LAS VEGAS – Ronald Schaefer, MD, a hospitalist with Hawaii Pacific Health who also works on creating digital templates for his hospital, can’t input hemoglobin A1c levels from three different labs into his electronic medical records (EMR) system the same way.

Hospitalist George Dimitriou, MD, FHM, who splits his time at Allegheny Health Network in Pittsburgh between clinical work and medical informatics, worries there are so many fields in his EMR that physicians can get distracted.

Yevgeniy “Eugene” Gitelman, MD, a clinical informatics manager at the Perelman School of Medicine at University of Pennsylvania Health in Philadelphia, wonders how good any systems can be with the privacy concerns related to HIPAA.

This was the nexus of IT and HM17, a time when hospitalists said they are stymied and frustrated by continuing issues of interoperability, functionality, and access. The meeting highlighted new smartphone and tablet applications, as well as medical devices available to hospitalists, but tech-focused physicians say the biggest issue remains the day-to-day workings of EMR.

“If you build something really good, people will use it. If you build something that makes their documentation process a lot easier and a lot faster and a lot better, they’ll use it,” said Dr. Schaefer. “The tools aren’t there yet. I don’t think the technology is mature enough.”

If the tech hasn’t yet come of full age, the concerns surely have. SHM unveiled a white paper at HM17 that codified hospitalists’ worries about the current state of IT. The report, “Hospitalist Perspectives on Electronic Medical Records,” found that “a staggering” 85% of providers said they spend more time interacting with their inpatient EMR than their actual inpatients.

Rupesh Prasad, MD, MPH, SFHM, chair of SHM’s Health IT Committee, says the report is meant to foster discussion about the issues surrounding EMRs. The data points, generated from 462 respondents, are stark. Just 40% said they were happy with their EMR. Some 52% would change vendors if they could. One-quarter of respondents would revert to using paper if given the option.

“By sharing these results, we hope to raise awareness of the unacceptable performance of existing systems,” the report states. “This continues to contribute to our slower than desired improvement in quality and safety, as well as increasing provider frustration. We strongly believe that we need a renewed focus on initial goals of technology adoption in health care.”

Dr. Prasad said that he hopes hospitalists heed that call to action and use the report in discussions with various stakeholders, including vendors, public policy officials, and their own bosses.

“We want to give hospitalists ammunition to go back to their systems and talk to their administrators to see if they can influence [it],” he said.

Dr. Prasad is pleased that the society is sensitive to the issues surrounding technology. He encourages hospitalists to actively participate in HMX, SHM’s online portal to discuss health IT issues and crowd-source potential solutions. Patrick Vulgamore, MPH, SHM’s director of governance and practice management, said the society is formulating a potential special-interest working group to further seek to solve problems.

Hospitalists were also urged to apply for American Board of Medical Specialties (ABMS) certification in clinical informatics. Physicians can grandfather into eligibility via the “practice pathway” through the end of the year, if they’ve been working in informatics professionally for at least 25% of their time during any three of the previous five years. Next year, only graduates of two-year Accreditation Council for Graduate Medical Education–accredited fellowships will be board eligible.

“As end users of technology, we understand the problems better than anybody else,” Dr. Prasad said. “Obviously, the next step would be try to solve the problems. And what better way then to get involved and become experts in what you do?”

While much of the meeting’s tech talk was frustration, both former National Coordinator for Health IT Karen DeSalvo, MD, MPH, MSc, and HM Dean Robert Wachter, MD, MHM, forecast a future when artificial intelligence and intuitive computers work alongside physicians. Imagine the user-friendliness of Apple’s Siri or Google’s Alexa married to the existing functionalities provided by firms such as Epic or Cerner.

But that’s years away, and hospitalists like Dr. Dimitriou want help now.

“The speed of medicine, the speed of what’s happening in real time, is still faster than what our electronic tools seem to be able to keep up with,” he said. “There are encouraging signs that we’ve definitely moved in the right direction. We’ve come a long way ... but again, the speed at which things are moving? We aren’t keeping up. We’ve got to do more.”

LAS VEGAS – Ronald Schaefer, MD, a hospitalist with Hawaii Pacific Health who also works on creating digital templates for his hospital, can’t input hemoglobin A1c levels from three different labs into his electronic medical records (EMR) system the same way.

Hospitalist George Dimitriou, MD, FHM, who splits his time at Allegheny Health Network in Pittsburgh between clinical work and medical informatics, worries there are so many fields in his EMR that physicians can get distracted.

Yevgeniy “Eugene” Gitelman, MD, a clinical informatics manager at the Perelman School of Medicine at University of Pennsylvania Health in Philadelphia, wonders how good any systems can be with the privacy concerns related to HIPAA.

This was the nexus of IT and HM17, a time when hospitalists said they are stymied and frustrated by continuing issues of interoperability, functionality, and access. The meeting highlighted new smartphone and tablet applications, as well as medical devices available to hospitalists, but tech-focused physicians say the biggest issue remains the day-to-day workings of EMR.

“If you build something really good, people will use it. If you build something that makes their documentation process a lot easier and a lot faster and a lot better, they’ll use it,” said Dr. Schaefer. “The tools aren’t there yet. I don’t think the technology is mature enough.”

If the tech hasn’t yet come of full age, the concerns surely have. SHM unveiled a white paper at HM17 that codified hospitalists’ worries about the current state of IT. The report, “Hospitalist Perspectives on Electronic Medical Records,” found that “a staggering” 85% of providers said they spend more time interacting with their inpatient EMR than their actual inpatients.

Rupesh Prasad, MD, MPH, SFHM, chair of SHM’s Health IT Committee, says the report is meant to foster discussion about the issues surrounding EMRs. The data points, generated from 462 respondents, are stark. Just 40% said they were happy with their EMR. Some 52% would change vendors if they could. One-quarter of respondents would revert to using paper if given the option.

“By sharing these results, we hope to raise awareness of the unacceptable performance of existing systems,” the report states. “This continues to contribute to our slower than desired improvement in quality and safety, as well as increasing provider frustration. We strongly believe that we need a renewed focus on initial goals of technology adoption in health care.”

Dr. Prasad said that he hopes hospitalists heed that call to action and use the report in discussions with various stakeholders, including vendors, public policy officials, and their own bosses.

“We want to give hospitalists ammunition to go back to their systems and talk to their administrators to see if they can influence [it],” he said.

Dr. Prasad is pleased that the society is sensitive to the issues surrounding technology. He encourages hospitalists to actively participate in HMX, SHM’s online portal to discuss health IT issues and crowd-source potential solutions. Patrick Vulgamore, MPH, SHM’s director of governance and practice management, said the society is formulating a potential special-interest working group to further seek to solve problems.

Hospitalists were also urged to apply for American Board of Medical Specialties (ABMS) certification in clinical informatics. Physicians can grandfather into eligibility via the “practice pathway” through the end of the year, if they’ve been working in informatics professionally for at least 25% of their time during any three of the previous five years. Next year, only graduates of two-year Accreditation Council for Graduate Medical Education–accredited fellowships will be board eligible.

“As end users of technology, we understand the problems better than anybody else,” Dr. Prasad said. “Obviously, the next step would be try to solve the problems. And what better way then to get involved and become experts in what you do?”

While much of the meeting’s tech talk was frustration, both former National Coordinator for Health IT Karen DeSalvo, MD, MPH, MSc, and HM Dean Robert Wachter, MD, MHM, forecast a future when artificial intelligence and intuitive computers work alongside physicians. Imagine the user-friendliness of Apple’s Siri or Google’s Alexa married to the existing functionalities provided by firms such as Epic or Cerner.

But that’s years away, and hospitalists like Dr. Dimitriou want help now.

“The speed of medicine, the speed of what’s happening in real time, is still faster than what our electronic tools seem to be able to keep up with,” he said. “There are encouraging signs that we’ve definitely moved in the right direction. We’ve come a long way ... but again, the speed at which things are moving? We aren’t keeping up. We’ve got to do more.”

LAS VEGAS – Ronald Schaefer, MD, a hospitalist with Hawaii Pacific Health who also works on creating digital templates for his hospital, can’t input hemoglobin A1c levels from three different labs into his electronic medical records (EMR) system the same way.

Hospitalist George Dimitriou, MD, FHM, who splits his time at Allegheny Health Network in Pittsburgh between clinical work and medical informatics, worries there are so many fields in his EMR that physicians can get distracted.

Yevgeniy “Eugene” Gitelman, MD, a clinical informatics manager at the Perelman School of Medicine at University of Pennsylvania Health in Philadelphia, wonders how good any systems can be with the privacy concerns related to HIPAA.

This was the nexus of IT and HM17, a time when hospitalists said they are stymied and frustrated by continuing issues of interoperability, functionality, and access. The meeting highlighted new smartphone and tablet applications, as well as medical devices available to hospitalists, but tech-focused physicians say the biggest issue remains the day-to-day workings of EMR.

“If you build something really good, people will use it. If you build something that makes their documentation process a lot easier and a lot faster and a lot better, they’ll use it,” said Dr. Schaefer. “The tools aren’t there yet. I don’t think the technology is mature enough.”

If the tech hasn’t yet come of full age, the concerns surely have. SHM unveiled a white paper at HM17 that codified hospitalists’ worries about the current state of IT. The report, “Hospitalist Perspectives on Electronic Medical Records,” found that “a staggering” 85% of providers said they spend more time interacting with their inpatient EMR than their actual inpatients.

Rupesh Prasad, MD, MPH, SFHM, chair of SHM’s Health IT Committee, says the report is meant to foster discussion about the issues surrounding EMRs. The data points, generated from 462 respondents, are stark. Just 40% said they were happy with their EMR. Some 52% would change vendors if they could. One-quarter of respondents would revert to using paper if given the option.

“By sharing these results, we hope to raise awareness of the unacceptable performance of existing systems,” the report states. “This continues to contribute to our slower than desired improvement in quality and safety, as well as increasing provider frustration. We strongly believe that we need a renewed focus on initial goals of technology adoption in health care.”

Dr. Prasad said that he hopes hospitalists heed that call to action and use the report in discussions with various stakeholders, including vendors, public policy officials, and their own bosses.

“We want to give hospitalists ammunition to go back to their systems and talk to their administrators to see if they can influence [it],” he said.

Dr. Prasad is pleased that the society is sensitive to the issues surrounding technology. He encourages hospitalists to actively participate in HMX, SHM’s online portal to discuss health IT issues and crowd-source potential solutions. Patrick Vulgamore, MPH, SHM’s director of governance and practice management, said the society is formulating a potential special-interest working group to further seek to solve problems.

Hospitalists were also urged to apply for American Board of Medical Specialties (ABMS) certification in clinical informatics. Physicians can grandfather into eligibility via the “practice pathway” through the end of the year, if they’ve been working in informatics professionally for at least 25% of their time during any three of the previous five years. Next year, only graduates of two-year Accreditation Council for Graduate Medical Education–accredited fellowships will be board eligible.

“As end users of technology, we understand the problems better than anybody else,” Dr. Prasad said. “Obviously, the next step would be try to solve the problems. And what better way then to get involved and become experts in what you do?”

While much of the meeting’s tech talk was frustration, both former National Coordinator for Health IT Karen DeSalvo, MD, MPH, MSc, and HM Dean Robert Wachter, MD, MHM, forecast a future when artificial intelligence and intuitive computers work alongside physicians. Imagine the user-friendliness of Apple’s Siri or Google’s Alexa married to the existing functionalities provided by firms such as Epic or Cerner.

But that’s years away, and hospitalists like Dr. Dimitriou want help now.

“The speed of medicine, the speed of what’s happening in real time, is still faster than what our electronic tools seem to be able to keep up with,” he said. “There are encouraging signs that we’ve definitely moved in the right direction. We’ve come a long way ... but again, the speed at which things are moving? We aren’t keeping up. We’ve got to do more.”

SAN FRANCISCO – Serum leukocytosis, pyuria, and urine leukocyte esterase have been identified as predictors of urinary tract infection (UTI) in infants younger than 90 days of age, with males being more likely to develop UTI than females.

The chance of the infection declined in older infants.

“Really young infants have a less well developed immune system, which may increase their susceptibility to UTIs,” said Sarah Berman, DO, a pediatric resident at Winthrop-University Hospital, Mineola, N.Y.

Brian Hoyle/Frontline Medical News

SAN FRANCISCO – Serum leukocytosis, pyuria, and urine leukocyte esterase have been identified as predictors of urinary tract infection (UTI) in infants younger than 90 days of age, with males being more likely to develop UTI than females.

The chance of the infection declined in older infants.

“Really young infants have a less well developed immune system, which may increase their susceptibility to UTIs,” said Sarah Berman, DO, a pediatric resident at Winthrop-University Hospital, Mineola, N.Y.

Brian Hoyle/Frontline Medical News

SAN FRANCISCO – Serum leukocytosis, pyuria, and urine leukocyte esterase have been identified as predictors of urinary tract infection (UTI) in infants younger than 90 days of age, with males being more likely to develop UTI than females.

The chance of the infection declined in older infants.

“Really young infants have a less well developed immune system, which may increase their susceptibility to UTIs,” said Sarah Berman, DO, a pediatric resident at Winthrop-University Hospital, Mineola, N.Y.

Brian Hoyle/Frontline Medical News

To the Editor:

Verrucous porokeratosis of the gluteal cleft is a rare skin condition that has distinct clinical and histologic features. A review of 5 cases described a characteristic clinical presentation of a butterfly-shaped bilateral gluteal cleft lesion on most patients.¹ We present an unusual case of verrucous porokeratosis presenting as a unilateral single lesion in the gluteal area that emulated seborrheic keratosis with histology consistent with verrucous porokeratosis. This case adds to the variable presentation of this unusual disease.

A 40-year-old man who presented to the dermatology clinic for a follow-up on a basal cell carcinoma of the temple region was concerned about a lesion on the left buttock of 1 year’s duration. Physical examination revealed a unilateral hyperkeratotic plaque that clinically resembled seborrheic keratosis (Figure 1). Biopsy revealed hyperkeratosis with numerous columns of parakeratosis, psoriasiform epidermal hyperplasia (Figures 2A and 2B), dyskeratotic keratinocytes (Figure 2C), pigment incontinence, and mild superficial chronic inflammation consistent with verrucous porokeratosis. The patient was treated with urea lotion but ultimately was lost to follow-up.

We present a unique case of unilateral verrucous porokeratosis of the gluteal cleft. The clinical differential diagnosis included seborrheic keratosis, condyloma acuminata, and inflammatory linear verrucous epidermal nevus. Histopathology was consistent with verrucous porokeratosis. Porokeratosis is a heterogeneous group of keratinization disorders containing several described variants such as classici porokeratosis of Mibelli, disseminated superficial porokeratosis, porokeratosis palmaris et plantaris disseminata, linear porokeratosis, and punctuate porokeratosis.^1,2 Most patients present clinically with plaquelike bilateral (butterfly) lesions with threadlike (ridge) borders, though some patients initially have a unilateral lesion that subsequently develops into a bilateral lesion.¹ The clinical course is slow growing, but it can potentially give rise to malignancies such as squamous cell carcinoma.³ Histologically, numerous columns of parakeratosis overlying epidermal cells with attenuated granular layer are observed with the concentric cornoid lamellae considered unique to the verrucous variant.¹ Although our patient had only a single unilateral lesion on the gluteal cleft, the histology was consistent with verrucous porokeratosis. Our case adds to the growing clinical presentations of this unusual disease.

RELATED CONTENT: Diagnosing Porokeratosis of Mibelli Every Time: A Novel Biopsy Technique to Maximize Histopathologic Confirmation

To the Editor:

Verrucous porokeratosis of the gluteal cleft is a rare skin condition that has distinct clinical and histologic features. A review of 5 cases described a characteristic clinical presentation of a butterfly-shaped bilateral gluteal cleft lesion on most patients.¹ We present an unusual case of verrucous porokeratosis presenting as a unilateral single lesion in the gluteal area that emulated seborrheic keratosis with histology consistent with verrucous porokeratosis. This case adds to the variable presentation of this unusual disease.

A 40-year-old man who presented to the dermatology clinic for a follow-up on a basal cell carcinoma of the temple region was concerned about a lesion on the left buttock of 1 year’s duration. Physical examination revealed a unilateral hyperkeratotic plaque that clinically resembled seborrheic keratosis (Figure 1). Biopsy revealed hyperkeratosis with numerous columns of parakeratosis, psoriasiform epidermal hyperplasia (Figures 2A and 2B), dyskeratotic keratinocytes (Figure 2C), pigment incontinence, and mild superficial chronic inflammation consistent with verrucous porokeratosis. The patient was treated with urea lotion but ultimately was lost to follow-up.

We present a unique case of unilateral verrucous porokeratosis of the gluteal cleft. The clinical differential diagnosis included seborrheic keratosis, condyloma acuminata, and inflammatory linear verrucous epidermal nevus. Histopathology was consistent with verrucous porokeratosis. Porokeratosis is a heterogeneous group of keratinization disorders containing several described variants such as classici porokeratosis of Mibelli, disseminated superficial porokeratosis, porokeratosis palmaris et plantaris disseminata, linear porokeratosis, and punctuate porokeratosis.^1,2 Most patients present clinically with plaquelike bilateral (butterfly) lesions with threadlike (ridge) borders, though some patients initially have a unilateral lesion that subsequently develops into a bilateral lesion.¹ The clinical course is slow growing, but it can potentially give rise to malignancies such as squamous cell carcinoma.³ Histologically, numerous columns of parakeratosis overlying epidermal cells with attenuated granular layer are observed with the concentric cornoid lamellae considered unique to the verrucous variant.¹ Although our patient had only a single unilateral lesion on the gluteal cleft, the histology was consistent with verrucous porokeratosis. Our case adds to the growing clinical presentations of this unusual disease.

RELATED CONTENT: Diagnosing Porokeratosis of Mibelli Every Time: A Novel Biopsy Technique to Maximize Histopathologic Confirmation

To the Editor:

Verrucous porokeratosis of the gluteal cleft is a rare skin condition that has distinct clinical and histologic features. A review of 5 cases described a characteristic clinical presentation of a butterfly-shaped bilateral gluteal cleft lesion on most patients.¹ We present an unusual case of verrucous porokeratosis presenting as a unilateral single lesion in the gluteal area that emulated seborrheic keratosis with histology consistent with verrucous porokeratosis. This case adds to the variable presentation of this unusual disease.

A 40-year-old man who presented to the dermatology clinic for a follow-up on a basal cell carcinoma of the temple region was concerned about a lesion on the left buttock of 1 year’s duration. Physical examination revealed a unilateral hyperkeratotic plaque that clinically resembled seborrheic keratosis (Figure 1). Biopsy revealed hyperkeratosis with numerous columns of parakeratosis, psoriasiform epidermal hyperplasia (Figures 2A and 2B), dyskeratotic keratinocytes (Figure 2C), pigment incontinence, and mild superficial chronic inflammation consistent with verrucous porokeratosis. The patient was treated with urea lotion but ultimately was lost to follow-up.

We present a unique case of unilateral verrucous porokeratosis of the gluteal cleft. The clinical differential diagnosis included seborrheic keratosis, condyloma acuminata, and inflammatory linear verrucous epidermal nevus. Histopathology was consistent with verrucous porokeratosis. Porokeratosis is a heterogeneous group of keratinization disorders containing several described variants such as classici porokeratosis of Mibelli, disseminated superficial porokeratosis, porokeratosis palmaris et plantaris disseminata, linear porokeratosis, and punctuate porokeratosis.^1,2 Most patients present clinically with plaquelike bilateral (butterfly) lesions with threadlike (ridge) borders, though some patients initially have a unilateral lesion that subsequently develops into a bilateral lesion.¹ The clinical course is slow growing, but it can potentially give rise to malignancies such as squamous cell carcinoma.³ Histologically, numerous columns of parakeratosis overlying epidermal cells with attenuated granular layer are observed with the concentric cornoid lamellae considered unique to the verrucous variant.¹ Although our patient had only a single unilateral lesion on the gluteal cleft, the histology was consistent with verrucous porokeratosis. Our case adds to the growing clinical presentations of this unusual disease.

RELATED CONTENT: Diagnosing Porokeratosis of Mibelli Every Time: A Novel Biopsy Technique to Maximize Histopathologic Confirmation

Click Here to Read the Full Supplement.

Topics include:

• The Pathway for Biosimilar Approval
• The Difference between Biosimilars and Generics
• Draft Interchangeablity Guidelines
• ACR Position Statement on Biosimilars
• Effect of the Reimbursement Model on Biosimilars

Click Here to Read the Full Supplement.

Click Here to Read the Full Supplement.

Topics include:

• The Pathway for Biosimilar Approval
• The Difference between Biosimilars and Generics
• Draft Interchangeablity Guidelines
• ACR Position Statement on Biosimilars
• Effect of the Reimbursement Model on Biosimilars

Click Here to Read the Full Supplement.

Click Here to Read the Full Supplement.

Topics include:

• The Pathway for Biosimilar Approval
• The Difference between Biosimilars and Generics
• Draft Interchangeablity Guidelines
• ACR Position Statement on Biosimilars
• Effect of the Reimbursement Model on Biosimilars

Click Here to Read the Full Supplement.

LAS VEGAS – Determination of whether excision of persistent breast cancer metastases can benefit the patient and even prolong survival depends on the location of the metastatic lesions, an investigator said at the annual meeting of the American Society of Breast Surgeons.

Before making the decision, it’s important to restage the patient’s disease and to recheck the receptor status if a biopsy is accessible, said Roshni Rao, MD, of the University of Texas Southwestern Medical Center.

Brain

Survival is worse when there are concurrent extracranial metastases or when brain metastases are greater than 5 cm, in patients with triple negative tumors, and in patients with a Karnofsky score of 70 or less, Dr. Rao said.

Surgery has the greatest benefit in patients with a single metastasis, with no extracranial disease, and who are able to undergo adjuvant whole brain radiation. In these cases, surgery improves survival, lowers recurrence rates, and reduces the risk of death neurological causes, she said.

Long-term survival is most common with continuous adjuvant therapy, either trastuzumab or hormonal, and in patients with a longer time interval to development of metastases. One series showed a 20-month survival increase.

Liver

Approximately 15% of patients with synchronous metastases will have liver metastases, and about half of stage IV patients will experience liver metastases at some point during treatment.

There is evidence from colorectal cancer that removing liver metastases is beneficial, and that has prompted interest in a similar approach in breast cancer. Liver resection has also become safer with new advances.

Dr. Rao discussed a single-institution study which took an aggressive approach to liver resection in 85 patients (Ann Surg. 2006;244:897-907). The researchers found that increased survival was associated with a good response to adjuvant chemotherapy, an r0 or r1 resection, and in patients who had a previous liver resection and were healthy enough to undergo another resection.

Overall, existing studies support liver resection if there are one to three lesions, if negative margins can be achieved, if the tumors are hormone receptor positive, and if the cancer is hormone positive and has good response to chemotherapy.

Dr. Rao emphasized that liver resections should be performed with a multidisciplinary team and should only be attempted at centers with low morbidity and where the doctors are experienced with liver resection.

When it’s possible, liver resection is beneficial. “There have been multiple reports of long-term survivors with no evidence of disease. There is likely a survival benefit with careful selection of these patients,” Dr. Rao said.

Lung

Lung surgeries are becoming safer, especially with the availability of video-assisted techniques, and pulmonary metastases are increasingly being spotted using more sensitive techniques such as higher resolution computed tomography.

A lung metastasis registry analysis showed three factors improved survival: prolonged disease-free survival, especially longer than 36 months; a complete resection; and a small number of metastases and success in resecting them all (Eur J Cardiothorac Surg. 2002;22:335-44). A more recent meta-analysis showed the same results (J Thorac Dis. 2015;7:1441-51).

Bone

Bone metastases remain rare choices for surgical treatment. Most of the time, morbidity will be too high, and there are good options for systemic treatment. That leaves surgery reserved mostly for stabilization or the treatment of fractures.

However, there are a couple of exceptions, according to Dr. Rao. One multi-institutional randomized trial looked at metastatic epidural spinal cord compression. Subjects either underwent decompressive surgery with stabilization and radiation or radiation alone. Patients in the surgical group had a longer ambulatory period and had a lower usage rate of steroids and opioids. Morbidity outcomes were similar in both groups. Patients whose primary tumor was in the breast seemed to benefit the most with respect to ambulatory time (Lancet. 2005;9486:643-8; J Neurosurg Spine. 2008;8:271-8).

Sternal metastases represent another special case. 70% of the time, patients with sternal metastases have it as their only metastatic site. A French series of 33 patients who underwent aggressive chest wall and rib resection reported a 36% complication rate, while another study of 28 patients showed a 21% complication rate. Those complications are a problem, “but if you’re able to perform this in a resected tumor, there are long term survivors. As usual, triple negative breast cancers predicted a worse prognosis,” said Dr. Rao.

Dr. Rao concluded that resection of metastatic sites has a role. “I think it’s our responsibility as breast surgeons who are many times continuously following these patients to consider appropriate operations,” said Dr. Rao.

However, she did sound one note of caution. Surgery can interrupt therapy that is helping a patient. “Let’s say you have someone get a big liver resection, and then they have a tough time with recovery. There could be a long period of time they can’t get the therapy that was keeping them alive. That’s the real concern,” she said.

LAS VEGAS – Determination of whether excision of persistent breast cancer metastases can benefit the patient and even prolong survival depends on the location of the metastatic lesions, an investigator said at the annual meeting of the American Society of Breast Surgeons.

Before making the decision, it’s important to restage the patient’s disease and to recheck the receptor status if a biopsy is accessible, said Roshni Rao, MD, of the University of Texas Southwestern Medical Center.

Brain

Survival is worse when there are concurrent extracranial metastases or when brain metastases are greater than 5 cm, in patients with triple negative tumors, and in patients with a Karnofsky score of 70 or less, Dr. Rao said.

Surgery has the greatest benefit in patients with a single metastasis, with no extracranial disease, and who are able to undergo adjuvant whole brain radiation. In these cases, surgery improves survival, lowers recurrence rates, and reduces the risk of death neurological causes, she said.

Long-term survival is most common with continuous adjuvant therapy, either trastuzumab or hormonal, and in patients with a longer time interval to development of metastases. One series showed a 20-month survival increase.

Liver

Approximately 15% of patients with synchronous metastases will have liver metastases, and about half of stage IV patients will experience liver metastases at some point during treatment.

There is evidence from colorectal cancer that removing liver metastases is beneficial, and that has prompted interest in a similar approach in breast cancer. Liver resection has also become safer with new advances.

Dr. Rao discussed a single-institution study which took an aggressive approach to liver resection in 85 patients (Ann Surg. 2006;244:897-907). The researchers found that increased survival was associated with a good response to adjuvant chemotherapy, an r0 or r1 resection, and in patients who had a previous liver resection and were healthy enough to undergo another resection.

Overall, existing studies support liver resection if there are one to three lesions, if negative margins can be achieved, if the tumors are hormone receptor positive, and if the cancer is hormone positive and has good response to chemotherapy.

Dr. Rao emphasized that liver resections should be performed with a multidisciplinary team and should only be attempted at centers with low morbidity and where the doctors are experienced with liver resection.

When it’s possible, liver resection is beneficial. “There have been multiple reports of long-term survivors with no evidence of disease. There is likely a survival benefit with careful selection of these patients,” Dr. Rao said.

Lung

Lung surgeries are becoming safer, especially with the availability of video-assisted techniques, and pulmonary metastases are increasingly being spotted using more sensitive techniques such as higher resolution computed tomography.

A lung metastasis registry analysis showed three factors improved survival: prolonged disease-free survival, especially longer than 36 months; a complete resection; and a small number of metastases and success in resecting them all (Eur J Cardiothorac Surg. 2002;22:335-44). A more recent meta-analysis showed the same results (J Thorac Dis. 2015;7:1441-51).

Bone

Bone metastases remain rare choices for surgical treatment. Most of the time, morbidity will be too high, and there are good options for systemic treatment. That leaves surgery reserved mostly for stabilization or the treatment of fractures.

However, there are a couple of exceptions, according to Dr. Rao. One multi-institutional randomized trial looked at metastatic epidural spinal cord compression. Subjects either underwent decompressive surgery with stabilization and radiation or radiation alone. Patients in the surgical group had a longer ambulatory period and had a lower usage rate of steroids and opioids. Morbidity outcomes were similar in both groups. Patients whose primary tumor was in the breast seemed to benefit the most with respect to ambulatory time (Lancet. 2005;9486:643-8; J Neurosurg Spine. 2008;8:271-8).

Sternal metastases represent another special case. 70% of the time, patients with sternal metastases have it as their only metastatic site. A French series of 33 patients who underwent aggressive chest wall and rib resection reported a 36% complication rate, while another study of 28 patients showed a 21% complication rate. Those complications are a problem, “but if you’re able to perform this in a resected tumor, there are long term survivors. As usual, triple negative breast cancers predicted a worse prognosis,” said Dr. Rao.

Dr. Rao concluded that resection of metastatic sites has a role. “I think it’s our responsibility as breast surgeons who are many times continuously following these patients to consider appropriate operations,” said Dr. Rao.

However, she did sound one note of caution. Surgery can interrupt therapy that is helping a patient. “Let’s say you have someone get a big liver resection, and then they have a tough time with recovery. There could be a long period of time they can’t get the therapy that was keeping them alive. That’s the real concern,” she said.

LAS VEGAS – Determination of whether excision of persistent breast cancer metastases can benefit the patient and even prolong survival depends on the location of the metastatic lesions, an investigator said at the annual meeting of the American Society of Breast Surgeons.

Before making the decision, it’s important to restage the patient’s disease and to recheck the receptor status if a biopsy is accessible, said Roshni Rao, MD, of the University of Texas Southwestern Medical Center.

Brain

Survival is worse when there are concurrent extracranial metastases or when brain metastases are greater than 5 cm, in patients with triple negative tumors, and in patients with a Karnofsky score of 70 or less, Dr. Rao said.

Surgery has the greatest benefit in patients with a single metastasis, with no extracranial disease, and who are able to undergo adjuvant whole brain radiation. In these cases, surgery improves survival, lowers recurrence rates, and reduces the risk of death neurological causes, she said.

Long-term survival is most common with continuous adjuvant therapy, either trastuzumab or hormonal, and in patients with a longer time interval to development of metastases. One series showed a 20-month survival increase.

Liver

Approximately 15% of patients with synchronous metastases will have liver metastases, and about half of stage IV patients will experience liver metastases at some point during treatment.

There is evidence from colorectal cancer that removing liver metastases is beneficial, and that has prompted interest in a similar approach in breast cancer. Liver resection has also become safer with new advances.

Dr. Rao discussed a single-institution study which took an aggressive approach to liver resection in 85 patients (Ann Surg. 2006;244:897-907). The researchers found that increased survival was associated with a good response to adjuvant chemotherapy, an r0 or r1 resection, and in patients who had a previous liver resection and were healthy enough to undergo another resection.

Overall, existing studies support liver resection if there are one to three lesions, if negative margins can be achieved, if the tumors are hormone receptor positive, and if the cancer is hormone positive and has good response to chemotherapy.

Dr. Rao emphasized that liver resections should be performed with a multidisciplinary team and should only be attempted at centers with low morbidity and where the doctors are experienced with liver resection.

When it’s possible, liver resection is beneficial. “There have been multiple reports of long-term survivors with no evidence of disease. There is likely a survival benefit with careful selection of these patients,” Dr. Rao said.

Lung

Lung surgeries are becoming safer, especially with the availability of video-assisted techniques, and pulmonary metastases are increasingly being spotted using more sensitive techniques such as higher resolution computed tomography.

A lung metastasis registry analysis showed three factors improved survival: prolonged disease-free survival, especially longer than 36 months; a complete resection; and a small number of metastases and success in resecting them all (Eur J Cardiothorac Surg. 2002;22:335-44). A more recent meta-analysis showed the same results (J Thorac Dis. 2015;7:1441-51).

Bone

Bone metastases remain rare choices for surgical treatment. Most of the time, morbidity will be too high, and there are good options for systemic treatment. That leaves surgery reserved mostly for stabilization or the treatment of fractures.

However, there are a couple of exceptions, according to Dr. Rao. One multi-institutional randomized trial looked at metastatic epidural spinal cord compression. Subjects either underwent decompressive surgery with stabilization and radiation or radiation alone. Patients in the surgical group had a longer ambulatory period and had a lower usage rate of steroids and opioids. Morbidity outcomes were similar in both groups. Patients whose primary tumor was in the breast seemed to benefit the most with respect to ambulatory time (Lancet. 2005;9486:643-8; J Neurosurg Spine. 2008;8:271-8).

Sternal metastases represent another special case. 70% of the time, patients with sternal metastases have it as their only metastatic site. A French series of 33 patients who underwent aggressive chest wall and rib resection reported a 36% complication rate, while another study of 28 patients showed a 21% complication rate. Those complications are a problem, “but if you’re able to perform this in a resected tumor, there are long term survivors. As usual, triple negative breast cancers predicted a worse prognosis,” said Dr. Rao.

Dr. Rao concluded that resection of metastatic sites has a role. “I think it’s our responsibility as breast surgeons who are many times continuously following these patients to consider appropriate operations,” said Dr. Rao.

However, she did sound one note of caution. Surgery can interrupt therapy that is helping a patient. “Let’s say you have someone get a big liver resection, and then they have a tough time with recovery. There could be a long period of time they can’t get the therapy that was keeping them alive. That’s the real concern,” she said.

The Diagnosis: Toxicodendron Dermatitis

Toxicodendron dermatitis is an allergic contact dermatitis that can occur after exposure to a plant from the Toxicodendron genus including poison ivy (Toxicodendron radicans), poison oak (Toxicodendron diversilobum), and poison sumac (Toxicodendron vernix). These plants produce urushiol in their oleoresinous sap, which causes intense pruritus, streaks of erythema, and edematous papules followed by vesicles and bullae. Previously sensitized individuals develop symptoms as quickly as 24 to 48 hours after exposure, with a range of 5 hours to 15 days.^1-3 Rarely, black spots also can be found on the skin, most prominently after 72 hours of exposure.⁴

The color change of urushiol-containing sap from pale to black was first documented by Peter Kalm, a Swedish botanist who traveled to North America in the 1700s.⁵ The black-spot test can be used to identify Toxicodendron species because the sap will turn black when expressed on white paper after a few minutes.⁶ Manifestation of black lacquer streaks on the skin is rare because concentrated sap is necessary, which typically requires an unusually prolonged exposure with Toxicodendron plants.⁷

Without treatment, typical Toxicodendron dermatitis resolves in approximately 3 weeks, though it may take up to 6 weeks to clear.² Early intervention is critical, as urushiol will fully absorb after 30 minutes.² After contact, complete removal of the oleoresin by washing with mild soap and water within 10 minutes can prevent dermatitis. Early topical corticosteroid application can reduce erythema and pruritus. Extensive or severe involvement, which includes Toxicodendron dermatitis with black spots, is treated with systemic corticosteroids such as prednisone that is tapered over 2 to 3 weeks.¹

Our patient had classic findings of Toxicodendron dermatitis; however, initially there was concern for levamisole toxicity by the emergency department, as well-demarcated purpuric or dark skin lesions can be due to morbid conditions such as leukocytoclastic vasculitis or skin necrosis from drug toxicities or infectious etiologies. Dermatology was consulted and these concerns were alleviated on closer skin examination and further questioning. The patient reported that he spent several hours cutting brush that was known to be T vernix (poison sumac) 3 days prior to presentation. Interestingly, the patient did not have similar black streaks on the left side of the face, as he held the weed-trimming saw in his right hand and in effect protected the left side of the face from debris. Furthermore, he had pruritic erythematous plaques on both forearms. The facial black lacquer-like streaks were the result of urushiol oxidation in the setting of prolonged exposure to the poison sumac oleoresin sap during weed trimming. After dermatologic evaluation, the patient was discharged from the emergency department on a 15-day taper of oral prednisone, and he was instructed to wash involved areas and exposed clothing with soap and water, which led to complete resolution.

The Diagnosis: Toxicodendron Dermatitis

Toxicodendron dermatitis is an allergic contact dermatitis that can occur after exposure to a plant from the Toxicodendron genus including poison ivy (Toxicodendron radicans), poison oak (Toxicodendron diversilobum), and poison sumac (Toxicodendron vernix). These plants produce urushiol in their oleoresinous sap, which causes intense pruritus, streaks of erythema, and edematous papules followed by vesicles and bullae. Previously sensitized individuals develop symptoms as quickly as 24 to 48 hours after exposure, with a range of 5 hours to 15 days.^1-3 Rarely, black spots also can be found on the skin, most prominently after 72 hours of exposure.⁴

The color change of urushiol-containing sap from pale to black was first documented by Peter Kalm, a Swedish botanist who traveled to North America in the 1700s.⁵ The black-spot test can be used to identify Toxicodendron species because the sap will turn black when expressed on white paper after a few minutes.⁶ Manifestation of black lacquer streaks on the skin is rare because concentrated sap is necessary, which typically requires an unusually prolonged exposure with Toxicodendron plants.⁷

Without treatment, typical Toxicodendron dermatitis resolves in approximately 3 weeks, though it may take up to 6 weeks to clear.² Early intervention is critical, as urushiol will fully absorb after 30 minutes.² After contact, complete removal of the oleoresin by washing with mild soap and water within 10 minutes can prevent dermatitis. Early topical corticosteroid application can reduce erythema and pruritus. Extensive or severe involvement, which includes Toxicodendron dermatitis with black spots, is treated with systemic corticosteroids such as prednisone that is tapered over 2 to 3 weeks.¹

Our patient had classic findings of Toxicodendron dermatitis; however, initially there was concern for levamisole toxicity by the emergency department, as well-demarcated purpuric or dark skin lesions can be due to morbid conditions such as leukocytoclastic vasculitis or skin necrosis from drug toxicities or infectious etiologies. Dermatology was consulted and these concerns were alleviated on closer skin examination and further questioning. The patient reported that he spent several hours cutting brush that was known to be T vernix (poison sumac) 3 days prior to presentation. Interestingly, the patient did not have similar black streaks on the left side of the face, as he held the weed-trimming saw in his right hand and in effect protected the left side of the face from debris. Furthermore, he had pruritic erythematous plaques on both forearms. The facial black lacquer-like streaks were the result of urushiol oxidation in the setting of prolonged exposure to the poison sumac oleoresin sap during weed trimming. After dermatologic evaluation, the patient was discharged from the emergency department on a 15-day taper of oral prednisone, and he was instructed to wash involved areas and exposed clothing with soap and water, which led to complete resolution.

The Diagnosis: Toxicodendron Dermatitis

Toxicodendron dermatitis is an allergic contact dermatitis that can occur after exposure to a plant from the Toxicodendron genus including poison ivy (Toxicodendron radicans), poison oak (Toxicodendron diversilobum), and poison sumac (Toxicodendron vernix). These plants produce urushiol in their oleoresinous sap, which causes intense pruritus, streaks of erythema, and edematous papules followed by vesicles and bullae. Previously sensitized individuals develop symptoms as quickly as 24 to 48 hours after exposure, with a range of 5 hours to 15 days.^1-3 Rarely, black spots also can be found on the skin, most prominently after 72 hours of exposure.⁴

The color change of urushiol-containing sap from pale to black was first documented by Peter Kalm, a Swedish botanist who traveled to North America in the 1700s.⁵ The black-spot test can be used to identify Toxicodendron species because the sap will turn black when expressed on white paper after a few minutes.⁶ Manifestation of black lacquer streaks on the skin is rare because concentrated sap is necessary, which typically requires an unusually prolonged exposure with Toxicodendron plants.⁷

Without treatment, typical Toxicodendron dermatitis resolves in approximately 3 weeks, though it may take up to 6 weeks to clear.² Early intervention is critical, as urushiol will fully absorb after 30 minutes.² After contact, complete removal of the oleoresin by washing with mild soap and water within 10 minutes can prevent dermatitis. Early topical corticosteroid application can reduce erythema and pruritus. Extensive or severe involvement, which includes Toxicodendron dermatitis with black spots, is treated with systemic corticosteroids such as prednisone that is tapered over 2 to 3 weeks.¹

Our patient had classic findings of Toxicodendron dermatitis; however, initially there was concern for levamisole toxicity by the emergency department, as well-demarcated purpuric or dark skin lesions can be due to morbid conditions such as leukocytoclastic vasculitis or skin necrosis from drug toxicities or infectious etiologies. Dermatology was consulted and these concerns were alleviated on closer skin examination and further questioning. The patient reported that he spent several hours cutting brush that was known to be T vernix (poison sumac) 3 days prior to presentation. Interestingly, the patient did not have similar black streaks on the left side of the face, as he held the weed-trimming saw in his right hand and in effect protected the left side of the face from debris. Furthermore, he had pruritic erythematous plaques on both forearms. The facial black lacquer-like streaks were the result of urushiol oxidation in the setting of prolonged exposure to the poison sumac oleoresin sap during weed trimming. After dermatologic evaluation, the patient was discharged from the emergency department on a 15-day taper of oral prednisone, and he was instructed to wash involved areas and exposed clothing with soap and water, which led to complete resolution.

SAN FRANCISCO – The good news of a prospective, multicenter study presented at the Pediatric Academic Societies meeting was that neonates who were breastfed were less likely to require neonatal abstinence syndrome (NAS) treatment and displayed milder symptoms.

The study also identified other risk factors associated with the need for NAS treatment and the severity of NAS.

“These findings are important because many of these risk factors are modifiable. Prenatal care providers strive to provide the best treatments for both the mother and the fetus. Our findings regarding the association of NAS with some maternal drug exposures can be shared with opiate-dependent mothers during general counseling about tobacco and illicit use in pregnancy and in counseling about NAS,” explained Megan Stover, MD, a fellow in maternal-fetal medicine and genetics at Tufts Medical Center in Boston.

The current standard of care for opioid-dependent pregnant women is medication-assisted treatment with either methadone or buprenorphine. The intervention can be effective in curbing continued opioid abuse and preventing relapse. However, for many of their unborn children, the damage has already been done.

The scope of the problem in the United States is staggering. Between 2004 and 2013, there was a fourfold to fivefold increase in the rate of admissions to neonatal intensive care units (NICUs) for NAS. “It has been estimated that, every minute in the United States, one neonate will require treatment for NAS,” said Dr. Stover. The glum reality for the Tufts researchers is that 50%-80% of opiate-exposed infants will require treatment for NAS. The aim is to reduce this rate.

Dr. Stover was part of a study conducted at hospitals on the U.S. East Coast that aimed to clarify factors before and after birth that were associated with NAS. The enrolled mothers had been treated during their third trimester or following admission for birth for opioid dependence or had received an opioid for relief of chronic pain. They had given birth to their child at term.

Neonates who were born prematurely or who had comorbidities judged to be significant were not part of the analyses. Of the 306 neonates included, 52% required treatment for NAS and 48% did not. The two groups were similar in age of the mother and for neonatal characteristics of gestational age, sex, ethnicity, and body measurements at birth. The severity of NAS was gauged in two ways. One was the number of days of treatment required to free the neonates from the opioid-induced symptoms, with less than 10 days indicating mild NAS, greater than 30 days indicating severe NAS, and the intervening days indicating moderate NAS. Severe NAS also was indicated by the use of two or more medications.

There was good news. Neonates were significantly less likely to require NAS treatment if they were breastfed exclusively, compared with formula fed babies (15% vs 67%; P less than .0001). NAS was usually mild in breastfed babies and often severe in formula-fed babies (P less than .002).

“Our findings regarding the favorable outcomes seen with breastfeeding support recent research regarding the influence of nonpharmacologic approaches to the prevention and management of NAS, namely that more soothing environments, like those outside the NICU, may be more optimal settings for infants undergoing surveillance for NAS,” said Dr. Stover.

Neonatal treatment was more prevalent for women whose opioid substitution therapy involved methadone (54% vs 28% of untreated neonates; P less than .0001). When therapy used buprenorphine, 62% of the neonates did not display NAS. The drug used for substitution therapy had no effect on the length of treatment of the neonates.

“Our data regarding methadone exposure [versus buprenorphine] adds to a growing literature surrounding more favorable neonatal effects seen with this opiate maintenance agent over methadone,” commented Dr. Stover.

NAS treatment was more prevalent for mothers who smoked during pregnancy, compared with those who did not (76% vs 42%; P equal to .02), and for maternal use of illicit drugs (50% vs 34%; P equal to .002), with no effect on length of neonatal treatment.

Maternal psychiatric diagnosis was associated with neonatal NAS (P equal to .03), as was prescription benzodiazepine use in the third trimester of pregnancy (P equal to .02). Benzodiazepine use did not influence the length of treatment. However, maternal alprazolam use did, as it was associated with more severe NAS (P less than .001). Use of selective serotonin reuptake inhibitor during pregnancy was also associated with more severe NAS (P equal to 0.01).

The researchers are currently sifting through the genetic data gathered in the study. The goal is to combine the clinical and genetic data to create a risk score that will be used to tailor care before birth and in the early weeks following birth.

The study was sponsored by Tufts Medical Center and was funded by National Institute on Drug Abuse. Dr. Stover reported having no relevant financial disclosures.

SAN FRANCISCO – The good news of a prospective, multicenter study presented at the Pediatric Academic Societies meeting was that neonates who were breastfed were less likely to require neonatal abstinence syndrome (NAS) treatment and displayed milder symptoms.

The study also identified other risk factors associated with the need for NAS treatment and the severity of NAS.

“These findings are important because many of these risk factors are modifiable. Prenatal care providers strive to provide the best treatments for both the mother and the fetus. Our findings regarding the association of NAS with some maternal drug exposures can be shared with opiate-dependent mothers during general counseling about tobacco and illicit use in pregnancy and in counseling about NAS,” explained Megan Stover, MD, a fellow in maternal-fetal medicine and genetics at Tufts Medical Center in Boston.

The current standard of care for opioid-dependent pregnant women is medication-assisted treatment with either methadone or buprenorphine. The intervention can be effective in curbing continued opioid abuse and preventing relapse. However, for many of their unborn children, the damage has already been done.

The scope of the problem in the United States is staggering. Between 2004 and 2013, there was a fourfold to fivefold increase in the rate of admissions to neonatal intensive care units (NICUs) for NAS. “It has been estimated that, every minute in the United States, one neonate will require treatment for NAS,” said Dr. Stover. The glum reality for the Tufts researchers is that 50%-80% of opiate-exposed infants will require treatment for NAS. The aim is to reduce this rate.

Dr. Stover was part of a study conducted at hospitals on the U.S. East Coast that aimed to clarify factors before and after birth that were associated with NAS. The enrolled mothers had been treated during their third trimester or following admission for birth for opioid dependence or had received an opioid for relief of chronic pain. They had given birth to their child at term.

Neonates who were born prematurely or who had comorbidities judged to be significant were not part of the analyses. Of the 306 neonates included, 52% required treatment for NAS and 48% did not. The two groups were similar in age of the mother and for neonatal characteristics of gestational age, sex, ethnicity, and body measurements at birth. The severity of NAS was gauged in two ways. One was the number of days of treatment required to free the neonates from the opioid-induced symptoms, with less than 10 days indicating mild NAS, greater than 30 days indicating severe NAS, and the intervening days indicating moderate NAS. Severe NAS also was indicated by the use of two or more medications.

There was good news. Neonates were significantly less likely to require NAS treatment if they were breastfed exclusively, compared with formula fed babies (15% vs 67%; P less than .0001). NAS was usually mild in breastfed babies and often severe in formula-fed babies (P less than .002).

“Our findings regarding the favorable outcomes seen with breastfeeding support recent research regarding the influence of nonpharmacologic approaches to the prevention and management of NAS, namely that more soothing environments, like those outside the NICU, may be more optimal settings for infants undergoing surveillance for NAS,” said Dr. Stover.

Neonatal treatment was more prevalent for women whose opioid substitution therapy involved methadone (54% vs 28% of untreated neonates; P less than .0001). When therapy used buprenorphine, 62% of the neonates did not display NAS. The drug used for substitution therapy had no effect on the length of treatment of the neonates.

“Our data regarding methadone exposure [versus buprenorphine] adds to a growing literature surrounding more favorable neonatal effects seen with this opiate maintenance agent over methadone,” commented Dr. Stover.

NAS treatment was more prevalent for mothers who smoked during pregnancy, compared with those who did not (76% vs 42%; P equal to .02), and for maternal use of illicit drugs (50% vs 34%; P equal to .002), with no effect on length of neonatal treatment.

Maternal psychiatric diagnosis was associated with neonatal NAS (P equal to .03), as was prescription benzodiazepine use in the third trimester of pregnancy (P equal to .02). Benzodiazepine use did not influence the length of treatment. However, maternal alprazolam use did, as it was associated with more severe NAS (P less than .001). Use of selective serotonin reuptake inhibitor during pregnancy was also associated with more severe NAS (P equal to 0.01).

The researchers are currently sifting through the genetic data gathered in the study. The goal is to combine the clinical and genetic data to create a risk score that will be used to tailor care before birth and in the early weeks following birth.

The study was sponsored by Tufts Medical Center and was funded by National Institute on Drug Abuse. Dr. Stover reported having no relevant financial disclosures.

SAN FRANCISCO – The good news of a prospective, multicenter study presented at the Pediatric Academic Societies meeting was that neonates who were breastfed were less likely to require neonatal abstinence syndrome (NAS) treatment and displayed milder symptoms.

The study also identified other risk factors associated with the need for NAS treatment and the severity of NAS.

“These findings are important because many of these risk factors are modifiable. Prenatal care providers strive to provide the best treatments for both the mother and the fetus. Our findings regarding the association of NAS with some maternal drug exposures can be shared with opiate-dependent mothers during general counseling about tobacco and illicit use in pregnancy and in counseling about NAS,” explained Megan Stover, MD, a fellow in maternal-fetal medicine and genetics at Tufts Medical Center in Boston.

The current standard of care for opioid-dependent pregnant women is medication-assisted treatment with either methadone or buprenorphine. The intervention can be effective in curbing continued opioid abuse and preventing relapse. However, for many of their unborn children, the damage has already been done.

The scope of the problem in the United States is staggering. Between 2004 and 2013, there was a fourfold to fivefold increase in the rate of admissions to neonatal intensive care units (NICUs) for NAS. “It has been estimated that, every minute in the United States, one neonate will require treatment for NAS,” said Dr. Stover. The glum reality for the Tufts researchers is that 50%-80% of opiate-exposed infants will require treatment for NAS. The aim is to reduce this rate.

Dr. Stover was part of a study conducted at hospitals on the U.S. East Coast that aimed to clarify factors before and after birth that were associated with NAS. The enrolled mothers had been treated during their third trimester or following admission for birth for opioid dependence or had received an opioid for relief of chronic pain. They had given birth to their child at term.

Neonates who were born prematurely or who had comorbidities judged to be significant were not part of the analyses. Of the 306 neonates included, 52% required treatment for NAS and 48% did not. The two groups were similar in age of the mother and for neonatal characteristics of gestational age, sex, ethnicity, and body measurements at birth. The severity of NAS was gauged in two ways. One was the number of days of treatment required to free the neonates from the opioid-induced symptoms, with less than 10 days indicating mild NAS, greater than 30 days indicating severe NAS, and the intervening days indicating moderate NAS. Severe NAS also was indicated by the use of two or more medications.

There was good news. Neonates were significantly less likely to require NAS treatment if they were breastfed exclusively, compared with formula fed babies (15% vs 67%; P less than .0001). NAS was usually mild in breastfed babies and often severe in formula-fed babies (P less than .002).

“Our findings regarding the favorable outcomes seen with breastfeeding support recent research regarding the influence of nonpharmacologic approaches to the prevention and management of NAS, namely that more soothing environments, like those outside the NICU, may be more optimal settings for infants undergoing surveillance for NAS,” said Dr. Stover.

Neonatal treatment was more prevalent for women whose opioid substitution therapy involved methadone (54% vs 28% of untreated neonates; P less than .0001). When therapy used buprenorphine, 62% of the neonates did not display NAS. The drug used for substitution therapy had no effect on the length of treatment of the neonates.

“Our data regarding methadone exposure [versus buprenorphine] adds to a growing literature surrounding more favorable neonatal effects seen with this opiate maintenance agent over methadone,” commented Dr. Stover.

NAS treatment was more prevalent for mothers who smoked during pregnancy, compared with those who did not (76% vs 42%; P equal to .02), and for maternal use of illicit drugs (50% vs 34%; P equal to .002), with no effect on length of neonatal treatment.

Maternal psychiatric diagnosis was associated with neonatal NAS (P equal to .03), as was prescription benzodiazepine use in the third trimester of pregnancy (P equal to .02). Benzodiazepine use did not influence the length of treatment. However, maternal alprazolam use did, as it was associated with more severe NAS (P less than .001). Use of selective serotonin reuptake inhibitor during pregnancy was also associated with more severe NAS (P equal to 0.01).

The researchers are currently sifting through the genetic data gathered in the study. The goal is to combine the clinical and genetic data to create a risk score that will be used to tailor care before birth and in the early weeks following birth.

The study was sponsored by Tufts Medical Center and was funded by National Institute on Drug Abuse. Dr. Stover reported having no relevant financial disclosures.

The U.S. Preventive Services Task Force recommends against screening asymptomatic adults for thyroid cancer, because the harms of such screening outweigh the benefits, according to a recommendation statement published May 9 in JAMA.

The USPSTF makes recommendations about the effectiveness of specific health care services for patients who don’t have related signs or symptoms. In this case, the recommendation statement addresses screening of adults who have no signs or symptoms of thyroid cancer by using neck palpation or ultrasonography, said Kirsten Bibbins-Domingo, MD, PhD, chair of the organization and lead author of the recommendation statement, and her associates (JAMA. 2017 May 9;317[18]:1882-7).

This document is an update of the previous USPSTF recommendation statement issued in 1996 and was undertaken because there have been several major advances related to the disease since that time.

However, despite a comprehensive review of the current literature, the group found no direct evidence supporting a change to their original advice against such screening.

They emphasized that this applies only to asymptomatic adults, not to those who have hoarseness, throat pain, difficulty swallowing, lumps in the neck, swelling, or asymmetry of the neck; nor to those who have a history of exposure to ionizing radiation, a family history of thyroid cancer, or a genetic susceptibility to the disease.

The results of the literature review were summarized in an evidence report by Jennifer S. Lin, MD, of Kaiser Permanente Center for Health Research, Portland, Ore., and her associates. They examined 67 studies involving nearly 584,000 patients, including 10 studies that addressed screening test performance, 3 that addressed the possible harms of screening, 2 that addressed treatment benefits, and 52 that addressed treatment harms.

No good-quality studies assessed the net benefit of thyroid cancer screening, nor whether “early” treatment of screen-detected cancers improved patient outcomes. However, the preponderance of evidence suggested that most thyroid cancers detected by screening are indolent.

So, treatment is likely unnecessary but exposes patients to “nontrivial” harms, including an increased risk of second primary malignancy, permanent adverse effects on the salivary glands, laryngeal nerve injury, hypoparathyroidism, and the need for lifelong thyroid replacement therapy and monitoring for cancer recurrence, Dr. Lin and her associates said in their evidence report (JAMA. 2017 May 9;317[18]:1888-1903).

The task force noted that no professional medical society currently recommends population-based screening for thyroid cancer. The American Cancer Society, American Thyroid Association, American Association of Clinical Endocrinologists, and American College of Endocrinology all have no specific recommendations for screening asymptomatic patients, while the American Academy of Family Physicians recommends against such screening, said Dr. Bibbins-Domingo, who is also a professor of medicine at the University of California, San Francisco, and her associates.

Further information regarding the recommendation statement and the evidence report is available at www.uspreventiveservicestaskforce.org.

The USPSTF is an independent voluntary group supported by the Agency for Healthcare Research and Quality. The authors’ conflict of interest disclosures are available at www.uspreventiveservicestaskforce.org.

The U.S. Preventive Services Task Force recommends against screening asymptomatic adults for thyroid cancer, because the harms of such screening outweigh the benefits, according to a recommendation statement published May 9 in JAMA.

The USPSTF makes recommendations about the effectiveness of specific health care services for patients who don’t have related signs or symptoms. In this case, the recommendation statement addresses screening of adults who have no signs or symptoms of thyroid cancer by using neck palpation or ultrasonography, said Kirsten Bibbins-Domingo, MD, PhD, chair of the organization and lead author of the recommendation statement, and her associates (JAMA. 2017 May 9;317[18]:1882-7).

This document is an update of the previous USPSTF recommendation statement issued in 1996 and was undertaken because there have been several major advances related to the disease since that time.

However, despite a comprehensive review of the current literature, the group found no direct evidence supporting a change to their original advice against such screening.

They emphasized that this applies only to asymptomatic adults, not to those who have hoarseness, throat pain, difficulty swallowing, lumps in the neck, swelling, or asymmetry of the neck; nor to those who have a history of exposure to ionizing radiation, a family history of thyroid cancer, or a genetic susceptibility to the disease.

The results of the literature review were summarized in an evidence report by Jennifer S. Lin, MD, of Kaiser Permanente Center for Health Research, Portland, Ore., and her associates. They examined 67 studies involving nearly 584,000 patients, including 10 studies that addressed screening test performance, 3 that addressed the possible harms of screening, 2 that addressed treatment benefits, and 52 that addressed treatment harms.

No good-quality studies assessed the net benefit of thyroid cancer screening, nor whether “early” treatment of screen-detected cancers improved patient outcomes. However, the preponderance of evidence suggested that most thyroid cancers detected by screening are indolent.

So, treatment is likely unnecessary but exposes patients to “nontrivial” harms, including an increased risk of second primary malignancy, permanent adverse effects on the salivary glands, laryngeal nerve injury, hypoparathyroidism, and the need for lifelong thyroid replacement therapy and monitoring for cancer recurrence, Dr. Lin and her associates said in their evidence report (JAMA. 2017 May 9;317[18]:1888-1903).

The task force noted that no professional medical society currently recommends population-based screening for thyroid cancer. The American Cancer Society, American Thyroid Association, American Association of Clinical Endocrinologists, and American College of Endocrinology all have no specific recommendations for screening asymptomatic patients, while the American Academy of Family Physicians recommends against such screening, said Dr. Bibbins-Domingo, who is also a professor of medicine at the University of California, San Francisco, and her associates.

Further information regarding the recommendation statement and the evidence report is available at www.uspreventiveservicestaskforce.org.

The USPSTF is an independent voluntary group supported by the Agency for Healthcare Research and Quality. The authors’ conflict of interest disclosures are available at www.uspreventiveservicestaskforce.org.

The U.S. Preventive Services Task Force recommends against screening asymptomatic adults for thyroid cancer, because the harms of such screening outweigh the benefits, according to a recommendation statement published May 9 in JAMA.

The USPSTF makes recommendations about the effectiveness of specific health care services for patients who don’t have related signs or symptoms. In this case, the recommendation statement addresses screening of adults who have no signs or symptoms of thyroid cancer by using neck palpation or ultrasonography, said Kirsten Bibbins-Domingo, MD, PhD, chair of the organization and lead author of the recommendation statement, and her associates (JAMA. 2017 May 9;317[18]:1882-7).

This document is an update of the previous USPSTF recommendation statement issued in 1996 and was undertaken because there have been several major advances related to the disease since that time.

However, despite a comprehensive review of the current literature, the group found no direct evidence supporting a change to their original advice against such screening.

They emphasized that this applies only to asymptomatic adults, not to those who have hoarseness, throat pain, difficulty swallowing, lumps in the neck, swelling, or asymmetry of the neck; nor to those who have a history of exposure to ionizing radiation, a family history of thyroid cancer, or a genetic susceptibility to the disease.

The results of the literature review were summarized in an evidence report by Jennifer S. Lin, MD, of Kaiser Permanente Center for Health Research, Portland, Ore., and her associates. They examined 67 studies involving nearly 584,000 patients, including 10 studies that addressed screening test performance, 3 that addressed the possible harms of screening, 2 that addressed treatment benefits, and 52 that addressed treatment harms.

No good-quality studies assessed the net benefit of thyroid cancer screening, nor whether “early” treatment of screen-detected cancers improved patient outcomes. However, the preponderance of evidence suggested that most thyroid cancers detected by screening are indolent.

So, treatment is likely unnecessary but exposes patients to “nontrivial” harms, including an increased risk of second primary malignancy, permanent adverse effects on the salivary glands, laryngeal nerve injury, hypoparathyroidism, and the need for lifelong thyroid replacement therapy and monitoring for cancer recurrence, Dr. Lin and her associates said in their evidence report (JAMA. 2017 May 9;317[18]:1888-1903).

The task force noted that no professional medical society currently recommends population-based screening for thyroid cancer. The American Cancer Society, American Thyroid Association, American Association of Clinical Endocrinologists, and American College of Endocrinology all have no specific recommendations for screening asymptomatic patients, while the American Academy of Family Physicians recommends against such screening, said Dr. Bibbins-Domingo, who is also a professor of medicine at the University of California, San Francisco, and her associates.

Further information regarding the recommendation statement and the evidence report is available at www.uspreventiveservicestaskforce.org.

The USPSTF is an independent voluntary group supported by the Agency for Healthcare Research and Quality. The authors’ conflict of interest disclosures are available at www.uspreventiveservicestaskforce.org.

Cyclosporine is more cost effective than prednisolone for treating patients with large pyoderma gangrenosum lesions , based on data from a multicenter, randomized trial published online in the British Journal of Dermatology.

In the STOP-GAP trial, researchers recruited 112 adults with pyoderma gangrenosum and similar baseline demographics. The patients were randomized to receive cyclosporine or prednisolone and were assessed at 6 weeks and 6 months. The researchers also collected quality of life data and cost and resource information.

Healing rates within 6 months were approximately 47% for the cyclosporine and prednisolone groups. Adverse reactions were similar between the two groups at 68% and 66%, respectively.

“Having found no difference for a range of objective and patient-reported outcomes, the trialists concluded that treatment decisions for individual patients should be guided by the different side effect profiles of the two drugs and patient preference,” wrote James M. Mason, MD, of the University of Warwick (England), and his colleagues. Compared with prednisolone, cyclosporine reduced the costs of treatment by 1,100 British pounds, the researchers noted. However, most of that cost savings was seen in patients with lesions of 20 cm² or greater; the decreased cost for these patients averaged 5,310 British pounds. The cost savings were 1,007 British pounds for patients with lesions less than 20 cm² (Br J Dermatol. 2017. doi: 10.1111/bjd.15561). “These differences were driven by the pattern of hospitalization, which predominantly occurred in patients receiving prednisolone and may be linked to the occurrence of serious adverse events,” the researchers wrote.

Quality of life was assessed using the EuroQol questionnaire and the Dermatology Life Quality Index.

No significant differences were noted between the two treatments in terms of quality of life scores, although there was a slight increase in quality of life scores among cyclosporine-treated patients over the 24-week follow-up period.

The findings were limited by incomplete data and the use of a base case analysis to complete the gaps, the researchers said. However, the results suggest that cyclosporine may be a cost-effective strategy for patients with larger lesions; no clear advantage was seen for cyclosporine vs. prednisolone treatment in patients with smaller lesions.

The study was supported in part by a grant from the National Institute for Health Research. The researchers had no financial conflicts to disclose.

[email protected]

Cyclosporine is more cost effective than prednisolone for treating patients with large pyoderma gangrenosum lesions , based on data from a multicenter, randomized trial published online in the British Journal of Dermatology.

In the STOP-GAP trial, researchers recruited 112 adults with pyoderma gangrenosum and similar baseline demographics. The patients were randomized to receive cyclosporine or prednisolone and were assessed at 6 weeks and 6 months. The researchers also collected quality of life data and cost and resource information.

Healing rates within 6 months were approximately 47% for the cyclosporine and prednisolone groups. Adverse reactions were similar between the two groups at 68% and 66%, respectively.

“Having found no difference for a range of objective and patient-reported outcomes, the trialists concluded that treatment decisions for individual patients should be guided by the different side effect profiles of the two drugs and patient preference,” wrote James M. Mason, MD, of the University of Warwick (England), and his colleagues. Compared with prednisolone, cyclosporine reduced the costs of treatment by 1,100 British pounds, the researchers noted. However, most of that cost savings was seen in patients with lesions of 20 cm² or greater; the decreased cost for these patients averaged 5,310 British pounds. The cost savings were 1,007 British pounds for patients with lesions less than 20 cm² (Br J Dermatol. 2017. doi: 10.1111/bjd.15561). “These differences were driven by the pattern of hospitalization, which predominantly occurred in patients receiving prednisolone and may be linked to the occurrence of serious adverse events,” the researchers wrote.

Quality of life was assessed using the EuroQol questionnaire and the Dermatology Life Quality Index.

No significant differences were noted between the two treatments in terms of quality of life scores, although there was a slight increase in quality of life scores among cyclosporine-treated patients over the 24-week follow-up period.

The findings were limited by incomplete data and the use of a base case analysis to complete the gaps, the researchers said. However, the results suggest that cyclosporine may be a cost-effective strategy for patients with larger lesions; no clear advantage was seen for cyclosporine vs. prednisolone treatment in patients with smaller lesions.

The study was supported in part by a grant from the National Institute for Health Research. The researchers had no financial conflicts to disclose.

[email protected]

Cyclosporine is more cost effective than prednisolone for treating patients with large pyoderma gangrenosum lesions , based on data from a multicenter, randomized trial published online in the British Journal of Dermatology.

In the STOP-GAP trial, researchers recruited 112 adults with pyoderma gangrenosum and similar baseline demographics. The patients were randomized to receive cyclosporine or prednisolone and were assessed at 6 weeks and 6 months. The researchers also collected quality of life data and cost and resource information.

Healing rates within 6 months were approximately 47% for the cyclosporine and prednisolone groups. Adverse reactions were similar between the two groups at 68% and 66%, respectively.

“Having found no difference for a range of objective and patient-reported outcomes, the trialists concluded that treatment decisions for individual patients should be guided by the different side effect profiles of the two drugs and patient preference,” wrote James M. Mason, MD, of the University of Warwick (England), and his colleagues. Compared with prednisolone, cyclosporine reduced the costs of treatment by 1,100 British pounds, the researchers noted. However, most of that cost savings was seen in patients with lesions of 20 cm² or greater; the decreased cost for these patients averaged 5,310 British pounds. The cost savings were 1,007 British pounds for patients with lesions less than 20 cm² (Br J Dermatol. 2017. doi: 10.1111/bjd.15561). “These differences were driven by the pattern of hospitalization, which predominantly occurred in patients receiving prednisolone and may be linked to the occurrence of serious adverse events,” the researchers wrote.

Quality of life was assessed using the EuroQol questionnaire and the Dermatology Life Quality Index.

No significant differences were noted between the two treatments in terms of quality of life scores, although there was a slight increase in quality of life scores among cyclosporine-treated patients over the 24-week follow-up period.

The findings were limited by incomplete data and the use of a base case analysis to complete the gaps, the researchers said. However, the results suggest that cyclosporine may be a cost-effective strategy for patients with larger lesions; no clear advantage was seen for cyclosporine vs. prednisolone treatment in patients with smaller lesions.

The study was supported in part by a grant from the National Institute for Health Research. The researchers had no financial conflicts to disclose.

[email protected]

LAS VEGAS – Patients with knee osteoarthritis (OA) and a meniscal tear who underwent arthroscopic partial meniscectomy (APM) subsequently experienced accelerated structural progression of their OA, compared with those randomized to physical therapy alone in the randomized METEOR trial.

“In discussing treatment options for symptomatic meniscal tear, patients and providers must weigh the potential benefits and risks of arthroscopic partial meniscectomy, including this increased risk of structural progression,” Jamie E. Collins, PhD, said at the World Congress on Osteoarthritis.

Bruce Jancin/Frontline Medical News

[email protected]

LAS VEGAS – Patients with knee osteoarthritis (OA) and a meniscal tear who underwent arthroscopic partial meniscectomy (APM) subsequently experienced accelerated structural progression of their OA, compared with those randomized to physical therapy alone in the randomized METEOR trial.

“In discussing treatment options for symptomatic meniscal tear, patients and providers must weigh the potential benefits and risks of arthroscopic partial meniscectomy, including this increased risk of structural progression,” Jamie E. Collins, PhD, said at the World Congress on Osteoarthritis.

Bruce Jancin/Frontline Medical News

[email protected]

LAS VEGAS – Patients with knee osteoarthritis (OA) and a meniscal tear who underwent arthroscopic partial meniscectomy (APM) subsequently experienced accelerated structural progression of their OA, compared with those randomized to physical therapy alone in the randomized METEOR trial.

“In discussing treatment options for symptomatic meniscal tear, patients and providers must weigh the potential benefits and risks of arthroscopic partial meniscectomy, including this increased risk of structural progression,” Jamie E. Collins, PhD, said at the World Congress on Osteoarthritis.

Bruce Jancin/Frontline Medical News

[email protected]