To the Editor:
Vismodegib, a first-in-class inhibitor of the hedgehog signaling pathway, is useful in the treatment of advanced basal cell carcinomas (BCCs).¹ Common side effects of vismodegib include alopecia (58%), muscle spasms (71%), and dysgeusia (71%).² Some of these side effects have been hypothesized to be mechanism related.^3,4 Keratoacanthomas have been reported to occur after vismodegib treatment of BCC.⁵ We report 3 cases illustrating reversible cutaneous side effects of vismodegib: alopecia, follicular dermatitis, and drug hypersensitivity reaction.

A 53-year-old man with a locally advanced BCC of the right medial canthus began experiencing progressive and diffuse hair loss on the beard area, parietal scalp, eyelashes, and eyebrows after 2 months of vismodegib treatment. At 12 months of treatment, he had complete loss of eyelashes and eyebrows (Figure, A). After vismodegib was discontinued due to disease progression, all of his hair began regrowing within several months, with complete hair regrowth observed at 20 months after the last dose (Figure, B).

A 55-year-old man with several locally advanced BCCs developed new-onset mildly pruritic, acneform lesions on the chest and back after 4 months of vismodegib treatment. Biopsy of the lesions showed a folliculocentric mixed dermal infiltrate. The patient did not have a history of follicular dermatitis. The dermatitis resolved several months after onset without treatment, despite continued vismodegib.

A 55-year-old man with locally advanced BCCs developed erythematous dermal plaques on the arms and chest after 2 months of vismodegib treatment. Lesions were asymptomatic. He was not using any other medications and did not have any contact allergen exposures. Punch biopsy showed superficial and deep perivascular dermatitis with occasional eosinophils, consistent with drug hypersensitivity. Although lesions spontaneously resolved without treatment after 1 month, he experienced a couple more bouts of these lesions over the next year. He continued vismodegib for 2 years without return of this eruption.

The average time frame for hair regrowth after vismodegib cessation has not been characterized and awaits future larger studies. The frequency of follicular dermatitis and drug eruption also has not been determined and may require careful observation by dermatologists in larger numbers of treated patients. 

Because the hedgehog pathway is critical for normal hair follicle function, follicle-based toxicities of vismodegib including alopecia and folliculitis could be hypothesized to reflect effective blockade of the pathway.⁶ Currently, there are no data that these changes correlate with tumor response. 

Although alopecia is a recognized side effect of vismodegib, regrowth has not been previously reported.^1,2 Knowledge of the reversibility of alopecia as well as other toxicities has the potential to influence patient decision-making on drug initiation and adherence.

To the Editor:
Vismodegib, a first-in-class inhibitor of the hedgehog signaling pathway, is useful in the treatment of advanced basal cell carcinomas (BCCs).¹ Common side effects of vismodegib include alopecia (58%), muscle spasms (71%), and dysgeusia (71%).² Some of these side effects have been hypothesized to be mechanism related.^3,4 Keratoacanthomas have been reported to occur after vismodegib treatment of BCC.⁵ We report 3 cases illustrating reversible cutaneous side effects of vismodegib: alopecia, follicular dermatitis, and drug hypersensitivity reaction.

A 53-year-old man with a locally advanced BCC of the right medial canthus began experiencing progressive and diffuse hair loss on the beard area, parietal scalp, eyelashes, and eyebrows after 2 months of vismodegib treatment. At 12 months of treatment, he had complete loss of eyelashes and eyebrows (Figure, A). After vismodegib was discontinued due to disease progression, all of his hair began regrowing within several months, with complete hair regrowth observed at 20 months after the last dose (Figure, B).

A 55-year-old man with several locally advanced BCCs developed new-onset mildly pruritic, acneform lesions on the chest and back after 4 months of vismodegib treatment. Biopsy of the lesions showed a folliculocentric mixed dermal infiltrate. The patient did not have a history of follicular dermatitis. The dermatitis resolved several months after onset without treatment, despite continued vismodegib.

A 55-year-old man with locally advanced BCCs developed erythematous dermal plaques on the arms and chest after 2 months of vismodegib treatment. Lesions were asymptomatic. He was not using any other medications and did not have any contact allergen exposures. Punch biopsy showed superficial and deep perivascular dermatitis with occasional eosinophils, consistent with drug hypersensitivity. Although lesions spontaneously resolved without treatment after 1 month, he experienced a couple more bouts of these lesions over the next year. He continued vismodegib for 2 years without return of this eruption.

The average time frame for hair regrowth after vismodegib cessation has not been characterized and awaits future larger studies. The frequency of follicular dermatitis and drug eruption also has not been determined and may require careful observation by dermatologists in larger numbers of treated patients. 

Because the hedgehog pathway is critical for normal hair follicle function, follicle-based toxicities of vismodegib including alopecia and folliculitis could be hypothesized to reflect effective blockade of the pathway.⁶ Currently, there are no data that these changes correlate with tumor response. 

Although alopecia is a recognized side effect of vismodegib, regrowth has not been previously reported.^1,2 Knowledge of the reversibility of alopecia as well as other toxicities has the potential to influence patient decision-making on drug initiation and adherence.

To the Editor:
Vismodegib, a first-in-class inhibitor of the hedgehog signaling pathway, is useful in the treatment of advanced basal cell carcinomas (BCCs).¹ Common side effects of vismodegib include alopecia (58%), muscle spasms (71%), and dysgeusia (71%).² Some of these side effects have been hypothesized to be mechanism related.^3,4 Keratoacanthomas have been reported to occur after vismodegib treatment of BCC.⁵ We report 3 cases illustrating reversible cutaneous side effects of vismodegib: alopecia, follicular dermatitis, and drug hypersensitivity reaction.

A 53-year-old man with a locally advanced BCC of the right medial canthus began experiencing progressive and diffuse hair loss on the beard area, parietal scalp, eyelashes, and eyebrows after 2 months of vismodegib treatment. At 12 months of treatment, he had complete loss of eyelashes and eyebrows (Figure, A). After vismodegib was discontinued due to disease progression, all of his hair began regrowing within several months, with complete hair regrowth observed at 20 months after the last dose (Figure, B).

A 55-year-old man with several locally advanced BCCs developed new-onset mildly pruritic, acneform lesions on the chest and back after 4 months of vismodegib treatment. Biopsy of the lesions showed a folliculocentric mixed dermal infiltrate. The patient did not have a history of follicular dermatitis. The dermatitis resolved several months after onset without treatment, despite continued vismodegib.

A 55-year-old man with locally advanced BCCs developed erythematous dermal plaques on the arms and chest after 2 months of vismodegib treatment. Lesions were asymptomatic. He was not using any other medications and did not have any contact allergen exposures. Punch biopsy showed superficial and deep perivascular dermatitis with occasional eosinophils, consistent with drug hypersensitivity. Although lesions spontaneously resolved without treatment after 1 month, he experienced a couple more bouts of these lesions over the next year. He continued vismodegib for 2 years without return of this eruption.

The average time frame for hair regrowth after vismodegib cessation has not been characterized and awaits future larger studies. The frequency of follicular dermatitis and drug eruption also has not been determined and may require careful observation by dermatologists in larger numbers of treated patients. 

Because the hedgehog pathway is critical for normal hair follicle function, follicle-based toxicities of vismodegib including alopecia and folliculitis could be hypothesized to reflect effective blockade of the pathway.⁶ Currently, there are no data that these changes correlate with tumor response. 

Although alopecia is a recognized side effect of vismodegib, regrowth has not been previously reported.^1,2 Knowledge of the reversibility of alopecia as well as other toxicities has the potential to influence patient decision-making on drug initiation and adherence.

ORLANDO – A large proportion of patients with advanced non–small cell lung cancer (NSCLC) are not being tested for tumor associated–epidermal growth factor receptor (EGFR) and anaplastic lymphoma kinase (ALK) alterations according to national guidelines. This situation may be leading to suboptimal treatment, a large retrospective cohort study suggests.

Guidelines from the American Society of Clinical Oncology and the National Comprehensive Cancer Network recommend testing before first-line therapy for all treatment-eligible patients with nonsquamous histology and for those patients with squamous histology who are nonsmokers or who have mixed cell types or small tumor samples. Additionally, the guidelines recommend that results be made available within 2 weeks of the lab’s receipt of the sample so that they can be used to inform treatment decisions.

Study details

For the study, the investigators identified 16,316 patients with advanced NSCLC from 206 community clinics across the United States participating in the Flatiron Network. All patients were treated between 2014 and 2016.

Cross-checking of the total Flatiron population against the National Program of Cancer Registries and Surveillance, Epidemiology, and End Results databases suggested that it is a good national representation, according to Mr. Rughani.

A record review showed that the rate of EGFR and ALK testing among study patients ranged widely across clinics, from 0% to 100% for both the nonsquamous cases and the squamous cases, according to results reported in a poster session. The median was 79% for the former and 16% for the latter.

Overall, 22% of the nonsquamous cohort and 79% of the squamous cohort did not have any evidence of testing in their records. For the latter, a sampling of records was unable to verify whether testing was appropriately matched to eligibility criteria.

When testing was performed, 35% of EGFR test results and 37% of ALK test results were not available to the treating clinician until more than 4 weeks after the date of the advanced cancer diagnosis.

“The delays were mostly attributed to nonlab factors. When we isolated the time that the lab took to turn it around, it was under 2 weeks for the vast majority of patients,” Mr. Rughani reported. Possible nonlab culprit factors include clinic work flows, insurance-related issues, and families’ and patients’ hesitancy to be tested, he said.

Delays in receipt of positive test results appeared to influence choice of first-line therapy. Among patients in whom these results were available before first-line therapy, 80% of those found to have an EGFR-mutated tumor received an EGFR–tyrosine kinase inhibitor, and 77% of those found to have ALK-rearranged tumors received an ALK inhibitor.

In sharp contrast, among patients in whom positive test results did not become available until after the start of first-line therapy, respective values were just 43% and 42%.

“Anecdotally, we saw that some patients would go on to Avastin [bevacizumab] in the front line when the results were delayed, and then, ultimately, they would have the opportunity to receive an EGFR[–tyrosine kinase inhibitor] or something like that in later lines,” commented Mr. Rughani. “So, that impacted treatment decisions there.”

Mr. Rughani disclosed stock and other ownership interests in Flatiron Health.

[email protected]

ORLANDO – A large proportion of patients with advanced non–small cell lung cancer (NSCLC) are not being tested for tumor associated–epidermal growth factor receptor (EGFR) and anaplastic lymphoma kinase (ALK) alterations according to national guidelines. This situation may be leading to suboptimal treatment, a large retrospective cohort study suggests.

Guidelines from the American Society of Clinical Oncology and the National Comprehensive Cancer Network recommend testing before first-line therapy for all treatment-eligible patients with nonsquamous histology and for those patients with squamous histology who are nonsmokers or who have mixed cell types or small tumor samples. Additionally, the guidelines recommend that results be made available within 2 weeks of the lab’s receipt of the sample so that they can be used to inform treatment decisions.

Study details

For the study, the investigators identified 16,316 patients with advanced NSCLC from 206 community clinics across the United States participating in the Flatiron Network. All patients were treated between 2014 and 2016.

Cross-checking of the total Flatiron population against the National Program of Cancer Registries and Surveillance, Epidemiology, and End Results databases suggested that it is a good national representation, according to Mr. Rughani.

A record review showed that the rate of EGFR and ALK testing among study patients ranged widely across clinics, from 0% to 100% for both the nonsquamous cases and the squamous cases, according to results reported in a poster session. The median was 79% for the former and 16% for the latter.

Overall, 22% of the nonsquamous cohort and 79% of the squamous cohort did not have any evidence of testing in their records. For the latter, a sampling of records was unable to verify whether testing was appropriately matched to eligibility criteria.

When testing was performed, 35% of EGFR test results and 37% of ALK test results were not available to the treating clinician until more than 4 weeks after the date of the advanced cancer diagnosis.

“The delays were mostly attributed to nonlab factors. When we isolated the time that the lab took to turn it around, it was under 2 weeks for the vast majority of patients,” Mr. Rughani reported. Possible nonlab culprit factors include clinic work flows, insurance-related issues, and families’ and patients’ hesitancy to be tested, he said.

Delays in receipt of positive test results appeared to influence choice of first-line therapy. Among patients in whom these results were available before first-line therapy, 80% of those found to have an EGFR-mutated tumor received an EGFR–tyrosine kinase inhibitor, and 77% of those found to have ALK-rearranged tumors received an ALK inhibitor.

In sharp contrast, among patients in whom positive test results did not become available until after the start of first-line therapy, respective values were just 43% and 42%.

“Anecdotally, we saw that some patients would go on to Avastin [bevacizumab] in the front line when the results were delayed, and then, ultimately, they would have the opportunity to receive an EGFR[–tyrosine kinase inhibitor] or something like that in later lines,” commented Mr. Rughani. “So, that impacted treatment decisions there.”

Mr. Rughani disclosed stock and other ownership interests in Flatiron Health.

[email protected]

ORLANDO – A large proportion of patients with advanced non–small cell lung cancer (NSCLC) are not being tested for tumor associated–epidermal growth factor receptor (EGFR) and anaplastic lymphoma kinase (ALK) alterations according to national guidelines. This situation may be leading to suboptimal treatment, a large retrospective cohort study suggests.

Guidelines from the American Society of Clinical Oncology and the National Comprehensive Cancer Network recommend testing before first-line therapy for all treatment-eligible patients with nonsquamous histology and for those patients with squamous histology who are nonsmokers or who have mixed cell types or small tumor samples. Additionally, the guidelines recommend that results be made available within 2 weeks of the lab’s receipt of the sample so that they can be used to inform treatment decisions.

Study details

For the study, the investigators identified 16,316 patients with advanced NSCLC from 206 community clinics across the United States participating in the Flatiron Network. All patients were treated between 2014 and 2016.

Cross-checking of the total Flatiron population against the National Program of Cancer Registries and Surveillance, Epidemiology, and End Results databases suggested that it is a good national representation, according to Mr. Rughani.

A record review showed that the rate of EGFR and ALK testing among study patients ranged widely across clinics, from 0% to 100% for both the nonsquamous cases and the squamous cases, according to results reported in a poster session. The median was 79% for the former and 16% for the latter.

Overall, 22% of the nonsquamous cohort and 79% of the squamous cohort did not have any evidence of testing in their records. For the latter, a sampling of records was unable to verify whether testing was appropriately matched to eligibility criteria.

When testing was performed, 35% of EGFR test results and 37% of ALK test results were not available to the treating clinician until more than 4 weeks after the date of the advanced cancer diagnosis.

“The delays were mostly attributed to nonlab factors. When we isolated the time that the lab took to turn it around, it was under 2 weeks for the vast majority of patients,” Mr. Rughani reported. Possible nonlab culprit factors include clinic work flows, insurance-related issues, and families’ and patients’ hesitancy to be tested, he said.

Delays in receipt of positive test results appeared to influence choice of first-line therapy. Among patients in whom these results were available before first-line therapy, 80% of those found to have an EGFR-mutated tumor received an EGFR–tyrosine kinase inhibitor, and 77% of those found to have ALK-rearranged tumors received an ALK inhibitor.

In sharp contrast, among patients in whom positive test results did not become available until after the start of first-line therapy, respective values were just 43% and 42%.

“Anecdotally, we saw that some patients would go on to Avastin [bevacizumab] in the front line when the results were delayed, and then, ultimately, they would have the opportunity to receive an EGFR[–tyrosine kinase inhibitor] or something like that in later lines,” commented Mr. Rughani. “So, that impacted treatment decisions there.”

Mr. Rughani disclosed stock and other ownership interests in Flatiron Health.

[email protected]

The decline in U.S. influenza activity that started in February paused during the week ending March 11, according to the U.S. Centers for Disease Control and Prevention.

The proportion of outpatient visits for influenza-like illness (ILI) stayed at 3.7% for a second consecutive week after declining for 3 weeks in a row. The peak for the season, 5.2%, came during the week ending Feb. 11, CDC data show. The national baseline is 2.2%.

[email protected]

The decline in U.S. influenza activity that started in February paused during the week ending March 11, according to the U.S. Centers for Disease Control and Prevention.

The proportion of outpatient visits for influenza-like illness (ILI) stayed at 3.7% for a second consecutive week after declining for 3 weeks in a row. The peak for the season, 5.2%, came during the week ending Feb. 11, CDC data show. The national baseline is 2.2%.

[email protected]

The decline in U.S. influenza activity that started in February paused during the week ending March 11, according to the U.S. Centers for Disease Control and Prevention.

The proportion of outpatient visits for influenza-like illness (ILI) stayed at 3.7% for a second consecutive week after declining for 3 weeks in a row. The peak for the season, 5.2%, came during the week ending Feb. 11, CDC data show. The national baseline is 2.2%.

[email protected]

At one time, respiratory failure was the primary cause of death in young men and boys with muscular dystrophies, but since improvements in ventilator support have addressed this problem, cardiac complications such as cardiomyopathy have become the main cause of death in this group, with the highest risk of death in people with Duchenne muscular dystrophy (DMD). Researchers from Rome have reported that the novel use of ventricular assist devices in this population can prolong life.

Gianluigi Perri, MD, PhD, of University Hospital and Bambino Gesù Children Hospital in Rome, and his coauthors, shared their experience treating seven patients with dystrophinopathies and dilated cardiomyopathy (DCM) with left ventricular assist devices (LVADs) from February 2011 to February 2016 (J Thorac Cardiovasc Surg. 2017 March;153:669-74). “Our experience indicates that the use of an LVAD as destination therapy in patients with dystrophinopathies with end-stage DCM is feasible, suggesting that it may be suitable as a palliative therapy for the treatment of these patients with no other therapeutic options,” Dr. Perri and his coauthors said.

Heart transplantation is considered the procedure of choice for children with severe advanced heart failure, but transplantation is contraindicated for children with dystrophinopathies because of the risk of respiratory failure and progression of skeletal myopathy leads to limited functional capacity. Hence, Dr. Perri and his coauthors developed their alternative treatment for end-stage heart failure in these children. They used the Jarvik 2000 LVAD (Jarvik Heart Inc., New York) as destination therapy.

Six of the seven patients they operated on had DMD and one had beta-2 sarcoglycan deficit. Their ages ranged from 14.2 to 23.4 years. Two patients had early complications: retropharyngeal bleeding and cholecystectomy; and abdominal bleeding and splenectomy. Two different patients had late complications: gastrostomy; and osteolysis and infection at the pedestal site. Three patients died after the operation: one of stroke at 15 months; one of severe bleeding about 28 months later; and one of lung infection 45 months afterward. Follow-up for the surviving patients ranged from about 2 months to 40 months. Median hospital stay was 77 days.

Dr. Perri and his coauthors noted that the DMD Care Considerations Working Group expanded acceptable therapies for DMD cardiomyopathy to include novel treatments such as mechanical circulatory support and implantable cardioverter-defibrillators.

“Although the best approach remains unclear, it does seem clear that treatment should be more aggressive,” the researchers said. The limited life expectancy of these patients makes transplantation a complicated choice when a shortage of donors is a concern. “Therefore, the alternative therapeutic option is the use of LVAD,” Dr. Perri and his coauthors said.

These patients need care at centers “with a high level of experience of patients with DMD,” the researchers stated. Common comorbidities such as severe kyphoscoliosis and respiratory muscle weakness in this population increase surgical risks.

Dr. Perri and his coauthors used a surgical technique that involved avoiding the left thoracotomy approach common in adults who undergo VAD implantation, because of respiratory insufficiency in these younger patients. They also used cardiopulmonary bypass in all but one patient who had a minimally invasive off-pump procedure through a left anterior minithoracotomy.

The researchers “strongly suggest” noninvasive ventilation after surgery to assist in pulmonary function often compromised by scoliosis and muscle weakness. “Our experience shows that postoperative care can be extremely challenging and is often burdened by unexpected complications,” they noted.

Kyphoscoliosis poses challenges when placing drains, and complications of these patients should be treated only in a specialized center. “Indeed, one of our patients died in a peripheral hospital because they underwent bronchoscopic examination with an endoscope that caused severe and intractable retropharyngeal bleeding,” they said.

The researchers no relevant financial relationships to disclose.

At one time, respiratory failure was the primary cause of death in young men and boys with muscular dystrophies, but since improvements in ventilator support have addressed this problem, cardiac complications such as cardiomyopathy have become the main cause of death in this group, with the highest risk of death in people with Duchenne muscular dystrophy (DMD). Researchers from Rome have reported that the novel use of ventricular assist devices in this population can prolong life.

Gianluigi Perri, MD, PhD, of University Hospital and Bambino Gesù Children Hospital in Rome, and his coauthors, shared their experience treating seven patients with dystrophinopathies and dilated cardiomyopathy (DCM) with left ventricular assist devices (LVADs) from February 2011 to February 2016 (J Thorac Cardiovasc Surg. 2017 March;153:669-74). “Our experience indicates that the use of an LVAD as destination therapy in patients with dystrophinopathies with end-stage DCM is feasible, suggesting that it may be suitable as a palliative therapy for the treatment of these patients with no other therapeutic options,” Dr. Perri and his coauthors said.

Heart transplantation is considered the procedure of choice for children with severe advanced heart failure, but transplantation is contraindicated for children with dystrophinopathies because of the risk of respiratory failure and progression of skeletal myopathy leads to limited functional capacity. Hence, Dr. Perri and his coauthors developed their alternative treatment for end-stage heart failure in these children. They used the Jarvik 2000 LVAD (Jarvik Heart Inc., New York) as destination therapy.

Six of the seven patients they operated on had DMD and one had beta-2 sarcoglycan deficit. Their ages ranged from 14.2 to 23.4 years. Two patients had early complications: retropharyngeal bleeding and cholecystectomy; and abdominal bleeding and splenectomy. Two different patients had late complications: gastrostomy; and osteolysis and infection at the pedestal site. Three patients died after the operation: one of stroke at 15 months; one of severe bleeding about 28 months later; and one of lung infection 45 months afterward. Follow-up for the surviving patients ranged from about 2 months to 40 months. Median hospital stay was 77 days.

Dr. Perri and his coauthors noted that the DMD Care Considerations Working Group expanded acceptable therapies for DMD cardiomyopathy to include novel treatments such as mechanical circulatory support and implantable cardioverter-defibrillators.

“Although the best approach remains unclear, it does seem clear that treatment should be more aggressive,” the researchers said. The limited life expectancy of these patients makes transplantation a complicated choice when a shortage of donors is a concern. “Therefore, the alternative therapeutic option is the use of LVAD,” Dr. Perri and his coauthors said.

These patients need care at centers “with a high level of experience of patients with DMD,” the researchers stated. Common comorbidities such as severe kyphoscoliosis and respiratory muscle weakness in this population increase surgical risks.

Dr. Perri and his coauthors used a surgical technique that involved avoiding the left thoracotomy approach common in adults who undergo VAD implantation, because of respiratory insufficiency in these younger patients. They also used cardiopulmonary bypass in all but one patient who had a minimally invasive off-pump procedure through a left anterior minithoracotomy.

The researchers “strongly suggest” noninvasive ventilation after surgery to assist in pulmonary function often compromised by scoliosis and muscle weakness. “Our experience shows that postoperative care can be extremely challenging and is often burdened by unexpected complications,” they noted.

Kyphoscoliosis poses challenges when placing drains, and complications of these patients should be treated only in a specialized center. “Indeed, one of our patients died in a peripheral hospital because they underwent bronchoscopic examination with an endoscope that caused severe and intractable retropharyngeal bleeding,” they said.

The researchers no relevant financial relationships to disclose.

At one time, respiratory failure was the primary cause of death in young men and boys with muscular dystrophies, but since improvements in ventilator support have addressed this problem, cardiac complications such as cardiomyopathy have become the main cause of death in this group, with the highest risk of death in people with Duchenne muscular dystrophy (DMD). Researchers from Rome have reported that the novel use of ventricular assist devices in this population can prolong life.

Gianluigi Perri, MD, PhD, of University Hospital and Bambino Gesù Children Hospital in Rome, and his coauthors, shared their experience treating seven patients with dystrophinopathies and dilated cardiomyopathy (DCM) with left ventricular assist devices (LVADs) from February 2011 to February 2016 (J Thorac Cardiovasc Surg. 2017 March;153:669-74). “Our experience indicates that the use of an LVAD as destination therapy in patients with dystrophinopathies with end-stage DCM is feasible, suggesting that it may be suitable as a palliative therapy for the treatment of these patients with no other therapeutic options,” Dr. Perri and his coauthors said.

Heart transplantation is considered the procedure of choice for children with severe advanced heart failure, but transplantation is contraindicated for children with dystrophinopathies because of the risk of respiratory failure and progression of skeletal myopathy leads to limited functional capacity. Hence, Dr. Perri and his coauthors developed their alternative treatment for end-stage heart failure in these children. They used the Jarvik 2000 LVAD (Jarvik Heart Inc., New York) as destination therapy.

Six of the seven patients they operated on had DMD and one had beta-2 sarcoglycan deficit. Their ages ranged from 14.2 to 23.4 years. Two patients had early complications: retropharyngeal bleeding and cholecystectomy; and abdominal bleeding and splenectomy. Two different patients had late complications: gastrostomy; and osteolysis and infection at the pedestal site. Three patients died after the operation: one of stroke at 15 months; one of severe bleeding about 28 months later; and one of lung infection 45 months afterward. Follow-up for the surviving patients ranged from about 2 months to 40 months. Median hospital stay was 77 days.

Dr. Perri and his coauthors noted that the DMD Care Considerations Working Group expanded acceptable therapies for DMD cardiomyopathy to include novel treatments such as mechanical circulatory support and implantable cardioverter-defibrillators.

“Although the best approach remains unclear, it does seem clear that treatment should be more aggressive,” the researchers said. The limited life expectancy of these patients makes transplantation a complicated choice when a shortage of donors is a concern. “Therefore, the alternative therapeutic option is the use of LVAD,” Dr. Perri and his coauthors said.

These patients need care at centers “with a high level of experience of patients with DMD,” the researchers stated. Common comorbidities such as severe kyphoscoliosis and respiratory muscle weakness in this population increase surgical risks.

Dr. Perri and his coauthors used a surgical technique that involved avoiding the left thoracotomy approach common in adults who undergo VAD implantation, because of respiratory insufficiency in these younger patients. They also used cardiopulmonary bypass in all but one patient who had a minimally invasive off-pump procedure through a left anterior minithoracotomy.

The researchers “strongly suggest” noninvasive ventilation after surgery to assist in pulmonary function often compromised by scoliosis and muscle weakness. “Our experience shows that postoperative care can be extremely challenging and is often burdened by unexpected complications,” they noted.

Kyphoscoliosis poses challenges when placing drains, and complications of these patients should be treated only in a specialized center. “Indeed, one of our patients died in a peripheral hospital because they underwent bronchoscopic examination with an endoscope that caused severe and intractable retropharyngeal bleeding,” they said.

The researchers no relevant financial relationships to disclose.

ORLANDO – Ignorance and exposure are teaming up to put Latinos in the bull’s-eye of skin cancer.

Many believe that they are not at risk for either melanoma or nonmelanoma skin cancers – and too often, their physicians believe the same, Maritza Perez, MD, said at the annual meeting of the American Academy of Dermatology. Because of such incorrect perceptions, Latino patients get little counseling about risky behaviors, and so their exposure to those dangers continues unabated.

“The behavior of many Hispanic patients is very risky,” said Dr. Perez, a clinical professor of dermatology, at Mount Sinai Medical Center, New York. “They don’t wear sunscreen. They don’t do skin self-exams. They use tanning beds. And because of these beliefs, they don’t educate their children about sun safety.”

[email protected]

On Twitter @Alz_Gal

ORLANDO – Ignorance and exposure are teaming up to put Latinos in the bull’s-eye of skin cancer.

Many believe that they are not at risk for either melanoma or nonmelanoma skin cancers – and too often, their physicians believe the same, Maritza Perez, MD, said at the annual meeting of the American Academy of Dermatology. Because of such incorrect perceptions, Latino patients get little counseling about risky behaviors, and so their exposure to those dangers continues unabated.

“The behavior of many Hispanic patients is very risky,” said Dr. Perez, a clinical professor of dermatology, at Mount Sinai Medical Center, New York. “They don’t wear sunscreen. They don’t do skin self-exams. They use tanning beds. And because of these beliefs, they don’t educate their children about sun safety.”

[email protected]

On Twitter @Alz_Gal

ORLANDO – Ignorance and exposure are teaming up to put Latinos in the bull’s-eye of skin cancer.

Many believe that they are not at risk for either melanoma or nonmelanoma skin cancers – and too often, their physicians believe the same, Maritza Perez, MD, said at the annual meeting of the American Academy of Dermatology. Because of such incorrect perceptions, Latino patients get little counseling about risky behaviors, and so their exposure to those dangers continues unabated.

“The behavior of many Hispanic patients is very risky,” said Dr. Perez, a clinical professor of dermatology, at Mount Sinai Medical Center, New York. “They don’t wear sunscreen. They don’t do skin self-exams. They use tanning beds. And because of these beliefs, they don’t educate their children about sun safety.”

[email protected]

On Twitter @Alz_Gal

WAILEA, HAWAII – Oral apremilast is a drug in search of a compelling indication, Craig L. Leonardi, MD, declared at the Hawaii Dermatology Seminar provided by Global Academy for Medical Education/Skin Disease Research Foundation.

“Apremilast is the least effective systemic agent for the treatment of psoriasis. That’s a statement of fact. I think the drug is mismatched for the treatment of moderate to severe plaque psoriasis. In fact, many of us gave the company that advice early on, but it was a program that was set in stone at that point,” according to Dr. Leonardi, a dermatologist at Saint Louis University and a prominent psoriasis clinical trialist.

Bruce Jancin/Frontline Medical News

What efficacy can be anticipated?

In the pivotal phase III ESTEEM I trial conducted in 844 patients with moderate to severe psoriasis (J Am Acad Dermatol. 2015 Jul;73[1]:37-49), the overall PASI-75 response rate at week 16 in patients assigned to apremilast at 30 mg twice daily was 33%, significantly better than the 5% placebo response rate, but substantially less than what’s achieved with the tumor necrosis factor inhibitors and other injectable biologic agents.

Moreover, in the pivotal phase III PALACE 1 study of apremilast for the treatment of psoriatic arthritis, the primary outcome of at least a 20% improvement in the modified American College of Rheumatology response criteria at week 16 was achieved in 40% of patients randomized to apremilast at 30 mg twice daily, compared with 19% on placebo (Ann Rheum Dis. 2014 Jun;73[6]:1020-6). Again, that doesn’t approach the efficacy of a TNF inhibitor, Dr. Leonardi noted.

On the plus side, an oral agent such as apremilast is an attractive option for treatment-adherent patients. Plus, the drug has a favorable safety profile and is well tolerated, with mild to moderate side effects that appear early and are self-limited. In ESTEEM I, for example, more than 96% of patients had either no or only mild to moderate adverse events. The incidence of the two most common adverse events, diarrhea and nausea, at 19% and 16%, respectively, was more than double that in placebo-treated controls, but rates of other adverse events were similar in the two treatment arms.

Symposium codirector Linda Stein Gold, MD, director of dermatology research at the Henry Ford Health System in Detroit, said a clinical trial of apremilast conducted specifically in patients with moderate psoriasis has recently been completed. When those results become available they should shore up the drug’s use in that population.
 

Finding potential in off-label use

“This drug may have been brought to market for psoriasis, but I think its utility is so much more in other diseases where inflammation is an important mechanism,” said Neal Bhatia, MD, director of clinical dermatology at Therapeutics Clinical Research in San Diego. “Most of my use of apremilast is off-label for atopic dermatitis, for lichen planus, and I’ve tried it in a lot of patients where it has worked for discoid lupus. There’s so much potential for apremilast,” said Dr. Bhatia.

Dr. Leonardi remained unpersuaded.

“Your glass of water is half full, mine is half empty in this case,” he replied. “This drug has been approved now for at least 3 years, and we are still looking at the occasional favorable case report that flies up. I’ve got to say this drug is having a hard time finding a place outside of psoriasis, but we’ll all see.”

Dr. Leonardi reported having financial relationships with more than a dozen pharmaceutical companies, including Celgene, which markets apremilast. Dr. Stein Gold, too, has received research grants from and serves as a consultant to numerous drug companies, including Celgene. Dr. Bhatia declared having financial relationships with more than two dozen.

SDEF and this news organization are owned by the same parent company.

[email protected]

WAILEA, HAWAII – Oral apremilast is a drug in search of a compelling indication, Craig L. Leonardi, MD, declared at the Hawaii Dermatology Seminar provided by Global Academy for Medical Education/Skin Disease Research Foundation.

“Apremilast is the least effective systemic agent for the treatment of psoriasis. That’s a statement of fact. I think the drug is mismatched for the treatment of moderate to severe plaque psoriasis. In fact, many of us gave the company that advice early on, but it was a program that was set in stone at that point,” according to Dr. Leonardi, a dermatologist at Saint Louis University and a prominent psoriasis clinical trialist.

Bruce Jancin/Frontline Medical News

What efficacy can be anticipated?

In the pivotal phase III ESTEEM I trial conducted in 844 patients with moderate to severe psoriasis (J Am Acad Dermatol. 2015 Jul;73[1]:37-49), the overall PASI-75 response rate at week 16 in patients assigned to apremilast at 30 mg twice daily was 33%, significantly better than the 5% placebo response rate, but substantially less than what’s achieved with the tumor necrosis factor inhibitors and other injectable biologic agents.

Moreover, in the pivotal phase III PALACE 1 study of apremilast for the treatment of psoriatic arthritis, the primary outcome of at least a 20% improvement in the modified American College of Rheumatology response criteria at week 16 was achieved in 40% of patients randomized to apremilast at 30 mg twice daily, compared with 19% on placebo (Ann Rheum Dis. 2014 Jun;73[6]:1020-6). Again, that doesn’t approach the efficacy of a TNF inhibitor, Dr. Leonardi noted.

On the plus side, an oral agent such as apremilast is an attractive option for treatment-adherent patients. Plus, the drug has a favorable safety profile and is well tolerated, with mild to moderate side effects that appear early and are self-limited. In ESTEEM I, for example, more than 96% of patients had either no or only mild to moderate adverse events. The incidence of the two most common adverse events, diarrhea and nausea, at 19% and 16%, respectively, was more than double that in placebo-treated controls, but rates of other adverse events were similar in the two treatment arms.

Symposium codirector Linda Stein Gold, MD, director of dermatology research at the Henry Ford Health System in Detroit, said a clinical trial of apremilast conducted specifically in patients with moderate psoriasis has recently been completed. When those results become available they should shore up the drug’s use in that population.
 

Finding potential in off-label use

“This drug may have been brought to market for psoriasis, but I think its utility is so much more in other diseases where inflammation is an important mechanism,” said Neal Bhatia, MD, director of clinical dermatology at Therapeutics Clinical Research in San Diego. “Most of my use of apremilast is off-label for atopic dermatitis, for lichen planus, and I’ve tried it in a lot of patients where it has worked for discoid lupus. There’s so much potential for apremilast,” said Dr. Bhatia.

Dr. Leonardi remained unpersuaded.

“Your glass of water is half full, mine is half empty in this case,” he replied. “This drug has been approved now for at least 3 years, and we are still looking at the occasional favorable case report that flies up. I’ve got to say this drug is having a hard time finding a place outside of psoriasis, but we’ll all see.”

Dr. Leonardi reported having financial relationships with more than a dozen pharmaceutical companies, including Celgene, which markets apremilast. Dr. Stein Gold, too, has received research grants from and serves as a consultant to numerous drug companies, including Celgene. Dr. Bhatia declared having financial relationships with more than two dozen.

SDEF and this news organization are owned by the same parent company.

[email protected]

WAILEA, HAWAII – Oral apremilast is a drug in search of a compelling indication, Craig L. Leonardi, MD, declared at the Hawaii Dermatology Seminar provided by Global Academy for Medical Education/Skin Disease Research Foundation.

“Apremilast is the least effective systemic agent for the treatment of psoriasis. That’s a statement of fact. I think the drug is mismatched for the treatment of moderate to severe plaque psoriasis. In fact, many of us gave the company that advice early on, but it was a program that was set in stone at that point,” according to Dr. Leonardi, a dermatologist at Saint Louis University and a prominent psoriasis clinical trialist.

Bruce Jancin/Frontline Medical News

What efficacy can be anticipated?

In the pivotal phase III ESTEEM I trial conducted in 844 patients with moderate to severe psoriasis (J Am Acad Dermatol. 2015 Jul;73[1]:37-49), the overall PASI-75 response rate at week 16 in patients assigned to apremilast at 30 mg twice daily was 33%, significantly better than the 5% placebo response rate, but substantially less than what’s achieved with the tumor necrosis factor inhibitors and other injectable biologic agents.

Moreover, in the pivotal phase III PALACE 1 study of apremilast for the treatment of psoriatic arthritis, the primary outcome of at least a 20% improvement in the modified American College of Rheumatology response criteria at week 16 was achieved in 40% of patients randomized to apremilast at 30 mg twice daily, compared with 19% on placebo (Ann Rheum Dis. 2014 Jun;73[6]:1020-6). Again, that doesn’t approach the efficacy of a TNF inhibitor, Dr. Leonardi noted.

On the plus side, an oral agent such as apremilast is an attractive option for treatment-adherent patients. Plus, the drug has a favorable safety profile and is well tolerated, with mild to moderate side effects that appear early and are self-limited. In ESTEEM I, for example, more than 96% of patients had either no or only mild to moderate adverse events. The incidence of the two most common adverse events, diarrhea and nausea, at 19% and 16%, respectively, was more than double that in placebo-treated controls, but rates of other adverse events were similar in the two treatment arms.

Symposium codirector Linda Stein Gold, MD, director of dermatology research at the Henry Ford Health System in Detroit, said a clinical trial of apremilast conducted specifically in patients with moderate psoriasis has recently been completed. When those results become available they should shore up the drug’s use in that population.
 

Finding potential in off-label use

“This drug may have been brought to market for psoriasis, but I think its utility is so much more in other diseases where inflammation is an important mechanism,” said Neal Bhatia, MD, director of clinical dermatology at Therapeutics Clinical Research in San Diego. “Most of my use of apremilast is off-label for atopic dermatitis, for lichen planus, and I’ve tried it in a lot of patients where it has worked for discoid lupus. There’s so much potential for apremilast,” said Dr. Bhatia.

Dr. Leonardi remained unpersuaded.

“Your glass of water is half full, mine is half empty in this case,” he replied. “This drug has been approved now for at least 3 years, and we are still looking at the occasional favorable case report that flies up. I’ve got to say this drug is having a hard time finding a place outside of psoriasis, but we’ll all see.”

Dr. Leonardi reported having financial relationships with more than a dozen pharmaceutical companies, including Celgene, which markets apremilast. Dr. Stein Gold, too, has received research grants from and serves as a consultant to numerous drug companies, including Celgene. Dr. Bhatia declared having financial relationships with more than two dozen.

SDEF and this news organization are owned by the same parent company.

[email protected]

About a quarter of high school seniors have taken prescription opioids, medically or nonmedically, but exposures have declined over the past 2 years, according to a study.

“The recent declines in medical use of prescription opioids and nonmedical use of prescribed opioids from 2013 through 2015 found in the current study coincide with similar recent declines in U.S. opioid analgesic prescribing,” reported Sean Esteban McCabe, PhD, of the University of Michigan, Ann Arbor, and his associates (Pediatrics 2017 March 20. doi: 10.1542/peds.2016-2387). “Among adolescents who report both medical use of prescription opioids and nonmedical use of prescribed opioids, medical use before initiating nonmedical use of prescribed opioids tended to be most prevalent, and this pattern may be driven by the one-third of adolescents who report nonmedical use of prescribed opioids involving leftover opioid medications from their own previous prescriptions.”

The researchers analyzed data from the Monitoring the Future study from 1976 through 2015, an annual cross-sectional survey of high school seniors from 135 public and private high schools in the United States. Cohorts were nationally representative and varied in size from 2,181 to 3,791 students.

Students were asked whether they had ever been prescribed opioids by a doctor and how often they had ever taken opioids nonmedically. The list of opioids included all the ones available that year, including Vicodin, OxyContin, Percodan, Percocet, Demerol, Ultram, methadone, morphine, opium, and codeine.

Use of opioids for any reason ranged from 16.5% to 24% over the 4 decades, with medical use ranging from a low of 8.5% in 2000 to a peak of 14.4% in 1989. Though 16% of teens had used medical opioids in 1976, prevalence rose to 20% in 1989, then dropped to 13% in 1997 and remained stable. Rates sharply increased to 20% in 2002 – the year Vicodin, OxyContin, and Percocet were included in the questions – and then began declining again in 2013.

Nonmedical use correlated with medical use though remained less prevalent throughout the study period. This correlation was stronger for males, who are more likely to use opioids recreationally, than for females, who are more likely to use them to self-treat pain, the authors wrote.

Both medical and nonmedical use were more prevalent among white students than black students, in line with previous research showing “health disparities for receiving prescription opioids among racial minority patients,” the authors wrote.

Black teens are more often motivated to use opioids for pain relief, suggesting that their lower exposure rates “could result from a lack of adequate treatment, insufficient availability, overprescribing among white populations or underprescribing among nonwhite populations,” they wrote.

One limitation of the study was that absent students or those who had dropped out have a higher risk of opioid use, thereby possibly contributing to underreporting.

The National Institute on Drug Abuse and the National Institutes of Health funded the research. The researchers had no disclosures.

About a quarter of high school seniors have taken prescription opioids, medically or nonmedically, but exposures have declined over the past 2 years, according to a study.

“The recent declines in medical use of prescription opioids and nonmedical use of prescribed opioids from 2013 through 2015 found in the current study coincide with similar recent declines in U.S. opioid analgesic prescribing,” reported Sean Esteban McCabe, PhD, of the University of Michigan, Ann Arbor, and his associates (Pediatrics 2017 March 20. doi: 10.1542/peds.2016-2387). “Among adolescents who report both medical use of prescription opioids and nonmedical use of prescribed opioids, medical use before initiating nonmedical use of prescribed opioids tended to be most prevalent, and this pattern may be driven by the one-third of adolescents who report nonmedical use of prescribed opioids involving leftover opioid medications from their own previous prescriptions.”

The researchers analyzed data from the Monitoring the Future study from 1976 through 2015, an annual cross-sectional survey of high school seniors from 135 public and private high schools in the United States. Cohorts were nationally representative and varied in size from 2,181 to 3,791 students.

Students were asked whether they had ever been prescribed opioids by a doctor and how often they had ever taken opioids nonmedically. The list of opioids included all the ones available that year, including Vicodin, OxyContin, Percodan, Percocet, Demerol, Ultram, methadone, morphine, opium, and codeine.

Use of opioids for any reason ranged from 16.5% to 24% over the 4 decades, with medical use ranging from a low of 8.5% in 2000 to a peak of 14.4% in 1989. Though 16% of teens had used medical opioids in 1976, prevalence rose to 20% in 1989, then dropped to 13% in 1997 and remained stable. Rates sharply increased to 20% in 2002 – the year Vicodin, OxyContin, and Percocet were included in the questions – and then began declining again in 2013.

Nonmedical use correlated with medical use though remained less prevalent throughout the study period. This correlation was stronger for males, who are more likely to use opioids recreationally, than for females, who are more likely to use them to self-treat pain, the authors wrote.

Both medical and nonmedical use were more prevalent among white students than black students, in line with previous research showing “health disparities for receiving prescription opioids among racial minority patients,” the authors wrote.

Black teens are more often motivated to use opioids for pain relief, suggesting that their lower exposure rates “could result from a lack of adequate treatment, insufficient availability, overprescribing among white populations or underprescribing among nonwhite populations,” they wrote.

One limitation of the study was that absent students or those who had dropped out have a higher risk of opioid use, thereby possibly contributing to underreporting.

The National Institute on Drug Abuse and the National Institutes of Health funded the research. The researchers had no disclosures.

About a quarter of high school seniors have taken prescription opioids, medically or nonmedically, but exposures have declined over the past 2 years, according to a study.

“The recent declines in medical use of prescription opioids and nonmedical use of prescribed opioids from 2013 through 2015 found in the current study coincide with similar recent declines in U.S. opioid analgesic prescribing,” reported Sean Esteban McCabe, PhD, of the University of Michigan, Ann Arbor, and his associates (Pediatrics 2017 March 20. doi: 10.1542/peds.2016-2387). “Among adolescents who report both medical use of prescription opioids and nonmedical use of prescribed opioids, medical use before initiating nonmedical use of prescribed opioids tended to be most prevalent, and this pattern may be driven by the one-third of adolescents who report nonmedical use of prescribed opioids involving leftover opioid medications from their own previous prescriptions.”

The researchers analyzed data from the Monitoring the Future study from 1976 through 2015, an annual cross-sectional survey of high school seniors from 135 public and private high schools in the United States. Cohorts were nationally representative and varied in size from 2,181 to 3,791 students.

Students were asked whether they had ever been prescribed opioids by a doctor and how often they had ever taken opioids nonmedically. The list of opioids included all the ones available that year, including Vicodin, OxyContin, Percodan, Percocet, Demerol, Ultram, methadone, morphine, opium, and codeine.

Use of opioids for any reason ranged from 16.5% to 24% over the 4 decades, with medical use ranging from a low of 8.5% in 2000 to a peak of 14.4% in 1989. Though 16% of teens had used medical opioids in 1976, prevalence rose to 20% in 1989, then dropped to 13% in 1997 and remained stable. Rates sharply increased to 20% in 2002 – the year Vicodin, OxyContin, and Percocet were included in the questions – and then began declining again in 2013.

Nonmedical use correlated with medical use though remained less prevalent throughout the study period. This correlation was stronger for males, who are more likely to use opioids recreationally, than for females, who are more likely to use them to self-treat pain, the authors wrote.

Both medical and nonmedical use were more prevalent among white students than black students, in line with previous research showing “health disparities for receiving prescription opioids among racial minority patients,” the authors wrote.

Black teens are more often motivated to use opioids for pain relief, suggesting that their lower exposure rates “could result from a lack of adequate treatment, insufficient availability, overprescribing among white populations or underprescribing among nonwhite populations,” they wrote.

One limitation of the study was that absent students or those who had dropped out have a higher risk of opioid use, thereby possibly contributing to underreporting.

The National Institute on Drug Abuse and the National Institutes of Health funded the research. The researchers had no disclosures.

ORLANDO – A two-step regimen of high-potency topical antioxidants followed by a mineral-based sunscreen may help repair light-induced skin damage and protect against new damage in patients with melasma.

Recent studies suggest that the antioxidants tamp down inflammatory cytokines and damage of oxidative stress, Maria Ivonne Arellano-Mendoza, MD, said during a special focus session on Latino skin held at the annual meeting of the American Academy of Dermatology.

“Many compounds are being studied for this purpose,” said Dr. Arellano-Mendoza, head of the dermatology department of the General Hospital of Mexico, Mexico City. “One combination is vitamin C, vitamin E, ubiquinone, and grape-seed extract. This effectively prevented infrared-A radiation–induced matrix metalloproteinase-1 messenger RNA expression in human skin. This combination can be found now in some sunscreens and daily care products.”

Another effective combination seems to be a mixture of ferulic acid, tocopherol, and vitamin C, she said.

The two-step process of regularly using a topical product with antioxidants before applying a sunscreen is all there is for now, she added, because so far it’s been impossible to combine the agents in a single product.

“The challenge will be how to create a product that stays on the surface of the skin to protect it from light, while liberating the antioxidants to penetrate the skin,” she commented.

The antioxidants’ benefits, however, will be obliterated by the continued effects of some light wavelengths that aggravate melasma unless they are used in sequence with a light-scattering sunscreen.

Sunscreens are critical components of a melasma treatment regimen, Dr. Arellano-Mendoza said. “Sunscreens are a cornerstone of treatment. We clearly tell our patients that sunscreens have to be used every day, forever, and if they are not used properly, they will have no improvement.”

Patients with hyperpigmentation disorders are susceptible to longer wavelengths that aren’t covered by chemically derived sunscreens. Longer wavelengths, including infrared light and visible light, have been shown to increase expression of matrix metalloproteinase (MMP) -1 and -9, decrease expression of type 1 procollagen, and can induce macrophage infiltration. These wavelengths also increase reactive oxygen species and proinflammatory cytokines in vitro, Dr. Arellano-Mendoza noted.

Visible light can cause erythema, transient and long-lasting hyperpigmentation, thermal damage, free radical production, and premature photoaging. It also can stimulate the production of reactive oxygen species that can damage DNA.

Mineral-based, inorganic sunscreens, however – like those with titanium dioxide, zinc oxide, and iron oxide – scatter all wavelengths.

“These micronized forms of metal oxides not only scatter and reflect light, they also absorb ultraviolet radiation. The compounds aren’t new,” she said. In 1991, Dr. Elaine Kaye of Harvard University, Boston, and associates described (Arch Dermatol. 1991;127:351-5) opaque physical sunscreens that were useful blockers of visible light and found that transmittance of light can be lowered by adding iron oxide, Dr. Arellano-Mendoza pointed out.

The inorganic sunscreens have never been widely adopted because they are highly pigmented with white or, in the case of iron oxide, with red. “Not many people accepted [the iron-containing compounds] because of the redness, but now different shades are going to be hitting the market soon,” and the hope is that consumers will find them more appealing, she said.

This is good news, as the data emerging around iron oxide are intriguingly positive. A 2015 study showed that a sunscreen with iron oxides prevented melasma relapse during the summer months. Patients were randomized to the same ultraviolet filter topical sunscreen, but for one group, micronized iron oxide was added to it. After 6 months, the median melasma area severity index score was significantly better in the group using the iron oxide compound (J Am Acad Dermatol. 2015 Jan;72[1]:189-90.e1).

Support for the two-step regimen appeared in 2014, when a small study randomized 30 healthy volunteers to an SPF 30 sunscreen or the same sunscreen supplemented with an antioxidant cocktail of grape seed extract, vitamin E, ubiquinone, and vitamin C. The endpoint was MMP-1 upregulation after exposure to infrared-A light. Skin treated with the combination regimen showed significantly lower MMP-1 activation, leading the authors to conclude that the combination of topical antioxidants conferred protection against the irradiation (Photochem Photobiol. 2015 Jan-Feb;91[1]:248-50).

Those same authors published a companion article (Photodermatol Photoimmunol Photomed. 2014;30:167-74) suggesting that another antioxidant mixture (ferulic acid, tocopherol, and vitamin C) was similarly effective.

Using a combination of antioxidants is important, Dr. Arellano-Mendoza said, because different antioxidants work differently. Some (catalase, glutathione peroxidase, and superoxide dismutase) are enzymatic, catalyzing reactions that convert free radicals to oxygen and water. Others terminate free radicals by preventing the propagation of oxidative chain reactions (vitamins A and C, flavonoids, uric acid, bilirubin, albumin, and members of the thiol group). A third group consists of metal-binding proteins that sequester free iron or copper to prevent free radical production (ferritin, transferrin, lactoferrin, and ceruloplasmin).

“I think we can now consider antioxidants a part of the tools we use in treating some pigmentary disorders as melasma,” she said. “We need to choose the compounds carefully, and we definitely need more in vivo research, but the findings are very encouraging.”

Dr. Arellano-Mendoza had no relevant financial disclosures.

This article was updated 3/20/17.
 

[email protected]

On Twitter @Alz_Gal

ORLANDO – A two-step regimen of high-potency topical antioxidants followed by a mineral-based sunscreen may help repair light-induced skin damage and protect against new damage in patients with melasma.

Recent studies suggest that the antioxidants tamp down inflammatory cytokines and damage of oxidative stress, Maria Ivonne Arellano-Mendoza, MD, said during a special focus session on Latino skin held at the annual meeting of the American Academy of Dermatology.

“Many compounds are being studied for this purpose,” said Dr. Arellano-Mendoza, head of the dermatology department of the General Hospital of Mexico, Mexico City. “One combination is vitamin C, vitamin E, ubiquinone, and grape-seed extract. This effectively prevented infrared-A radiation–induced matrix metalloproteinase-1 messenger RNA expression in human skin. This combination can be found now in some sunscreens and daily care products.”

Another effective combination seems to be a mixture of ferulic acid, tocopherol, and vitamin C, she said.

The two-step process of regularly using a topical product with antioxidants before applying a sunscreen is all there is for now, she added, because so far it’s been impossible to combine the agents in a single product.

“The challenge will be how to create a product that stays on the surface of the skin to protect it from light, while liberating the antioxidants to penetrate the skin,” she commented.

The antioxidants’ benefits, however, will be obliterated by the continued effects of some light wavelengths that aggravate melasma unless they are used in sequence with a light-scattering sunscreen.

Sunscreens are critical components of a melasma treatment regimen, Dr. Arellano-Mendoza said. “Sunscreens are a cornerstone of treatment. We clearly tell our patients that sunscreens have to be used every day, forever, and if they are not used properly, they will have no improvement.”

Patients with hyperpigmentation disorders are susceptible to longer wavelengths that aren’t covered by chemically derived sunscreens. Longer wavelengths, including infrared light and visible light, have been shown to increase expression of matrix metalloproteinase (MMP) -1 and -9, decrease expression of type 1 procollagen, and can induce macrophage infiltration. These wavelengths also increase reactive oxygen species and proinflammatory cytokines in vitro, Dr. Arellano-Mendoza noted.

Visible light can cause erythema, transient and long-lasting hyperpigmentation, thermal damage, free radical production, and premature photoaging. It also can stimulate the production of reactive oxygen species that can damage DNA.

Mineral-based, inorganic sunscreens, however – like those with titanium dioxide, zinc oxide, and iron oxide – scatter all wavelengths.

“These micronized forms of metal oxides not only scatter and reflect light, they also absorb ultraviolet radiation. The compounds aren’t new,” she said. In 1991, Dr. Elaine Kaye of Harvard University, Boston, and associates described (Arch Dermatol. 1991;127:351-5) opaque physical sunscreens that were useful blockers of visible light and found that transmittance of light can be lowered by adding iron oxide, Dr. Arellano-Mendoza pointed out.

The inorganic sunscreens have never been widely adopted because they are highly pigmented with white or, in the case of iron oxide, with red. “Not many people accepted [the iron-containing compounds] because of the redness, but now different shades are going to be hitting the market soon,” and the hope is that consumers will find them more appealing, she said.

This is good news, as the data emerging around iron oxide are intriguingly positive. A 2015 study showed that a sunscreen with iron oxides prevented melasma relapse during the summer months. Patients were randomized to the same ultraviolet filter topical sunscreen, but for one group, micronized iron oxide was added to it. After 6 months, the median melasma area severity index score was significantly better in the group using the iron oxide compound (J Am Acad Dermatol. 2015 Jan;72[1]:189-90.e1).

Support for the two-step regimen appeared in 2014, when a small study randomized 30 healthy volunteers to an SPF 30 sunscreen or the same sunscreen supplemented with an antioxidant cocktail of grape seed extract, vitamin E, ubiquinone, and vitamin C. The endpoint was MMP-1 upregulation after exposure to infrared-A light. Skin treated with the combination regimen showed significantly lower MMP-1 activation, leading the authors to conclude that the combination of topical antioxidants conferred protection against the irradiation (Photochem Photobiol. 2015 Jan-Feb;91[1]:248-50).

Those same authors published a companion article (Photodermatol Photoimmunol Photomed. 2014;30:167-74) suggesting that another antioxidant mixture (ferulic acid, tocopherol, and vitamin C) was similarly effective.

Using a combination of antioxidants is important, Dr. Arellano-Mendoza said, because different antioxidants work differently. Some (catalase, glutathione peroxidase, and superoxide dismutase) are enzymatic, catalyzing reactions that convert free radicals to oxygen and water. Others terminate free radicals by preventing the propagation of oxidative chain reactions (vitamins A and C, flavonoids, uric acid, bilirubin, albumin, and members of the thiol group). A third group consists of metal-binding proteins that sequester free iron or copper to prevent free radical production (ferritin, transferrin, lactoferrin, and ceruloplasmin).

“I think we can now consider antioxidants a part of the tools we use in treating some pigmentary disorders as melasma,” she said. “We need to choose the compounds carefully, and we definitely need more in vivo research, but the findings are very encouraging.”

Dr. Arellano-Mendoza had no relevant financial disclosures.

This article was updated 3/20/17.
 

[email protected]

On Twitter @Alz_Gal

ORLANDO – A two-step regimen of high-potency topical antioxidants followed by a mineral-based sunscreen may help repair light-induced skin damage and protect against new damage in patients with melasma.

Recent studies suggest that the antioxidants tamp down inflammatory cytokines and damage of oxidative stress, Maria Ivonne Arellano-Mendoza, MD, said during a special focus session on Latino skin held at the annual meeting of the American Academy of Dermatology.

“Many compounds are being studied for this purpose,” said Dr. Arellano-Mendoza, head of the dermatology department of the General Hospital of Mexico, Mexico City. “One combination is vitamin C, vitamin E, ubiquinone, and grape-seed extract. This effectively prevented infrared-A radiation–induced matrix metalloproteinase-1 messenger RNA expression in human skin. This combination can be found now in some sunscreens and daily care products.”

Another effective combination seems to be a mixture of ferulic acid, tocopherol, and vitamin C, she said.

The two-step process of regularly using a topical product with antioxidants before applying a sunscreen is all there is for now, she added, because so far it’s been impossible to combine the agents in a single product.

“The challenge will be how to create a product that stays on the surface of the skin to protect it from light, while liberating the antioxidants to penetrate the skin,” she commented.

The antioxidants’ benefits, however, will be obliterated by the continued effects of some light wavelengths that aggravate melasma unless they are used in sequence with a light-scattering sunscreen.

Sunscreens are critical components of a melasma treatment regimen, Dr. Arellano-Mendoza said. “Sunscreens are a cornerstone of treatment. We clearly tell our patients that sunscreens have to be used every day, forever, and if they are not used properly, they will have no improvement.”

Patients with hyperpigmentation disorders are susceptible to longer wavelengths that aren’t covered by chemically derived sunscreens. Longer wavelengths, including infrared light and visible light, have been shown to increase expression of matrix metalloproteinase (MMP) -1 and -9, decrease expression of type 1 procollagen, and can induce macrophage infiltration. These wavelengths also increase reactive oxygen species and proinflammatory cytokines in vitro, Dr. Arellano-Mendoza noted.

Visible light can cause erythema, transient and long-lasting hyperpigmentation, thermal damage, free radical production, and premature photoaging. It also can stimulate the production of reactive oxygen species that can damage DNA.

Mineral-based, inorganic sunscreens, however – like those with titanium dioxide, zinc oxide, and iron oxide – scatter all wavelengths.

“These micronized forms of metal oxides not only scatter and reflect light, they also absorb ultraviolet radiation. The compounds aren’t new,” she said. In 1991, Dr. Elaine Kaye of Harvard University, Boston, and associates described (Arch Dermatol. 1991;127:351-5) opaque physical sunscreens that were useful blockers of visible light and found that transmittance of light can be lowered by adding iron oxide, Dr. Arellano-Mendoza pointed out.

The inorganic sunscreens have never been widely adopted because they are highly pigmented with white or, in the case of iron oxide, with red. “Not many people accepted [the iron-containing compounds] because of the redness, but now different shades are going to be hitting the market soon,” and the hope is that consumers will find them more appealing, she said.

This is good news, as the data emerging around iron oxide are intriguingly positive. A 2015 study showed that a sunscreen with iron oxides prevented melasma relapse during the summer months. Patients were randomized to the same ultraviolet filter topical sunscreen, but for one group, micronized iron oxide was added to it. After 6 months, the median melasma area severity index score was significantly better in the group using the iron oxide compound (J Am Acad Dermatol. 2015 Jan;72[1]:189-90.e1).

Support for the two-step regimen appeared in 2014, when a small study randomized 30 healthy volunteers to an SPF 30 sunscreen or the same sunscreen supplemented with an antioxidant cocktail of grape seed extract, vitamin E, ubiquinone, and vitamin C. The endpoint was MMP-1 upregulation after exposure to infrared-A light. Skin treated with the combination regimen showed significantly lower MMP-1 activation, leading the authors to conclude that the combination of topical antioxidants conferred protection against the irradiation (Photochem Photobiol. 2015 Jan-Feb;91[1]:248-50).

Those same authors published a companion article (Photodermatol Photoimmunol Photomed. 2014;30:167-74) suggesting that another antioxidant mixture (ferulic acid, tocopherol, and vitamin C) was similarly effective.

Using a combination of antioxidants is important, Dr. Arellano-Mendoza said, because different antioxidants work differently. Some (catalase, glutathione peroxidase, and superoxide dismutase) are enzymatic, catalyzing reactions that convert free radicals to oxygen and water. Others terminate free radicals by preventing the propagation of oxidative chain reactions (vitamins A and C, flavonoids, uric acid, bilirubin, albumin, and members of the thiol group). A third group consists of metal-binding proteins that sequester free iron or copper to prevent free radical production (ferritin, transferrin, lactoferrin, and ceruloplasmin).

“I think we can now consider antioxidants a part of the tools we use in treating some pigmentary disorders as melasma,” she said. “We need to choose the compounds carefully, and we definitely need more in vivo research, but the findings are very encouraging.”

Dr. Arellano-Mendoza had no relevant financial disclosures.

This article was updated 3/20/17.
 

[email protected]

On Twitter @Alz_Gal

HOUSTON – Thrombolytic therapy for U.S. patients experiencing an acute ischemic stroke is no longer the poster child for proven, but neglected, therapies.

Long bemoaned since its introduction in the mid-1990s as an effective but woefully underused treatment, thrombolytic therapy with tissue plasminogen activator (tPA) has seen robust growth in U.S. practice recently, largely due to the promotion and quality-improvement efforts of a voluntary, non-profit program, Get With the Guidelines (GWTG)-Stroke.

Mitchel L. Zoler/Frontline Medical News

Mitchel L. Zoler/Frontline Medical News

What is GWTG-Stroke?

GWTG was launched in 2000 by the American Heart Association as a hospital-based–quality improvement initiative focused on U.S. management of acute MI. In 2003, acute stroke became another focus of the program and inspired added participation of the American Stroke Association.

“Improvements in tPA use in eligible patients were seen soon after the introduction of GWTG-Stroke in 2003, but there was minimal improvement in the percentage of patients with door-to-needle times within 60 minutes despite national guidelines,” recalled Dr. Fonarow. This slow rate of advance led him, Dr. Schwamm, and others to create a more activist program within GWTG-Stroke, Target Stroke, that not only provided resources and collected data from participating hospitals but also set acute-treatment goals that challenged participating hospitals to up their game. Target Stroke phase I asked them to try to achieve a tPA door-to-needle time within 60 minutes in at least 50% of eligible patients. By mid-2013, the program reached this goal with 53% of patients treated in the allotted time frame (JAMA. 2014 Apr 23;311[16]:1632-40).

Mitchel L. Zoler/Frontline Medical News

Growing the program

The success of GWTG-Stroke in transforming U.S. acute stroke care has not only relied on setting aggressive performance goals but also on advancing by boosting the number of U.S. hospitals participating of more U.S. hospitals. During the Target Stroke years since the start of 2010, the number of hospitals active in GWTG-Stroke jumped from 1427 to 1,950 by mid-2016, including a 12% year-over-year jump in 2016, compared with 2015. During October 2015-October 2016, participating hospitals treated more than 570,000 acute stroke patients, or roughly 71% of the estimated 800,000 U.S. patients who have an acute stroke each year.

These numbers seem on track to continue expanding. “With the recent evidence showing that participating in GWTG-Stroke improves care and outcomes there has been even greater interest by hospitals, recently, in joining,” said Dr. Fonarow. “While many hospitals currently participate, ideally all would join and be active.”

“Hospitals now feel that they can’t afford not to focus on stroke as a quality improvement program, so they join,” said Dr. Schwamm. He believes that essentially all of the roughly 200 certified U.S. Comprehensive Stroke Centers and of the roughly 1,000 certified U.S. Primary Stroke Centers are already members of GWTG-Stroke. “We’re now in all the high-value hospitals, based on their higher numbers of patients. It’s the Acute Stroke Ready hospitals where we now have the greatest potential to penetrate, hospitals that generally treat about 20-50 stroke patients a year,” he said.

Joining GWTG-Stroke holds major attraction for hospitals because the program gives them a tool for measuring their performance, data that hospitals often now need to prove the value of the care they deliver to insurers and to avoid penalization for readmissions. However, the barrier to hospitals, especially smaller hospitals, is that data collection can be expensive. It’s something that larger hospitals now routinely do, but smaller hospitals have often balked because of the expense. To address this, the GWTG-Stroke program is trying to develop a “lighter” version of their data collection tool that involves a smaller financial burden.

“I think we can sell a trimmed down version of GWTG-Stroke to smaller hospitals that is affordable and use it to recruit another 1,000 hospitals. That’s a realistic goal,” Dr. Schwamm said.

What is also notable about GWTG-Stroke is that hospitals sign up despite the somewhat ambiguous payback they receive.

Get With the Guidelines-Stroke is a program of the American Heart Association and American Stroke Association and uses funding provided by several drug companies. Dr. Smith, Dr. Fonarow, Dr. Schwamm and Dr. Messe had no relevant commercial disclosures.

[email protected]

On Twitter @mitchelzoler

HOUSTON – Thrombolytic therapy for U.S. patients experiencing an acute ischemic stroke is no longer the poster child for proven, but neglected, therapies.

Long bemoaned since its introduction in the mid-1990s as an effective but woefully underused treatment, thrombolytic therapy with tissue plasminogen activator (tPA) has seen robust growth in U.S. practice recently, largely due to the promotion and quality-improvement efforts of a voluntary, non-profit program, Get With the Guidelines (GWTG)-Stroke.

Mitchel L. Zoler/Frontline Medical News

Mitchel L. Zoler/Frontline Medical News

What is GWTG-Stroke?

GWTG was launched in 2000 by the American Heart Association as a hospital-based–quality improvement initiative focused on U.S. management of acute MI. In 2003, acute stroke became another focus of the program and inspired added participation of the American Stroke Association.

“Improvements in tPA use in eligible patients were seen soon after the introduction of GWTG-Stroke in 2003, but there was minimal improvement in the percentage of patients with door-to-needle times within 60 minutes despite national guidelines,” recalled Dr. Fonarow. This slow rate of advance led him, Dr. Schwamm, and others to create a more activist program within GWTG-Stroke, Target Stroke, that not only provided resources and collected data from participating hospitals but also set acute-treatment goals that challenged participating hospitals to up their game. Target Stroke phase I asked them to try to achieve a tPA door-to-needle time within 60 minutes in at least 50% of eligible patients. By mid-2013, the program reached this goal with 53% of patients treated in the allotted time frame (JAMA. 2014 Apr 23;311[16]:1632-40).

Mitchel L. Zoler/Frontline Medical News

Growing the program

The success of GWTG-Stroke in transforming U.S. acute stroke care has not only relied on setting aggressive performance goals but also on advancing by boosting the number of U.S. hospitals participating of more U.S. hospitals. During the Target Stroke years since the start of 2010, the number of hospitals active in GWTG-Stroke jumped from 1427 to 1,950 by mid-2016, including a 12% year-over-year jump in 2016, compared with 2015. During October 2015-October 2016, participating hospitals treated more than 570,000 acute stroke patients, or roughly 71% of the estimated 800,000 U.S. patients who have an acute stroke each year.

These numbers seem on track to continue expanding. “With the recent evidence showing that participating in GWTG-Stroke improves care and outcomes there has been even greater interest by hospitals, recently, in joining,” said Dr. Fonarow. “While many hospitals currently participate, ideally all would join and be active.”

“Hospitals now feel that they can’t afford not to focus on stroke as a quality improvement program, so they join,” said Dr. Schwamm. He believes that essentially all of the roughly 200 certified U.S. Comprehensive Stroke Centers and of the roughly 1,000 certified U.S. Primary Stroke Centers are already members of GWTG-Stroke. “We’re now in all the high-value hospitals, based on their higher numbers of patients. It’s the Acute Stroke Ready hospitals where we now have the greatest potential to penetrate, hospitals that generally treat about 20-50 stroke patients a year,” he said.

Joining GWTG-Stroke holds major attraction for hospitals because the program gives them a tool for measuring their performance, data that hospitals often now need to prove the value of the care they deliver to insurers and to avoid penalization for readmissions. However, the barrier to hospitals, especially smaller hospitals, is that data collection can be expensive. It’s something that larger hospitals now routinely do, but smaller hospitals have often balked because of the expense. To address this, the GWTG-Stroke program is trying to develop a “lighter” version of their data collection tool that involves a smaller financial burden.

“I think we can sell a trimmed down version of GWTG-Stroke to smaller hospitals that is affordable and use it to recruit another 1,000 hospitals. That’s a realistic goal,” Dr. Schwamm said.

What is also notable about GWTG-Stroke is that hospitals sign up despite the somewhat ambiguous payback they receive.

Get With the Guidelines-Stroke is a program of the American Heart Association and American Stroke Association and uses funding provided by several drug companies. Dr. Smith, Dr. Fonarow, Dr. Schwamm and Dr. Messe had no relevant commercial disclosures.

[email protected]

On Twitter @mitchelzoler

HOUSTON – Thrombolytic therapy for U.S. patients experiencing an acute ischemic stroke is no longer the poster child for proven, but neglected, therapies.

Long bemoaned since its introduction in the mid-1990s as an effective but woefully underused treatment, thrombolytic therapy with tissue plasminogen activator (tPA) has seen robust growth in U.S. practice recently, largely due to the promotion and quality-improvement efforts of a voluntary, non-profit program, Get With the Guidelines (GWTG)-Stroke.

Mitchel L. Zoler/Frontline Medical News

Mitchel L. Zoler/Frontline Medical News

What is GWTG-Stroke?

GWTG was launched in 2000 by the American Heart Association as a hospital-based–quality improvement initiative focused on U.S. management of acute MI. In 2003, acute stroke became another focus of the program and inspired added participation of the American Stroke Association.

“Improvements in tPA use in eligible patients were seen soon after the introduction of GWTG-Stroke in 2003, but there was minimal improvement in the percentage of patients with door-to-needle times within 60 minutes despite national guidelines,” recalled Dr. Fonarow. This slow rate of advance led him, Dr. Schwamm, and others to create a more activist program within GWTG-Stroke, Target Stroke, that not only provided resources and collected data from participating hospitals but also set acute-treatment goals that challenged participating hospitals to up their game. Target Stroke phase I asked them to try to achieve a tPA door-to-needle time within 60 minutes in at least 50% of eligible patients. By mid-2013, the program reached this goal with 53% of patients treated in the allotted time frame (JAMA. 2014 Apr 23;311[16]:1632-40).

Mitchel L. Zoler/Frontline Medical News

Growing the program

The success of GWTG-Stroke in transforming U.S. acute stroke care has not only relied on setting aggressive performance goals but also on advancing by boosting the number of U.S. hospitals participating of more U.S. hospitals. During the Target Stroke years since the start of 2010, the number of hospitals active in GWTG-Stroke jumped from 1427 to 1,950 by mid-2016, including a 12% year-over-year jump in 2016, compared with 2015. During October 2015-October 2016, participating hospitals treated more than 570,000 acute stroke patients, or roughly 71% of the estimated 800,000 U.S. patients who have an acute stroke each year.

These numbers seem on track to continue expanding. “With the recent evidence showing that participating in GWTG-Stroke improves care and outcomes there has been even greater interest by hospitals, recently, in joining,” said Dr. Fonarow. “While many hospitals currently participate, ideally all would join and be active.”

“Hospitals now feel that they can’t afford not to focus on stroke as a quality improvement program, so they join,” said Dr. Schwamm. He believes that essentially all of the roughly 200 certified U.S. Comprehensive Stroke Centers and of the roughly 1,000 certified U.S. Primary Stroke Centers are already members of GWTG-Stroke. “We’re now in all the high-value hospitals, based on their higher numbers of patients. It’s the Acute Stroke Ready hospitals where we now have the greatest potential to penetrate, hospitals that generally treat about 20-50 stroke patients a year,” he said.

Joining GWTG-Stroke holds major attraction for hospitals because the program gives them a tool for measuring their performance, data that hospitals often now need to prove the value of the care they deliver to insurers and to avoid penalization for readmissions. However, the barrier to hospitals, especially smaller hospitals, is that data collection can be expensive. It’s something that larger hospitals now routinely do, but smaller hospitals have often balked because of the expense. To address this, the GWTG-Stroke program is trying to develop a “lighter” version of their data collection tool that involves a smaller financial burden.

“I think we can sell a trimmed down version of GWTG-Stroke to smaller hospitals that is affordable and use it to recruit another 1,000 hospitals. That’s a realistic goal,” Dr. Schwamm said.

What is also notable about GWTG-Stroke is that hospitals sign up despite the somewhat ambiguous payback they receive.

Get With the Guidelines-Stroke is a program of the American Heart Association and American Stroke Association and uses funding provided by several drug companies. Dr. Smith, Dr. Fonarow, Dr. Schwamm and Dr. Messe had no relevant commercial disclosures.

[email protected]

On Twitter @mitchelzoler

“Exercising my ‘reasoned judgment,’ I have no doubt that the right to a climate system capable of sustaining human life is fundamental to a free and ordered society.”

– U.S. District Judge Ann Aiken in Kelsey Cascadia Rose Juliana vs. United States of America, et al.

In many areas of the world, the simple act of breathing has become hazardous to people’s health.

According to the World Health Organization, more people die every day from air pollution than from HIV/AIDS, tuberculosis, and road injuries combined. In China, more than 1 million deaths annually are linked to polluted air (76/100,000); in India the number of deaths is more than 600,000 annually (49/100,000); and in the United States, that figure comes to more than 38,000 (12/100,000).

Rob Wilson

The health effects of climate change

Black carbon found in air pollution leads to drug-resistant bacteria and alters antibiotic tolerance.¹ The pollution also is associated with multiple cancers: lung, liver, ovarian, and, possibly, breast.^2,3,4,5 It causes inflammation linked to the development of coronary artery disease (seen even in children!) and plaque formation leading to heart attacks and cardiac arrhythmias – including atrial fibrillation. Air pollution causes, triggers, or worsens respiratory illnesses – chronic obstructive pulmonary disease, emphysema, asthma, infections – and is responsible for lifelong diminished lung volume in children (a reason families are leaving Beijing.) Exponentially increased rates of autism are linked to bad air quality, as are autoimmune diseases, which also are on the rise.^6,7 Polluted air causes brain inflammation – living near sources of air pollution increases the risk of dementia – and other neurodegenerative diseases such as Alzheimer’s disease, Parkinson’s, and amyotrophic lateral sclerosis.⁸ The blood brain barrier protects the brain from most foreign matter, but particulate matter, especially ultrafine particulate matter of less than 1 mcm such as magnetite, can cross directly into the brain via the olfactory nerve. (Magnetite has been identified in the brain tissue of residents living in areas where the substance is produced as a result of industrial waste.) While particulate matter of 2.5 mcmis measured in the United States, ultrafine particulate matter is not.

Psychiatric symptoms and chronic psychiatric disorders also are associated with polluted air: On days with poor air quality, a statistically significant increase is seen in suicide threats and visits to emergency departments for panic attacks.^9,10

A rise in aggression occurs when there are abnormally high temperatures and significant changes in rainfall. More assaults, murders, suicides, domestic violence, and child abuse can be expected, and a rise in unrest around the world should come as no surprise.

As a consequence of increased CO₂ in the atmosphere, temperatures have already risen by 2° F: Sixteen of the hottest years on record have occurred in the last 17 years, with 2016 as the hottest year ever recorded. In Iraq and Kuwait, the temperature last summer reached 129.2° F.

We are experiencing more frequent and extreme weather events, chronic climate conditions, and the cascading disruption of ecosystems. Drought and sea level rise are leading to physical and psychological impacts – both direct and indirect. Some regions of the world have become destabilized, triggering migrations and the refugee crisis.

Along with these psychological impacts, CO₂ affects cognition: A recent study by the Harvard School of Public Health, Boston, shows that the indoor levels of CO₂ to which American workers typically are exposed impair cognitive functioning, particularly in the areas of strategic thinking, information processing, and crisis management.¹¹

^{What do we do about it?}

As mental health professionals, we know that aggression can be overt or passive (from inaction). Overwhelming evidence shows harm to public health from burning fossil fuels, and yet, though we are making progress, resistance still exists in the transition to clean, renewable energy critical for the health of our families and communities. When political will is what stands between us and getting back on a path to breathing clean air, how can inaction be understood as anything but an act of aggression?

This issue has reached U.S. courts: In a landmark case, 21 youths aged 9-20 years represented by “Our Children’s Trust” are suing the U.S. government in the Oregon U.S. District Court for failure to act on climate. The case, heard by Judge Ann Aiken, is now headed to trial.

All of us have a duty to collectively, repeatedly, and forcefully call on policy makers to take action.

That leads me to what we can do as doctors. In this effort to quickly transition to safe, clean renewable energy, we all have a role to play. The notion that we can’t do anything as individuals is no more credible than saying “my vote doesn’t matter.” Just as our actions as voters in a democracy demonstrate the collective civic responsibility we owe one another, so too do our actions on climate. As global citizens, all actions that we take to help us live within the planet’s means are opportunities to restore balance.

What we do collectively drives markets and determines the social norms that powerfully influence the decisions of others – sometimes even unconsciously.

As doctors, we have a unique role to play in the places we work – urging hospitals, clinics, academic centers, and other organizations and facilities to lead by example, become role models for energy efficiency, and choose clean renewable energy sources over the ones harming our health. We can start by choosing wind and solar to power our homes and influencing others to do the same.

We are the voices because this is a health message.
 

Dr. Van Susteren is a practicing general and forensic psychiatrist in Washington. She serves on the advisory board of the Center for Health and the Global Environment at Harvard T.H. Chan School of Public Health, Boston. Dr. Van Susteren is a former member of the board of directors of the National Wildlife Federation and coauthor of group’s report, “The Psychological Effects of Global Warming on the United States – Why the U.S. Mental Health System is Not Prepared.” In 2006, Dr. Van Susteren sought the Democratic nomination for a U.S. Senate seat in Maryland. She also founded Lucky Planet Foods, a company that provides plant-based, low carbon foods.

References

1. Environ Microbiol. 2017 Feb 14. doi: 10.1111/1462-2920.13686.

2. Environ Health Perspect. 2017 Mar;125[3]:378-84.

3. J Hepatol. 2015;63[6]:1397-1404.

4. J Toxicol Environ Health A. 2012;75[3]:174-82.

5. Environ Health Perspect. 2012 Nov; 118[11]:1578-83.

6. J Child Psychol Psychiatry. 2016; 57[3]:271-92.

7. Curr Opin Pediatr. 2010;22[2]219-25.

8. Inhal Toxicol. 2008;20[5]:499-506.

9. J Psychiatr Res. 2015 Mar;62:130-5.

10. Schizophr Res. 2016 Oct 5. doi: 10.1016/j.schres.2016.10.003.

11. Environ Health Perspect. 2016 Jun;124[6]:805-12.

“Exercising my ‘reasoned judgment,’ I have no doubt that the right to a climate system capable of sustaining human life is fundamental to a free and ordered society.”

– U.S. District Judge Ann Aiken in Kelsey Cascadia Rose Juliana vs. United States of America, et al.

In many areas of the world, the simple act of breathing has become hazardous to people’s health.

According to the World Health Organization, more people die every day from air pollution than from HIV/AIDS, tuberculosis, and road injuries combined. In China, more than 1 million deaths annually are linked to polluted air (76/100,000); in India the number of deaths is more than 600,000 annually (49/100,000); and in the United States, that figure comes to more than 38,000 (12/100,000).

Rob Wilson

The health effects of climate change

Black carbon found in air pollution leads to drug-resistant bacteria and alters antibiotic tolerance.¹ The pollution also is associated with multiple cancers: lung, liver, ovarian, and, possibly, breast.^2,3,4,5 It causes inflammation linked to the development of coronary artery disease (seen even in children!) and plaque formation leading to heart attacks and cardiac arrhythmias – including atrial fibrillation. Air pollution causes, triggers, or worsens respiratory illnesses – chronic obstructive pulmonary disease, emphysema, asthma, infections – and is responsible for lifelong diminished lung volume in children (a reason families are leaving Beijing.) Exponentially increased rates of autism are linked to bad air quality, as are autoimmune diseases, which also are on the rise.^6,7 Polluted air causes brain inflammation – living near sources of air pollution increases the risk of dementia – and other neurodegenerative diseases such as Alzheimer’s disease, Parkinson’s, and amyotrophic lateral sclerosis.⁸ The blood brain barrier protects the brain from most foreign matter, but particulate matter, especially ultrafine particulate matter of less than 1 mcm such as magnetite, can cross directly into the brain via the olfactory nerve. (Magnetite has been identified in the brain tissue of residents living in areas where the substance is produced as a result of industrial waste.) While particulate matter of 2.5 mcmis measured in the United States, ultrafine particulate matter is not.

Psychiatric symptoms and chronic psychiatric disorders also are associated with polluted air: On days with poor air quality, a statistically significant increase is seen in suicide threats and visits to emergency departments for panic attacks.^9,10

A rise in aggression occurs when there are abnormally high temperatures and significant changes in rainfall. More assaults, murders, suicides, domestic violence, and child abuse can be expected, and a rise in unrest around the world should come as no surprise.

As a consequence of increased CO₂ in the atmosphere, temperatures have already risen by 2° F: Sixteen of the hottest years on record have occurred in the last 17 years, with 2016 as the hottest year ever recorded. In Iraq and Kuwait, the temperature last summer reached 129.2° F.

We are experiencing more frequent and extreme weather events, chronic climate conditions, and the cascading disruption of ecosystems. Drought and sea level rise are leading to physical and psychological impacts – both direct and indirect. Some regions of the world have become destabilized, triggering migrations and the refugee crisis.

Along with these psychological impacts, CO₂ affects cognition: A recent study by the Harvard School of Public Health, Boston, shows that the indoor levels of CO₂ to which American workers typically are exposed impair cognitive functioning, particularly in the areas of strategic thinking, information processing, and crisis management.¹¹

^{What do we do about it?}

As mental health professionals, we know that aggression can be overt or passive (from inaction). Overwhelming evidence shows harm to public health from burning fossil fuels, and yet, though we are making progress, resistance still exists in the transition to clean, renewable energy critical for the health of our families and communities. When political will is what stands between us and getting back on a path to breathing clean air, how can inaction be understood as anything but an act of aggression?

This issue has reached U.S. courts: In a landmark case, 21 youths aged 9-20 years represented by “Our Children’s Trust” are suing the U.S. government in the Oregon U.S. District Court for failure to act on climate. The case, heard by Judge Ann Aiken, is now headed to trial.

All of us have a duty to collectively, repeatedly, and forcefully call on policy makers to take action.

That leads me to what we can do as doctors. In this effort to quickly transition to safe, clean renewable energy, we all have a role to play. The notion that we can’t do anything as individuals is no more credible than saying “my vote doesn’t matter.” Just as our actions as voters in a democracy demonstrate the collective civic responsibility we owe one another, so too do our actions on climate. As global citizens, all actions that we take to help us live within the planet’s means are opportunities to restore balance.

What we do collectively drives markets and determines the social norms that powerfully influence the decisions of others – sometimes even unconsciously.

As doctors, we have a unique role to play in the places we work – urging hospitals, clinics, academic centers, and other organizations and facilities to lead by example, become role models for energy efficiency, and choose clean renewable energy sources over the ones harming our health. We can start by choosing wind and solar to power our homes and influencing others to do the same.

We are the voices because this is a health message.
 

Dr. Van Susteren is a practicing general and forensic psychiatrist in Washington. She serves on the advisory board of the Center for Health and the Global Environment at Harvard T.H. Chan School of Public Health, Boston. Dr. Van Susteren is a former member of the board of directors of the National Wildlife Federation and coauthor of group’s report, “The Psychological Effects of Global Warming on the United States – Why the U.S. Mental Health System is Not Prepared.” In 2006, Dr. Van Susteren sought the Democratic nomination for a U.S. Senate seat in Maryland. She also founded Lucky Planet Foods, a company that provides plant-based, low carbon foods.

References

1. Environ Microbiol. 2017 Feb 14. doi: 10.1111/1462-2920.13686.

2. Environ Health Perspect. 2017 Mar;125[3]:378-84.

3. J Hepatol. 2015;63[6]:1397-1404.

4. J Toxicol Environ Health A. 2012;75[3]:174-82.

5. Environ Health Perspect. 2012 Nov; 118[11]:1578-83.

6. J Child Psychol Psychiatry. 2016; 57[3]:271-92.

7. Curr Opin Pediatr. 2010;22[2]219-25.

8. Inhal Toxicol. 2008;20[5]:499-506.

9. J Psychiatr Res. 2015 Mar;62:130-5.

10. Schizophr Res. 2016 Oct 5. doi: 10.1016/j.schres.2016.10.003.

11. Environ Health Perspect. 2016 Jun;124[6]:805-12.

“Exercising my ‘reasoned judgment,’ I have no doubt that the right to a climate system capable of sustaining human life is fundamental to a free and ordered society.”

– U.S. District Judge Ann Aiken in Kelsey Cascadia Rose Juliana vs. United States of America, et al.

In many areas of the world, the simple act of breathing has become hazardous to people’s health.

According to the World Health Organization, more people die every day from air pollution than from HIV/AIDS, tuberculosis, and road injuries combined. In China, more than 1 million deaths annually are linked to polluted air (76/100,000); in India the number of deaths is more than 600,000 annually (49/100,000); and in the United States, that figure comes to more than 38,000 (12/100,000).

Rob Wilson

The health effects of climate change

Black carbon found in air pollution leads to drug-resistant bacteria and alters antibiotic tolerance.¹ The pollution also is associated with multiple cancers: lung, liver, ovarian, and, possibly, breast.^2,3,4,5 It causes inflammation linked to the development of coronary artery disease (seen even in children!) and plaque formation leading to heart attacks and cardiac arrhythmias – including atrial fibrillation. Air pollution causes, triggers, or worsens respiratory illnesses – chronic obstructive pulmonary disease, emphysema, asthma, infections – and is responsible for lifelong diminished lung volume in children (a reason families are leaving Beijing.) Exponentially increased rates of autism are linked to bad air quality, as are autoimmune diseases, which also are on the rise.^6,7 Polluted air causes brain inflammation – living near sources of air pollution increases the risk of dementia – and other neurodegenerative diseases such as Alzheimer’s disease, Parkinson’s, and amyotrophic lateral sclerosis.⁸ The blood brain barrier protects the brain from most foreign matter, but particulate matter, especially ultrafine particulate matter of less than 1 mcm such as magnetite, can cross directly into the brain via the olfactory nerve. (Magnetite has been identified in the brain tissue of residents living in areas where the substance is produced as a result of industrial waste.) While particulate matter of 2.5 mcmis measured in the United States, ultrafine particulate matter is not.

Psychiatric symptoms and chronic psychiatric disorders also are associated with polluted air: On days with poor air quality, a statistically significant increase is seen in suicide threats and visits to emergency departments for panic attacks.^9,10

A rise in aggression occurs when there are abnormally high temperatures and significant changes in rainfall. More assaults, murders, suicides, domestic violence, and child abuse can be expected, and a rise in unrest around the world should come as no surprise.

As a consequence of increased CO₂ in the atmosphere, temperatures have already risen by 2° F: Sixteen of the hottest years on record have occurred in the last 17 years, with 2016 as the hottest year ever recorded. In Iraq and Kuwait, the temperature last summer reached 129.2° F.

We are experiencing more frequent and extreme weather events, chronic climate conditions, and the cascading disruption of ecosystems. Drought and sea level rise are leading to physical and psychological impacts – both direct and indirect. Some regions of the world have become destabilized, triggering migrations and the refugee crisis.

Along with these psychological impacts, CO₂ affects cognition: A recent study by the Harvard School of Public Health, Boston, shows that the indoor levels of CO₂ to which American workers typically are exposed impair cognitive functioning, particularly in the areas of strategic thinking, information processing, and crisis management.¹¹

^{What do we do about it?}

As mental health professionals, we know that aggression can be overt or passive (from inaction). Overwhelming evidence shows harm to public health from burning fossil fuels, and yet, though we are making progress, resistance still exists in the transition to clean, renewable energy critical for the health of our families and communities. When political will is what stands between us and getting back on a path to breathing clean air, how can inaction be understood as anything but an act of aggression?

This issue has reached U.S. courts: In a landmark case, 21 youths aged 9-20 years represented by “Our Children’s Trust” are suing the U.S. government in the Oregon U.S. District Court for failure to act on climate. The case, heard by Judge Ann Aiken, is now headed to trial.

All of us have a duty to collectively, repeatedly, and forcefully call on policy makers to take action.

That leads me to what we can do as doctors. In this effort to quickly transition to safe, clean renewable energy, we all have a role to play. The notion that we can’t do anything as individuals is no more credible than saying “my vote doesn’t matter.” Just as our actions as voters in a democracy demonstrate the collective civic responsibility we owe one another, so too do our actions on climate. As global citizens, all actions that we take to help us live within the planet’s means are opportunities to restore balance.

What we do collectively drives markets and determines the social norms that powerfully influence the decisions of others – sometimes even unconsciously.

As doctors, we have a unique role to play in the places we work – urging hospitals, clinics, academic centers, and other organizations and facilities to lead by example, become role models for energy efficiency, and choose clean renewable energy sources over the ones harming our health. We can start by choosing wind and solar to power our homes and influencing others to do the same.

We are the voices because this is a health message.
 

Dr. Van Susteren is a practicing general and forensic psychiatrist in Washington. She serves on the advisory board of the Center for Health and the Global Environment at Harvard T.H. Chan School of Public Health, Boston. Dr. Van Susteren is a former member of the board of directors of the National Wildlife Federation and coauthor of group’s report, “The Psychological Effects of Global Warming on the United States – Why the U.S. Mental Health System is Not Prepared.” In 2006, Dr. Van Susteren sought the Democratic nomination for a U.S. Senate seat in Maryland. She also founded Lucky Planet Foods, a company that provides plant-based, low carbon foods.

References

1. Environ Microbiol. 2017 Feb 14. doi: 10.1111/1462-2920.13686.

2. Environ Health Perspect. 2017 Mar;125[3]:378-84.

3. J Hepatol. 2015;63[6]:1397-1404.

4. J Toxicol Environ Health A. 2012;75[3]:174-82.

5. Environ Health Perspect. 2012 Nov; 118[11]:1578-83.

6. J Child Psychol Psychiatry. 2016; 57[3]:271-92.

7. Curr Opin Pediatr. 2010;22[2]219-25.

8. Inhal Toxicol. 2008;20[5]:499-506.

9. J Psychiatr Res. 2015 Mar;62:130-5.

10. Schizophr Res. 2016 Oct 5. doi: 10.1016/j.schres.2016.10.003.

11. Environ Health Perspect. 2016 Jun;124[6]:805-12.