User login
Topical imiquimod boosted response to intradermal hepatitis B vaccine
VIENNA – Topical imiquimod appeared to enhance the immunogenicity of an intradermal hepatitis B vaccine in patients on renal replacement therapy.
Patients on hemodialysis or peritoneal dialysis who got the combination developed significantly higher seroprotection and antibody levels than those who got either the typical intramuscular vaccination or an intradermal vaccination on unprepared skin, Ivan Fan-Ngai Hung, MD, said at the European Conference on Clinical Microbiology and Infectious Diseases. By 1 year, the protection and titers did begin to fall, but they still remained significantly higher than in the two comparator groups, said Dr. Hung, a clinical professor at the University of Hong Kong.
Dr. Hung and his colleagues have been investigating imiquimod’s immunogenicity-boosting potential for several years. Their initial murine work with an H1N1 influenza virus appeared in 2014 (Clin Vaccine Immunol. 2014 Apr;21[4]: 570-9). The investigators intraperitoneally immunized mice with a monovalent A(H1N1) vaccine combined with imiquimod (VIC) then intranasally inoculated them with a lethal dose of the virus. When compared with mice who received only vaccine, only imiquimod, or only placebo, the VIC group showed significantly greater and significantly longer survival. Virus-specific serum immunoglobulin M, IgG, and neutralizing antibodies were all significantly higher.
The investigators theorized that imiquimod, a Toll-like receptor 7 agonist, plays several key roles in boosting immune response, including inducing the differentiation and migration of dendritic cells, enhancing B cell differentiation, and increasing long-term B cell memory.
Within the past 2 years, the group has advanced to human influenza trials in healthy young adults and elders with comorbidities.
Both studies employed a 5% imiquimod cream delivering 250 mg of the drug. It was applied at the injection site 5 minutes before vaccination. In the elder study, 90% of the 91 subjects who got the combination achieved seroconversion, compared with 13% of those who got an intramuscular injection and 39% of those who got an intradermal injection plus placebo cream. The geometric mean titers went up faster and stayed elevated longer. The better immunogenicity was associated with fewer hospitalizations for influenza or pneumonia (Clin Infect Dis. 2014;59[9]:1246-55).
The immunogenicity findings were similar in the study of 160 healthy young people. This study had a surprising twist too, Dr. Hung said in his talk. Not only did the combination significantly improve immunogenicity against the vaccine influenza strains, it increased immunogenicity against the nonvaccine strains, especially the antigenically drifted H3N2 strain of 2015, which was not included in the 2013-2014 recommended vaccine (Lancet Inf Dis. 2016 Feb;16(2):209-18).
The study Dr. Hung presented in Vienna was an interim analysis of the first to apply this technique to a hepatitis B vaccine. It enrolled 69 patients (51 on peritoneal dialysis and 18 on hemodialysis). They were a mean 65 years old. All received 10 mcg of the Sci-B-Vac at baseline, 1 month, and 6 months. Vaccine was delivered in a trineedle unit designed for shallow intradermal penetration (MicronJet600; NanoPass Technologies) Group IQ received topical imiquimod along with the intradermal vaccine. Group ID received a placebo cream and the intradermal vaccine. Group IM received a placebo cream and an intramuscular vaccination.
Anti–hepatitis B titers were measured at baseline and at 1, 3, 6, and 12 months. The primary outcome was seroprotection at 1 month. The secondary outcomes were seroprotection at 3, 6, and 12 months; anti–hepatitis B antibody titer; and safety.
By 1 month, seroprotection was already significantly higher in the IQ group than in the ID and IM groups (60% vs. 50% and 38%, respectively).
By 3 months, the seroprotection rate in group IQ had risen to 85%. It remained elevated there at 6 months then tailed off to about 70% by 12 months. The ID and IM groups followed this same rising and falling curve but remained significantly lower at all time points. At 12 months, seroprotection was similar in both these groups – about 40%.
The anti–hepatitis B antibody titers told a similar story. Titers in the IQ group rose more rapidly and sharply, to 544 mIU/mL at 6 months and 566 mIU/mL at 12 months. The ID group also experienced a strong response, rising to 489 mIU/mL at 6 months. However, by 12 months, titer levels had dropped to 170 mIU/mL.
Titers in the IM group barely moved at all during the entire follow-up period, never rising above 21 mIU/mL.
There were no differences in systemic reactions among the three groups, but those who got the intradermal vaccines reported slightly more swelling and induration at the injection site.
“Since this is an interim analysis, we cannot determine long-term protection or antibody titers,” Dr. Hung cautioned. “However, we are starting a similar study in elderly patients and also one for those who are on low-dose immunosuppressants. We believe this regimen will also work for them.”
Dr. Hung has been on advisory boards for Pfizer and Gilead Sciences.
[email protected]
On Twitter @alz_gal
VIENNA – Topical imiquimod appeared to enhance the immunogenicity of an intradermal hepatitis B vaccine in patients on renal replacement therapy.
Patients on hemodialysis or peritoneal dialysis who got the combination developed significantly higher seroprotection and antibody levels than those who got either the typical intramuscular vaccination or an intradermal vaccination on unprepared skin, Ivan Fan-Ngai Hung, MD, said at the European Conference on Clinical Microbiology and Infectious Diseases. By 1 year, the protection and titers did begin to fall, but they still remained significantly higher than in the two comparator groups, said Dr. Hung, a clinical professor at the University of Hong Kong.
Dr. Hung and his colleagues have been investigating imiquimod’s immunogenicity-boosting potential for several years. Their initial murine work with an H1N1 influenza virus appeared in 2014 (Clin Vaccine Immunol. 2014 Apr;21[4]: 570-9). The investigators intraperitoneally immunized mice with a monovalent A(H1N1) vaccine combined with imiquimod (VIC) then intranasally inoculated them with a lethal dose of the virus. When compared with mice who received only vaccine, only imiquimod, or only placebo, the VIC group showed significantly greater and significantly longer survival. Virus-specific serum immunoglobulin M, IgG, and neutralizing antibodies were all significantly higher.
The investigators theorized that imiquimod, a Toll-like receptor 7 agonist, plays several key roles in boosting immune response, including inducing the differentiation and migration of dendritic cells, enhancing B cell differentiation, and increasing long-term B cell memory.
Within the past 2 years, the group has advanced to human influenza trials in healthy young adults and elders with comorbidities.
Both studies employed a 5% imiquimod cream delivering 250 mg of the drug. It was applied at the injection site 5 minutes before vaccination. In the elder study, 90% of the 91 subjects who got the combination achieved seroconversion, compared with 13% of those who got an intramuscular injection and 39% of those who got an intradermal injection plus placebo cream. The geometric mean titers went up faster and stayed elevated longer. The better immunogenicity was associated with fewer hospitalizations for influenza or pneumonia (Clin Infect Dis. 2014;59[9]:1246-55).
The immunogenicity findings were similar in the study of 160 healthy young people. This study had a surprising twist too, Dr. Hung said in his talk. Not only did the combination significantly improve immunogenicity against the vaccine influenza strains, it increased immunogenicity against the nonvaccine strains, especially the antigenically drifted H3N2 strain of 2015, which was not included in the 2013-2014 recommended vaccine (Lancet Inf Dis. 2016 Feb;16(2):209-18).
The study Dr. Hung presented in Vienna was an interim analysis of the first to apply this technique to a hepatitis B vaccine. It enrolled 69 patients (51 on peritoneal dialysis and 18 on hemodialysis). They were a mean 65 years old. All received 10 mcg of the Sci-B-Vac at baseline, 1 month, and 6 months. Vaccine was delivered in a trineedle unit designed for shallow intradermal penetration (MicronJet600; NanoPass Technologies) Group IQ received topical imiquimod along with the intradermal vaccine. Group ID received a placebo cream and the intradermal vaccine. Group IM received a placebo cream and an intramuscular vaccination.
Anti–hepatitis B titers were measured at baseline and at 1, 3, 6, and 12 months. The primary outcome was seroprotection at 1 month. The secondary outcomes were seroprotection at 3, 6, and 12 months; anti–hepatitis B antibody titer; and safety.
By 1 month, seroprotection was already significantly higher in the IQ group than in the ID and IM groups (60% vs. 50% and 38%, respectively).
By 3 months, the seroprotection rate in group IQ had risen to 85%. It remained elevated there at 6 months then tailed off to about 70% by 12 months. The ID and IM groups followed this same rising and falling curve but remained significantly lower at all time points. At 12 months, seroprotection was similar in both these groups – about 40%.
The anti–hepatitis B antibody titers told a similar story. Titers in the IQ group rose more rapidly and sharply, to 544 mIU/mL at 6 months and 566 mIU/mL at 12 months. The ID group also experienced a strong response, rising to 489 mIU/mL at 6 months. However, by 12 months, titer levels had dropped to 170 mIU/mL.
Titers in the IM group barely moved at all during the entire follow-up period, never rising above 21 mIU/mL.
There were no differences in systemic reactions among the three groups, but those who got the intradermal vaccines reported slightly more swelling and induration at the injection site.
“Since this is an interim analysis, we cannot determine long-term protection or antibody titers,” Dr. Hung cautioned. “However, we are starting a similar study in elderly patients and also one for those who are on low-dose immunosuppressants. We believe this regimen will also work for them.”
Dr. Hung has been on advisory boards for Pfizer and Gilead Sciences.
[email protected]
On Twitter @alz_gal
VIENNA – Topical imiquimod appeared to enhance the immunogenicity of an intradermal hepatitis B vaccine in patients on renal replacement therapy.
Patients on hemodialysis or peritoneal dialysis who got the combination developed significantly higher seroprotection and antibody levels than those who got either the typical intramuscular vaccination or an intradermal vaccination on unprepared skin, Ivan Fan-Ngai Hung, MD, said at the European Conference on Clinical Microbiology and Infectious Diseases. By 1 year, the protection and titers did begin to fall, but they still remained significantly higher than in the two comparator groups, said Dr. Hung, a clinical professor at the University of Hong Kong.
Dr. Hung and his colleagues have been investigating imiquimod’s immunogenicity-boosting potential for several years. Their initial murine work with an H1N1 influenza virus appeared in 2014 (Clin Vaccine Immunol. 2014 Apr;21[4]: 570-9). The investigators intraperitoneally immunized mice with a monovalent A(H1N1) vaccine combined with imiquimod (VIC) then intranasally inoculated them with a lethal dose of the virus. When compared with mice who received only vaccine, only imiquimod, or only placebo, the VIC group showed significantly greater and significantly longer survival. Virus-specific serum immunoglobulin M, IgG, and neutralizing antibodies were all significantly higher.
The investigators theorized that imiquimod, a Toll-like receptor 7 agonist, plays several key roles in boosting immune response, including inducing the differentiation and migration of dendritic cells, enhancing B cell differentiation, and increasing long-term B cell memory.
Within the past 2 years, the group has advanced to human influenza trials in healthy young adults and elders with comorbidities.
Both studies employed a 5% imiquimod cream delivering 250 mg of the drug. It was applied at the injection site 5 minutes before vaccination. In the elder study, 90% of the 91 subjects who got the combination achieved seroconversion, compared with 13% of those who got an intramuscular injection and 39% of those who got an intradermal injection plus placebo cream. The geometric mean titers went up faster and stayed elevated longer. The better immunogenicity was associated with fewer hospitalizations for influenza or pneumonia (Clin Infect Dis. 2014;59[9]:1246-55).
The immunogenicity findings were similar in the study of 160 healthy young people. This study had a surprising twist too, Dr. Hung said in his talk. Not only did the combination significantly improve immunogenicity against the vaccine influenza strains, it increased immunogenicity against the nonvaccine strains, especially the antigenically drifted H3N2 strain of 2015, which was not included in the 2013-2014 recommended vaccine (Lancet Inf Dis. 2016 Feb;16(2):209-18).
The study Dr. Hung presented in Vienna was an interim analysis of the first to apply this technique to a hepatitis B vaccine. It enrolled 69 patients (51 on peritoneal dialysis and 18 on hemodialysis). They were a mean 65 years old. All received 10 mcg of the Sci-B-Vac at baseline, 1 month, and 6 months. Vaccine was delivered in a trineedle unit designed for shallow intradermal penetration (MicronJet600; NanoPass Technologies) Group IQ received topical imiquimod along with the intradermal vaccine. Group ID received a placebo cream and the intradermal vaccine. Group IM received a placebo cream and an intramuscular vaccination.
Anti–hepatitis B titers were measured at baseline and at 1, 3, 6, and 12 months. The primary outcome was seroprotection at 1 month. The secondary outcomes were seroprotection at 3, 6, and 12 months; anti–hepatitis B antibody titer; and safety.
By 1 month, seroprotection was already significantly higher in the IQ group than in the ID and IM groups (60% vs. 50% and 38%, respectively).
By 3 months, the seroprotection rate in group IQ had risen to 85%. It remained elevated there at 6 months then tailed off to about 70% by 12 months. The ID and IM groups followed this same rising and falling curve but remained significantly lower at all time points. At 12 months, seroprotection was similar in both these groups – about 40%.
The anti–hepatitis B antibody titers told a similar story. Titers in the IQ group rose more rapidly and sharply, to 544 mIU/mL at 6 months and 566 mIU/mL at 12 months. The ID group also experienced a strong response, rising to 489 mIU/mL at 6 months. However, by 12 months, titer levels had dropped to 170 mIU/mL.
Titers in the IM group barely moved at all during the entire follow-up period, never rising above 21 mIU/mL.
There were no differences in systemic reactions among the three groups, but those who got the intradermal vaccines reported slightly more swelling and induration at the injection site.
“Since this is an interim analysis, we cannot determine long-term protection or antibody titers,” Dr. Hung cautioned. “However, we are starting a similar study in elderly patients and also one for those who are on low-dose immunosuppressants. We believe this regimen will also work for them.”
Dr. Hung has been on advisory boards for Pfizer and Gilead Sciences.
[email protected]
On Twitter @alz_gal
AT ECCMID 2017
Key clinical point:
Major finding: By 1 month, seroprotection was significantly higher in the imiquimod group than in those who got an intradermal vaccination without imiquimod and those who had an intramuscular injection only (60% vs. 50% and 38%, respectively).
Data source: The four-armed randomized study comprised 69 patients on hemodialysis or peritoneal dialysis.
Disclosures: Dr. Hung has served on advisory boards for Pfizer and Gilead Sciences.
Lung cancer metastatic sites differ by histology, tumor factors
GENEVA – A review of data on more than 75,000 patients with lung cancer has revealed distinct patterns of metastasis according to subtype, a finding that could help in surveillance, treatment planning, and prophylaxis, an investigator contends.
Patients with small cell lung cancer (SCLC) had significantly higher rates of liver metastases than patients with non–small cell lung cancer (NSCLC), while patients with NSCLC had significantly higher rates of metastases to bone, reported Mohamed Hendawi, MD, a visiting scholar at the Ohio State University Medical Center in Columbus.
“Predictors for liver metastasis were small cell and adenocarcinoma histology, lower and upper lobe locations, and high grade tumors. Predictors for metastasis to brain were advanced age at diagnosis, adenocarcinoma and small-cell histology, lower lobe [and] main bronchus locations, and high grade tumors,” he wrote in a scientific poster presented at the European Lung Cancer Conference.
Dr. Hendawi drew records on all patients with metastatic lung cancer included in the 2010-2013 Surveillance, Epidemiology, and End Results database. He used univariate and multivariate logistic regression models to evaluate predictors of metastasis.
The data set included a total of 76,254 patients with metastatic lung cancer, of which 17% were SCLC and 83% were NSCLC tumors. In 54% of patients, the primary tumor was in the right lung; in 38%, it was in the left lung; and, in 8% of patients, the primary tumor was bilateral.
The rates of metastases to bone were high in both major lung cancer types but, as noted before, were significantly higher in patients with NSCLC: 37% compared with 34% for patients with SCLC (P less than .001).
In contrast, the incidence of liver metastases in SCLC was more than double that of NSCLC: 46% vs. 20%, respectively (P less than .001). There were slightly, but significantly, fewer cases of brain metastases at the time of diagnosis among patients with SCLC: 25% vs. 26% (P = .003).
Histologic subtypes significantly associated with both brain and liver metastases were, in descending order, adenocarcinomas, small cell, and squamous cell cancers.
Although carcinoid lung cancers accounted for only 2.1% of all tumors, they were associated with a high rate of metastasis to brain at diagnosis (44.8%).
As noted, independent risk factors for liver metastasis were small cell and adenocarcinoma histologies (P less than .001), tumors in the upper lobe (P = .028), and high-grade tumor (P less than .001).
Independent predictors for brain metastases were advanced age at diagnosis (P less than .001), adenocarcinoma and small-cell histologies (P less than .001), lower lobe or main bronchus locations (P = .004), and higher-grade tumors (P less than .001).
In a poster discussion session, Paolo Boffetta, MD, MPH, from the Icahn School of Medicine at Mount Sinai in New York City, the invited discussant, commented that, while he thought that the data were interesting, “the main issue I had with this poster is that it’s limited to patients with metastasis, so we cannot really evaluate the risk of metastasis according to the different histological types and the absolute risk of developing metastases in one or the other organ but only the relative risk of developing metastasis in one organ versus the other having one or the other histology.”
“So, we really don’t know whether the risk is increased in one group or decreased in the other one that generates these differences,” he said.
The study did not receive outside support. Dr. Hendawi declared no conflicts of interest.
GENEVA – A review of data on more than 75,000 patients with lung cancer has revealed distinct patterns of metastasis according to subtype, a finding that could help in surveillance, treatment planning, and prophylaxis, an investigator contends.
Patients with small cell lung cancer (SCLC) had significantly higher rates of liver metastases than patients with non–small cell lung cancer (NSCLC), while patients with NSCLC had significantly higher rates of metastases to bone, reported Mohamed Hendawi, MD, a visiting scholar at the Ohio State University Medical Center in Columbus.
“Predictors for liver metastasis were small cell and adenocarcinoma histology, lower and upper lobe locations, and high grade tumors. Predictors for metastasis to brain were advanced age at diagnosis, adenocarcinoma and small-cell histology, lower lobe [and] main bronchus locations, and high grade tumors,” he wrote in a scientific poster presented at the European Lung Cancer Conference.
Dr. Hendawi drew records on all patients with metastatic lung cancer included in the 2010-2013 Surveillance, Epidemiology, and End Results database. He used univariate and multivariate logistic regression models to evaluate predictors of metastasis.
The data set included a total of 76,254 patients with metastatic lung cancer, of which 17% were SCLC and 83% were NSCLC tumors. In 54% of patients, the primary tumor was in the right lung; in 38%, it was in the left lung; and, in 8% of patients, the primary tumor was bilateral.
The rates of metastases to bone were high in both major lung cancer types but, as noted before, were significantly higher in patients with NSCLC: 37% compared with 34% for patients with SCLC (P less than .001).
In contrast, the incidence of liver metastases in SCLC was more than double that of NSCLC: 46% vs. 20%, respectively (P less than .001). There were slightly, but significantly, fewer cases of brain metastases at the time of diagnosis among patients with SCLC: 25% vs. 26% (P = .003).
Histologic subtypes significantly associated with both brain and liver metastases were, in descending order, adenocarcinomas, small cell, and squamous cell cancers.
Although carcinoid lung cancers accounted for only 2.1% of all tumors, they were associated with a high rate of metastasis to brain at diagnosis (44.8%).
As noted, independent risk factors for liver metastasis were small cell and adenocarcinoma histologies (P less than .001), tumors in the upper lobe (P = .028), and high-grade tumor (P less than .001).
Independent predictors for brain metastases were advanced age at diagnosis (P less than .001), adenocarcinoma and small-cell histologies (P less than .001), lower lobe or main bronchus locations (P = .004), and higher-grade tumors (P less than .001).
In a poster discussion session, Paolo Boffetta, MD, MPH, from the Icahn School of Medicine at Mount Sinai in New York City, the invited discussant, commented that, while he thought that the data were interesting, “the main issue I had with this poster is that it’s limited to patients with metastasis, so we cannot really evaluate the risk of metastasis according to the different histological types and the absolute risk of developing metastases in one or the other organ but only the relative risk of developing metastasis in one organ versus the other having one or the other histology.”
“So, we really don’t know whether the risk is increased in one group or decreased in the other one that generates these differences,” he said.
The study did not receive outside support. Dr. Hendawi declared no conflicts of interest.
GENEVA – A review of data on more than 75,000 patients with lung cancer has revealed distinct patterns of metastasis according to subtype, a finding that could help in surveillance, treatment planning, and prophylaxis, an investigator contends.
Patients with small cell lung cancer (SCLC) had significantly higher rates of liver metastases than patients with non–small cell lung cancer (NSCLC), while patients with NSCLC had significantly higher rates of metastases to bone, reported Mohamed Hendawi, MD, a visiting scholar at the Ohio State University Medical Center in Columbus.
“Predictors for liver metastasis were small cell and adenocarcinoma histology, lower and upper lobe locations, and high grade tumors. Predictors for metastasis to brain were advanced age at diagnosis, adenocarcinoma and small-cell histology, lower lobe [and] main bronchus locations, and high grade tumors,” he wrote in a scientific poster presented at the European Lung Cancer Conference.
Dr. Hendawi drew records on all patients with metastatic lung cancer included in the 2010-2013 Surveillance, Epidemiology, and End Results database. He used univariate and multivariate logistic regression models to evaluate predictors of metastasis.
The data set included a total of 76,254 patients with metastatic lung cancer, of which 17% were SCLC and 83% were NSCLC tumors. In 54% of patients, the primary tumor was in the right lung; in 38%, it was in the left lung; and, in 8% of patients, the primary tumor was bilateral.
The rates of metastases to bone were high in both major lung cancer types but, as noted before, were significantly higher in patients with NSCLC: 37% compared with 34% for patients with SCLC (P less than .001).
In contrast, the incidence of liver metastases in SCLC was more than double that of NSCLC: 46% vs. 20%, respectively (P less than .001). There were slightly, but significantly, fewer cases of brain metastases at the time of diagnosis among patients with SCLC: 25% vs. 26% (P = .003).
Histologic subtypes significantly associated with both brain and liver metastases were, in descending order, adenocarcinomas, small cell, and squamous cell cancers.
Although carcinoid lung cancers accounted for only 2.1% of all tumors, they were associated with a high rate of metastasis to brain at diagnosis (44.8%).
As noted, independent risk factors for liver metastasis were small cell and adenocarcinoma histologies (P less than .001), tumors in the upper lobe (P = .028), and high-grade tumor (P less than .001).
Independent predictors for brain metastases were advanced age at diagnosis (P less than .001), adenocarcinoma and small-cell histologies (P less than .001), lower lobe or main bronchus locations (P = .004), and higher-grade tumors (P less than .001).
In a poster discussion session, Paolo Boffetta, MD, MPH, from the Icahn School of Medicine at Mount Sinai in New York City, the invited discussant, commented that, while he thought that the data were interesting, “the main issue I had with this poster is that it’s limited to patients with metastasis, so we cannot really evaluate the risk of metastasis according to the different histological types and the absolute risk of developing metastases in one or the other organ but only the relative risk of developing metastasis in one organ versus the other having one or the other histology.”
“So, we really don’t know whether the risk is increased in one group or decreased in the other one that generates these differences,” he said.
The study did not receive outside support. Dr. Hendawi declared no conflicts of interest.
FROM ELCC
Key clinical point: Lung cancers tend to metastasize to different organs based on histology and other clinical factors.
Major finding: The incidence of metastasis to bone was higher in patients with NSCLC than SCLC, while liver metastases were more than twice as high among patients with SCLC.
Data source: Review of Surveillance, Epidemiology, and End Results data on 76,254 patients with metastatic lung cancer.
Disclosures: The study did not receive outside support. Dr. Hendawi declared no conflicts of interest.
Molecular tests for GAS pharyngitis could spur overuse of antibiotics
SAN FRANCISCO – The diagnosis of pharyngitis due to infection by group A streptococcus (GAS) based on the detection of nucleic acid is fast and accurate. But this benefit brings the possibility of overuse of antibiotics, with treatment offered to those who, in the era of growth-based detection of the bacteria, would not have received treatment, according to Robert R. Tanz, MD.
Dr. Tanz, professor of pediatrics at Northwestern University, Chicago, delivered this cautionary note at the meeting of the Pediatrics Academics Societies.
“The short turnaround time, high sensitivity, and high specificity of newer molecular tests for GAS will make their use increasingly common. Many of the additional patients identified by molecular testing may not have an illness attributable to GAS. The increase in positive tests will probably be associated with increased antibiotic prescribing. This may not be beneficial, especially in areas with low rates of acute rheumatic fever,” said Dr. Tanz, who practices at Ann & Robert Lurie Children’s Hospital of Chicago.
Nowadays, diagnosis of GAS at Ann & Robert Lurie Children’s Hospital uses the Illumigene system. Its use has been approved by the Food and Drug Administration for diagnosis without the need for backup culture of throat swabs. Results are available in about 1 hour.
Dr. Tanz and his colleagues took a retrospective look at patient records during 2013, when testing was still growth-based, and in 2014 and 2015, after the hospital had shifted to the molecular analysis of throat swabs. The aim was to determine the proportion of tests positive for GAS prior to and after the switch.
The positive detection rate of 9.6% (96 of 997 samples) in 2013 climbed to 17% (152 of 894) in 2014 and 16% (138 of 859) in 2015. The difference was highly significant (P less than .00001).
Sore throats increase in the colder months when people tend to be indoors more often, and this seasonality was evident in 2013. However, detection was more consistent throughout the 12 months in 2014 (2013 vs 2014, P less than .000001) and 2015 (2013 vs 2015, P less than .00001). The detection rates in 2014 and 2015 were similar (P equal to .59), according to Dr. Tanz.
The new era of molecular testing circumvents what is known as the spectrum effect, in which culture-based tests are more often positive in patients with symptoms that are consistent with the infection, he said. In contrast, molecular tests can increase the identification of the target bacterium, here GAS, in patients who have sore throat caused by a viral infection.
Preliminary results presented by Dr. Tanz indicated a significantly greater detection of GAS in children not displaying symptoms of infection. In decades past, these children would not have been treated.
“The increase in positive tests for group A strep is likely associated with increased antibiotic prescribing. This may or may not represent a benefit to patients, as the additional identified patients may not have an illness actually attributable to group A strep,” said Dr. Tanz.
“Our findings support rigorous selectivity in choosing which patients to test, specifically excluding those with overt viral symptoms, as recommended in the guidelines from the [Infectious Diseases Society of America], [American Academy of Pediatrics], and other groups,” he said, adding that clinician guidance on the use of molecular diagnostic tests for pharyngitis caused by group A strep is a prudent step.
Features suggestive of GAS may include sudden onset of sore throat, age 5-15 years, fever, headache, nausea, vomiting, and abdominal pain, tonsillopharyngeal inflammation and patchy tonsillopharyngeal exudates, palatal petechiae, tender nodes, and scarlatiniform rash. Viral pharyngitis features include conjunctivitis, coryza, cough, diarrhea, discrete ulcerative stomatitis, viral exanthema, and hoarseness, according to the 2012 Infectious Diseases Society of American guidelines (Clin Infect Dis. 2012. doi: 10.1093/cid/cis629).
For most people, a sore throat is more of a temporary inconvenience rather than a looming health threat, but GAS easily spreads from person to person and can lead to the more serious condition of acute rheumatic fever, Dr. Tanz said. Hence the concern with diagnosing the cause of sore throat and, when the cause is bacterial, alleviating the infection using antibiotics.
The study was conducted at Ann & Robert H. Lurie Children’s Hospital of Chicago and was not funded. Dr. Tanz reported having received support from Meridian Bioscience, manufacturer of the Illumigene Group A Streptococcus assay. Meridian Bioscience did not support this study.
SAN FRANCISCO – The diagnosis of pharyngitis due to infection by group A streptococcus (GAS) based on the detection of nucleic acid is fast and accurate. But this benefit brings the possibility of overuse of antibiotics, with treatment offered to those who, in the era of growth-based detection of the bacteria, would not have received treatment, according to Robert R. Tanz, MD.
Dr. Tanz, professor of pediatrics at Northwestern University, Chicago, delivered this cautionary note at the meeting of the Pediatrics Academics Societies.
“The short turnaround time, high sensitivity, and high specificity of newer molecular tests for GAS will make their use increasingly common. Many of the additional patients identified by molecular testing may not have an illness attributable to GAS. The increase in positive tests will probably be associated with increased antibiotic prescribing. This may not be beneficial, especially in areas with low rates of acute rheumatic fever,” said Dr. Tanz, who practices at Ann & Robert Lurie Children’s Hospital of Chicago.
Nowadays, diagnosis of GAS at Ann & Robert Lurie Children’s Hospital uses the Illumigene system. Its use has been approved by the Food and Drug Administration for diagnosis without the need for backup culture of throat swabs. Results are available in about 1 hour.
Dr. Tanz and his colleagues took a retrospective look at patient records during 2013, when testing was still growth-based, and in 2014 and 2015, after the hospital had shifted to the molecular analysis of throat swabs. The aim was to determine the proportion of tests positive for GAS prior to and after the switch.
The positive detection rate of 9.6% (96 of 997 samples) in 2013 climbed to 17% (152 of 894) in 2014 and 16% (138 of 859) in 2015. The difference was highly significant (P less than .00001).
Sore throats increase in the colder months when people tend to be indoors more often, and this seasonality was evident in 2013. However, detection was more consistent throughout the 12 months in 2014 (2013 vs 2014, P less than .000001) and 2015 (2013 vs 2015, P less than .00001). The detection rates in 2014 and 2015 were similar (P equal to .59), according to Dr. Tanz.
The new era of molecular testing circumvents what is known as the spectrum effect, in which culture-based tests are more often positive in patients with symptoms that are consistent with the infection, he said. In contrast, molecular tests can increase the identification of the target bacterium, here GAS, in patients who have sore throat caused by a viral infection.
Preliminary results presented by Dr. Tanz indicated a significantly greater detection of GAS in children not displaying symptoms of infection. In decades past, these children would not have been treated.
“The increase in positive tests for group A strep is likely associated with increased antibiotic prescribing. This may or may not represent a benefit to patients, as the additional identified patients may not have an illness actually attributable to group A strep,” said Dr. Tanz.
“Our findings support rigorous selectivity in choosing which patients to test, specifically excluding those with overt viral symptoms, as recommended in the guidelines from the [Infectious Diseases Society of America], [American Academy of Pediatrics], and other groups,” he said, adding that clinician guidance on the use of molecular diagnostic tests for pharyngitis caused by group A strep is a prudent step.
Features suggestive of GAS may include sudden onset of sore throat, age 5-15 years, fever, headache, nausea, vomiting, and abdominal pain, tonsillopharyngeal inflammation and patchy tonsillopharyngeal exudates, palatal petechiae, tender nodes, and scarlatiniform rash. Viral pharyngitis features include conjunctivitis, coryza, cough, diarrhea, discrete ulcerative stomatitis, viral exanthema, and hoarseness, according to the 2012 Infectious Diseases Society of American guidelines (Clin Infect Dis. 2012. doi: 10.1093/cid/cis629).
For most people, a sore throat is more of a temporary inconvenience rather than a looming health threat, but GAS easily spreads from person to person and can lead to the more serious condition of acute rheumatic fever, Dr. Tanz said. Hence the concern with diagnosing the cause of sore throat and, when the cause is bacterial, alleviating the infection using antibiotics.
The study was conducted at Ann & Robert H. Lurie Children’s Hospital of Chicago and was not funded. Dr. Tanz reported having received support from Meridian Bioscience, manufacturer of the Illumigene Group A Streptococcus assay. Meridian Bioscience did not support this study.
SAN FRANCISCO – The diagnosis of pharyngitis due to infection by group A streptococcus (GAS) based on the detection of nucleic acid is fast and accurate. But this benefit brings the possibility of overuse of antibiotics, with treatment offered to those who, in the era of growth-based detection of the bacteria, would not have received treatment, according to Robert R. Tanz, MD.
Dr. Tanz, professor of pediatrics at Northwestern University, Chicago, delivered this cautionary note at the meeting of the Pediatrics Academics Societies.
“The short turnaround time, high sensitivity, and high specificity of newer molecular tests for GAS will make their use increasingly common. Many of the additional patients identified by molecular testing may not have an illness attributable to GAS. The increase in positive tests will probably be associated with increased antibiotic prescribing. This may not be beneficial, especially in areas with low rates of acute rheumatic fever,” said Dr. Tanz, who practices at Ann & Robert Lurie Children’s Hospital of Chicago.
Nowadays, diagnosis of GAS at Ann & Robert Lurie Children’s Hospital uses the Illumigene system. Its use has been approved by the Food and Drug Administration for diagnosis without the need for backup culture of throat swabs. Results are available in about 1 hour.
Dr. Tanz and his colleagues took a retrospective look at patient records during 2013, when testing was still growth-based, and in 2014 and 2015, after the hospital had shifted to the molecular analysis of throat swabs. The aim was to determine the proportion of tests positive for GAS prior to and after the switch.
The positive detection rate of 9.6% (96 of 997 samples) in 2013 climbed to 17% (152 of 894) in 2014 and 16% (138 of 859) in 2015. The difference was highly significant (P less than .00001).
Sore throats increase in the colder months when people tend to be indoors more often, and this seasonality was evident in 2013. However, detection was more consistent throughout the 12 months in 2014 (2013 vs 2014, P less than .000001) and 2015 (2013 vs 2015, P less than .00001). The detection rates in 2014 and 2015 were similar (P equal to .59), according to Dr. Tanz.
The new era of molecular testing circumvents what is known as the spectrum effect, in which culture-based tests are more often positive in patients with symptoms that are consistent with the infection, he said. In contrast, molecular tests can increase the identification of the target bacterium, here GAS, in patients who have sore throat caused by a viral infection.
Preliminary results presented by Dr. Tanz indicated a significantly greater detection of GAS in children not displaying symptoms of infection. In decades past, these children would not have been treated.
“The increase in positive tests for group A strep is likely associated with increased antibiotic prescribing. This may or may not represent a benefit to patients, as the additional identified patients may not have an illness actually attributable to group A strep,” said Dr. Tanz.
“Our findings support rigorous selectivity in choosing which patients to test, specifically excluding those with overt viral symptoms, as recommended in the guidelines from the [Infectious Diseases Society of America], [American Academy of Pediatrics], and other groups,” he said, adding that clinician guidance on the use of molecular diagnostic tests for pharyngitis caused by group A strep is a prudent step.
Features suggestive of GAS may include sudden onset of sore throat, age 5-15 years, fever, headache, nausea, vomiting, and abdominal pain, tonsillopharyngeal inflammation and patchy tonsillopharyngeal exudates, palatal petechiae, tender nodes, and scarlatiniform rash. Viral pharyngitis features include conjunctivitis, coryza, cough, diarrhea, discrete ulcerative stomatitis, viral exanthema, and hoarseness, according to the 2012 Infectious Diseases Society of American guidelines (Clin Infect Dis. 2012. doi: 10.1093/cid/cis629).
For most people, a sore throat is more of a temporary inconvenience rather than a looming health threat, but GAS easily spreads from person to person and can lead to the more serious condition of acute rheumatic fever, Dr. Tanz said. Hence the concern with diagnosing the cause of sore throat and, when the cause is bacterial, alleviating the infection using antibiotics.
The study was conducted at Ann & Robert H. Lurie Children’s Hospital of Chicago and was not funded. Dr. Tanz reported having received support from Meridian Bioscience, manufacturer of the Illumigene Group A Streptococcus assay. Meridian Bioscience did not support this study.
Key clinical point: The increased molecular-based detection of group A streptococci could led to antibiotic overuse, with prescriptions for patients who do not have bacterial infections.
Major finding: In the most recent year of culture-based testing at Lurie Children’s Hospital, the detection rate of group A streptococci was 9.6%; detection rates were 17.0% and 16.1% in the next 2 years when molecular-based analysis was implemented.
Data source: Quality assessment study involving a retrospective review of hospital electronic medical records.
Disclosures: The study was conducted at Ann & Robert H. Lurie Children’s Hospital of Chicago and was not funded. Dr. Tanz reported having received support from Meridian Bioscience, manufacturer of the Illumigene Group A Streptococcus assay. Meridian Bioscience did not support this study.
Survival in the first 3 years of ART continues to improve
Mortality continues to decline for patients in the first 3 years of combination antiretroviral therapy (ART) for HIV-1 infection, according to an analysis of 18 different cohorts from 1996 to 2013.
The Antiretroviral Therapy Cohort Collaboration (ART-CC) combined data from participating cohorts from Europe and North America. Patients were at least 16 years of age, naive to ART, and starting treatment with three or more antiretroviral drugs between 1996 and 2010. Of 88,504 patients, 2% died in the first year of ART, and 3% died in the second or third year of ART.
Where the ART-CC previously reported that mortality within 1 year of starting ART had not improved from 1998 to 2003, the current analysis found lower mortality in the first year for patients starting ART in the years 2008 to 2010, compared with patients starting ART in the years 2000 to 2003 (hazard ratio, 0.71; 95% confidence interval, 0.61-0.83).
All-cause mortality also was decreased in the second and third years of ART for those respective calendar periods (HR, 0.57; 95% CI, 0.49-0.67).
“Patients who started ART during 2008-2010 whose CD4 counts exceeded 350 cells per microL 1 year after ART initiation have estimated life expectancy approaching that of the general population,” Dr. Trickey and his colleagues said.
The authors speculate that the improvements in mortality may result from better ART regimens and improved adherence. Declines in all-cause mortality may reflect better management of comorbidities.
Given the high effectiveness of ART today, for further improvement “lifestyle issues that affect adherence to ART and non-AIDS mortality, and diagnosis and treatment of comorbidities in people living with HIV will need to be addressed,” Dr. Trickey and his coauthors concluded.
The study received funding from the United Kingdom Medical Research Council, the United Kingdom Department for International Development, and the European Union European & Developing Countries Clinical Trials Partnership (EDCTP2) program. Dr. Trickey reported no conflicts of interest. Some members of the writing committee received fees from various drug companies for work unrelated to this study.
This article was updated on 5/18/17.
Mortality continues to decline for patients in the first 3 years of combination antiretroviral therapy (ART) for HIV-1 infection, according to an analysis of 18 different cohorts from 1996 to 2013.
The Antiretroviral Therapy Cohort Collaboration (ART-CC) combined data from participating cohorts from Europe and North America. Patients were at least 16 years of age, naive to ART, and starting treatment with three or more antiretroviral drugs between 1996 and 2010. Of 88,504 patients, 2% died in the first year of ART, and 3% died in the second or third year of ART.
Where the ART-CC previously reported that mortality within 1 year of starting ART had not improved from 1998 to 2003, the current analysis found lower mortality in the first year for patients starting ART in the years 2008 to 2010, compared with patients starting ART in the years 2000 to 2003 (hazard ratio, 0.71; 95% confidence interval, 0.61-0.83).
All-cause mortality also was decreased in the second and third years of ART for those respective calendar periods (HR, 0.57; 95% CI, 0.49-0.67).
“Patients who started ART during 2008-2010 whose CD4 counts exceeded 350 cells per microL 1 year after ART initiation have estimated life expectancy approaching that of the general population,” Dr. Trickey and his colleagues said.
The authors speculate that the improvements in mortality may result from better ART regimens and improved adherence. Declines in all-cause mortality may reflect better management of comorbidities.
Given the high effectiveness of ART today, for further improvement “lifestyle issues that affect adherence to ART and non-AIDS mortality, and diagnosis and treatment of comorbidities in people living with HIV will need to be addressed,” Dr. Trickey and his coauthors concluded.
The study received funding from the United Kingdom Medical Research Council, the United Kingdom Department for International Development, and the European Union European & Developing Countries Clinical Trials Partnership (EDCTP2) program. Dr. Trickey reported no conflicts of interest. Some members of the writing committee received fees from various drug companies for work unrelated to this study.
This article was updated on 5/18/17.
Mortality continues to decline for patients in the first 3 years of combination antiretroviral therapy (ART) for HIV-1 infection, according to an analysis of 18 different cohorts from 1996 to 2013.
The Antiretroviral Therapy Cohort Collaboration (ART-CC) combined data from participating cohorts from Europe and North America. Patients were at least 16 years of age, naive to ART, and starting treatment with three or more antiretroviral drugs between 1996 and 2010. Of 88,504 patients, 2% died in the first year of ART, and 3% died in the second or third year of ART.
Where the ART-CC previously reported that mortality within 1 year of starting ART had not improved from 1998 to 2003, the current analysis found lower mortality in the first year for patients starting ART in the years 2008 to 2010, compared with patients starting ART in the years 2000 to 2003 (hazard ratio, 0.71; 95% confidence interval, 0.61-0.83).
All-cause mortality also was decreased in the second and third years of ART for those respective calendar periods (HR, 0.57; 95% CI, 0.49-0.67).
“Patients who started ART during 2008-2010 whose CD4 counts exceeded 350 cells per microL 1 year after ART initiation have estimated life expectancy approaching that of the general population,” Dr. Trickey and his colleagues said.
The authors speculate that the improvements in mortality may result from better ART regimens and improved adherence. Declines in all-cause mortality may reflect better management of comorbidities.
Given the high effectiveness of ART today, for further improvement “lifestyle issues that affect adherence to ART and non-AIDS mortality, and diagnosis and treatment of comorbidities in people living with HIV will need to be addressed,” Dr. Trickey and his coauthors concluded.
The study received funding from the United Kingdom Medical Research Council, the United Kingdom Department for International Development, and the European Union European & Developing Countries Clinical Trials Partnership (EDCTP2) program. Dr. Trickey reported no conflicts of interest. Some members of the writing committee received fees from various drug companies for work unrelated to this study.
This article was updated on 5/18/17.
FROM THE LANCET HIV
Key clinical point: Mortality continues to decline for patients in the first 3 years of taking ART for HIV-1 infection.
Major finding: The current analysis found lower mortality in the first year for patients starting ART in the years 2008 to 2010, compared with patients starting ART in the years 2000 to 2003 (HR, 0.71; 95% CI, 0.61-0.83).
Data source: An analysis of 18 different cohorts in Europe and North America from 1996 to 2013.
Disclosures: The study received funding from the United Kingdom Medical Research Council, the United Kingdom Department for International Development, and the European Union European & Developing Countries Clinical Trials Partnership (EDCTP2) program. Some members of the writing committee received fees from various drug companies for work unrelated to this study.
Children exposed to violence show accelerated cellular aging
SAN FRANCISCO – Children exposed to high levels of urban violence demonstrate accelerated cellular aging beyond their chronologic years, Vasiliki Michopoulos, PhD, reported at the annual conference of the Anxiety and Depression Association of America.
This fast-running cellular biologic clock is not a good thing. Neither is their blunted heart rate variability in response to stress, an indicator of autonomic dysfunction that constitutes a cardiovascular risk factor, she added.
Accelerated cellular aging as measured by DNA methylation in blood or saliva samples has become a red hot research area. Investigators have shown that a person’s DNA methylation age, also known as epigenetic age, predicts all-cause mortality risk in later life. In adults, accelerated cellular aging as reflected in a 5-year discrepancy between DNA methylation age and chronologic age is predictive of an adjusted 16% increased mortality risk independent of social class, education level, lifestyle factors, and chronic diseases, including diabetes and cardiovascular disease (Genome Biol. 2015 Jan 30;16:25).
Lifetime exposure to stress has been convincingly shown to accelerate epigenetic aging, as reflected by DNA methylation level. But, prior to Dr. Michopoulos’s study, it wasn’t known if exposure to violence during childhood influences epigenetic aging or if perhaps only later-life trauma is relevant.
To address this question, she and her coinvestigators recruited 101 African American children aged 6-11 years and their mothers. Of note, medical attention wasn’t being sought for the children. Rather, their mothers were approached regarding study participation while attending primary care clinics at Atlanta’s Grady Memorial Hospital. Children were not eligible to participate if they had been diagnosed with autism spectrum disorder, bipolar disorder, cognitive impairment, or a psychotic disorder.
The children had been exposed to a lot of violence, both witnessed and directly experienced, as reflected in their mean total score of 18.9 on the Violence Exposure Scale for Children-Revised (VEX-R). More than 80% of the children had witnessed an assault and 30% a murder. Stabbings, shootings, drug trafficking, and arrests were other common exposures.
One-quarter of the children showed accelerated cellular aging. They had experienced twice as much violence exposure as reflected in their VEX-R scores, compared with children whose epigenetic and chronologic ages were the same.
The children with accelerated cellular aging also demonstrated decreased heart rate variability in response to a standardized stressor, which involved a startle experience in a darkened room. Their heart rate in the stressor situation shot up on average by 17 bpm less than the children whose cellular age as measured by DNA methylation matched their chronologic age.
“Our data suggest that DNA methylation may serve as a biomarker by which to identify at-risk individuals who may benefit from interventions that decrease risk for cardiometabolic disorders in adulthood,” Dr. Michopoulos said. “It’ll be really interesting to see, as these kids grow up and develop, whether their phenotype stays static, reverses, or changes completely.”
Dr. Michopoulos reported having no financial conflicts regarding the study, conducted as part of the Grady Trauma Project (www.gradytraumaproject.com) with funding from the National Institute of Mental Health and Emory University and Grady Memorial Hospital, both in Atlanta.
SAN FRANCISCO – Children exposed to high levels of urban violence demonstrate accelerated cellular aging beyond their chronologic years, Vasiliki Michopoulos, PhD, reported at the annual conference of the Anxiety and Depression Association of America.
This fast-running cellular biologic clock is not a good thing. Neither is their blunted heart rate variability in response to stress, an indicator of autonomic dysfunction that constitutes a cardiovascular risk factor, she added.
Accelerated cellular aging as measured by DNA methylation in blood or saliva samples has become a red hot research area. Investigators have shown that a person’s DNA methylation age, also known as epigenetic age, predicts all-cause mortality risk in later life. In adults, accelerated cellular aging as reflected in a 5-year discrepancy between DNA methylation age and chronologic age is predictive of an adjusted 16% increased mortality risk independent of social class, education level, lifestyle factors, and chronic diseases, including diabetes and cardiovascular disease (Genome Biol. 2015 Jan 30;16:25).
Lifetime exposure to stress has been convincingly shown to accelerate epigenetic aging, as reflected by DNA methylation level. But, prior to Dr. Michopoulos’s study, it wasn’t known if exposure to violence during childhood influences epigenetic aging or if perhaps only later-life trauma is relevant.
To address this question, she and her coinvestigators recruited 101 African American children aged 6-11 years and their mothers. Of note, medical attention wasn’t being sought for the children. Rather, their mothers were approached regarding study participation while attending primary care clinics at Atlanta’s Grady Memorial Hospital. Children were not eligible to participate if they had been diagnosed with autism spectrum disorder, bipolar disorder, cognitive impairment, or a psychotic disorder.
The children had been exposed to a lot of violence, both witnessed and directly experienced, as reflected in their mean total score of 18.9 on the Violence Exposure Scale for Children-Revised (VEX-R). More than 80% of the children had witnessed an assault and 30% a murder. Stabbings, shootings, drug trafficking, and arrests were other common exposures.
One-quarter of the children showed accelerated cellular aging. They had experienced twice as much violence exposure as reflected in their VEX-R scores, compared with children whose epigenetic and chronologic ages were the same.
The children with accelerated cellular aging also demonstrated decreased heart rate variability in response to a standardized stressor, which involved a startle experience in a darkened room. Their heart rate in the stressor situation shot up on average by 17 bpm less than the children whose cellular age as measured by DNA methylation matched their chronologic age.
“Our data suggest that DNA methylation may serve as a biomarker by which to identify at-risk individuals who may benefit from interventions that decrease risk for cardiometabolic disorders in adulthood,” Dr. Michopoulos said. “It’ll be really interesting to see, as these kids grow up and develop, whether their phenotype stays static, reverses, or changes completely.”
Dr. Michopoulos reported having no financial conflicts regarding the study, conducted as part of the Grady Trauma Project (www.gradytraumaproject.com) with funding from the National Institute of Mental Health and Emory University and Grady Memorial Hospital, both in Atlanta.
SAN FRANCISCO – Children exposed to high levels of urban violence demonstrate accelerated cellular aging beyond their chronologic years, Vasiliki Michopoulos, PhD, reported at the annual conference of the Anxiety and Depression Association of America.
This fast-running cellular biologic clock is not a good thing. Neither is their blunted heart rate variability in response to stress, an indicator of autonomic dysfunction that constitutes a cardiovascular risk factor, she added.
Accelerated cellular aging as measured by DNA methylation in blood or saliva samples has become a red hot research area. Investigators have shown that a person’s DNA methylation age, also known as epigenetic age, predicts all-cause mortality risk in later life. In adults, accelerated cellular aging as reflected in a 5-year discrepancy between DNA methylation age and chronologic age is predictive of an adjusted 16% increased mortality risk independent of social class, education level, lifestyle factors, and chronic diseases, including diabetes and cardiovascular disease (Genome Biol. 2015 Jan 30;16:25).
Lifetime exposure to stress has been convincingly shown to accelerate epigenetic aging, as reflected by DNA methylation level. But, prior to Dr. Michopoulos’s study, it wasn’t known if exposure to violence during childhood influences epigenetic aging or if perhaps only later-life trauma is relevant.
To address this question, she and her coinvestigators recruited 101 African American children aged 6-11 years and their mothers. Of note, medical attention wasn’t being sought for the children. Rather, their mothers were approached regarding study participation while attending primary care clinics at Atlanta’s Grady Memorial Hospital. Children were not eligible to participate if they had been diagnosed with autism spectrum disorder, bipolar disorder, cognitive impairment, or a psychotic disorder.
The children had been exposed to a lot of violence, both witnessed and directly experienced, as reflected in their mean total score of 18.9 on the Violence Exposure Scale for Children-Revised (VEX-R). More than 80% of the children had witnessed an assault and 30% a murder. Stabbings, shootings, drug trafficking, and arrests were other common exposures.
One-quarter of the children showed accelerated cellular aging. They had experienced twice as much violence exposure as reflected in their VEX-R scores, compared with children whose epigenetic and chronologic ages were the same.
The children with accelerated cellular aging also demonstrated decreased heart rate variability in response to a standardized stressor, which involved a startle experience in a darkened room. Their heart rate in the stressor situation shot up on average by 17 bpm less than the children whose cellular age as measured by DNA methylation matched their chronologic age.
“Our data suggest that DNA methylation may serve as a biomarker by which to identify at-risk individuals who may benefit from interventions that decrease risk for cardiometabolic disorders in adulthood,” Dr. Michopoulos said. “It’ll be really interesting to see, as these kids grow up and develop, whether their phenotype stays static, reverses, or changes completely.”
Dr. Michopoulos reported having no financial conflicts regarding the study, conducted as part of the Grady Trauma Project (www.gradytraumaproject.com) with funding from the National Institute of Mental Health and Emory University and Grady Memorial Hospital, both in Atlanta.
AT THE ANXIETY AND DEPRESSION CONFERENCE 2017
Key clinical point:
Major finding: Children who demonstrated advanced cellular aging based on DNA methylation levels had experienced twice as much exposure to violence as those whose epigenetic and chronologic ages matched.
Data source: This cross-sectional study included 101 urban African American children aged 6-11 years.
Disclosures: The presenter reported having no financial conflicts regarding the study, which was funded by the National Institute of Mental Health and Emory University and Grady Memorial Hospital, both in Atlanta.
Intensive BP lowering may reduce larger hematoma expansion in ICH
BOSTON – Intensive systolic blood pressure reduction did not significantly reduce hematoma expansion, compared with standard systolic blood pressure reduction in the Antihypertensive Treatment of Acute Cerebral Hemorrhage (ATACH) II trial, but, in a post hoc analysis, it did show a strong trend toward reducing hematoma expansion in those with a larger initial hematoma volume.
In 450 patients randomized to receive intensive treatment and 426 randomized to receive standard treatment in the large, international, phase III randomized trial, the proportion of patients with any hematoma expansion was 46.4% and 52.3% , respectively (relative risk, 0.89; 95% confidence interval, 0.73-1.07). The proportion with hematoma expansion with an increase of greater than 33% was 18.9% and 24.4%, respectively (RR, 0.77; 95% CI, 0.58-1.03), Joshua N. Goldstein, MD, reported at the annual meeting of the American Academy of Neurology.
The confidence intervals suggested only a trend toward improvement, as the difference between the groups did not reach statistical significance, he said.
To determine if intensive systolic blood pressure reduction might have more of an impact among higher-risk patients, the investigators conducted a post hoc, secondary analysis in those with relatively larger hematomas. Among patients with an initial hematoma volume of at least 10 mL (at least half of the study population had smaller hematomas), the proportion with any hematoma expansion was 53.8% in the intensive treatment group and 61.3% in the standard treatment group (RR, 0.88; 95% CI, 0.67-1.13), and the proportion of patients with hematoma expansion of greater than 33% was 18% and 27.6%, respectively (RR, 0.67; 95% CI, 0.45-1.00), said Dr. Goldstein of Massachusetts General Hospital, Boston.
In those with an expansion greater than 33% and a hematoma volume of at least 6 cc, the finding was similar.
“The trend looks a little bit more aggressive,” he said, but the 95% confidence interval in those with larger hematomas reached 1.
Study subjects had elevated blood pressure at arrival, a Glasgow coma scale score of at least 5, and a hematoma volume of less than 60 cc. They were enrolled and randomized within 4.5 hours of symptom onset. Those in the intensive treatment group were treated with a goal of achieving between 110 and 139 mm Hg within 24 hours, and those in the standard treatment group were treated with a goal of achieving between 140 mm Hg and 179 mm Hg within 24 hours. They underwent baseline and 24-hour computed tomography scans, which were analyzed centrally by blinded investigators who recorded any increase of 0.5 mL or more, an increase of more than 33% , an increase of more than 33% or more than 6 mL, and an intraventricular hemorrhage volume greater than 2 mL.
These measures were correlated with death and disability, and hematoma enlargement was shown to be significantly associated with those outcomes at 3 months after randomization (RR, 1.59; 95% CI, 1.25-2.02), Dr. Goldstein said.
Previous studies have suggested that intensive lowering of systolic BP in patients with intracerebral hemorrhage can reduce the rate of hematoma expansion. As such, the hypothesis of the current study was that the intensive treatment of elevated blood pressures – arriving systolic blood pressure of greater than 180 mm Hg – would reduce the likelihood of death and disability at 3 months, Dr. Goldstein said,
The question is whether the biomarker – hematoma expansion – is really linked to clinical outcome, he said, “because a lot of our attempts to treat hematoma expansion are based on the assumption that, if we reduce hematoma expansion, we’re going to improve clinical outcomes.”
“In this trial ... the expanders had more death and disability than nonexpanders, and this was statistically significant, so hematoma expansion does seem to be a statistically significant predictor of poor outcome,” he said.
Thus, the strong trend toward a reduced risk of hematoma expansion with intensive blood pressure lowering in patients with larger hematoma volumes at baseline in this analysis is noteworthy, he said.
“It appears that the treatment is affecting the biomarker, that the treatment is affecting hematoma expansion ... and hematoma expansion was a significant predictor of death and disability ... so why didn’t we get the result we wanted from the trial?” he asked.
It may be that a greater magnitude of reduction in the risk of hematoma expansion was necessary, he said.
“In other words, even if our treatment is having an effect, it’s just not having a big enough effect to change outcomes,” he said, adding that future trials probably need to involve a much bigger impact on the risk of expansion to translate to a change in clinical outcomes.”
This study was sponsored by the National Institute of Neurological Disorders and Stroke. Dr. Goldstein reported having no disclosures.
BOSTON – Intensive systolic blood pressure reduction did not significantly reduce hematoma expansion, compared with standard systolic blood pressure reduction in the Antihypertensive Treatment of Acute Cerebral Hemorrhage (ATACH) II trial, but, in a post hoc analysis, it did show a strong trend toward reducing hematoma expansion in those with a larger initial hematoma volume.
In 450 patients randomized to receive intensive treatment and 426 randomized to receive standard treatment in the large, international, phase III randomized trial, the proportion of patients with any hematoma expansion was 46.4% and 52.3% , respectively (relative risk, 0.89; 95% confidence interval, 0.73-1.07). The proportion with hematoma expansion with an increase of greater than 33% was 18.9% and 24.4%, respectively (RR, 0.77; 95% CI, 0.58-1.03), Joshua N. Goldstein, MD, reported at the annual meeting of the American Academy of Neurology.
The confidence intervals suggested only a trend toward improvement, as the difference between the groups did not reach statistical significance, he said.
To determine if intensive systolic blood pressure reduction might have more of an impact among higher-risk patients, the investigators conducted a post hoc, secondary analysis in those with relatively larger hematomas. Among patients with an initial hematoma volume of at least 10 mL (at least half of the study population had smaller hematomas), the proportion with any hematoma expansion was 53.8% in the intensive treatment group and 61.3% in the standard treatment group (RR, 0.88; 95% CI, 0.67-1.13), and the proportion of patients with hematoma expansion of greater than 33% was 18% and 27.6%, respectively (RR, 0.67; 95% CI, 0.45-1.00), said Dr. Goldstein of Massachusetts General Hospital, Boston.
In those with an expansion greater than 33% and a hematoma volume of at least 6 cc, the finding was similar.
“The trend looks a little bit more aggressive,” he said, but the 95% confidence interval in those with larger hematomas reached 1.
Study subjects had elevated blood pressure at arrival, a Glasgow coma scale score of at least 5, and a hematoma volume of less than 60 cc. They were enrolled and randomized within 4.5 hours of symptom onset. Those in the intensive treatment group were treated with a goal of achieving between 110 and 139 mm Hg within 24 hours, and those in the standard treatment group were treated with a goal of achieving between 140 mm Hg and 179 mm Hg within 24 hours. They underwent baseline and 24-hour computed tomography scans, which were analyzed centrally by blinded investigators who recorded any increase of 0.5 mL or more, an increase of more than 33% , an increase of more than 33% or more than 6 mL, and an intraventricular hemorrhage volume greater than 2 mL.
These measures were correlated with death and disability, and hematoma enlargement was shown to be significantly associated with those outcomes at 3 months after randomization (RR, 1.59; 95% CI, 1.25-2.02), Dr. Goldstein said.
Previous studies have suggested that intensive lowering of systolic BP in patients with intracerebral hemorrhage can reduce the rate of hematoma expansion. As such, the hypothesis of the current study was that the intensive treatment of elevated blood pressures – arriving systolic blood pressure of greater than 180 mm Hg – would reduce the likelihood of death and disability at 3 months, Dr. Goldstein said,
The question is whether the biomarker – hematoma expansion – is really linked to clinical outcome, he said, “because a lot of our attempts to treat hematoma expansion are based on the assumption that, if we reduce hematoma expansion, we’re going to improve clinical outcomes.”
“In this trial ... the expanders had more death and disability than nonexpanders, and this was statistically significant, so hematoma expansion does seem to be a statistically significant predictor of poor outcome,” he said.
Thus, the strong trend toward a reduced risk of hematoma expansion with intensive blood pressure lowering in patients with larger hematoma volumes at baseline in this analysis is noteworthy, he said.
“It appears that the treatment is affecting the biomarker, that the treatment is affecting hematoma expansion ... and hematoma expansion was a significant predictor of death and disability ... so why didn’t we get the result we wanted from the trial?” he asked.
It may be that a greater magnitude of reduction in the risk of hematoma expansion was necessary, he said.
“In other words, even if our treatment is having an effect, it’s just not having a big enough effect to change outcomes,” he said, adding that future trials probably need to involve a much bigger impact on the risk of expansion to translate to a change in clinical outcomes.”
This study was sponsored by the National Institute of Neurological Disorders and Stroke. Dr. Goldstein reported having no disclosures.
BOSTON – Intensive systolic blood pressure reduction did not significantly reduce hematoma expansion, compared with standard systolic blood pressure reduction in the Antihypertensive Treatment of Acute Cerebral Hemorrhage (ATACH) II trial, but, in a post hoc analysis, it did show a strong trend toward reducing hematoma expansion in those with a larger initial hematoma volume.
In 450 patients randomized to receive intensive treatment and 426 randomized to receive standard treatment in the large, international, phase III randomized trial, the proportion of patients with any hematoma expansion was 46.4% and 52.3% , respectively (relative risk, 0.89; 95% confidence interval, 0.73-1.07). The proportion with hematoma expansion with an increase of greater than 33% was 18.9% and 24.4%, respectively (RR, 0.77; 95% CI, 0.58-1.03), Joshua N. Goldstein, MD, reported at the annual meeting of the American Academy of Neurology.
The confidence intervals suggested only a trend toward improvement, as the difference between the groups did not reach statistical significance, he said.
To determine if intensive systolic blood pressure reduction might have more of an impact among higher-risk patients, the investigators conducted a post hoc, secondary analysis in those with relatively larger hematomas. Among patients with an initial hematoma volume of at least 10 mL (at least half of the study population had smaller hematomas), the proportion with any hematoma expansion was 53.8% in the intensive treatment group and 61.3% in the standard treatment group (RR, 0.88; 95% CI, 0.67-1.13), and the proportion of patients with hematoma expansion of greater than 33% was 18% and 27.6%, respectively (RR, 0.67; 95% CI, 0.45-1.00), said Dr. Goldstein of Massachusetts General Hospital, Boston.
In those with an expansion greater than 33% and a hematoma volume of at least 6 cc, the finding was similar.
“The trend looks a little bit more aggressive,” he said, but the 95% confidence interval in those with larger hematomas reached 1.
Study subjects had elevated blood pressure at arrival, a Glasgow coma scale score of at least 5, and a hematoma volume of less than 60 cc. They were enrolled and randomized within 4.5 hours of symptom onset. Those in the intensive treatment group were treated with a goal of achieving between 110 and 139 mm Hg within 24 hours, and those in the standard treatment group were treated with a goal of achieving between 140 mm Hg and 179 mm Hg within 24 hours. They underwent baseline and 24-hour computed tomography scans, which were analyzed centrally by blinded investigators who recorded any increase of 0.5 mL or more, an increase of more than 33% , an increase of more than 33% or more than 6 mL, and an intraventricular hemorrhage volume greater than 2 mL.
These measures were correlated with death and disability, and hematoma enlargement was shown to be significantly associated with those outcomes at 3 months after randomization (RR, 1.59; 95% CI, 1.25-2.02), Dr. Goldstein said.
Previous studies have suggested that intensive lowering of systolic BP in patients with intracerebral hemorrhage can reduce the rate of hematoma expansion. As such, the hypothesis of the current study was that the intensive treatment of elevated blood pressures – arriving systolic blood pressure of greater than 180 mm Hg – would reduce the likelihood of death and disability at 3 months, Dr. Goldstein said,
The question is whether the biomarker – hematoma expansion – is really linked to clinical outcome, he said, “because a lot of our attempts to treat hematoma expansion are based on the assumption that, if we reduce hematoma expansion, we’re going to improve clinical outcomes.”
“In this trial ... the expanders had more death and disability than nonexpanders, and this was statistically significant, so hematoma expansion does seem to be a statistically significant predictor of poor outcome,” he said.
Thus, the strong trend toward a reduced risk of hematoma expansion with intensive blood pressure lowering in patients with larger hematoma volumes at baseline in this analysis is noteworthy, he said.
“It appears that the treatment is affecting the biomarker, that the treatment is affecting hematoma expansion ... and hematoma expansion was a significant predictor of death and disability ... so why didn’t we get the result we wanted from the trial?” he asked.
It may be that a greater magnitude of reduction in the risk of hematoma expansion was necessary, he said.
“In other words, even if our treatment is having an effect, it’s just not having a big enough effect to change outcomes,” he said, adding that future trials probably need to involve a much bigger impact on the risk of expansion to translate to a change in clinical outcomes.”
This study was sponsored by the National Institute of Neurological Disorders and Stroke. Dr. Goldstein reported having no disclosures.
Key clinical point:
Major finding: Among patients with larger initial hematoma volume, expansion greater than 33% occurred in 18% vs. 28% in those with intense vs. standard blood pressure lowering, respectively (RR, 0.67).
Data source: The randomized phase III ATACH II trial involving 876 patients.
Disclosures: This study was sponsored by the National Institute of Neurological Disorders and Stroke. Dr. Goldstein reported having no disclosures.
Health care reform survey: What would make a difference for you?
[polldaddy:{"method":"iframe","type":"survey","src":"//clinicalpolls.polldaddy.com/s/health-care-reform-survey-what-would-make-a-difference-for-you?iframe=1"}]
[polldaddy:{"method":"iframe","type":"survey","src":"//clinicalpolls.polldaddy.com/s/health-care-reform-survey-what-would-make-a-difference-for-you?iframe=1"}]
[polldaddy:{"method":"iframe","type":"survey","src":"//clinicalpolls.polldaddy.com/s/health-care-reform-survey-what-would-make-a-difference-for-you?iframe=1"}]
On 15 years: Celebrating a nocturnist’s career longevity
“Nocturnist years are like dog years. So really we’re celebrating you for 105 years of service!”
Shawn Lee, MD, a day shift hospitalist at Overlake Medical Center in Bellevue, Wash. (where I work), said this about our colleague, Arash Nadershahi, MD, on the occasion of his 15th anniversary as a nocturnist with our group. Every hospitalist group should be so lucky to have someone like Arash among them, whether working nights or days.
When Arash joined our group the job simply entailed turning on the pager at 9 p.m. and coming in to the hospital only when the need arose. Some nights meant only answering some “cross-cover” calls from home, while other nights started with one or more patients needing admission right at the start of the shift.
As the months went by, patient volume climbed rapidly and Arash, as well as the nocturnists who joined us subsequently, began arriving at the hospital no later than the 9:00 p.m. shift start and staying in-house until 7 a.m. We never had a meeting or contentious conversation to make it official that the night shift changed to in-house all night instead of call-from-home. It just evolved that way to meet the need.
We all value Arash’s steady demeanor, excellent clinical skills, and good relationships with ED staff and nurses as well as patients. And for many years he and our other two nocturnists have covered all night shifts, including filling in when one of them is unexpectedly out for the birth of a child, illness, or other reason. The day doctors have never been called upon to work night shifts to cover an unexpected nocturnist absence.
Configuring the nocturnist position
A full-time nocturnist in our group works ten 10-hour night shifts and two 6-hour evening shifts (5-11 p.m.) per month. I like to think this has contributed to longevity for our nocturnists. One left last year after working nights for 10 years, and another just started his 9th year in the group.
The three nocturnists can work any schedule they like as long as one of them is on duty each night. For more than 10 years they’ve worked 7 consecutive night shifts followed by 14 off (that is sometimes interrupted by an evening shift). To my way of thinking, though, they’re essentially devoting 9 days to the practice for every seven consecutive shifts. The days before they start their rotation and after they complete it are spent preparing/recovering by adjusting their sleep, so aren’t really days of R&R.
For this work their compensation is very similar to that of full-time day shift doctors. The idea is that their compensation premium for working nights comes in the form of less work rather than more money; they work fewer and shorter shifts than their daytime counterparts. And we discourage moonlighting during all those days off. We want to provide the conditions for a healthy lifestyle to offset night work.
The longest-tenured nocturnist?
At 15 years of full-time work as a nocturnist, Arash may be one of the longest-tenured doctors in this role nationally. (I would love to hear about others who’ve been at it longer.) I like to think that our “pay ’em the same and work ’em less” approach may be a meaningful contributor to his longevity in the role, but I’m convinced his personal attributes are also a big factor.
His interests and creativity find their way into our workplace. For a while the day shift doctors would arrive to find our office full of motorcycle parts in various stages of assembly. Many of his doodles and drawings and witty writings are taped to the walls and cabinets. A few years ago he started writing haikus and before long everyone in the group joined in. This even led to one of our docs hosting a really fun party at which every guest wrote haikus and all had to guess the author of each one.
Other groups can’t count on finding someone as valuable as Arash, but they’ll have the best chance of it if they think carefully about how the nocturnist role is configured.
Dr. Nelson has had a career in clinical practice as a hospitalist starting in 1988. He is cofounder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is codirector for SHM’s practice management courses.
“Nocturnist years are like dog years. So really we’re celebrating you for 105 years of service!”
Shawn Lee, MD, a day shift hospitalist at Overlake Medical Center in Bellevue, Wash. (where I work), said this about our colleague, Arash Nadershahi, MD, on the occasion of his 15th anniversary as a nocturnist with our group. Every hospitalist group should be so lucky to have someone like Arash among them, whether working nights or days.
When Arash joined our group the job simply entailed turning on the pager at 9 p.m. and coming in to the hospital only when the need arose. Some nights meant only answering some “cross-cover” calls from home, while other nights started with one or more patients needing admission right at the start of the shift.
As the months went by, patient volume climbed rapidly and Arash, as well as the nocturnists who joined us subsequently, began arriving at the hospital no later than the 9:00 p.m. shift start and staying in-house until 7 a.m. We never had a meeting or contentious conversation to make it official that the night shift changed to in-house all night instead of call-from-home. It just evolved that way to meet the need.
We all value Arash’s steady demeanor, excellent clinical skills, and good relationships with ED staff and nurses as well as patients. And for many years he and our other two nocturnists have covered all night shifts, including filling in when one of them is unexpectedly out for the birth of a child, illness, or other reason. The day doctors have never been called upon to work night shifts to cover an unexpected nocturnist absence.
Configuring the nocturnist position
A full-time nocturnist in our group works ten 10-hour night shifts and two 6-hour evening shifts (5-11 p.m.) per month. I like to think this has contributed to longevity for our nocturnists. One left last year after working nights for 10 years, and another just started his 9th year in the group.
The three nocturnists can work any schedule they like as long as one of them is on duty each night. For more than 10 years they’ve worked 7 consecutive night shifts followed by 14 off (that is sometimes interrupted by an evening shift). To my way of thinking, though, they’re essentially devoting 9 days to the practice for every seven consecutive shifts. The days before they start their rotation and after they complete it are spent preparing/recovering by adjusting their sleep, so aren’t really days of R&R.
For this work their compensation is very similar to that of full-time day shift doctors. The idea is that their compensation premium for working nights comes in the form of less work rather than more money; they work fewer and shorter shifts than their daytime counterparts. And we discourage moonlighting during all those days off. We want to provide the conditions for a healthy lifestyle to offset night work.
The longest-tenured nocturnist?
At 15 years of full-time work as a nocturnist, Arash may be one of the longest-tenured doctors in this role nationally. (I would love to hear about others who’ve been at it longer.) I like to think that our “pay ’em the same and work ’em less” approach may be a meaningful contributor to his longevity in the role, but I’m convinced his personal attributes are also a big factor.
His interests and creativity find their way into our workplace. For a while the day shift doctors would arrive to find our office full of motorcycle parts in various stages of assembly. Many of his doodles and drawings and witty writings are taped to the walls and cabinets. A few years ago he started writing haikus and before long everyone in the group joined in. This even led to one of our docs hosting a really fun party at which every guest wrote haikus and all had to guess the author of each one.
Other groups can’t count on finding someone as valuable as Arash, but they’ll have the best chance of it if they think carefully about how the nocturnist role is configured.
Dr. Nelson has had a career in clinical practice as a hospitalist starting in 1988. He is cofounder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is codirector for SHM’s practice management courses.
“Nocturnist years are like dog years. So really we’re celebrating you for 105 years of service!”
Shawn Lee, MD, a day shift hospitalist at Overlake Medical Center in Bellevue, Wash. (where I work), said this about our colleague, Arash Nadershahi, MD, on the occasion of his 15th anniversary as a nocturnist with our group. Every hospitalist group should be so lucky to have someone like Arash among them, whether working nights or days.
When Arash joined our group the job simply entailed turning on the pager at 9 p.m. and coming in to the hospital only when the need arose. Some nights meant only answering some “cross-cover” calls from home, while other nights started with one or more patients needing admission right at the start of the shift.
As the months went by, patient volume climbed rapidly and Arash, as well as the nocturnists who joined us subsequently, began arriving at the hospital no later than the 9:00 p.m. shift start and staying in-house until 7 a.m. We never had a meeting or contentious conversation to make it official that the night shift changed to in-house all night instead of call-from-home. It just evolved that way to meet the need.
We all value Arash’s steady demeanor, excellent clinical skills, and good relationships with ED staff and nurses as well as patients. And for many years he and our other two nocturnists have covered all night shifts, including filling in when one of them is unexpectedly out for the birth of a child, illness, or other reason. The day doctors have never been called upon to work night shifts to cover an unexpected nocturnist absence.
Configuring the nocturnist position
A full-time nocturnist in our group works ten 10-hour night shifts and two 6-hour evening shifts (5-11 p.m.) per month. I like to think this has contributed to longevity for our nocturnists. One left last year after working nights for 10 years, and another just started his 9th year in the group.
The three nocturnists can work any schedule they like as long as one of them is on duty each night. For more than 10 years they’ve worked 7 consecutive night shifts followed by 14 off (that is sometimes interrupted by an evening shift). To my way of thinking, though, they’re essentially devoting 9 days to the practice for every seven consecutive shifts. The days before they start their rotation and after they complete it are spent preparing/recovering by adjusting their sleep, so aren’t really days of R&R.
For this work their compensation is very similar to that of full-time day shift doctors. The idea is that their compensation premium for working nights comes in the form of less work rather than more money; they work fewer and shorter shifts than their daytime counterparts. And we discourage moonlighting during all those days off. We want to provide the conditions for a healthy lifestyle to offset night work.
The longest-tenured nocturnist?
At 15 years of full-time work as a nocturnist, Arash may be one of the longest-tenured doctors in this role nationally. (I would love to hear about others who’ve been at it longer.) I like to think that our “pay ’em the same and work ’em less” approach may be a meaningful contributor to his longevity in the role, but I’m convinced his personal attributes are also a big factor.
His interests and creativity find their way into our workplace. For a while the day shift doctors would arrive to find our office full of motorcycle parts in various stages of assembly. Many of his doodles and drawings and witty writings are taped to the walls and cabinets. A few years ago he started writing haikus and before long everyone in the group joined in. This even led to one of our docs hosting a really fun party at which every guest wrote haikus and all had to guess the author of each one.
Other groups can’t count on finding someone as valuable as Arash, but they’ll have the best chance of it if they think carefully about how the nocturnist role is configured.
Dr. Nelson has had a career in clinical practice as a hospitalist starting in 1988. He is cofounder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is codirector for SHM’s practice management courses.
Survey highlights care gaps for transgender men
SAN DIEGO – Most transgender men have visited a gynecologist’s office at least once, but just 37% attend annual visits, results from a small survey showed.
“We’re seeing a large need and lack of access to gynecologic care,” Adriana J. Wong, the study author, said in an interview at the annual meeting of the American College of Obstetricians and Gynecologists. “Some barriers that we’ve identified are fear of mistreatment, a perceived lack of informed providers, and gender dysphoria.”
In an effort to assess transgender men’s experiences with, ability to access, and understanding of gynecologic care, Ms. Wong and her associates distributed an anonymous Web-based and paper-based survey to a convenience sample of transgender men in the Miami area. The mean age of the 41 respondents was 28 years, 56% were white, 41% had a high school diploma, 27% had a college degree, and 17% had a graduate degree.
The majority of survey participants (78%) reported having been to a gynecologist, 37% attended annual visits, 78% had health insurance, 56% delayed care because of gender identity concerns, and 20% experienced mistreatment at a gynecologist’s office.
Respondents reported delaying or avoiding care because they “felt uncomfortable with the extremely gendered experience of [gynecologic] care,” “fear of mistreatment,” and “my dysphoria prevented me. Plus, I wasn’t sure if there were friendly ob.gyns. around.”
“One of the most distinctive things to me is that we had a pretty well-insured population in our sample, and they were mostly Caucasian,” said Ms. Wong, a second-year medical student at the University of Miami. “Even though almost 80% were insured, [fewer] than 40% were receiving annual visits. This is the population that would potentially have the best possibility of receiving care, but they’re not seeking it out.”
The researchers reported having no relevant financial disclosures.
SAN DIEGO – Most transgender men have visited a gynecologist’s office at least once, but just 37% attend annual visits, results from a small survey showed.
“We’re seeing a large need and lack of access to gynecologic care,” Adriana J. Wong, the study author, said in an interview at the annual meeting of the American College of Obstetricians and Gynecologists. “Some barriers that we’ve identified are fear of mistreatment, a perceived lack of informed providers, and gender dysphoria.”
In an effort to assess transgender men’s experiences with, ability to access, and understanding of gynecologic care, Ms. Wong and her associates distributed an anonymous Web-based and paper-based survey to a convenience sample of transgender men in the Miami area. The mean age of the 41 respondents was 28 years, 56% were white, 41% had a high school diploma, 27% had a college degree, and 17% had a graduate degree.
The majority of survey participants (78%) reported having been to a gynecologist, 37% attended annual visits, 78% had health insurance, 56% delayed care because of gender identity concerns, and 20% experienced mistreatment at a gynecologist’s office.
Respondents reported delaying or avoiding care because they “felt uncomfortable with the extremely gendered experience of [gynecologic] care,” “fear of mistreatment,” and “my dysphoria prevented me. Plus, I wasn’t sure if there were friendly ob.gyns. around.”
“One of the most distinctive things to me is that we had a pretty well-insured population in our sample, and they were mostly Caucasian,” said Ms. Wong, a second-year medical student at the University of Miami. “Even though almost 80% were insured, [fewer] than 40% were receiving annual visits. This is the population that would potentially have the best possibility of receiving care, but they’re not seeking it out.”
The researchers reported having no relevant financial disclosures.
SAN DIEGO – Most transgender men have visited a gynecologist’s office at least once, but just 37% attend annual visits, results from a small survey showed.
“We’re seeing a large need and lack of access to gynecologic care,” Adriana J. Wong, the study author, said in an interview at the annual meeting of the American College of Obstetricians and Gynecologists. “Some barriers that we’ve identified are fear of mistreatment, a perceived lack of informed providers, and gender dysphoria.”
In an effort to assess transgender men’s experiences with, ability to access, and understanding of gynecologic care, Ms. Wong and her associates distributed an anonymous Web-based and paper-based survey to a convenience sample of transgender men in the Miami area. The mean age of the 41 respondents was 28 years, 56% were white, 41% had a high school diploma, 27% had a college degree, and 17% had a graduate degree.
The majority of survey participants (78%) reported having been to a gynecologist, 37% attended annual visits, 78% had health insurance, 56% delayed care because of gender identity concerns, and 20% experienced mistreatment at a gynecologist’s office.
Respondents reported delaying or avoiding care because they “felt uncomfortable with the extremely gendered experience of [gynecologic] care,” “fear of mistreatment,” and “my dysphoria prevented me. Plus, I wasn’t sure if there were friendly ob.gyns. around.”
“One of the most distinctive things to me is that we had a pretty well-insured population in our sample, and they were mostly Caucasian,” said Ms. Wong, a second-year medical student at the University of Miami. “Even though almost 80% were insured, [fewer] than 40% were receiving annual visits. This is the population that would potentially have the best possibility of receiving care, but they’re not seeking it out.”
The researchers reported having no relevant financial disclosures.
AT ACOG 2017
Key clinical point:
Major finding: Most transgender men (78%) have been to a gynecologist at least once, but just 37% attend annual visits.
Data source: Responses from a survey of 41 transgender men in the Miami area.
Disclosures: The researchers reported having no relevant financial disclosures.
It Pays to Get Screened for Colon Cancer
Although cancer death rates have been decreasing for the general population, they’ve been increasing for American Indians, according to the American Indian Cancer Foundation (AICAF). The AICAF cites a number of barriers to prevention and care, such as low awareness of risks, distrust of medical systems and research, health beliefs that may conflict with prevention practices, and low awareness of screening options.
The Northern Plains region has some of the highest rates of cancer diagnoses and death in the U.S. Colon cancer, for example, is 53% higher in Northern Plains American Indians, AICAF says. Although screening rates are improving, fewer than half of Northern Plains American Indians aged ≥ 50 years have had a colorectal cancer screening, according to the Association of American Indian Physicians.
The cancer mortality rates are the result of a “complex set of factors” that the AICAF is beginning to address with a comprehensive set of approaches. For instance, in addition to educating the public, AICAF, in partnership with the Minnesota Department of Health and Get Your Rear in Gear Colon Cancer Coalition is putting money where its mouth is, with the “Refer-a-Relative” program.
“We are all related,” the campaign says: “Help your community and end colon cancer!” Refer-a-Relative encourages Native Americans in the Minneapolis-St. Paul metropolitan area to get screened, and then to refer up to 5 relatives aged ≥ 50 years for screening. Patients receive a $20 gift card for completing screening, and $10 for each relative who completes screening. The relatives receive a $20 gift card and can refer more people.
The screening project is 1 branch of the AICAF’s interest in innovating clinical systems at IHS, Tribal, and Urban (ITU) clinics. Much of the work is based on the Improving Northern Plains American Indian Colorectal Cancer Screening (INPACS) project with ITU clinics. The AICAF invites interested ITU clinics to join the Clinical Cancer Screening Network. For more information, infographics, and other patient education materials, visit www.americanindiancancer.org.
Although cancer death rates have been decreasing for the general population, they’ve been increasing for American Indians, according to the American Indian Cancer Foundation (AICAF). The AICAF cites a number of barriers to prevention and care, such as low awareness of risks, distrust of medical systems and research, health beliefs that may conflict with prevention practices, and low awareness of screening options.
The Northern Plains region has some of the highest rates of cancer diagnoses and death in the U.S. Colon cancer, for example, is 53% higher in Northern Plains American Indians, AICAF says. Although screening rates are improving, fewer than half of Northern Plains American Indians aged ≥ 50 years have had a colorectal cancer screening, according to the Association of American Indian Physicians.
The cancer mortality rates are the result of a “complex set of factors” that the AICAF is beginning to address with a comprehensive set of approaches. For instance, in addition to educating the public, AICAF, in partnership with the Minnesota Department of Health and Get Your Rear in Gear Colon Cancer Coalition is putting money where its mouth is, with the “Refer-a-Relative” program.
“We are all related,” the campaign says: “Help your community and end colon cancer!” Refer-a-Relative encourages Native Americans in the Minneapolis-St. Paul metropolitan area to get screened, and then to refer up to 5 relatives aged ≥ 50 years for screening. Patients receive a $20 gift card for completing screening, and $10 for each relative who completes screening. The relatives receive a $20 gift card and can refer more people.
The screening project is 1 branch of the AICAF’s interest in innovating clinical systems at IHS, Tribal, and Urban (ITU) clinics. Much of the work is based on the Improving Northern Plains American Indian Colorectal Cancer Screening (INPACS) project with ITU clinics. The AICAF invites interested ITU clinics to join the Clinical Cancer Screening Network. For more information, infographics, and other patient education materials, visit www.americanindiancancer.org.
Although cancer death rates have been decreasing for the general population, they’ve been increasing for American Indians, according to the American Indian Cancer Foundation (AICAF). The AICAF cites a number of barriers to prevention and care, such as low awareness of risks, distrust of medical systems and research, health beliefs that may conflict with prevention practices, and low awareness of screening options.
The Northern Plains region has some of the highest rates of cancer diagnoses and death in the U.S. Colon cancer, for example, is 53% higher in Northern Plains American Indians, AICAF says. Although screening rates are improving, fewer than half of Northern Plains American Indians aged ≥ 50 years have had a colorectal cancer screening, according to the Association of American Indian Physicians.
The cancer mortality rates are the result of a “complex set of factors” that the AICAF is beginning to address with a comprehensive set of approaches. For instance, in addition to educating the public, AICAF, in partnership with the Minnesota Department of Health and Get Your Rear in Gear Colon Cancer Coalition is putting money where its mouth is, with the “Refer-a-Relative” program.
“We are all related,” the campaign says: “Help your community and end colon cancer!” Refer-a-Relative encourages Native Americans in the Minneapolis-St. Paul metropolitan area to get screened, and then to refer up to 5 relatives aged ≥ 50 years for screening. Patients receive a $20 gift card for completing screening, and $10 for each relative who completes screening. The relatives receive a $20 gift card and can refer more people.
The screening project is 1 branch of the AICAF’s interest in innovating clinical systems at IHS, Tribal, and Urban (ITU) clinics. Much of the work is based on the Improving Northern Plains American Indian Colorectal Cancer Screening (INPACS) project with ITU clinics. The AICAF invites interested ITU clinics to join the Clinical Cancer Screening Network. For more information, infographics, and other patient education materials, visit www.americanindiancancer.org.