A radial nerve injury in association with a humeral shaft fracture is not an infrequent occurrence.^1,2 The nerve injury typically is thought to be a neurapraxia caused by a contusion, as spontaneous recovery rates range from 70% to 90%.^2-4 In cases in which acute nerve exploration and open reduction and internal fixation (ORIF) are not indicated, patient and clinician wait months for the nerve to recover. In some conservatively treated cases, the nerve is lacerated or entrapped. Patients with a lacerated or entrapped nerve may have better outcomes with early operative management.

We report on a rare case of the radial nerve entrapped within a nondisplaced segment of a closed humeral shaft fracture and describe the clinical outcome of early operative management. The patient provided written informed consent for print and electronic publication of this case report.

Case Report

An intoxicated, restrained 18-year-old driver in a motor vehicle collision sustained multiple injuries, including rib fracture, apical pneumothorax with pulmonary contusion, and corneal abrasion. Orthopedic injuries included right subtrochanteric femur fracture and midshaft right humeral shaft fracture (Figure 1).

Initial orthopedic evaluation of the right arm revealed decreased sensation in the radial nerve distribution. Motor function in the radial nerve was absent; the patient was incapable of active wrist extension or finger extension. Median and ulnar nerves were motor- and sensory-intact. Radiographs showed a displaced transverse midshaft humeral shaft fracture with a minimally displaced vertical fracture line extending from the fracture site about 3 cm into the proximal segment. The patient was placed in a coaptation splint. The femur fracture was treated with an antegrade piriformis entry intramedullary nail.

ORIF of the humerus was performed to facilitate mobilization of this polytrauma patient. He was positioned prone on a flat-top table with his right arm over a radiolucent extension. The arm was abducted at the shoulder and the elbow flexed. A posterior midline skin incision was made to reflect the triceps in a lateral-to-medial direction, facilitating dissection of the lateral brachial cutaneous nerve on the lateral aspect of the triceps, with resultant localization of the radial nerve. At that time, the radial nerve was noted to be entrapped in the fracture site (Figure 2). In the proximal segment was a sagittal split, displaced about 1 mm, and it was in this interval the nerve was held. This sagittal fracture appeared incomplete as it was followed more proximally. A unicortical Kirschner wire was placed in a posterior-to-anterior direction in each fragment alongside the nerve. A lamina spreader engaged the wires and distracted the fracture site as the tines were spread apart, releasing the nerve (Figure 3). The nerve was in continuity but was severely contused at that location. After the sagittal split was reduced, two 2.7-mm lag screws were used in lag fashion, and the transverse midshaft component was fixed with a 10-hole, 4.5-mm narrow locking compression plate. The radial nerve lay on the posterior aspect of the plate, between holes 4 and 5 (Figures 4, 5). The wound was closed, and the patient was made weight-bearing as tolerated in the right upper extremity. He was sent to occupational therapy, and static and dynamic splints were made for his wrist and hand.

Two months after injury, radial nerve examination findings were unchanged: decreased sensation on dorsum of hand and no motor function. At 3 months, electrodiagnostic testing showed neurophysiologic evidence of severe right radial neuropathy proximal to the innervation of the right brachioradialis. There were electrodiagnostic signs of ongoing axonal loss and no signs of ongoing reinnervation. At 4 months, only motor strength in wrist extension was improved (2/5). At 5 months, the patient had 4–/5 wrist extension, 3/5 metacarpophalangeal (MCP) extension of fingers, and 0/5 MCP/interphalangeal extension of thumb. Sensation in the radial nerve distribution was still decreased. At 7 months, strength in wrist extension and finger MCP extension was 4+/5. The fracture was now well healed, with maintained alignment and no changes in hardware appearance.

Discussion

In most cases, closed treatment of a humeral shaft fracture with an associated radial nerve injury has a successful outcome.⁵ The etiology of the neurapraxia likely is nerve contusion after the fracture. A neurapraxia is by definition a temporary injury to the myelin sheath with an intact nerve; the nerve function recovers rapidly.

Some humeral shaft fractures, however, have been associated with radial nerve injuries more severe than contusions, resulting in axonotmesis or neurotmesis. These more severe injuries make up 10% to 30% of humeral shaft fractures, including those with a frank laceration of the nerve and those with an entrapped nerve.^2,3 Shao and colleagues² reported a 90% recovery rate for patients who delayed extrication of the entrapped radial nerve. Although there is no consensus on timing of surgical exploration, motor and sensory function of the nerve is temporally related, which may indicate that earlier diagnosis and treatment lead to improved outcome.^6,7 Loss of radial nerve function can have devastating effects on upper extremity function. Often, patients lose all or some extension of the wrist and fingers and abduction and extension of the thumb.

In a standard history or physical examination, there are no particular features indicating nerve entrapment. Absolute indications for humeral shaft fractures with radial palsy are limited to open fractures, vascular injuries, and unacceptable fracture alignment. Relative indications are polytrauma and secondary palsy after attempted fracture reduction. For all other humeral shaft fractures with radial nerve palsy, observation is still the mainstay of treatment, with spontaneous recovery occurring in up to 90% of patients.^2,8-12 Our patient did not have an absolute indication for operative treatment; surgery was nevertheless performed to address the polytrauma and to facilitate earlier mobilization.

Electromyelogram (EMG) studies typically are not useful after acute injury. EMG studies are better used serially to evaluate reinnervation after the acute phase. Bodner and colleagues^13,14 used ultrasonography to identify the radial nerve in a patient with unimproved radial nerve palsy 6 weeks after humeral shaft fracture. They found the nerve within the fracture site, whereas magnetic resonance imaging (MRI) could not follow its course. Neither ultrasonography nor MRI would likely be used after acute injury. More research is needed to improve evaluation of patients with continued palsy after nonoperative treatment.

In the case of our patient’s humeral shaft fracture, surgery was performed early because of polytrauma and radial nerve entrapment. If left interposed between 2 fracture fragments, the nerve would have been subjected to continued ischemia and likely would not have recovered spontaneously. Ikeda and Osamura⁷ reported on a case of radial nerve palsy that occurred after humerus shaft fracture. The nerve, entrapped between fracture fragments, was explored later, after function failed to return. As it was found within callus, the nerve was cut and then repaired end-to-end. In our patient’s case, early exploration led to release of the radial nerve from the fracture site—preventing irreversible nerve damage and allowing for spontaneous recovery over subsequent months.

Surgery for polytrauma patients with a humeral shaft fracture and radial nerve palsy may also be beneficial with respect to early nerve exploration and early mobilization. Although our patient’s fracture was well aligned and as an isolated injury would not have required surgery, the polytrauma called for early surgical management, which revealed radial nerve entrapment and led to early recovery of nerve function.

A radial nerve injury in association with a humeral shaft fracture is not an infrequent occurrence.^1,2 The nerve injury typically is thought to be a neurapraxia caused by a contusion, as spontaneous recovery rates range from 70% to 90%.^2-4 In cases in which acute nerve exploration and open reduction and internal fixation (ORIF) are not indicated, patient and clinician wait months for the nerve to recover. In some conservatively treated cases, the nerve is lacerated or entrapped. Patients with a lacerated or entrapped nerve may have better outcomes with early operative management.

We report on a rare case of the radial nerve entrapped within a nondisplaced segment of a closed humeral shaft fracture and describe the clinical outcome of early operative management. The patient provided written informed consent for print and electronic publication of this case report.

Case Report

An intoxicated, restrained 18-year-old driver in a motor vehicle collision sustained multiple injuries, including rib fracture, apical pneumothorax with pulmonary contusion, and corneal abrasion. Orthopedic injuries included right subtrochanteric femur fracture and midshaft right humeral shaft fracture (Figure 1).

Initial orthopedic evaluation of the right arm revealed decreased sensation in the radial nerve distribution. Motor function in the radial nerve was absent; the patient was incapable of active wrist extension or finger extension. Median and ulnar nerves were motor- and sensory-intact. Radiographs showed a displaced transverse midshaft humeral shaft fracture with a minimally displaced vertical fracture line extending from the fracture site about 3 cm into the proximal segment. The patient was placed in a coaptation splint. The femur fracture was treated with an antegrade piriformis entry intramedullary nail.

ORIF of the humerus was performed to facilitate mobilization of this polytrauma patient. He was positioned prone on a flat-top table with his right arm over a radiolucent extension. The arm was abducted at the shoulder and the elbow flexed. A posterior midline skin incision was made to reflect the triceps in a lateral-to-medial direction, facilitating dissection of the lateral brachial cutaneous nerve on the lateral aspect of the triceps, with resultant localization of the radial nerve. At that time, the radial nerve was noted to be entrapped in the fracture site (Figure 2). In the proximal segment was a sagittal split, displaced about 1 mm, and it was in this interval the nerve was held. This sagittal fracture appeared incomplete as it was followed more proximally. A unicortical Kirschner wire was placed in a posterior-to-anterior direction in each fragment alongside the nerve. A lamina spreader engaged the wires and distracted the fracture site as the tines were spread apart, releasing the nerve (Figure 3). The nerve was in continuity but was severely contused at that location. After the sagittal split was reduced, two 2.7-mm lag screws were used in lag fashion, and the transverse midshaft component was fixed with a 10-hole, 4.5-mm narrow locking compression plate. The radial nerve lay on the posterior aspect of the plate, between holes 4 and 5 (Figures 4, 5). The wound was closed, and the patient was made weight-bearing as tolerated in the right upper extremity. He was sent to occupational therapy, and static and dynamic splints were made for his wrist and hand.

Two months after injury, radial nerve examination findings were unchanged: decreased sensation on dorsum of hand and no motor function. At 3 months, electrodiagnostic testing showed neurophysiologic evidence of severe right radial neuropathy proximal to the innervation of the right brachioradialis. There were electrodiagnostic signs of ongoing axonal loss and no signs of ongoing reinnervation. At 4 months, only motor strength in wrist extension was improved (2/5). At 5 months, the patient had 4–/5 wrist extension, 3/5 metacarpophalangeal (MCP) extension of fingers, and 0/5 MCP/interphalangeal extension of thumb. Sensation in the radial nerve distribution was still decreased. At 7 months, strength in wrist extension and finger MCP extension was 4+/5. The fracture was now well healed, with maintained alignment and no changes in hardware appearance.

Discussion

In most cases, closed treatment of a humeral shaft fracture with an associated radial nerve injury has a successful outcome.⁵ The etiology of the neurapraxia likely is nerve contusion after the fracture. A neurapraxia is by definition a temporary injury to the myelin sheath with an intact nerve; the nerve function recovers rapidly.

Some humeral shaft fractures, however, have been associated with radial nerve injuries more severe than contusions, resulting in axonotmesis or neurotmesis. These more severe injuries make up 10% to 30% of humeral shaft fractures, including those with a frank laceration of the nerve and those with an entrapped nerve.^2,3 Shao and colleagues² reported a 90% recovery rate for patients who delayed extrication of the entrapped radial nerve. Although there is no consensus on timing of surgical exploration, motor and sensory function of the nerve is temporally related, which may indicate that earlier diagnosis and treatment lead to improved outcome.^6,7 Loss of radial nerve function can have devastating effects on upper extremity function. Often, patients lose all or some extension of the wrist and fingers and abduction and extension of the thumb.

In a standard history or physical examination, there are no particular features indicating nerve entrapment. Absolute indications for humeral shaft fractures with radial palsy are limited to open fractures, vascular injuries, and unacceptable fracture alignment. Relative indications are polytrauma and secondary palsy after attempted fracture reduction. For all other humeral shaft fractures with radial nerve palsy, observation is still the mainstay of treatment, with spontaneous recovery occurring in up to 90% of patients.^2,8-12 Our patient did not have an absolute indication for operative treatment; surgery was nevertheless performed to address the polytrauma and to facilitate earlier mobilization.

Electromyelogram (EMG) studies typically are not useful after acute injury. EMG studies are better used serially to evaluate reinnervation after the acute phase. Bodner and colleagues^13,14 used ultrasonography to identify the radial nerve in a patient with unimproved radial nerve palsy 6 weeks after humeral shaft fracture. They found the nerve within the fracture site, whereas magnetic resonance imaging (MRI) could not follow its course. Neither ultrasonography nor MRI would likely be used after acute injury. More research is needed to improve evaluation of patients with continued palsy after nonoperative treatment.

In the case of our patient’s humeral shaft fracture, surgery was performed early because of polytrauma and radial nerve entrapment. If left interposed between 2 fracture fragments, the nerve would have been subjected to continued ischemia and likely would not have recovered spontaneously. Ikeda and Osamura⁷ reported on a case of radial nerve palsy that occurred after humerus shaft fracture. The nerve, entrapped between fracture fragments, was explored later, after function failed to return. As it was found within callus, the nerve was cut and then repaired end-to-end. In our patient’s case, early exploration led to release of the radial nerve from the fracture site—preventing irreversible nerve damage and allowing for spontaneous recovery over subsequent months.

Surgery for polytrauma patients with a humeral shaft fracture and radial nerve palsy may also be beneficial with respect to early nerve exploration and early mobilization. Although our patient’s fracture was well aligned and as an isolated injury would not have required surgery, the polytrauma called for early surgical management, which revealed radial nerve entrapment and led to early recovery of nerve function.

A radial nerve injury in association with a humeral shaft fracture is not an infrequent occurrence.^1,2 The nerve injury typically is thought to be a neurapraxia caused by a contusion, as spontaneous recovery rates range from 70% to 90%.^2-4 In cases in which acute nerve exploration and open reduction and internal fixation (ORIF) are not indicated, patient and clinician wait months for the nerve to recover. In some conservatively treated cases, the nerve is lacerated or entrapped. Patients with a lacerated or entrapped nerve may have better outcomes with early operative management.

We report on a rare case of the radial nerve entrapped within a nondisplaced segment of a closed humeral shaft fracture and describe the clinical outcome of early operative management. The patient provided written informed consent for print and electronic publication of this case report.

Case Report

An intoxicated, restrained 18-year-old driver in a motor vehicle collision sustained multiple injuries, including rib fracture, apical pneumothorax with pulmonary contusion, and corneal abrasion. Orthopedic injuries included right subtrochanteric femur fracture and midshaft right humeral shaft fracture (Figure 1).

Initial orthopedic evaluation of the right arm revealed decreased sensation in the radial nerve distribution. Motor function in the radial nerve was absent; the patient was incapable of active wrist extension or finger extension. Median and ulnar nerves were motor- and sensory-intact. Radiographs showed a displaced transverse midshaft humeral shaft fracture with a minimally displaced vertical fracture line extending from the fracture site about 3 cm into the proximal segment. The patient was placed in a coaptation splint. The femur fracture was treated with an antegrade piriformis entry intramedullary nail.

ORIF of the humerus was performed to facilitate mobilization of this polytrauma patient. He was positioned prone on a flat-top table with his right arm over a radiolucent extension. The arm was abducted at the shoulder and the elbow flexed. A posterior midline skin incision was made to reflect the triceps in a lateral-to-medial direction, facilitating dissection of the lateral brachial cutaneous nerve on the lateral aspect of the triceps, with resultant localization of the radial nerve. At that time, the radial nerve was noted to be entrapped in the fracture site (Figure 2). In the proximal segment was a sagittal split, displaced about 1 mm, and it was in this interval the nerve was held. This sagittal fracture appeared incomplete as it was followed more proximally. A unicortical Kirschner wire was placed in a posterior-to-anterior direction in each fragment alongside the nerve. A lamina spreader engaged the wires and distracted the fracture site as the tines were spread apart, releasing the nerve (Figure 3). The nerve was in continuity but was severely contused at that location. After the sagittal split was reduced, two 2.7-mm lag screws were used in lag fashion, and the transverse midshaft component was fixed with a 10-hole, 4.5-mm narrow locking compression plate. The radial nerve lay on the posterior aspect of the plate, between holes 4 and 5 (Figures 4, 5). The wound was closed, and the patient was made weight-bearing as tolerated in the right upper extremity. He was sent to occupational therapy, and static and dynamic splints were made for his wrist and hand.

Two months after injury, radial nerve examination findings were unchanged: decreased sensation on dorsum of hand and no motor function. At 3 months, electrodiagnostic testing showed neurophysiologic evidence of severe right radial neuropathy proximal to the innervation of the right brachioradialis. There were electrodiagnostic signs of ongoing axonal loss and no signs of ongoing reinnervation. At 4 months, only motor strength in wrist extension was improved (2/5). At 5 months, the patient had 4–/5 wrist extension, 3/5 metacarpophalangeal (MCP) extension of fingers, and 0/5 MCP/interphalangeal extension of thumb. Sensation in the radial nerve distribution was still decreased. At 7 months, strength in wrist extension and finger MCP extension was 4+/5. The fracture was now well healed, with maintained alignment and no changes in hardware appearance.

Discussion

In most cases, closed treatment of a humeral shaft fracture with an associated radial nerve injury has a successful outcome.⁵ The etiology of the neurapraxia likely is nerve contusion after the fracture. A neurapraxia is by definition a temporary injury to the myelin sheath with an intact nerve; the nerve function recovers rapidly.

Some humeral shaft fractures, however, have been associated with radial nerve injuries more severe than contusions, resulting in axonotmesis or neurotmesis. These more severe injuries make up 10% to 30% of humeral shaft fractures, including those with a frank laceration of the nerve and those with an entrapped nerve.^2,3 Shao and colleagues² reported a 90% recovery rate for patients who delayed extrication of the entrapped radial nerve. Although there is no consensus on timing of surgical exploration, motor and sensory function of the nerve is temporally related, which may indicate that earlier diagnosis and treatment lead to improved outcome.^6,7 Loss of radial nerve function can have devastating effects on upper extremity function. Often, patients lose all or some extension of the wrist and fingers and abduction and extension of the thumb.

In a standard history or physical examination, there are no particular features indicating nerve entrapment. Absolute indications for humeral shaft fractures with radial palsy are limited to open fractures, vascular injuries, and unacceptable fracture alignment. Relative indications are polytrauma and secondary palsy after attempted fracture reduction. For all other humeral shaft fractures with radial nerve palsy, observation is still the mainstay of treatment, with spontaneous recovery occurring in up to 90% of patients.^2,8-12 Our patient did not have an absolute indication for operative treatment; surgery was nevertheless performed to address the polytrauma and to facilitate earlier mobilization.

Electromyelogram (EMG) studies typically are not useful after acute injury. EMG studies are better used serially to evaluate reinnervation after the acute phase. Bodner and colleagues^13,14 used ultrasonography to identify the radial nerve in a patient with unimproved radial nerve palsy 6 weeks after humeral shaft fracture. They found the nerve within the fracture site, whereas magnetic resonance imaging (MRI) could not follow its course. Neither ultrasonography nor MRI would likely be used after acute injury. More research is needed to improve evaluation of patients with continued palsy after nonoperative treatment.

In the case of our patient’s humeral shaft fracture, surgery was performed early because of polytrauma and radial nerve entrapment. If left interposed between 2 fracture fragments, the nerve would have been subjected to continued ischemia and likely would not have recovered spontaneously. Ikeda and Osamura⁷ reported on a case of radial nerve palsy that occurred after humerus shaft fracture. The nerve, entrapped between fracture fragments, was explored later, after function failed to return. As it was found within callus, the nerve was cut and then repaired end-to-end. In our patient’s case, early exploration led to release of the radial nerve from the fracture site—preventing irreversible nerve damage and allowing for spontaneous recovery over subsequent months.

Surgery for polytrauma patients with a humeral shaft fracture and radial nerve palsy may also be beneficial with respect to early nerve exploration and early mobilization. Although our patient’s fracture was well aligned and as an isolated injury would not have required surgery, the polytrauma called for early surgical management, which revealed radial nerve entrapment and led to early recovery of nerve function.

[WpProQuiz 9]

[WpProQuiz_toplist 9]

[WpProQuiz 9]

[WpProQuiz_toplist 9]

[WpProQuiz 9]

[WpProQuiz_toplist 9]

CHICAGO – Brentuximab vedotin appears to be safe and effective in eradicating residual disease after induction chemotherapy and may replace radiation for consolidation in patients with limited stage non-bulky Hodgkin lymphoma, Dr. Steven I. Park reported at the annual meeting of the American Society of Clinical Oncology.

After two cycles of ABVD [doxorubicin (Adriamycin), bleomycin, vinblastine, and dacarbazine], 72% of 40 evaluable patients achieved PET-negative disease. After completing brentuximab vedotin therapy, 90% of patients had PET-negative disease. With a median follow-up of 12 months, the estimated 1-year progression-free survival rate is 91%, and the overall survival rate is 96%.

The current standard therapy for limited stage Hodgkin lymphoma is about 4-6 cycles of chemotherapy with or without consolidative radiation therapy. The goal of the study was to reduce the number of cycles of chemotherapy and avoid radiation therapy, which has an unclear overall survival advantage and risks long-term side effects, noted Dr. Park of the University of North Carolina at Chapel Hill, Lineberger Comprehensive Cancer Center.

In this phase II multicenter study, 41 patients with previously untreated limited stage non-bulky Hodgkin lymphoma received ABVD followed by brentuximab vedotin (NCT01578967). Study patients’ median age was 29 years (range 19-67), and 46% presented with unfavorable disease. Over 90% of patients received four or fewer cycles of ABVD, and one patient received radiation due to disease progression.

Grade 3 or higher toxicities associated with brentuximab vedotin included neutropenia in three patients and peripheral neuropathy and rash in one patient each. One patient developed pancreatitis and died due to sepsis and hepatic failure, a rare complication of brentuximab vedotin that cautions regarding its use in patients with hepatic function limitations, Dr. Park said.

According to Seattle Genetics, the maker of brentuximab vedotin, the drug is an anti-CD30 monoclonal antibody attached by a protease-cleavable linker to the cytotoxic agent monomethyl auristatin E, which leads to target cell death when internalized into CD30-expressing tumor cells.

Dr. Park disclosed research funding from Seattle Genetics, the maker of brentuximab vedotin, as well as Teva.

[email protected]

On Twitter @maryjodales

CHICAGO – Brentuximab vedotin appears to be safe and effective in eradicating residual disease after induction chemotherapy and may replace radiation for consolidation in patients with limited stage non-bulky Hodgkin lymphoma, Dr. Steven I. Park reported at the annual meeting of the American Society of Clinical Oncology.

After two cycles of ABVD [doxorubicin (Adriamycin), bleomycin, vinblastine, and dacarbazine], 72% of 40 evaluable patients achieved PET-negative disease. After completing brentuximab vedotin therapy, 90% of patients had PET-negative disease. With a median follow-up of 12 months, the estimated 1-year progression-free survival rate is 91%, and the overall survival rate is 96%.

The current standard therapy for limited stage Hodgkin lymphoma is about 4-6 cycles of chemotherapy with or without consolidative radiation therapy. The goal of the study was to reduce the number of cycles of chemotherapy and avoid radiation therapy, which has an unclear overall survival advantage and risks long-term side effects, noted Dr. Park of the University of North Carolina at Chapel Hill, Lineberger Comprehensive Cancer Center.

In this phase II multicenter study, 41 patients with previously untreated limited stage non-bulky Hodgkin lymphoma received ABVD followed by brentuximab vedotin (NCT01578967). Study patients’ median age was 29 years (range 19-67), and 46% presented with unfavorable disease. Over 90% of patients received four or fewer cycles of ABVD, and one patient received radiation due to disease progression.

Grade 3 or higher toxicities associated with brentuximab vedotin included neutropenia in three patients and peripheral neuropathy and rash in one patient each. One patient developed pancreatitis and died due to sepsis and hepatic failure, a rare complication of brentuximab vedotin that cautions regarding its use in patients with hepatic function limitations, Dr. Park said.

According to Seattle Genetics, the maker of brentuximab vedotin, the drug is an anti-CD30 monoclonal antibody attached by a protease-cleavable linker to the cytotoxic agent monomethyl auristatin E, which leads to target cell death when internalized into CD30-expressing tumor cells.

Dr. Park disclosed research funding from Seattle Genetics, the maker of brentuximab vedotin, as well as Teva.

[email protected]

On Twitter @maryjodales

CHICAGO – Brentuximab vedotin appears to be safe and effective in eradicating residual disease after induction chemotherapy and may replace radiation for consolidation in patients with limited stage non-bulky Hodgkin lymphoma, Dr. Steven I. Park reported at the annual meeting of the American Society of Clinical Oncology.

After two cycles of ABVD [doxorubicin (Adriamycin), bleomycin, vinblastine, and dacarbazine], 72% of 40 evaluable patients achieved PET-negative disease. After completing brentuximab vedotin therapy, 90% of patients had PET-negative disease. With a median follow-up of 12 months, the estimated 1-year progression-free survival rate is 91%, and the overall survival rate is 96%.

The current standard therapy for limited stage Hodgkin lymphoma is about 4-6 cycles of chemotherapy with or without consolidative radiation therapy. The goal of the study was to reduce the number of cycles of chemotherapy and avoid radiation therapy, which has an unclear overall survival advantage and risks long-term side effects, noted Dr. Park of the University of North Carolina at Chapel Hill, Lineberger Comprehensive Cancer Center.

In this phase II multicenter study, 41 patients with previously untreated limited stage non-bulky Hodgkin lymphoma received ABVD followed by brentuximab vedotin (NCT01578967). Study patients’ median age was 29 years (range 19-67), and 46% presented with unfavorable disease. Over 90% of patients received four or fewer cycles of ABVD, and one patient received radiation due to disease progression.

Grade 3 or higher toxicities associated with brentuximab vedotin included neutropenia in three patients and peripheral neuropathy and rash in one patient each. One patient developed pancreatitis and died due to sepsis and hepatic failure, a rare complication of brentuximab vedotin that cautions regarding its use in patients with hepatic function limitations, Dr. Park said.

According to Seattle Genetics, the maker of brentuximab vedotin, the drug is an anti-CD30 monoclonal antibody attached by a protease-cleavable linker to the cytotoxic agent monomethyl auristatin E, which leads to target cell death when internalized into CD30-expressing tumor cells.

Dr. Park disclosed research funding from Seattle Genetics, the maker of brentuximab vedotin, as well as Teva.

[email protected]

On Twitter @maryjodales

CHICAGO – The investigational drug CPX-351 (Vyxeos) may become the new standard of care for older patients with secondary acute myeloid leukemia (AML), based on data presented at the annual meeting of the American Society of Clinical Oncology.

CPX-351 significantly improved overall survival, event-free survival, and treatment response without an increase in 60-day mortality or in the frequency and severity of adverse events as compared to the standard 7+3 regimen of cytarabine and daunorubicin.

In a video interview, primary investigator Dr. Jeffrey Lancet of H. Lee Moffitt Cancer Center & Research Institute, Tampa, Fla., discusses the data to be presented to the Food and Drug Administration for approval of the drug, and why the liposomal formulation of cytarabine and daunorubicin achieved superior results in these difficult to treat patients.

[email protected]

On Twitter @maryjodales

CHICAGO – The investigational drug CPX-351 (Vyxeos) may become the new standard of care for older patients with secondary acute myeloid leukemia (AML), based on data presented at the annual meeting of the American Society of Clinical Oncology.

CPX-351 significantly improved overall survival, event-free survival, and treatment response without an increase in 60-day mortality or in the frequency and severity of adverse events as compared to the standard 7+3 regimen of cytarabine and daunorubicin.

In a video interview, primary investigator Dr. Jeffrey Lancet of H. Lee Moffitt Cancer Center & Research Institute, Tampa, Fla., discusses the data to be presented to the Food and Drug Administration for approval of the drug, and why the liposomal formulation of cytarabine and daunorubicin achieved superior results in these difficult to treat patients.

[email protected]

On Twitter @maryjodales

CHICAGO – The investigational drug CPX-351 (Vyxeos) may become the new standard of care for older patients with secondary acute myeloid leukemia (AML), based on data presented at the annual meeting of the American Society of Clinical Oncology.

CPX-351 significantly improved overall survival, event-free survival, and treatment response without an increase in 60-day mortality or in the frequency and severity of adverse events as compared to the standard 7+3 regimen of cytarabine and daunorubicin.

In a video interview, primary investigator Dr. Jeffrey Lancet of H. Lee Moffitt Cancer Center & Research Institute, Tampa, Fla., discusses the data to be presented to the Food and Drug Administration for approval of the drug, and why the liposomal formulation of cytarabine and daunorubicin achieved superior results in these difficult to treat patients.

[email protected]

On Twitter @maryjodales

To improve patient care and outcomes, leading dermatologists offered their recommendations on body scrubs. Consideration must be given to:

• Almond Shower Scrub

• Gently Exfoliating Body Scrub

• Peppermint Body Scrub

• Shea Butter Ultra Rich Body Scrub

• Ultimate Man Body Scrub Soap

Cutis invites readers to send us their recommendations. Body scrubs, OTC acne treatments, and cleansing devices will be featured in upcoming editions of Cosmetic Corner. Please e-mail your recommendation(s) to the Editorial Office.

Disclaimer: Opinions expressed herein do not necessarily reflect those of Cutis or Frontline Medical Communications Inc. and shall not be used for product endorsement purposes. Any reference made to a specific commercial product does not indicate or imply that Cutis or Frontline Medical Communications Inc. endorses, recommends, or favors the product mentioned. No guarantee is given to the effects of recommended products.

To improve patient care and outcomes, leading dermatologists offered their recommendations on body scrubs. Consideration must be given to:

• Almond Shower Scrub

• Gently Exfoliating Body Scrub

• Peppermint Body Scrub

• Shea Butter Ultra Rich Body Scrub

• Ultimate Man Body Scrub Soap

Cutis invites readers to send us their recommendations. Body scrubs, OTC acne treatments, and cleansing devices will be featured in upcoming editions of Cosmetic Corner. Please e-mail your recommendation(s) to the Editorial Office.

Disclaimer: Opinions expressed herein do not necessarily reflect those of Cutis or Frontline Medical Communications Inc. and shall not be used for product endorsement purposes. Any reference made to a specific commercial product does not indicate or imply that Cutis or Frontline Medical Communications Inc. endorses, recommends, or favors the product mentioned. No guarantee is given to the effects of recommended products.

To improve patient care and outcomes, leading dermatologists offered their recommendations on body scrubs. Consideration must be given to:

• Almond Shower Scrub

• Gently Exfoliating Body Scrub

• Peppermint Body Scrub

• Shea Butter Ultra Rich Body Scrub

• Ultimate Man Body Scrub Soap

Cutis invites readers to send us their recommendations. Body scrubs, OTC acne treatments, and cleansing devices will be featured in upcoming editions of Cosmetic Corner. Please e-mail your recommendation(s) to the Editorial Office.

Disclaimer: Opinions expressed herein do not necessarily reflect those of Cutis or Frontline Medical Communications Inc. and shall not be used for product endorsement purposes. Any reference made to a specific commercial product does not indicate or imply that Cutis or Frontline Medical Communications Inc. endorses, recommends, or favors the product mentioned. No guarantee is given to the effects of recommended products.

Two tools – the Vascular Annual Meeting Mobile App and the Meeting Itinerary Planner – will make VAM 2016 a user-friendly experience.

The App

The SVS Vascular Annual Meeting Mobile App puts the entire meeting at attendees’ fingertips. It includes:

• All meeting content, including abstracts, speakers, sessions and more

• A searchable format, letting people locate sessions, abstracts, room locations and more

• Interactivity: People may network with colleagues, share photos and rate programs, take notes and use the activity feed available for each session.

 New this year is a link that lets participants access the CME and MOC sites, to take credit exams after a session ends. It also includes links to claim credits.

Download the app here.

The Itinerary Planner

The Itinerary Planner is a web-based tool that includes all VAM details, such as full and daily schedules; links to authors, abstracts and speaker bios; special events; programming for fellows/residents/students; registration information, Vascular Live details and all other VAM info.

The detailed Users will be able to build personal schedules with their own “must-attend” events and sessions by bookmarking items of interest, plus:

• View session, faculty and exhibitor information in real time.

• Search for presentations by day, type, individual or keyword.

• Add in personal meetings or events.

• Export and email their calendar to share with others.

• Access the site via mobile and traditional platforms.

Please note that schedules and agendas created on the Itinerary Planner do NOT sync with the schedule in the Mobile App.

Access the planner here.

Two tools – the Vascular Annual Meeting Mobile App and the Meeting Itinerary Planner – will make VAM 2016 a user-friendly experience.

The App

The SVS Vascular Annual Meeting Mobile App puts the entire meeting at attendees’ fingertips. It includes:

• All meeting content, including abstracts, speakers, sessions and more

• A searchable format, letting people locate sessions, abstracts, room locations and more

• Interactivity: People may network with colleagues, share photos and rate programs, take notes and use the activity feed available for each session.

 New this year is a link that lets participants access the CME and MOC sites, to take credit exams after a session ends. It also includes links to claim credits.

Download the app here.

The Itinerary Planner

The Itinerary Planner is a web-based tool that includes all VAM details, such as full and daily schedules; links to authors, abstracts and speaker bios; special events; programming for fellows/residents/students; registration information, Vascular Live details and all other VAM info.

The detailed Users will be able to build personal schedules with their own “must-attend” events and sessions by bookmarking items of interest, plus:

• View session, faculty and exhibitor information in real time.

• Search for presentations by day, type, individual or keyword.

• Add in personal meetings or events.

• Export and email their calendar to share with others.

• Access the site via mobile and traditional platforms.

Please note that schedules and agendas created on the Itinerary Planner do NOT sync with the schedule in the Mobile App.

Access the planner here.

Two tools – the Vascular Annual Meeting Mobile App and the Meeting Itinerary Planner – will make VAM 2016 a user-friendly experience.

The App

The SVS Vascular Annual Meeting Mobile App puts the entire meeting at attendees’ fingertips. It includes:

• All meeting content, including abstracts, speakers, sessions and more

• A searchable format, letting people locate sessions, abstracts, room locations and more

• Interactivity: People may network with colleagues, share photos and rate programs, take notes and use the activity feed available for each session.

 New this year is a link that lets participants access the CME and MOC sites, to take credit exams after a session ends. It also includes links to claim credits.

Download the app here.

The Itinerary Planner

The Itinerary Planner is a web-based tool that includes all VAM details, such as full and daily schedules; links to authors, abstracts and speaker bios; special events; programming for fellows/residents/students; registration information, Vascular Live details and all other VAM info.

The detailed Users will be able to build personal schedules with their own “must-attend” events and sessions by bookmarking items of interest, plus:

• View session, faculty and exhibitor information in real time.

• Search for presentations by day, type, individual or keyword.

• Add in personal meetings or events.

• Export and email their calendar to share with others.

• Access the site via mobile and traditional platforms.

Please note that schedules and agendas created on the Itinerary Planner do NOT sync with the schedule in the Mobile App.

Access the planner here.

Exhibits, speakers, plenaries, hands-on sessions. Networking, dinner with friends, alumni receptions, the Capitol Steps comedy act. All this and much more is on tap during the 2016 Vascular Annual Meeting slated for June 8-11, just outside Washington, D.C. Plenaries and exhibits begin June 9. Registration is open throughout the conference.

Vascular surgeons, specialists, medical professionals in related fields, device manufacturers and others will meet at the Gaylord National Resort & Convention Center in National Harbor, Maryland, just minutes away from Washington, D.C.

Thanks to popular demand, each year the annual meeting -- often called VAM -- expands a little more on Wednesday and Saturday to accommodate more events and opportunities. This year Wednesday and Saturday are filled with events and sessions that attendees won’t want to miss. Workshops ($100 fee), international events and a full day of Vascular Quality Initiative sessions will be on Wednesday. Thursday and Friday feature more plenaries, talks by vascular luminaries, receptions, breakfast and evening events. On Saturday the annual SVS business meeting, the exhibit hall and credit-worthy plenaries will be good reasons to stay through the end.

A highlight this year will be a Friday June 10 evening performance by the Capitol Steps, a comedy troupe based in D.C. known for their cutting edge, political humor. It will be open to all attendees, exhibitors and their guests.

2016 VAM offers a variety of postgraduate courses on Wednesday designed for surgeons, physicians in related specialties, trainees, interventional radiologists, physician assistants and vascular nurses, researchers, allied health professionals and medical students. Postgraduate courses are complimentary for SVS members but separate registration is required.

This year’s events offer a maximum of 30.25 AMA PRA Category 1 Credits™ with 13.25 AMA PRA Category 1 Credits™ counted toward MOC part 2. Each of the seven plenary sessions has individual self-assessments. This year, claiming your credits is easier than ever. A self-assessment exam is available on the meeting app and can be completed immediately following each session.

Registration is open through the end of the event, and may be completed online at www.vsweb.org/RegisterVAM16. There are 10 different registration fees that vary by category. For example, active members pay $650; medical students, $300; non-members $845. In addition, there are still some seats left in the hands-on workshops offered on Wednesday, June 8. Topics include Carotid Stenting, IVC Filters: Techniques in Deployment and Recovery and much more. See all topics.

The conference location, Gaylord National Resort & Convention Center, offers sweeping views of the Potomac River, Washington, D.C. and Old Town Alexandria. As the cornerstone of the new National Harbor project in Prince George’s County, Maryland, the resort includes an 18-story glass atrium overlooking the Potomac, three restaurants, including fine dining and casual, a rooftop lounge, express coffee outlet, unique shops, an indoor pool and a 20,000 square-foot spa and fitness center. The 300-acre site also features tree-lined promenades with shops and restaurants, two marinas, a Ferris wheel and much more. For a complete directory as well as an interactive map, please visit the Gaylord National Resort & Conference Center website.

The weather in Washington D.C. in early June averages a high of 83 and low of 65, Fahrenheit. Attire is business casual during the day and resort casual for hospitality events.

Click here for more 2016 VAM Information.

Exhibits, speakers, plenaries, hands-on sessions. Networking, dinner with friends, alumni receptions, the Capitol Steps comedy act. All this and much more is on tap during the 2016 Vascular Annual Meeting slated for June 8-11, just outside Washington, D.C. Plenaries and exhibits begin June 9. Registration is open throughout the conference.

Vascular surgeons, specialists, medical professionals in related fields, device manufacturers and others will meet at the Gaylord National Resort & Convention Center in National Harbor, Maryland, just minutes away from Washington, D.C.

Thanks to popular demand, each year the annual meeting -- often called VAM -- expands a little more on Wednesday and Saturday to accommodate more events and opportunities. This year Wednesday and Saturday are filled with events and sessions that attendees won’t want to miss. Workshops ($100 fee), international events and a full day of Vascular Quality Initiative sessions will be on Wednesday. Thursday and Friday feature more plenaries, talks by vascular luminaries, receptions, breakfast and evening events. On Saturday the annual SVS business meeting, the exhibit hall and credit-worthy plenaries will be good reasons to stay through the end.

A highlight this year will be a Friday June 10 evening performance by the Capitol Steps, a comedy troupe based in D.C. known for their cutting edge, political humor. It will be open to all attendees, exhibitors and their guests.

2016 VAM offers a variety of postgraduate courses on Wednesday designed for surgeons, physicians in related specialties, trainees, interventional radiologists, physician assistants and vascular nurses, researchers, allied health professionals and medical students. Postgraduate courses are complimentary for SVS members but separate registration is required.

This year’s events offer a maximum of 30.25 AMA PRA Category 1 Credits™ with 13.25 AMA PRA Category 1 Credits™ counted toward MOC part 2. Each of the seven plenary sessions has individual self-assessments. This year, claiming your credits is easier than ever. A self-assessment exam is available on the meeting app and can be completed immediately following each session.

Registration is open through the end of the event, and may be completed online at www.vsweb.org/RegisterVAM16. There are 10 different registration fees that vary by category. For example, active members pay $650; medical students, $300; non-members $845. In addition, there are still some seats left in the hands-on workshops offered on Wednesday, June 8. Topics include Carotid Stenting, IVC Filters: Techniques in Deployment and Recovery and much more. See all topics.

The conference location, Gaylord National Resort & Convention Center, offers sweeping views of the Potomac River, Washington, D.C. and Old Town Alexandria. As the cornerstone of the new National Harbor project in Prince George’s County, Maryland, the resort includes an 18-story glass atrium overlooking the Potomac, three restaurants, including fine dining and casual, a rooftop lounge, express coffee outlet, unique shops, an indoor pool and a 20,000 square-foot spa and fitness center. The 300-acre site also features tree-lined promenades with shops and restaurants, two marinas, a Ferris wheel and much more. For a complete directory as well as an interactive map, please visit the Gaylord National Resort & Conference Center website.

The weather in Washington D.C. in early June averages a high of 83 and low of 65, Fahrenheit. Attire is business casual during the day and resort casual for hospitality events.

Click here for more 2016 VAM Information.

Exhibits, speakers, plenaries, hands-on sessions. Networking, dinner with friends, alumni receptions, the Capitol Steps comedy act. All this and much more is on tap during the 2016 Vascular Annual Meeting slated for June 8-11, just outside Washington, D.C. Plenaries and exhibits begin June 9. Registration is open throughout the conference.

Vascular surgeons, specialists, medical professionals in related fields, device manufacturers and others will meet at the Gaylord National Resort & Convention Center in National Harbor, Maryland, just minutes away from Washington, D.C.

Thanks to popular demand, each year the annual meeting -- often called VAM -- expands a little more on Wednesday and Saturday to accommodate more events and opportunities. This year Wednesday and Saturday are filled with events and sessions that attendees won’t want to miss. Workshops ($100 fee), international events and a full day of Vascular Quality Initiative sessions will be on Wednesday. Thursday and Friday feature more plenaries, talks by vascular luminaries, receptions, breakfast and evening events. On Saturday the annual SVS business meeting, the exhibit hall and credit-worthy plenaries will be good reasons to stay through the end.

A highlight this year will be a Friday June 10 evening performance by the Capitol Steps, a comedy troupe based in D.C. known for their cutting edge, political humor. It will be open to all attendees, exhibitors and their guests.

2016 VAM offers a variety of postgraduate courses on Wednesday designed for surgeons, physicians in related specialties, trainees, interventional radiologists, physician assistants and vascular nurses, researchers, allied health professionals and medical students. Postgraduate courses are complimentary for SVS members but separate registration is required.

This year’s events offer a maximum of 30.25 AMA PRA Category 1 Credits™ with 13.25 AMA PRA Category 1 Credits™ counted toward MOC part 2. Each of the seven plenary sessions has individual self-assessments. This year, claiming your credits is easier than ever. A self-assessment exam is available on the meeting app and can be completed immediately following each session.

Registration is open through the end of the event, and may be completed online at www.vsweb.org/RegisterVAM16. There are 10 different registration fees that vary by category. For example, active members pay $650; medical students, $300; non-members $845. In addition, there are still some seats left in the hands-on workshops offered on Wednesday, June 8. Topics include Carotid Stenting, IVC Filters: Techniques in Deployment and Recovery and much more. See all topics.

The conference location, Gaylord National Resort & Convention Center, offers sweeping views of the Potomac River, Washington, D.C. and Old Town Alexandria. As the cornerstone of the new National Harbor project in Prince George’s County, Maryland, the resort includes an 18-story glass atrium overlooking the Potomac, three restaurants, including fine dining and casual, a rooftop lounge, express coffee outlet, unique shops, an indoor pool and a 20,000 square-foot spa and fitness center. The 300-acre site also features tree-lined promenades with shops and restaurants, two marinas, a Ferris wheel and much more. For a complete directory as well as an interactive map, please visit the Gaylord National Resort & Conference Center website.

The weather in Washington D.C. in early June averages a high of 83 and low of 65, Fahrenheit. Attire is business casual during the day and resort casual for hospitality events.

Click here for more 2016 VAM Information.

LOS ANGELES – The inpatient use of infliximab for severe ulcerative colitis does not avoid the need for colectomy in patients who fail steroid therapy, results from a single-center study demonstrated.

In an interview at the annual meeting of the American Society of Colon and Rectal Surgeons, lead study author Dr. Rachel E. Andrew, a third-year resident in the department of surgery at Penn State Hershey Medical Center in Hershey, Pa., said that despite recent interest in providing inpatient infliximab as an alternative to surgery for those with steroid-refractory disease, 82% of those who received salvage infliximab went on to undergo a total abdominal colectomy during the same admission.

“Our findings suggest that inpatient infliximab was not effective at improving the severity of colitis in these patients,” she said. “Further, infliximab was unreliable in avoiding the need for a total colectomy in this population of ulcerative colitis patients. One difference between our study and those previously published on this subject is that our study focuses on patients with a severity of colitis that resulted in their admission to a surgery service. In terms of evaluating the benefit of infliximab and providing a reliable avoidance of colectomy, we feel that this population of ulcerative colitis patients would be most appropriate to evaluate this issue. This possible difference in patient population may explain the difference in our study findings and those previously published.”

The researchers compared colectomy rates in 173 patients with severe ulcerative colitis who were admitted to the colorectal surgery service at Penn State Hershey Medical Center. Their mean age was 41 years, with 155 (90%) treated with high-dose steroids alone, and with 18 (10%) having received inpatient infliximab as salvage therapy due to a lack of response to steroids alone. Of the patients who received high-dose steroids alone, 81 (52%) required total colectomy, compared with 14 (82%) who received infliximab salvage therapy (P = .046).

The researchers observed no statistically significant differences between the two groups regarding rates of hospital readmission, superficial, deep and organ space surgical-site infections, unplanned return to the operating room, and all complication rates (P greater than .05). Among patients who required total colectomy, hospital costs were 27% higher among those who received infliximab compared with those who received high-dose steroids alone (a mean of $19,880 vs. $14,492, respectively), but because of the small sample size of the infliximab cohort this difference did not reach statistical significance.

“In our institution, salvage infliximab has not been shown to be effective,” Dr. Andrew said. “One key difference between our findings and other studies is that our study population had a high colectomy rate; 82% is much higher than the approximately 30% colectomy rate described in many reports from colleagues in gastroenterology. While there are several potential explanations for our higher rate of colectomy, including the potential concerns that surgeons might be inclined to opt for surgery more readily than non-surgical providers, it is likely that the patients in our study had more severe forms of colitis. It might be the case that there are certain severities of colitis that are beyond the ability of infliximab to salvage, which would be an important issue in selecting which patients to provide inpatient infliximab, so as to not unnecessarily delay surgery, increase hospital costs and to avoid escalating the degree of immunosuppression without a reasonable likelihood of clinical improvement.”

Dr. Andrew reported having no financial disclosures.

[email protected]

LOS ANGELES – The inpatient use of infliximab for severe ulcerative colitis does not avoid the need for colectomy in patients who fail steroid therapy, results from a single-center study demonstrated.

In an interview at the annual meeting of the American Society of Colon and Rectal Surgeons, lead study author Dr. Rachel E. Andrew, a third-year resident in the department of surgery at Penn State Hershey Medical Center in Hershey, Pa., said that despite recent interest in providing inpatient infliximab as an alternative to surgery for those with steroid-refractory disease, 82% of those who received salvage infliximab went on to undergo a total abdominal colectomy during the same admission.

“Our findings suggest that inpatient infliximab was not effective at improving the severity of colitis in these patients,” she said. “Further, infliximab was unreliable in avoiding the need for a total colectomy in this population of ulcerative colitis patients. One difference between our study and those previously published on this subject is that our study focuses on patients with a severity of colitis that resulted in their admission to a surgery service. In terms of evaluating the benefit of infliximab and providing a reliable avoidance of colectomy, we feel that this population of ulcerative colitis patients would be most appropriate to evaluate this issue. This possible difference in patient population may explain the difference in our study findings and those previously published.”

The researchers compared colectomy rates in 173 patients with severe ulcerative colitis who were admitted to the colorectal surgery service at Penn State Hershey Medical Center. Their mean age was 41 years, with 155 (90%) treated with high-dose steroids alone, and with 18 (10%) having received inpatient infliximab as salvage therapy due to a lack of response to steroids alone. Of the patients who received high-dose steroids alone, 81 (52%) required total colectomy, compared with 14 (82%) who received infliximab salvage therapy (P = .046).

The researchers observed no statistically significant differences between the two groups regarding rates of hospital readmission, superficial, deep and organ space surgical-site infections, unplanned return to the operating room, and all complication rates (P greater than .05). Among patients who required total colectomy, hospital costs were 27% higher among those who received infliximab compared with those who received high-dose steroids alone (a mean of $19,880 vs. $14,492, respectively), but because of the small sample size of the infliximab cohort this difference did not reach statistical significance.

“In our institution, salvage infliximab has not been shown to be effective,” Dr. Andrew said. “One key difference between our findings and other studies is that our study population had a high colectomy rate; 82% is much higher than the approximately 30% colectomy rate described in many reports from colleagues in gastroenterology. While there are several potential explanations for our higher rate of colectomy, including the potential concerns that surgeons might be inclined to opt for surgery more readily than non-surgical providers, it is likely that the patients in our study had more severe forms of colitis. It might be the case that there are certain severities of colitis that are beyond the ability of infliximab to salvage, which would be an important issue in selecting which patients to provide inpatient infliximab, so as to not unnecessarily delay surgery, increase hospital costs and to avoid escalating the degree of immunosuppression without a reasonable likelihood of clinical improvement.”

Dr. Andrew reported having no financial disclosures.

[email protected]

LOS ANGELES – The inpatient use of infliximab for severe ulcerative colitis does not avoid the need for colectomy in patients who fail steroid therapy, results from a single-center study demonstrated.

In an interview at the annual meeting of the American Society of Colon and Rectal Surgeons, lead study author Dr. Rachel E. Andrew, a third-year resident in the department of surgery at Penn State Hershey Medical Center in Hershey, Pa., said that despite recent interest in providing inpatient infliximab as an alternative to surgery for those with steroid-refractory disease, 82% of those who received salvage infliximab went on to undergo a total abdominal colectomy during the same admission.

“Our findings suggest that inpatient infliximab was not effective at improving the severity of colitis in these patients,” she said. “Further, infliximab was unreliable in avoiding the need for a total colectomy in this population of ulcerative colitis patients. One difference between our study and those previously published on this subject is that our study focuses on patients with a severity of colitis that resulted in their admission to a surgery service. In terms of evaluating the benefit of infliximab and providing a reliable avoidance of colectomy, we feel that this population of ulcerative colitis patients would be most appropriate to evaluate this issue. This possible difference in patient population may explain the difference in our study findings and those previously published.”

The researchers compared colectomy rates in 173 patients with severe ulcerative colitis who were admitted to the colorectal surgery service at Penn State Hershey Medical Center. Their mean age was 41 years, with 155 (90%) treated with high-dose steroids alone, and with 18 (10%) having received inpatient infliximab as salvage therapy due to a lack of response to steroids alone. Of the patients who received high-dose steroids alone, 81 (52%) required total colectomy, compared with 14 (82%) who received infliximab salvage therapy (P = .046).

The researchers observed no statistically significant differences between the two groups regarding rates of hospital readmission, superficial, deep and organ space surgical-site infections, unplanned return to the operating room, and all complication rates (P greater than .05). Among patients who required total colectomy, hospital costs were 27% higher among those who received infliximab compared with those who received high-dose steroids alone (a mean of $19,880 vs. $14,492, respectively), but because of the small sample size of the infliximab cohort this difference did not reach statistical significance.

“In our institution, salvage infliximab has not been shown to be effective,” Dr. Andrew said. “One key difference between our findings and other studies is that our study population had a high colectomy rate; 82% is much higher than the approximately 30% colectomy rate described in many reports from colleagues in gastroenterology. While there are several potential explanations for our higher rate of colectomy, including the potential concerns that surgeons might be inclined to opt for surgery more readily than non-surgical providers, it is likely that the patients in our study had more severe forms of colitis. It might be the case that there are certain severities of colitis that are beyond the ability of infliximab to salvage, which would be an important issue in selecting which patients to provide inpatient infliximab, so as to not unnecessarily delay surgery, increase hospital costs and to avoid escalating the degree of immunosuppression without a reasonable likelihood of clinical improvement.”

Dr. Andrew reported having no financial disclosures.

[email protected]

Clinical question: What is the association between detectable cardiac troponin (cTn) levels and outcomes in persons hospitalized with acute decompensated heart failure (ADHF)?

Background: There are millions of ADHF hospitalizations per year, and all-cause mortality and readmission rates are high. Efforts to better risk-stratify such patients have included measuring cTn levels and determining risk of increased length of stay, hospital readmission, and mortality.

Study design: Systematic review and meta-analysis.

Setting: Twenty-six observational cohort studies.

Synopsis: Compared with an undetectable cTn, detectable or elevated cTn levels were associated with greater length of stay (odds ratio [OR], 1.05; 95% CI, 1.01¬–1.10) and greater in-hospital death (OR, 2.57; 95% CI, 2.27–2.91). ADHF patients with detectable or elevated cTn were also at increased risk for mortality and composite of mortality and readmission over the short, intermediate, and long term. Reviewers eventually considered the overall association of a detectable or elevated troponin with mortality and readmission as moderate (relative association measure >2.0).

Meanwhile, few studies in this analysis showed a continuous and graded relationship between cTn levels and clinical outcomes.

Limitations of the review include arbitrarily stratifying groups by the level of cTn from assays whose lower limit of detection vary. The authors also admit the various associations are likely affected by several confounders for which they could not adjust because individual participant data were unavailable.

Finally, while acknowledging patients with chronic stable heart failure often have baseline elevated cTn levels, accounting for this in the analysis was limited.

Bottom line: A detectable or elevated level of cTn during ADHF hospitalization leads to worse outcomes both during and after discharge.

Citation: Yousufuddin M, Abdalrhim AD, Wang Z, Murad MH. Cardiac troponin in patients hospitalized with acute decompensated heart failure: a systematic review and meta-analysis [published online ahead of print February 18, 2016]. J Hosp Med. doi:10.1002/jhm.2558.

Clinical question: What is the association between detectable cardiac troponin (cTn) levels and outcomes in persons hospitalized with acute decompensated heart failure (ADHF)?

Background: There are millions of ADHF hospitalizations per year, and all-cause mortality and readmission rates are high. Efforts to better risk-stratify such patients have included measuring cTn levels and determining risk of increased length of stay, hospital readmission, and mortality.

Study design: Systematic review and meta-analysis.

Setting: Twenty-six observational cohort studies.

Synopsis: Compared with an undetectable cTn, detectable or elevated cTn levels were associated with greater length of stay (odds ratio [OR], 1.05; 95% CI, 1.01¬–1.10) and greater in-hospital death (OR, 2.57; 95% CI, 2.27–2.91). ADHF patients with detectable or elevated cTn were also at increased risk for mortality and composite of mortality and readmission over the short, intermediate, and long term. Reviewers eventually considered the overall association of a detectable or elevated troponin with mortality and readmission as moderate (relative association measure >2.0).

Meanwhile, few studies in this analysis showed a continuous and graded relationship between cTn levels and clinical outcomes.

Limitations of the review include arbitrarily stratifying groups by the level of cTn from assays whose lower limit of detection vary. The authors also admit the various associations are likely affected by several confounders for which they could not adjust because individual participant data were unavailable.

Finally, while acknowledging patients with chronic stable heart failure often have baseline elevated cTn levels, accounting for this in the analysis was limited.

Bottom line: A detectable or elevated level of cTn during ADHF hospitalization leads to worse outcomes both during and after discharge.

Citation: Yousufuddin M, Abdalrhim AD, Wang Z, Murad MH. Cardiac troponin in patients hospitalized with acute decompensated heart failure: a systematic review and meta-analysis [published online ahead of print February 18, 2016]. J Hosp Med. doi:10.1002/jhm.2558.

Clinical question: What is the association between detectable cardiac troponin (cTn) levels and outcomes in persons hospitalized with acute decompensated heart failure (ADHF)?

Background: There are millions of ADHF hospitalizations per year, and all-cause mortality and readmission rates are high. Efforts to better risk-stratify such patients have included measuring cTn levels and determining risk of increased length of stay, hospital readmission, and mortality.

Study design: Systematic review and meta-analysis.

Setting: Twenty-six observational cohort studies.

Synopsis: Compared with an undetectable cTn, detectable or elevated cTn levels were associated with greater length of stay (odds ratio [OR], 1.05; 95% CI, 1.01¬–1.10) and greater in-hospital death (OR, 2.57; 95% CI, 2.27–2.91). ADHF patients with detectable or elevated cTn were also at increased risk for mortality and composite of mortality and readmission over the short, intermediate, and long term. Reviewers eventually considered the overall association of a detectable or elevated troponin with mortality and readmission as moderate (relative association measure >2.0).

Meanwhile, few studies in this analysis showed a continuous and graded relationship between cTn levels and clinical outcomes.

Limitations of the review include arbitrarily stratifying groups by the level of cTn from assays whose lower limit of detection vary. The authors also admit the various associations are likely affected by several confounders for which they could not adjust because individual participant data were unavailable.

Finally, while acknowledging patients with chronic stable heart failure often have baseline elevated cTn levels, accounting for this in the analysis was limited.

Bottom line: A detectable or elevated level of cTn during ADHF hospitalization leads to worse outcomes both during and after discharge.

Citation: Yousufuddin M, Abdalrhim AD, Wang Z, Murad MH. Cardiac troponin in patients hospitalized with acute decompensated heart failure: a systematic review and meta-analysis [published online ahead of print February 18, 2016]. J Hosp Med. doi:10.1002/jhm.2558.

Clinical question: Which cardiovascular imaging modalities can augment triage of ED patients with chest pain?

Background: Because absolute event rates for patients with chest pain and normal initial ECG findings are not low enough to drive discharge triage decisions, and findings that patients with acute myocardial infarction (AMI) are inadvertently discharged because of less-sensitive troponin assays, there is great interest in what imaging modalities can facilitate safer triages.

Study design: Clinical guideline.

Setting: Meta-analysis of studies in multiple clinical settings.

Synopsis: This guideline adopted two pathways: an early assessment pathway, which considers imaging without the need for serial biomarker analysis, and an observational pathway, which involves serial biomarker testing.

For the early assessment pathway, when ECG and/or biomarker analysis is unequivocally positive for ischemia, all rest-imaging modalities are rarely appropriate. When the initial troponin level is equivocal, both rest single-photon emission computed tomography (SPECT) and coronary CT angiography (CCTA) are appropriate, though rest echocardiography and rest cardiovascular magnetic resonance (CMR) may be alternatives. Resting imaging may also be appropriate when chest pain resolves prior to evaluation and/or initial ECG plus troponin is non-ischemic/normal.

In the observational pathway, for patients with ECG changes and/or serial troponins unequivocally positive for AMI, only cardiac catheterization is recommended. When serial ECGs/troponins are borderline, stress-test modalities and CCTA are appropriate. When serial ECGs/ troponins are negative, outpatient testing may be appropriate.

Bottom line: Experts recommend cardiac catheterization as the imaging modality of choice for patients with an unequivocal AMI diagnosis. When ECG and/or biomarkers are equivocal or negative, outpatient evaluation may be appropriate.

Citation: Rybicki FJ, Udelson JE, Peacock WF, et al. Appropriate utilization of cardiovascular imaging in emergency department patients with chest pain: a joint document of the American College of Radiology Appropriateness Criteria Committee and the American College of Cardiology Appropriate Use Criteria Task Force. J Am Coll Radiol. 2016;(2):e1-e29. doi:10.1016/j.jacr.2015.07.007.

Short Take

Family Reflections on End-of-Life Cancer Care

In this multicenter, prospective, observational study, family members of patients with advanced-stage cancer who received aggressive care at end of life were less likely to report the overall quality of end-of-life care as “excellent” or “very good.”

Citation: Wright AA, Keating NL, Ayanian JZ, et al. Family perspectives on aggressive cancer care near the end of life. JAMA. 2016;315(3):284-292.

Clinical question: Which cardiovascular imaging modalities can augment triage of ED patients with chest pain?

Background: Because absolute event rates for patients with chest pain and normal initial ECG findings are not low enough to drive discharge triage decisions, and findings that patients with acute myocardial infarction (AMI) are inadvertently discharged because of less-sensitive troponin assays, there is great interest in what imaging modalities can facilitate safer triages.

Study design: Clinical guideline.

Setting: Meta-analysis of studies in multiple clinical settings.

Synopsis: This guideline adopted two pathways: an early assessment pathway, which considers imaging without the need for serial biomarker analysis, and an observational pathway, which involves serial biomarker testing.

For the early assessment pathway, when ECG and/or biomarker analysis is unequivocally positive for ischemia, all rest-imaging modalities are rarely appropriate. When the initial troponin level is equivocal, both rest single-photon emission computed tomography (SPECT) and coronary CT angiography (CCTA) are appropriate, though rest echocardiography and rest cardiovascular magnetic resonance (CMR) may be alternatives. Resting imaging may also be appropriate when chest pain resolves prior to evaluation and/or initial ECG plus troponin is non-ischemic/normal.

In the observational pathway, for patients with ECG changes and/or serial troponins unequivocally positive for AMI, only cardiac catheterization is recommended. When serial ECGs/troponins are borderline, stress-test modalities and CCTA are appropriate. When serial ECGs/ troponins are negative, outpatient testing may be appropriate.

Bottom line: Experts recommend cardiac catheterization as the imaging modality of choice for patients with an unequivocal AMI diagnosis. When ECG and/or biomarkers are equivocal or negative, outpatient evaluation may be appropriate.

Citation: Rybicki FJ, Udelson JE, Peacock WF, et al. Appropriate utilization of cardiovascular imaging in emergency department patients with chest pain: a joint document of the American College of Radiology Appropriateness Criteria Committee and the American College of Cardiology Appropriate Use Criteria Task Force. J Am Coll Radiol. 2016;(2):e1-e29. doi:10.1016/j.jacr.2015.07.007.

Short Take

Family Reflections on End-of-Life Cancer Care

In this multicenter, prospective, observational study, family members of patients with advanced-stage cancer who received aggressive care at end of life were less likely to report the overall quality of end-of-life care as “excellent” or “very good.”

Citation: Wright AA, Keating NL, Ayanian JZ, et al. Family perspectives on aggressive cancer care near the end of life. JAMA. 2016;315(3):284-292.

Clinical question: Which cardiovascular imaging modalities can augment triage of ED patients with chest pain?

Background: Because absolute event rates for patients with chest pain and normal initial ECG findings are not low enough to drive discharge triage decisions, and findings that patients with acute myocardial infarction (AMI) are inadvertently discharged because of less-sensitive troponin assays, there is great interest in what imaging modalities can facilitate safer triages.

Study design: Clinical guideline.

Setting: Meta-analysis of studies in multiple clinical settings.

Synopsis: This guideline adopted two pathways: an early assessment pathway, which considers imaging without the need for serial biomarker analysis, and an observational pathway, which involves serial biomarker testing.

For the early assessment pathway, when ECG and/or biomarker analysis is unequivocally positive for ischemia, all rest-imaging modalities are rarely appropriate. When the initial troponin level is equivocal, both rest single-photon emission computed tomography (SPECT) and coronary CT angiography (CCTA) are appropriate, though rest echocardiography and rest cardiovascular magnetic resonance (CMR) may be alternatives. Resting imaging may also be appropriate when chest pain resolves prior to evaluation and/or initial ECG plus troponin is non-ischemic/normal.

In the observational pathway, for patients with ECG changes and/or serial troponins unequivocally positive for AMI, only cardiac catheterization is recommended. When serial ECGs/troponins are borderline, stress-test modalities and CCTA are appropriate. When serial ECGs/ troponins are negative, outpatient testing may be appropriate.

Bottom line: Experts recommend cardiac catheterization as the imaging modality of choice for patients with an unequivocal AMI diagnosis. When ECG and/or biomarkers are equivocal or negative, outpatient evaluation may be appropriate.

Citation: Rybicki FJ, Udelson JE, Peacock WF, et al. Appropriate utilization of cardiovascular imaging in emergency department patients with chest pain: a joint document of the American College of Radiology Appropriateness Criteria Committee and the American College of Cardiology Appropriate Use Criteria Task Force. J Am Coll Radiol. 2016;(2):e1-e29. doi:10.1016/j.jacr.2015.07.007.

Short Take

Family Reflections on End-of-Life Cancer Care

In this multicenter, prospective, observational study, family members of patients with advanced-stage cancer who received aggressive care at end of life were less likely to report the overall quality of end-of-life care as “excellent” or “very good.”

Citation: Wright AA, Keating NL, Ayanian JZ, et al. Family perspectives on aggressive cancer care near the end of life. JAMA. 2016;315(3):284-292.