathesis, patients with HHT classically report recurrent epistaxis and gastrointestinal bleeding.7 A family history of HHT also is helpful for diagnosis, as the condition is autosomal dominant.1 Neither HHT or telangiectasia macularis eruptiva perstans, which also can be included in the differential diagnosis, demonstrate vessel wall hyalinization.
Treatment options for CCV are limited. Basso et al6 reported notable improvement in a patient with CCV treated with a combined 595-nm pulsed dye laser and 1064-nm Nd:YAG laser and optimized pulsed light. In one patient, treatment with a 585-nm pulsed dye laser produced a blanching response, suggesting that this may be a potential treatment option.7 Treatment with sclerotherapy has been ineffective.2
It is critical for both dermatologists and dermatopathologists to recognize and report this newly described entity, as the unique finding of vessel wall hyalinization in CCV may be indicative of a certain pathogenetic mechanism and effective treatment avenue that has yet to be established due to the relatively few number of reports that currently exist in the literature.
- Burdick LM, Lohser S, Somach SC, et al. Cutaneous collagenous vasculopathy: a rare cutaneous microangiopathy. J Cutan Pathol. 2012;39:741-746.
- Brady BG, Ortleb M, Boyd AS, et al. Cutaneous collagenous vasculopathy. J Clin Aesthet Dermatol. 2015;8:49-52.
- Salama S, Rosenthal D. Cutaneous collagenous vasculopathy with generalized telangiectasia: an immunohistochemical and structural study. J Cutan Pathol. 2000;27:40-48.
- Toda-Brito H, Resende C, Catorze G, et al. Cutaneous collagenous vasculopathy: a rare cause of generalised cutaneous telangiectasia. BMJ Case Rep. 2015. doi: 10.1136/bcr-2015-210635.
- Ma DL, Vano-Galvan S. Images in clinical medicine: cutaneous collagenous vasculopathy. N Engl J Med. 2015;373:E14.
- Basso D, Ribero S, Blazek C, et al. Cutaneous collagenous vasculopathy: a rare form of microangiopathy successfully treated with a combination of multiplex laser and optimized pulsed light with a review of the literature. Dermatology. 2016;232:107-111.
- Moteqi SI, Yasuda M, Yamanaka M, et al. Cutaneous collagenous vasculopathy: report of first Japanese case and review of the literature. Australas J Dermatol. 2017;58:145-149.
- González Fernández D, Gómez Bernal S, Vivanco Allende B, et al. Cutaneous collagenous vasculopathy: description of two new cases in elderly women and review of the literature. Dermatology. 2012;225:1-8.
- Burdick LM, Lohser S, Somach SC, et al. Cutaneous collagenous vasculopathy: a rare cutaneous microangiopathy. J Cutan Pathol. 2012;39:741-746.
- Brady BG, Ortleb M, Boyd AS, et al. Cutaneous collagenous vasculopathy. J Clin Aesthet Dermatol. 2015;8:49-52.
- Salama S, Rosenthal D. Cutaneous collagenous vasculopathy with generalized telangiectasia: an immunohistochemical and structural study. J Cutan Pathol. 2000;27:40-48.
- Toda-Brito H, Resende C, Catorze G, et al. Cutaneous collagenous vasculopathy: a rare cause of generalised cutaneous telangiectasia. BMJ Case Rep. 2015. doi: 10.1136/bcr-2015-210635.
- Ma DL, Vano-Galvan S. Images in clinical medicine: cutaneous collagenous vasculopathy. N Engl J Med. 2015;373:E14.
- Basso D, Ribero S, Blazek C, et al. Cutaneous collagenous vasculopathy: a rare form of microangiopathy successfully treated with a combination of multiplex laser and optimized pulsed light with a review of the literature. Dermatology. 2016;232:107-111.
- Moteqi SI, Yasuda M, Yamanaka M, et al. Cutaneous collagenous vasculopathy: report of first Japanese case and review of the literature. Australas J Dermatol. 2017;58:145-149.
- González Fernández D, Gómez Bernal S, Vivanco Allende B, et al. Cutaneous collagenous vasculopathy: description of two new cases in elderly women and review of the literature. Dermatology. 2012;225:1-8.
A 55-year-old woman presented for evaluation of widespread asymptomatic telangiectasias of several years' duration that first appeared on the legs and steadily progressed to involve the trunk and arms. A review of systems was remarkable for episodic glossitis and oral erosions that developed at the same time as the eruption. The patient had no history of bleeding diasthesis, and her family history was unremarkable. A laboratory workup (including autoimmune screening) and a malignancy workup were negative. Physical examination revealed confluent sheets of erythematous and purple blanching telangiectasias scattered symmetrically on the trunk, bilateral arms and legs, buttocks, and dorsal aspects of the feet with sparing of the palms, soles, and head and neck regions. A small, shallow erosion was present on the lateral aspect of the tongue. A 4-mm punch biopsy of a thigh lesion revealed ectatic blood vessels with hyalinized walls.
Keep pushing the envelope
By the time this column is published, we will have wrapped up Hospital Medicine 2018 in Orlando, it will be well into spring, and I will have completed my year as past president as well as my 6-year tenure on the Society of Hospital Medicine board of directors.
I can imagine that will feel like a relief and a milestone, and it also will feel like a loss to no longer be part of something that I have contributed my time, energy, passion, and emotion to for so long. I will retire at the ripe age of 48 – a pretty typical age for ending SHM board tenure, and it’s terribly important for SHM that I do so.
If you attended HM18, I hope you appreciated, as I do every year, the energy, enthusiasm, and youth – if not in years, then in spirit – of the event and of hospitalists. As a society and a profession, we take risks. We have set standards for excellence in hospital medicine programs. We have recognized a unique set of competencies and then not only attempted to expand them with education but also defined a specialty around them. We have welcomed practitioners and administrators as equals into our fold. These and many other accomplishments are the work of a board, committees, chapter leaders, and members who look for opportunity to expand our work into new and necessary domains, and not be limited by precedent.
On the SHM board and committees, we tackle issues of governance and strategy. For most of us, the SHM board is our first exposure to nonprofit oversight. And, to be sure, there is a steep learning curve as new members discover the issues and substance of the work of the society. I recall that I barely spoke the first year on the board, uncertain that I understood items fully, and I also was burned once or twice by making suggestions that reflected my lack of knowledge. While ignorance slowly gave way to experience, we also matured as a group as we found ways to debate and resolve tough, sometimes ambiguous, issues.
I came to appreciate that the strength of the board – and of SHM – is that we join the board naive to much of the past. After 6 years, while I may have come to understand issues with greater depth, I also see that the newer members bring fresher thinking, more creative energy, and even thoughts about how the group could function differently and perhaps better. Over the last few years, I realized that we veterans had developed a cadence and predictability to our work, and every year’s new members disrupt that rhythm. This disruption forces us to challenge each other and to be a better board – and hopefully – represent and advocate for you, our membership, better.
So, it’s time for me to move on. Even though I certainly feel like I still could contribute, it’s time to retire my own way of thinking from the leadership of SHM. The fact that we term-limit out at a (relatively) young age is, I believe, an extraordinary aspect of our organization, which is reflected in the work that our staff, our committees, and our members do.
SHM is an organization that, from the top down, embraces change in ways that few other organizations do. I believe we owe it to you to keep pushing the envelope of creativity – of what our goals are, of what a society can accomplish, of what an annual meeting can consist of. My ask of all of you is that you continue to challenge the leadership of SHM to be disruptive, to push the profession to better places, and to always strive to be more diverse, more inclusive, more communicative, more visible – and to stay young. In spirit and attitude if not in age. Thank you for giving me the opportunity to work on your behalf. It has been the greatest privilege of my career.
Dr. Harte is a past president of SHM and president of Cleveland Clinic Akron General and Southern Region.
By the time this column is published, we will have wrapped up Hospital Medicine 2018 in Orlando, it will be well into spring, and I will have completed my year as past president as well as my 6-year tenure on the Society of Hospital Medicine board of directors.
I can imagine that will feel like a relief and a milestone, and it also will feel like a loss to no longer be part of something that I have contributed my time, energy, passion, and emotion to for so long. I will retire at the ripe age of 48 – a pretty typical age for ending SHM board tenure, and it’s terribly important for SHM that I do so.
If you attended HM18, I hope you appreciated, as I do every year, the energy, enthusiasm, and youth – if not in years, then in spirit – of the event and of hospitalists. As a society and a profession, we take risks. We have set standards for excellence in hospital medicine programs. We have recognized a unique set of competencies and then not only attempted to expand them with education but also defined a specialty around them. We have welcomed practitioners and administrators as equals into our fold. These and many other accomplishments are the work of a board, committees, chapter leaders, and members who look for opportunity to expand our work into new and necessary domains, and not be limited by precedent.
On the SHM board and committees, we tackle issues of governance and strategy. For most of us, the SHM board is our first exposure to nonprofit oversight. And, to be sure, there is a steep learning curve as new members discover the issues and substance of the work of the society. I recall that I barely spoke the first year on the board, uncertain that I understood items fully, and I also was burned once or twice by making suggestions that reflected my lack of knowledge. While ignorance slowly gave way to experience, we also matured as a group as we found ways to debate and resolve tough, sometimes ambiguous, issues.
I came to appreciate that the strength of the board – and of SHM – is that we join the board naive to much of the past. After 6 years, while I may have come to understand issues with greater depth, I also see that the newer members bring fresher thinking, more creative energy, and even thoughts about how the group could function differently and perhaps better. Over the last few years, I realized that we veterans had developed a cadence and predictability to our work, and every year’s new members disrupt that rhythm. This disruption forces us to challenge each other and to be a better board – and hopefully – represent and advocate for you, our membership, better.
So, it’s time for me to move on. Even though I certainly feel like I still could contribute, it’s time to retire my own way of thinking from the leadership of SHM. The fact that we term-limit out at a (relatively) young age is, I believe, an extraordinary aspect of our organization, which is reflected in the work that our staff, our committees, and our members do.
SHM is an organization that, from the top down, embraces change in ways that few other organizations do. I believe we owe it to you to keep pushing the envelope of creativity – of what our goals are, of what a society can accomplish, of what an annual meeting can consist of. My ask of all of you is that you continue to challenge the leadership of SHM to be disruptive, to push the profession to better places, and to always strive to be more diverse, more inclusive, more communicative, more visible – and to stay young. In spirit and attitude if not in age. Thank you for giving me the opportunity to work on your behalf. It has been the greatest privilege of my career.
Dr. Harte is a past president of SHM and president of Cleveland Clinic Akron General and Southern Region.
By the time this column is published, we will have wrapped up Hospital Medicine 2018 in Orlando, it will be well into spring, and I will have completed my year as past president as well as my 6-year tenure on the Society of Hospital Medicine board of directors.
I can imagine that will feel like a relief and a milestone, and it also will feel like a loss to no longer be part of something that I have contributed my time, energy, passion, and emotion to for so long. I will retire at the ripe age of 48 – a pretty typical age for ending SHM board tenure, and it’s terribly important for SHM that I do so.
If you attended HM18, I hope you appreciated, as I do every year, the energy, enthusiasm, and youth – if not in years, then in spirit – of the event and of hospitalists. As a society and a profession, we take risks. We have set standards for excellence in hospital medicine programs. We have recognized a unique set of competencies and then not only attempted to expand them with education but also defined a specialty around them. We have welcomed practitioners and administrators as equals into our fold. These and many other accomplishments are the work of a board, committees, chapter leaders, and members who look for opportunity to expand our work into new and necessary domains, and not be limited by precedent.
On the SHM board and committees, we tackle issues of governance and strategy. For most of us, the SHM board is our first exposure to nonprofit oversight. And, to be sure, there is a steep learning curve as new members discover the issues and substance of the work of the society. I recall that I barely spoke the first year on the board, uncertain that I understood items fully, and I also was burned once or twice by making suggestions that reflected my lack of knowledge. While ignorance slowly gave way to experience, we also matured as a group as we found ways to debate and resolve tough, sometimes ambiguous, issues.
I came to appreciate that the strength of the board – and of SHM – is that we join the board naive to much of the past. After 6 years, while I may have come to understand issues with greater depth, I also see that the newer members bring fresher thinking, more creative energy, and even thoughts about how the group could function differently and perhaps better. Over the last few years, I realized that we veterans had developed a cadence and predictability to our work, and every year’s new members disrupt that rhythm. This disruption forces us to challenge each other and to be a better board – and hopefully – represent and advocate for you, our membership, better.
So, it’s time for me to move on. Even though I certainly feel like I still could contribute, it’s time to retire my own way of thinking from the leadership of SHM. The fact that we term-limit out at a (relatively) young age is, I believe, an extraordinary aspect of our organization, which is reflected in the work that our staff, our committees, and our members do.
SHM is an organization that, from the top down, embraces change in ways that few other organizations do. I believe we owe it to you to keep pushing the envelope of creativity – of what our goals are, of what a society can accomplish, of what an annual meeting can consist of. My ask of all of you is that you continue to challenge the leadership of SHM to be disruptive, to push the profession to better places, and to always strive to be more diverse, more inclusive, more communicative, more visible – and to stay young. In spirit and attitude if not in age. Thank you for giving me the opportunity to work on your behalf. It has been the greatest privilege of my career.
Dr. Harte is a past president of SHM and president of Cleveland Clinic Akron General and Southern Region.