A short course of prednisolone may help rheumatologists differentiate between patients with rheumatoid arthritis and osteoarthritis, a proof of concept study shows.

However, the investigators caution that a positive response to the 3-day steroid course does not confirm a diagnosis of rheumatoid arthritis (RA).

For many years, rheumatologists have been using short courses of prednisolone in unclear clinical situations to differentiate between inflammatory and non-inflammatory arthritis, according to the investigators led by Uta Kiltz, MD, from Rheumazentrum Ruhrgebiet, Herne, Germany.

A short course of prednisolone may help rheumatologists differentiate between patients with rheumatoid arthritis and osteoarthritis, a proof of concept study shows.

However, the investigators caution that a positive response to the 3-day steroid course does not confirm a diagnosis of rheumatoid arthritis (RA).

For many years, rheumatologists have been using short courses of prednisolone in unclear clinical situations to differentiate between inflammatory and non-inflammatory arthritis, according to the investigators led by Uta Kiltz, MD, from Rheumazentrum Ruhrgebiet, Herne, Germany.

A short course of prednisolone may help rheumatologists differentiate between patients with rheumatoid arthritis and osteoarthritis, a proof of concept study shows.

However, the investigators caution that a positive response to the 3-day steroid course does not confirm a diagnosis of rheumatoid arthritis (RA).

For many years, rheumatologists have been using short courses of prednisolone in unclear clinical situations to differentiate between inflammatory and non-inflammatory arthritis, according to the investigators led by Uta Kiltz, MD, from Rheumazentrum Ruhrgebiet, Herne, Germany.

WASHINGTON – Orbital atherectomy (OA) was associated with a lower risk of in-hospital mortality than rotational atherectomy (RA) in female, obese, and elderly study groups, according to data from a prospective observational study.

Each procedure was employed to treat coronary artery calcifications (CAC) in the elderly and the obese prior to percutaneous interventions (PCI).

The data comparing OA with RA in these populations were drawn from the Clinical Outcomes of Atherectomy Prior to PCI (COAP) study, for which Perwaiz M. Meraj, MD, director of structural heart and peripheral vascular disease at the North Shore-LIJ Hospital, Manhasset, N.Y., served as the senior author.

Each set of data, as well as a third set of data comparing OA to RA in female patients, was presented separately at CRT 2017, sponsored by the Cardiovascular Research Institute at Washington Hospital Center.

In the comparison of OA to RA in the elderly, a substudy known as COAP-75, the focus was on patients 75 years of age or older who underwent either OA or RA to remove calcified coronary lesions within the context of PCI. As with the obese and female subgroups, the elderly patients in this study were drawn from 35,590 patients who underwent PCI at one of five tertiary care hospitals in a recent 5-year period.

Of the 310 elderly patients undergoing atherectomy, 117 were treated with OA and 193 with RA. The median lesion lengths and diameters were not significantly different between the two groups. Although OA was less likely to be performed through femoral access (53% vs. 68.9%; P = .005), no other measured differences in procedure were significant, with one exception: Fluoroscopy exposure was of shorter duration in the OA, versus the RA, arm (24.0 minutes vs. 29.4 minutes; P = .005).

On univariate analysis, the lower rate of in-hospital deaths for OA did not reach statistical significance (0% vs. 1.55%; P = .176), but the difference was significant on multivariate-adjusted analysis (P = .034).

There were also higher numerical rates of perforation, tamponade, heart failure, and red blood cell transfusion in the RA group, versus the OA group, but only the latter was significant (P = .002) on multivariate-adjusted analysis.

In contrast, there was a higher rate of MI among those treated with OA, rather than RA (17.1% vs. 13.5%), which was not significant on univariate analysis (P = .573) but did reach significance on adjusted-multivariate analysis (P = .008).

Overall, the authors suggested that both OA and RA are safe procedures, but the mortality reduction suggests a potential relative advantage for OA.

Similar conclusions were reached in the substudy of patients with obesity, called COAP-BMI. In that study, 222 patients were evaluated, of which 91 were treated with OA and 131 were treated with RA.

In-hospital mortality was 0% in the group treated with OA, compared with 3.05% in the group treated with RA (P = .004). The rate of in-hospital major adverse cardiovascular events was also significantly lower in the OA group (15.4% vs. 16.3%; P = .007).

“The rate of secondary outcomes for myocardial infarction and stroke were similar between groups, as were individual procedural safety endpoints, including dissection, perforation, tamponade, or heart failure,” reported Evan Shlofmitz, MD, a cardiology fellow at Northwell Health, Manhasset, N.Y., who collaborated with Dr. Meraj and presented the data at the meeting.

As with the study in the elderly, for which Dr. Shlofmitz was also a coauthor, the study in the obese is the first to compare OA and RA, he noted.

In a third substudy, called COAP-Female, OA and RA were compared in 247 women with CAC who were undergoing PCI.

Again, in-hospital mortality rates were higher in those treated with RA, compared with OA, but the difference was not significant (0.79% vs. 0%; P = .254). There were also no significant differences in any secondary outcomes, including MI, or in any procedural complications, such as rates of dissection, perforation, or major bleeding.

The only significant difference identified in the study was a lower fluoroscopy time in those treated with OA relative to RA (21.3 minutes vs. 27.6 minutes; P = .001).

Although fluoroscopy time was not a primary endpoint, “a reduction in radiation exposure has important ramifications for both patients and operators,” Dr. Shlofmitz noted. He suggested that objective data on outcomes in females is needed, because this group has been “severely underrepresented in atherectomy trials.”

Overall, the substudies reinforce a large body of evidence that atherectomy is safe and effective for achieving revascularization in patients undergoing PCI who have CAC, Dr. Shlofmitz concluded. However, the significant mortality advantage for OA relative to RA in the elderly and the obese suggests that the approaches may not be interchangeable.

Dr. Shlofmitz reported no financial relationships to disclose.

WASHINGTON – Orbital atherectomy (OA) was associated with a lower risk of in-hospital mortality than rotational atherectomy (RA) in female, obese, and elderly study groups, according to data from a prospective observational study.

Each procedure was employed to treat coronary artery calcifications (CAC) in the elderly and the obese prior to percutaneous interventions (PCI).

The data comparing OA with RA in these populations were drawn from the Clinical Outcomes of Atherectomy Prior to PCI (COAP) study, for which Perwaiz M. Meraj, MD, director of structural heart and peripheral vascular disease at the North Shore-LIJ Hospital, Manhasset, N.Y., served as the senior author.

Each set of data, as well as a third set of data comparing OA to RA in female patients, was presented separately at CRT 2017, sponsored by the Cardiovascular Research Institute at Washington Hospital Center.

In the comparison of OA to RA in the elderly, a substudy known as COAP-75, the focus was on patients 75 years of age or older who underwent either OA or RA to remove calcified coronary lesions within the context of PCI. As with the obese and female subgroups, the elderly patients in this study were drawn from 35,590 patients who underwent PCI at one of five tertiary care hospitals in a recent 5-year period.

Of the 310 elderly patients undergoing atherectomy, 117 were treated with OA and 193 with RA. The median lesion lengths and diameters were not significantly different between the two groups. Although OA was less likely to be performed through femoral access (53% vs. 68.9%; P = .005), no other measured differences in procedure were significant, with one exception: Fluoroscopy exposure was of shorter duration in the OA, versus the RA, arm (24.0 minutes vs. 29.4 minutes; P = .005).

On univariate analysis, the lower rate of in-hospital deaths for OA did not reach statistical significance (0% vs. 1.55%; P = .176), but the difference was significant on multivariate-adjusted analysis (P = .034).

There were also higher numerical rates of perforation, tamponade, heart failure, and red blood cell transfusion in the RA group, versus the OA group, but only the latter was significant (P = .002) on multivariate-adjusted analysis.

In contrast, there was a higher rate of MI among those treated with OA, rather than RA (17.1% vs. 13.5%), which was not significant on univariate analysis (P = .573) but did reach significance on adjusted-multivariate analysis (P = .008).

Overall, the authors suggested that both OA and RA are safe procedures, but the mortality reduction suggests a potential relative advantage for OA.

Similar conclusions were reached in the substudy of patients with obesity, called COAP-BMI. In that study, 222 patients were evaluated, of which 91 were treated with OA and 131 were treated with RA.

In-hospital mortality was 0% in the group treated with OA, compared with 3.05% in the group treated with RA (P = .004). The rate of in-hospital major adverse cardiovascular events was also significantly lower in the OA group (15.4% vs. 16.3%; P = .007).

“The rate of secondary outcomes for myocardial infarction and stroke were similar between groups, as were individual procedural safety endpoints, including dissection, perforation, tamponade, or heart failure,” reported Evan Shlofmitz, MD, a cardiology fellow at Northwell Health, Manhasset, N.Y., who collaborated with Dr. Meraj and presented the data at the meeting.

As with the study in the elderly, for which Dr. Shlofmitz was also a coauthor, the study in the obese is the first to compare OA and RA, he noted.

In a third substudy, called COAP-Female, OA and RA were compared in 247 women with CAC who were undergoing PCI.

Again, in-hospital mortality rates were higher in those treated with RA, compared with OA, but the difference was not significant (0.79% vs. 0%; P = .254). There were also no significant differences in any secondary outcomes, including MI, or in any procedural complications, such as rates of dissection, perforation, or major bleeding.

The only significant difference identified in the study was a lower fluoroscopy time in those treated with OA relative to RA (21.3 minutes vs. 27.6 minutes; P = .001).

Although fluoroscopy time was not a primary endpoint, “a reduction in radiation exposure has important ramifications for both patients and operators,” Dr. Shlofmitz noted. He suggested that objective data on outcomes in females is needed, because this group has been “severely underrepresented in atherectomy trials.”

Overall, the substudies reinforce a large body of evidence that atherectomy is safe and effective for achieving revascularization in patients undergoing PCI who have CAC, Dr. Shlofmitz concluded. However, the significant mortality advantage for OA relative to RA in the elderly and the obese suggests that the approaches may not be interchangeable.

Dr. Shlofmitz reported no financial relationships to disclose.

WASHINGTON – Orbital atherectomy (OA) was associated with a lower risk of in-hospital mortality than rotational atherectomy (RA) in female, obese, and elderly study groups, according to data from a prospective observational study.

Each procedure was employed to treat coronary artery calcifications (CAC) in the elderly and the obese prior to percutaneous interventions (PCI).

The data comparing OA with RA in these populations were drawn from the Clinical Outcomes of Atherectomy Prior to PCI (COAP) study, for which Perwaiz M. Meraj, MD, director of structural heart and peripheral vascular disease at the North Shore-LIJ Hospital, Manhasset, N.Y., served as the senior author.

Each set of data, as well as a third set of data comparing OA to RA in female patients, was presented separately at CRT 2017, sponsored by the Cardiovascular Research Institute at Washington Hospital Center.

In the comparison of OA to RA in the elderly, a substudy known as COAP-75, the focus was on patients 75 years of age or older who underwent either OA or RA to remove calcified coronary lesions within the context of PCI. As with the obese and female subgroups, the elderly patients in this study were drawn from 35,590 patients who underwent PCI at one of five tertiary care hospitals in a recent 5-year period.

Of the 310 elderly patients undergoing atherectomy, 117 were treated with OA and 193 with RA. The median lesion lengths and diameters were not significantly different between the two groups. Although OA was less likely to be performed through femoral access (53% vs. 68.9%; P = .005), no other measured differences in procedure were significant, with one exception: Fluoroscopy exposure was of shorter duration in the OA, versus the RA, arm (24.0 minutes vs. 29.4 minutes; P = .005).

On univariate analysis, the lower rate of in-hospital deaths for OA did not reach statistical significance (0% vs. 1.55%; P = .176), but the difference was significant on multivariate-adjusted analysis (P = .034).

There were also higher numerical rates of perforation, tamponade, heart failure, and red blood cell transfusion in the RA group, versus the OA group, but only the latter was significant (P = .002) on multivariate-adjusted analysis.

In contrast, there was a higher rate of MI among those treated with OA, rather than RA (17.1% vs. 13.5%), which was not significant on univariate analysis (P = .573) but did reach significance on adjusted-multivariate analysis (P = .008).

Overall, the authors suggested that both OA and RA are safe procedures, but the mortality reduction suggests a potential relative advantage for OA.

Similar conclusions were reached in the substudy of patients with obesity, called COAP-BMI. In that study, 222 patients were evaluated, of which 91 were treated with OA and 131 were treated with RA.

In-hospital mortality was 0% in the group treated with OA, compared with 3.05% in the group treated with RA (P = .004). The rate of in-hospital major adverse cardiovascular events was also significantly lower in the OA group (15.4% vs. 16.3%; P = .007).

“The rate of secondary outcomes for myocardial infarction and stroke were similar between groups, as were individual procedural safety endpoints, including dissection, perforation, tamponade, or heart failure,” reported Evan Shlofmitz, MD, a cardiology fellow at Northwell Health, Manhasset, N.Y., who collaborated with Dr. Meraj and presented the data at the meeting.

As with the study in the elderly, for which Dr. Shlofmitz was also a coauthor, the study in the obese is the first to compare OA and RA, he noted.

In a third substudy, called COAP-Female, OA and RA were compared in 247 women with CAC who were undergoing PCI.

Again, in-hospital mortality rates were higher in those treated with RA, compared with OA, but the difference was not significant (0.79% vs. 0%; P = .254). There were also no significant differences in any secondary outcomes, including MI, or in any procedural complications, such as rates of dissection, perforation, or major bleeding.

The only significant difference identified in the study was a lower fluoroscopy time in those treated with OA relative to RA (21.3 minutes vs. 27.6 minutes; P = .001).

Although fluoroscopy time was not a primary endpoint, “a reduction in radiation exposure has important ramifications for both patients and operators,” Dr. Shlofmitz noted. He suggested that objective data on outcomes in females is needed, because this group has been “severely underrepresented in atherectomy trials.”

Overall, the substudies reinforce a large body of evidence that atherectomy is safe and effective for achieving revascularization in patients undergoing PCI who have CAC, Dr. Shlofmitz concluded. However, the significant mortality advantage for OA relative to RA in the elderly and the obese suggests that the approaches may not be interchangeable.

Dr. Shlofmitz reported no financial relationships to disclose.

At 12 weeks, 77% of psoriasis patients treated with risankizumab showed a 90% or greater reduction in Psoriasis Area and Severity Index (PASI) score, compared with 40% of ustekinumab patients, in a phase II randomized trial.

The results were published April 19 in the New England Journal of Medicine.

Ustekinumab (Stelara), approved by the Food and Drug Administration in 2009, blocks interleukin-12 and interleukin-23 and has demonstrated effectiveness in psoriasis patients. However, the humanized IgG1 monoclonal antibody risankizumab goes farther and “selectively inhibits interleukin-23 by specifically targeting p19,” wrote Kim A. Papp, MD, PhD, of K. Papp Clinical Research and Probity Medical Research, Waterloo, Ont., and associates (N. Engl. J. Med. 2017;376:1551-60. doi: 10.1056/NEJMoa1607017).

To compare clinical response and safety, the researchers enrolled 166 adults aged 18-75 years with moderate to severe plaque psoriasis, in the phase II study. Patients were randomized to subcutaneous injections of risankizumab at one of three doses, or ustekinumab at one of two doses. Risankizumab patients received a single 18-mg dose at week 0, or 90-mg or 180-mg doses at weeks 0, 4, and 16. Ustekinumab patients weighing 100 kg or less received 45 mg at weeks 0, 4, and 16; those weighing more than 100 kg received 90 mg at weeks 0, 4, and 16. Demographics were similar among the treatment groups.

The primary end point was a 90% or greater reduction in the PASI score at week 12, compared with baseline.

In pooled results of the risankizumab 90-mg and 180-mg groups, 77% of patients achieved a PASI 90 at 12 weeks (73% of the 90-mg group and 81% of the 180-mg group), vs. 40% of ustekinumab patients (P less than .001). Complete clearance of lesions (PASI 100) occurred among risankizumab patients in 14% of the 18-mg group, 41% of the 90-mg group, and 48% of the 180-mg group, compared with 18% of the ustekinumab group.

Among risankizumab patients, the rates of adverse events through 48 weeks were 81% in the 180-mg group, 80% in the 90-mg group, and 69% in the 180-mg group, compared with 72% in those on ustekinumab, with nasopharyngitis the most commonly reported adverse event in all the treatment groups. The rates of serious adverse events were 12% and 15% among those in the 18-mg and 90-mg risankizumab groups, respectively; 0% among those on the 180-mg dose, and 8% among those on ustekinumab.

The study was not large or long enough to provide conclusive safety data on risankizumab, and additional studies are needed to review psoriasis lesions over a longer time period and include both placebo and active comparators, researchers noted. However, the results suggest that “the selective blockade of interleukin-23 through the inhibition of the p19 subunit rather than p40 provides a more complete inhibition of interleukin-23 activity, potentially resulting in a greater efficacy in the treatment of plaque psoriasis at the doses used,” they said.

The study was supported by Boehringer Ingelheim. Several study coauthors, including lead author Dr. Papp, disclosed relationships with Boehringer Ingelheim and other companies. Several authors are Boehringer Ingelheim employees.
 

[email protected]

At 12 weeks, 77% of psoriasis patients treated with risankizumab showed a 90% or greater reduction in Psoriasis Area and Severity Index (PASI) score, compared with 40% of ustekinumab patients, in a phase II randomized trial.

The results were published April 19 in the New England Journal of Medicine.

Ustekinumab (Stelara), approved by the Food and Drug Administration in 2009, blocks interleukin-12 and interleukin-23 and has demonstrated effectiveness in psoriasis patients. However, the humanized IgG1 monoclonal antibody risankizumab goes farther and “selectively inhibits interleukin-23 by specifically targeting p19,” wrote Kim A. Papp, MD, PhD, of K. Papp Clinical Research and Probity Medical Research, Waterloo, Ont., and associates (N. Engl. J. Med. 2017;376:1551-60. doi: 10.1056/NEJMoa1607017).

To compare clinical response and safety, the researchers enrolled 166 adults aged 18-75 years with moderate to severe plaque psoriasis, in the phase II study. Patients were randomized to subcutaneous injections of risankizumab at one of three doses, or ustekinumab at one of two doses. Risankizumab patients received a single 18-mg dose at week 0, or 90-mg or 180-mg doses at weeks 0, 4, and 16. Ustekinumab patients weighing 100 kg or less received 45 mg at weeks 0, 4, and 16; those weighing more than 100 kg received 90 mg at weeks 0, 4, and 16. Demographics were similar among the treatment groups.

The primary end point was a 90% or greater reduction in the PASI score at week 12, compared with baseline.

In pooled results of the risankizumab 90-mg and 180-mg groups, 77% of patients achieved a PASI 90 at 12 weeks (73% of the 90-mg group and 81% of the 180-mg group), vs. 40% of ustekinumab patients (P less than .001). Complete clearance of lesions (PASI 100) occurred among risankizumab patients in 14% of the 18-mg group, 41% of the 90-mg group, and 48% of the 180-mg group, compared with 18% of the ustekinumab group.

Among risankizumab patients, the rates of adverse events through 48 weeks were 81% in the 180-mg group, 80% in the 90-mg group, and 69% in the 180-mg group, compared with 72% in those on ustekinumab, with nasopharyngitis the most commonly reported adverse event in all the treatment groups. The rates of serious adverse events were 12% and 15% among those in the 18-mg and 90-mg risankizumab groups, respectively; 0% among those on the 180-mg dose, and 8% among those on ustekinumab.

The study was not large or long enough to provide conclusive safety data on risankizumab, and additional studies are needed to review psoriasis lesions over a longer time period and include both placebo and active comparators, researchers noted. However, the results suggest that “the selective blockade of interleukin-23 through the inhibition of the p19 subunit rather than p40 provides a more complete inhibition of interleukin-23 activity, potentially resulting in a greater efficacy in the treatment of plaque psoriasis at the doses used,” they said.

The study was supported by Boehringer Ingelheim. Several study coauthors, including lead author Dr. Papp, disclosed relationships with Boehringer Ingelheim and other companies. Several authors are Boehringer Ingelheim employees.
 

[email protected]

At 12 weeks, 77% of psoriasis patients treated with risankizumab showed a 90% or greater reduction in Psoriasis Area and Severity Index (PASI) score, compared with 40% of ustekinumab patients, in a phase II randomized trial.

The results were published April 19 in the New England Journal of Medicine.

Ustekinumab (Stelara), approved by the Food and Drug Administration in 2009, blocks interleukin-12 and interleukin-23 and has demonstrated effectiveness in psoriasis patients. However, the humanized IgG1 monoclonal antibody risankizumab goes farther and “selectively inhibits interleukin-23 by specifically targeting p19,” wrote Kim A. Papp, MD, PhD, of K. Papp Clinical Research and Probity Medical Research, Waterloo, Ont., and associates (N. Engl. J. Med. 2017;376:1551-60. doi: 10.1056/NEJMoa1607017).

To compare clinical response and safety, the researchers enrolled 166 adults aged 18-75 years with moderate to severe plaque psoriasis, in the phase II study. Patients were randomized to subcutaneous injections of risankizumab at one of three doses, or ustekinumab at one of two doses. Risankizumab patients received a single 18-mg dose at week 0, or 90-mg or 180-mg doses at weeks 0, 4, and 16. Ustekinumab patients weighing 100 kg or less received 45 mg at weeks 0, 4, and 16; those weighing more than 100 kg received 90 mg at weeks 0, 4, and 16. Demographics were similar among the treatment groups.

The primary end point was a 90% or greater reduction in the PASI score at week 12, compared with baseline.

In pooled results of the risankizumab 90-mg and 180-mg groups, 77% of patients achieved a PASI 90 at 12 weeks (73% of the 90-mg group and 81% of the 180-mg group), vs. 40% of ustekinumab patients (P less than .001). Complete clearance of lesions (PASI 100) occurred among risankizumab patients in 14% of the 18-mg group, 41% of the 90-mg group, and 48% of the 180-mg group, compared with 18% of the ustekinumab group.

Among risankizumab patients, the rates of adverse events through 48 weeks were 81% in the 180-mg group, 80% in the 90-mg group, and 69% in the 180-mg group, compared with 72% in those on ustekinumab, with nasopharyngitis the most commonly reported adverse event in all the treatment groups. The rates of serious adverse events were 12% and 15% among those in the 18-mg and 90-mg risankizumab groups, respectively; 0% among those on the 180-mg dose, and 8% among those on ustekinumab.

The study was not large or long enough to provide conclusive safety data on risankizumab, and additional studies are needed to review psoriasis lesions over a longer time period and include both placebo and active comparators, researchers noted. However, the results suggest that “the selective blockade of interleukin-23 through the inhibition of the p19 subunit rather than p40 provides a more complete inhibition of interleukin-23 activity, potentially resulting in a greater efficacy in the treatment of plaque psoriasis at the doses used,” they said.

The study was supported by Boehringer Ingelheim. Several study coauthors, including lead author Dr. Papp, disclosed relationships with Boehringer Ingelheim and other companies. Several authors are Boehringer Ingelheim employees.
 

[email protected]

Histopathology findings of cytologic atypia, architectural disorder, and pagetoid spread are common in congenital melanocytic nevi (CMN) of all sizes in children aged 0-35 months, and tend to have benign outcomes, according to a retrospective study.

Emily A. Simons, MPH, and her associates at Boston Children’s Hospital studied 197 nevi in 179 patients with an average age of 14 months (range, 4 days to 35 months); 51% were female. Of those, 80% had skin types I-II, and 90% were white. The majority of the lesions involved the head or trunk and were predominantly medium in size, and 58% had a projected adult size of 1.5-10 cm. The study was retrospective; cases had been diagnosed between 1993 and 2013.

Cytologic atypia, architectural disorder, and pagetoid spread were the most frequent features – they were present in 73% of nevi and were closely associated. Combined histologic patterns of a blue nevus, spindle and Spitz nevus, or a deep penetrating nevus were identified in 40% of CMN. Proliferative nodules occurred in 5% of nevi.

Clinical outcomes were available for 130 patients, including 26 with large CMN and 8 with proliferative nodules. The children were alive and had not been diagnosed with melanoma at a mean follow-up of a mean of 8.4 years (range, 7 months to 21.3 years), even though margins of the last excision were positive in 41% of all CMN and in 77% of large CMN.

Malignant transformation of CMN certainly should be recognized, but the morbidity of overdiagnosis also needs to be considered. “Excision of larger CMN might require serial excisions under general anesthesia, the use of tissue expanders, and grafts,” Dr. Simons and her associates said.

Among the limitations of this study were that the majority of patients were white, so the results may not translate to children with darker skin types, they noted.

“The diagnosis of malignant melanoma should be made with great caution in this population,” they concluded, pointing out that the histopathologic features alone (cytologic atypia, architectural disorder, and pagetoid spread) “should not be interpreted as evidence for potential malignant behavior or serve as grounds for further excision.”

Read more in the Journal of the American Academy of Dermatology (2017 May;76[5]941-7).

The authors had no relevant financial disorders.

Histopathology findings of cytologic atypia, architectural disorder, and pagetoid spread are common in congenital melanocytic nevi (CMN) of all sizes in children aged 0-35 months, and tend to have benign outcomes, according to a retrospective study.

Emily A. Simons, MPH, and her associates at Boston Children’s Hospital studied 197 nevi in 179 patients with an average age of 14 months (range, 4 days to 35 months); 51% were female. Of those, 80% had skin types I-II, and 90% were white. The majority of the lesions involved the head or trunk and were predominantly medium in size, and 58% had a projected adult size of 1.5-10 cm. The study was retrospective; cases had been diagnosed between 1993 and 2013.

Cytologic atypia, architectural disorder, and pagetoid spread were the most frequent features – they were present in 73% of nevi and were closely associated. Combined histologic patterns of a blue nevus, spindle and Spitz nevus, or a deep penetrating nevus were identified in 40% of CMN. Proliferative nodules occurred in 5% of nevi.

Clinical outcomes were available for 130 patients, including 26 with large CMN and 8 with proliferative nodules. The children were alive and had not been diagnosed with melanoma at a mean follow-up of a mean of 8.4 years (range, 7 months to 21.3 years), even though margins of the last excision were positive in 41% of all CMN and in 77% of large CMN.

Malignant transformation of CMN certainly should be recognized, but the morbidity of overdiagnosis also needs to be considered. “Excision of larger CMN might require serial excisions under general anesthesia, the use of tissue expanders, and grafts,” Dr. Simons and her associates said.

Among the limitations of this study were that the majority of patients were white, so the results may not translate to children with darker skin types, they noted.

“The diagnosis of malignant melanoma should be made with great caution in this population,” they concluded, pointing out that the histopathologic features alone (cytologic atypia, architectural disorder, and pagetoid spread) “should not be interpreted as evidence for potential malignant behavior or serve as grounds for further excision.”

Read more in the Journal of the American Academy of Dermatology (2017 May;76[5]941-7).

The authors had no relevant financial disorders.

Histopathology findings of cytologic atypia, architectural disorder, and pagetoid spread are common in congenital melanocytic nevi (CMN) of all sizes in children aged 0-35 months, and tend to have benign outcomes, according to a retrospective study.

Emily A. Simons, MPH, and her associates at Boston Children’s Hospital studied 197 nevi in 179 patients with an average age of 14 months (range, 4 days to 35 months); 51% were female. Of those, 80% had skin types I-II, and 90% were white. The majority of the lesions involved the head or trunk and were predominantly medium in size, and 58% had a projected adult size of 1.5-10 cm. The study was retrospective; cases had been diagnosed between 1993 and 2013.

Cytologic atypia, architectural disorder, and pagetoid spread were the most frequent features – they were present in 73% of nevi and were closely associated. Combined histologic patterns of a blue nevus, spindle and Spitz nevus, or a deep penetrating nevus were identified in 40% of CMN. Proliferative nodules occurred in 5% of nevi.

Clinical outcomes were available for 130 patients, including 26 with large CMN and 8 with proliferative nodules. The children were alive and had not been diagnosed with melanoma at a mean follow-up of a mean of 8.4 years (range, 7 months to 21.3 years), even though margins of the last excision were positive in 41% of all CMN and in 77% of large CMN.

Malignant transformation of CMN certainly should be recognized, but the morbidity of overdiagnosis also needs to be considered. “Excision of larger CMN might require serial excisions under general anesthesia, the use of tissue expanders, and grafts,” Dr. Simons and her associates said.

Among the limitations of this study were that the majority of patients were white, so the results may not translate to children with darker skin types, they noted.

“The diagnosis of malignant melanoma should be made with great caution in this population,” they concluded, pointing out that the histopathologic features alone (cytologic atypia, architectural disorder, and pagetoid spread) “should not be interpreted as evidence for potential malignant behavior or serve as grounds for further excision.”

Read more in the Journal of the American Academy of Dermatology (2017 May;76[5]941-7).

The authors had no relevant financial disorders.

An increase in spike frequency does not help clinicians predict the outcome of surgery in patients with temporal lobe epilepsy. To reach that conclusion, researchers used scalp video monitoring data from patients who had anterior temporal lobe epilepsy to look for interictal epileptiform abnormalities, comparing patients with more than 60 spikes/hour to those with fewer spikes. They found no significant differences in seizure outcomes among patients who had undergone anterior temporal lobectomy.

Ngo L, Sperling MR, Skidmore C, Mintzer S, Nei M. Absolute spike frequency as a predictor of surgical outcome in temporal lobe epilepsy. Seizure. 2017;47:83-86.

An increase in spike frequency does not help clinicians predict the outcome of surgery in patients with temporal lobe epilepsy. To reach that conclusion, researchers used scalp video monitoring data from patients who had anterior temporal lobe epilepsy to look for interictal epileptiform abnormalities, comparing patients with more than 60 spikes/hour to those with fewer spikes. They found no significant differences in seizure outcomes among patients who had undergone anterior temporal lobectomy.

Ngo L, Sperling MR, Skidmore C, Mintzer S, Nei M. Absolute spike frequency as a predictor of surgical outcome in temporal lobe epilepsy. Seizure. 2017;47:83-86.

An increase in spike frequency does not help clinicians predict the outcome of surgery in patients with temporal lobe epilepsy. To reach that conclusion, researchers used scalp video monitoring data from patients who had anterior temporal lobe epilepsy to look for interictal epileptiform abnormalities, comparing patients with more than 60 spikes/hour to those with fewer spikes. They found no significant differences in seizure outcomes among patients who had undergone anterior temporal lobectomy.

Ngo L, Sperling MR, Skidmore C, Mintzer S, Nei M. Absolute spike frequency as a predictor of surgical outcome in temporal lobe epilepsy. Seizure. 2017;47:83-86.

Patients with refractory focal epilepsy seem to have older brains, suggests a study that used whole brain T1-weighted MRI scans to estimate the predicted brain age versus chronological age. On average, the difference between predicted brain age and chronological age in patients with refractory focal epilepsy was 4.5 years greater than the researchers observed in healthy adults. The researchers also found that an earlier onset of refractory focal epilepsy was linked to increased brain age.

Pardoe H, Cole JH, Blackmon K ,et al. Structural brain changes in medically refractory focal epilepsy resemble premature brain aging. Epilepsy Res. 2017;133:28-32.

Patients with refractory focal epilepsy seem to have older brains, suggests a study that used whole brain T1-weighted MRI scans to estimate the predicted brain age versus chronological age. On average, the difference between predicted brain age and chronological age in patients with refractory focal epilepsy was 4.5 years greater than the researchers observed in healthy adults. The researchers also found that an earlier onset of refractory focal epilepsy was linked to increased brain age.

Pardoe H, Cole JH, Blackmon K ,et al. Structural brain changes in medically refractory focal epilepsy resemble premature brain aging. Epilepsy Res. 2017;133:28-32.

Patients with refractory focal epilepsy seem to have older brains, suggests a study that used whole brain T1-weighted MRI scans to estimate the predicted brain age versus chronological age. On average, the difference between predicted brain age and chronological age in patients with refractory focal epilepsy was 4.5 years greater than the researchers observed in healthy adults. The researchers also found that an earlier onset of refractory focal epilepsy was linked to increased brain age.

Pardoe H, Cole JH, Blackmon K ,et al. Structural brain changes in medically refractory focal epilepsy resemble premature brain aging. Epilepsy Res. 2017;133:28-32.

Infliximab is safe to use in infants and young children with Kawasaki disease (KD) who have recently received live viral vaccinations, reported Aaron M. Lee, MS, and his associates at Rady Children’s Hospital-San Diego.

The study included 38 children, aged either less than 18 months or 4-6 years, who received either a 5 mg/kg or a 10 mg/kg dose of infliximab within 90 days of receiving a live vaccination of MMR, varicella-zoster virus, or rotavirus. During a 90-day follow-up period, no serious infections requiring antimicrobial therapy or hospitalization were reported. A single patient who received an MMR/VZV vaccine 42 days before infliximab treatment developed urticaria 15 minutes after the infliximab transfusion began, which was resolved with hydroxyzine.

“The data presented here suggest that a single dose of infliximab can be safely administered to acute KD patients regardless of recent live virus vaccination,” the investigators concluded.

Find the full report in the Pediatric Infectious Disease Journal (2017 Apr;36(4):435-7).

[email protected]

Infliximab is safe to use in infants and young children with Kawasaki disease (KD) who have recently received live viral vaccinations, reported Aaron M. Lee, MS, and his associates at Rady Children’s Hospital-San Diego.

The study included 38 children, aged either less than 18 months or 4-6 years, who received either a 5 mg/kg or a 10 mg/kg dose of infliximab within 90 days of receiving a live vaccination of MMR, varicella-zoster virus, or rotavirus. During a 90-day follow-up period, no serious infections requiring antimicrobial therapy or hospitalization were reported. A single patient who received an MMR/VZV vaccine 42 days before infliximab treatment developed urticaria 15 minutes after the infliximab transfusion began, which was resolved with hydroxyzine.

“The data presented here suggest that a single dose of infliximab can be safely administered to acute KD patients regardless of recent live virus vaccination,” the investigators concluded.

Find the full report in the Pediatric Infectious Disease Journal (2017 Apr;36(4):435-7).

[email protected]

Infliximab is safe to use in infants and young children with Kawasaki disease (KD) who have recently received live viral vaccinations, reported Aaron M. Lee, MS, and his associates at Rady Children’s Hospital-San Diego.

The study included 38 children, aged either less than 18 months or 4-6 years, who received either a 5 mg/kg or a 10 mg/kg dose of infliximab within 90 days of receiving a live vaccination of MMR, varicella-zoster virus, or rotavirus. During a 90-day follow-up period, no serious infections requiring antimicrobial therapy or hospitalization were reported. A single patient who received an MMR/VZV vaccine 42 days before infliximab treatment developed urticaria 15 minutes after the infliximab transfusion began, which was resolved with hydroxyzine.

“The data presented here suggest that a single dose of infliximab can be safely administered to acute KD patients regardless of recent live virus vaccination,” the investigators concluded.

Find the full report in the Pediatric Infectious Disease Journal (2017 Apr;36(4):435-7).

[email protected]

About 5% of patients who have had an ischemic stroke develop seizures, according to an analysis of data from the Framingham Heart Study. When researchers looked at the incidence of strokes between 1982 and 2003 and followed patients for 20 years, they found strokes had occurred in 469 patients, 25 of whom had experienced a seizure (5.3%). A third of these seizures happened within the first 24 hours of the stroke onset; half occurred within 30 days.

Stefanidou M, Das RR, Beiser AS, et al. Incidence of seizures following initial ischemic stroke in a community-based cohort: The Framingham Heart Study. Seizure. 2017;47:105-110.

About 5% of patients who have had an ischemic stroke develop seizures, according to an analysis of data from the Framingham Heart Study. When researchers looked at the incidence of strokes between 1982 and 2003 and followed patients for 20 years, they found strokes had occurred in 469 patients, 25 of whom had experienced a seizure (5.3%). A third of these seizures happened within the first 24 hours of the stroke onset; half occurred within 30 days.

Stefanidou M, Das RR, Beiser AS, et al. Incidence of seizures following initial ischemic stroke in a community-based cohort: The Framingham Heart Study. Seizure. 2017;47:105-110.

About 5% of patients who have had an ischemic stroke develop seizures, according to an analysis of data from the Framingham Heart Study. When researchers looked at the incidence of strokes between 1982 and 2003 and followed patients for 20 years, they found strokes had occurred in 469 patients, 25 of whom had experienced a seizure (5.3%). A third of these seizures happened within the first 24 hours of the stroke onset; half occurred within 30 days.

Stefanidou M, Das RR, Beiser AS, et al. Incidence of seizures following initial ischemic stroke in a community-based cohort: The Framingham Heart Study. Seizure. 2017;47:105-110.

Those of you who were in high school or middle school in 1987, when the DSM II-R first included “Attention Deficit Disorder With and Without Hyperactivity” for the first time, missed out on the “discovery,” and subsequent commercialization, of a condition that had been percolating under physicians’ noses for hundreds of years.

You may have wondered what primary care physicians did with their time before they were inundated with requests for evaluations and medications to treat ADHD. You may not realize that we didn’t always have ADHD specialists to help us or several dozen stimulant concoctions from which to choose. In the beginning, ADHD specialists had to invent themselves while the pharmaceutical companies scrambled to meet the demand for drugs that were longer lasting and more palatable.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].

Those of you who were in high school or middle school in 1987, when the DSM II-R first included “Attention Deficit Disorder With and Without Hyperactivity” for the first time, missed out on the “discovery,” and subsequent commercialization, of a condition that had been percolating under physicians’ noses for hundreds of years.

You may have wondered what primary care physicians did with their time before they were inundated with requests for evaluations and medications to treat ADHD. You may not realize that we didn’t always have ADHD specialists to help us or several dozen stimulant concoctions from which to choose. In the beginning, ADHD specialists had to invent themselves while the pharmaceutical companies scrambled to meet the demand for drugs that were longer lasting and more palatable.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].

Those of you who were in high school or middle school in 1987, when the DSM II-R first included “Attention Deficit Disorder With and Without Hyperactivity” for the first time, missed out on the “discovery,” and subsequent commercialization, of a condition that had been percolating under physicians’ noses for hundreds of years.

You may have wondered what primary care physicians did with their time before they were inundated with requests for evaluations and medications to treat ADHD. You may not realize that we didn’t always have ADHD specialists to help us or several dozen stimulant concoctions from which to choose. In the beginning, ADHD specialists had to invent themselves while the pharmaceutical companies scrambled to meet the demand for drugs that were longer lasting and more palatable.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].

“Honey, does this town make me look fat?”

“Yes, Dear, I’m afraid it does.”

No, that really wasn’t a typo in the first line. I intended to type “town” and not “gown.” A recent article by Dionysus Powell in healthcareinamerica.us has prompted me to think a bit more about the relationship between obesity and the communities we inhabit (“Fit Cities vs. Fat Cities – What available data can tell us about the difference in lifestyle and obesity between cities,” by Dionysus Powell, March 28, 2017). The author is a biotech researcher who has collected readily available Centers for Disease Control and Prevention data on body mass index (BMI) and self-reported sedentary behavior in almost 200 U.S. cities. He then sliced and diced these numbers with each cities’ walkability score, which is a crude measure of how easily citizens and visitors on foot can reach a variety of destinations such as shops, schools, churches, libraries, and municipal offices. You can easily find your own town’s score by going to walkscore.com.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].

“Honey, does this town make me look fat?”

“Yes, Dear, I’m afraid it does.”

No, that really wasn’t a typo in the first line. I intended to type “town” and not “gown.” A recent article by Dionysus Powell in healthcareinamerica.us has prompted me to think a bit more about the relationship between obesity and the communities we inhabit (“Fit Cities vs. Fat Cities – What available data can tell us about the difference in lifestyle and obesity between cities,” by Dionysus Powell, March 28, 2017). The author is a biotech researcher who has collected readily available Centers for Disease Control and Prevention data on body mass index (BMI) and self-reported sedentary behavior in almost 200 U.S. cities. He then sliced and diced these numbers with each cities’ walkability score, which is a crude measure of how easily citizens and visitors on foot can reach a variety of destinations such as shops, schools, churches, libraries, and municipal offices. You can easily find your own town’s score by going to walkscore.com.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].

“Honey, does this town make me look fat?”

“Yes, Dear, I’m afraid it does.”

No, that really wasn’t a typo in the first line. I intended to type “town” and not “gown.” A recent article by Dionysus Powell in healthcareinamerica.us has prompted me to think a bit more about the relationship between obesity and the communities we inhabit (“Fit Cities vs. Fat Cities – What available data can tell us about the difference in lifestyle and obesity between cities,” by Dionysus Powell, March 28, 2017). The author is a biotech researcher who has collected readily available Centers for Disease Control and Prevention data on body mass index (BMI) and self-reported sedentary behavior in almost 200 U.S. cities. He then sliced and diced these numbers with each cities’ walkability score, which is a crude measure of how easily citizens and visitors on foot can reach a variety of destinations such as shops, schools, churches, libraries, and municipal offices. You can easily find your own town’s score by going to walkscore.com.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].