Doctor consults with a cancer

patient and her father

Photo by Rhoda Baer

The American Cancer Society’s 2016 report on cancer in the US suggests that, in recent years, overall trends in cancer incidence have remained stable for women and declined for men.

However, the rates of certain malignancies are on the rise. This includes some leukemia subtypes for men and women, as well as myeloma for men.

Leukemia is the leading cause of cancer death for men ages 20 to 39, but leukemia is no longer the leading cause of cancer death among children and adolescents (of both genders).

These and other data are included in the report, which is published in CA: A Cancer Journal for Clinicians.

The report estimates there will be 1,685,210 new cancer cases and 595,690 cancer deaths in the US in 2016. This includes 81,080 new lymphoma cases and 21,270 lymphoma deaths, 60,140 new leukemia cases and 24,400 leukemia deaths, and 30,330 new myeloma cases and 12,650 myeloma deaths.

Cancer incidence over time

The report suggests the overall cancer incidence for women has been stable from 1998 to 2012. But the incidence for men has declined by 3.1% per year from 2009 to 2012, with one-half of the drop in men due to recent rapid declines in prostate cancer diagnoses as prostate-specific antigen testing decreases.

Incidence rates increased from 2003 to 2012 among both men and women for some leukemia subtypes and for cancers of the tongue, tonsil, small intestine, liver, pancreas, kidney, renal pelvis, and thyroid.

Incidence rates increased in men for melanoma, myeloma, and cancers of the breast, testis, and oropharynx. Among women, incidence rates increased for cancers of the anus, vulva, and uterine corpus.

Cancer deaths

The rate of cancer deaths in the US has dropped 23% from its peak in 1991 to 2012. The incidence of cancer death was 215.1 per 100,000 in 1991 and 166.4 per 100,000 in 2012.

The decline is larger in men (28% since 1990) than in women (19% since 1991). Over the past decade of data, the rate dropped by 1.8% per year in men and 1.4% per year in women.

The decline in cancer death rates over the past 2 decades is driven by continued decreases in death rates for the 4 major cancer sites: lung, breast, prostate, and colon/rectum.

Breast cancer is the leading cause of cancer death in women ages 20 to 59, while lung cancer is the leading cause of cancer death in women 60 and older.

Among men, leukemia is the leading cause of cancer death for those ages 20 to 39, whereas lung cancer ranks first among men 40 and older.

Among children and adolescents (0-19), brain cancer has surpassed leukemia as the leading cause of cancer death, a result of more rapid therapeutic advances against leukemia.

The report also features an analysis of leading causes of death by state. It shows that, even as cancer remains the second leading cause of death nationwide, steep drops in deaths from heart disease have made cancer the leading cause of death in 21 states: Alaska, Arizona, Colorado, Delaware, Florida, Georgia, Idaho, Kansas, Maine, Massachusetts, Minnesota, Montana, Nebraska, New Hampshire, New Mexico, North Carolina, Oregon, South Carolina, Vermont, Virginia, and Washington.

In addition, cancer is the leading cause of death among adults ages 40 to 79 and among both Hispanics and Asian/Pacific Islanders, who together make up one-quarter of the US population.

Heart disease remains the top cause of death overall in the US. In 2012, there were 599,711 (24%) deaths from heart disease, compared to 582,623 (23%) deaths from cancer.

“We’re gratified to see cancer death rates continuing to drop,” said Otis W. Brawley, MD, chief medical officer of the American Cancer Society.

“But the fact that cancer is nonetheless becoming the top cause of death in many populations is a strong reminder that the fight is not over.”

Doctor consults with a cancer

patient and her father

Photo by Rhoda Baer

The American Cancer Society’s 2016 report on cancer in the US suggests that, in recent years, overall trends in cancer incidence have remained stable for women and declined for men.

However, the rates of certain malignancies are on the rise. This includes some leukemia subtypes for men and women, as well as myeloma for men.

Leukemia is the leading cause of cancer death for men ages 20 to 39, but leukemia is no longer the leading cause of cancer death among children and adolescents (of both genders).

These and other data are included in the report, which is published in CA: A Cancer Journal for Clinicians.

The report estimates there will be 1,685,210 new cancer cases and 595,690 cancer deaths in the US in 2016. This includes 81,080 new lymphoma cases and 21,270 lymphoma deaths, 60,140 new leukemia cases and 24,400 leukemia deaths, and 30,330 new myeloma cases and 12,650 myeloma deaths.

Cancer incidence over time

The report suggests the overall cancer incidence for women has been stable from 1998 to 2012. But the incidence for men has declined by 3.1% per year from 2009 to 2012, with one-half of the drop in men due to recent rapid declines in prostate cancer diagnoses as prostate-specific antigen testing decreases.

Incidence rates increased from 2003 to 2012 among both men and women for some leukemia subtypes and for cancers of the tongue, tonsil, small intestine, liver, pancreas, kidney, renal pelvis, and thyroid.

Incidence rates increased in men for melanoma, myeloma, and cancers of the breast, testis, and oropharynx. Among women, incidence rates increased for cancers of the anus, vulva, and uterine corpus.

Cancer deaths

The rate of cancer deaths in the US has dropped 23% from its peak in 1991 to 2012. The incidence of cancer death was 215.1 per 100,000 in 1991 and 166.4 per 100,000 in 2012.

The decline is larger in men (28% since 1990) than in women (19% since 1991). Over the past decade of data, the rate dropped by 1.8% per year in men and 1.4% per year in women.

The decline in cancer death rates over the past 2 decades is driven by continued decreases in death rates for the 4 major cancer sites: lung, breast, prostate, and colon/rectum.

Breast cancer is the leading cause of cancer death in women ages 20 to 59, while lung cancer is the leading cause of cancer death in women 60 and older.

Among men, leukemia is the leading cause of cancer death for those ages 20 to 39, whereas lung cancer ranks first among men 40 and older.

Among children and adolescents (0-19), brain cancer has surpassed leukemia as the leading cause of cancer death, a result of more rapid therapeutic advances against leukemia.

The report also features an analysis of leading causes of death by state. It shows that, even as cancer remains the second leading cause of death nationwide, steep drops in deaths from heart disease have made cancer the leading cause of death in 21 states: Alaska, Arizona, Colorado, Delaware, Florida, Georgia, Idaho, Kansas, Maine, Massachusetts, Minnesota, Montana, Nebraska, New Hampshire, New Mexico, North Carolina, Oregon, South Carolina, Vermont, Virginia, and Washington.

In addition, cancer is the leading cause of death among adults ages 40 to 79 and among both Hispanics and Asian/Pacific Islanders, who together make up one-quarter of the US population.

Heart disease remains the top cause of death overall in the US. In 2012, there were 599,711 (24%) deaths from heart disease, compared to 582,623 (23%) deaths from cancer.

“We’re gratified to see cancer death rates continuing to drop,” said Otis W. Brawley, MD, chief medical officer of the American Cancer Society.

“But the fact that cancer is nonetheless becoming the top cause of death in many populations is a strong reminder that the fight is not over.”

Doctor consults with a cancer

patient and her father

Photo by Rhoda Baer

The American Cancer Society’s 2016 report on cancer in the US suggests that, in recent years, overall trends in cancer incidence have remained stable for women and declined for men.

However, the rates of certain malignancies are on the rise. This includes some leukemia subtypes for men and women, as well as myeloma for men.

Leukemia is the leading cause of cancer death for men ages 20 to 39, but leukemia is no longer the leading cause of cancer death among children and adolescents (of both genders).

These and other data are included in the report, which is published in CA: A Cancer Journal for Clinicians.

The report estimates there will be 1,685,210 new cancer cases and 595,690 cancer deaths in the US in 2016. This includes 81,080 new lymphoma cases and 21,270 lymphoma deaths, 60,140 new leukemia cases and 24,400 leukemia deaths, and 30,330 new myeloma cases and 12,650 myeloma deaths.

Cancer incidence over time

The report suggests the overall cancer incidence for women has been stable from 1998 to 2012. But the incidence for men has declined by 3.1% per year from 2009 to 2012, with one-half of the drop in men due to recent rapid declines in prostate cancer diagnoses as prostate-specific antigen testing decreases.

Incidence rates increased from 2003 to 2012 among both men and women for some leukemia subtypes and for cancers of the tongue, tonsil, small intestine, liver, pancreas, kidney, renal pelvis, and thyroid.

Incidence rates increased in men for melanoma, myeloma, and cancers of the breast, testis, and oropharynx. Among women, incidence rates increased for cancers of the anus, vulva, and uterine corpus.

Cancer deaths

The rate of cancer deaths in the US has dropped 23% from its peak in 1991 to 2012. The incidence of cancer death was 215.1 per 100,000 in 1991 and 166.4 per 100,000 in 2012.

The decline is larger in men (28% since 1990) than in women (19% since 1991). Over the past decade of data, the rate dropped by 1.8% per year in men and 1.4% per year in women.

The decline in cancer death rates over the past 2 decades is driven by continued decreases in death rates for the 4 major cancer sites: lung, breast, prostate, and colon/rectum.

Breast cancer is the leading cause of cancer death in women ages 20 to 59, while lung cancer is the leading cause of cancer death in women 60 and older.

Among men, leukemia is the leading cause of cancer death for those ages 20 to 39, whereas lung cancer ranks first among men 40 and older.

Among children and adolescents (0-19), brain cancer has surpassed leukemia as the leading cause of cancer death, a result of more rapid therapeutic advances against leukemia.

The report also features an analysis of leading causes of death by state. It shows that, even as cancer remains the second leading cause of death nationwide, steep drops in deaths from heart disease have made cancer the leading cause of death in 21 states: Alaska, Arizona, Colorado, Delaware, Florida, Georgia, Idaho, Kansas, Maine, Massachusetts, Minnesota, Montana, Nebraska, New Hampshire, New Mexico, North Carolina, Oregon, South Carolina, Vermont, Virginia, and Washington.

In addition, cancer is the leading cause of death among adults ages 40 to 79 and among both Hispanics and Asian/Pacific Islanders, who together make up one-quarter of the US population.

Heart disease remains the top cause of death overall in the US. In 2012, there were 599,711 (24%) deaths from heart disease, compared to 582,623 (23%) deaths from cancer.

“We’re gratified to see cancer death rates continuing to drop,” said Otis W. Brawley, MD, chief medical officer of the American Cancer Society.

“But the fact that cancer is nonetheless becoming the top cause of death in many populations is a strong reminder that the fight is not over.”

As Ob.Gyn. News celebrates 50 years of publication, we’re taking a look back at our first year – 1966.

Not surprisingly, medicine looked a lot different in the mid-1960s, largely driven by the culture and technology of the time. A review of the 1966 issues of Obstetrics and Gynecology (the Green Journal), offers a snapshot of the state of the science.

With scientists still struggling to develop a rapid test to detect pregnancy, researchers from the Brookdale Hospital Center in Brooklyn, N.Y., detailed the possibility of using elevated breast temperature to get faster results. They compared 50 pregnant and 50 nonpregnant women and found a consistent rise in breast temperature in all pregnant women as early as 1 week after the first missed period. In the March issue, they concluded that the use of temperature difference between the breast and a baseline area on the anterior chest wall could be a rapid, simple, and accurate pregnancy test (Obstet Gynecol. 1966 Mar;27[3]:378-80).

In August, researchers from Australia published promising data on the use of ultrasonic echoscopic examination of the uterus in late pregnancy. They found that the technology was useful in determining fetal position and possible abnormalities and could be repeated as often as necessary to observe changes and growth. The big advantage, they noted, would be the opportunity to avoid excessive fetal exposure to x-rays (Obstet Gynecol. 1966 Aug;28[2]:164-9).

Advertising directed at physicians – in both the Green Journal and in Ob.Gyn. News – provided a glimpse into the practice of medicine at the time. Ob.gyns. saw ads for products such as Eskatrol – a capsule that contained dextroamphetamine sulfate and prochlorperazine – promoted to help women control appetite and “relieve the emotional stress that causes overeating.” And doctors also saw ads for oral contraceptives, first approved by the Food and Drug Administration in 1960.

Ob.gyn. practice was different culturally as well. In a regular column titled “After Office Hours,” published in the Green Journal in January 1966, Dr. Malcolm S. Allan explored a relatively new idea – husband-attended deliveries. Dr. Allan, of Wesson Maternity Hospital in Springfield, Mass., explained that his hospital had conducted a nationwide survey of chiefs of obstetrics after they received a petition seeking to allow husbands into the delivery room, as well as more flexibility for fathers to room in with the mother and baby. The survey, which included responses from 267 hospitals, showed that 81% of hospitals did not allow husbands in the delivery room (Obstet Gynecol. 1966 Jan;27[1]:146-8).

After reviewing the survey results and talking to experts in the area, Dr. Allan and the leadership at Wesson decided not to allow husbands to witness deliveries. He concluded that “some patients in some of these ‘off-beat’ programs are being allowed to assume too much authority for determining the medical management of their pregnancies, while leaving the obstetrician with the responsibility for a healthy outcome.”

But in other ways, not much has changed since 1966. The March edition of “After Office Hours” bemoaned a looming manpower crisis in obstetrics (Obstet Gynecol. 1966 Mar;27[3]:449-52). Dr. Jan Schneider of the University of Michigan, Ann Arbor, wrote that even using conservative estimates of population growth, by 1970 there would be 20,000 obstetricians in the United States delivering on average of 225 babies each, a strain on the workforce. What were some of the factors? An uneven distribution of obstetricians throughout the country and increasing specialization.

In another familiar theme, Dr. Schneider urged physicians to consider team care as one part of the solution, allowing nurse midwives to provide prenatal care and perform normal deliveries under physician supervision.

Some of the clinical debates going on in 1966 are still unresolved. Consider the September 1966 issue of the Green Journal, which features an interim report on contraception with an intrauterine bow inserted immediately postpartum (Obstet Gynecol. 1966 Sep;28[3]:329-31). Five decades later, only about 12 state Medicaid programs cover the cost of insertion of an IUD immediately postpartum. And in the August 1966 issue of the Green Journal, Dr. Carl J. Pauerstein asked, “Once a Section, Always a Trial of Labor?” (Obstet Gynecol. 1966 Aug;28[2]:273-6). A look at the recent Master Class on vaginal birth after cesarean shows that those same questions are still being debated today.

So what will physicians and patients say about obstetrics and gynecology practice 50 years from now?

1966 at a glance

The Surgeon General

In a report to U.S. Surgeon General William H. Stewart titled “Protecting and Improving Health through the Radiological Sciences,” the National Advisory Committee on Radiation warned about emerging problems in the use of ionizing radiation in medicine.

Births

According to data provided by the Centers for Disease Control and Prevention, in 1966, there were 3.6 million births, for a birth rate of 18.4 and a fertility rate of 90.8; 8.4% of births were to unmarried women.

Women get organized

Courtesy of the National Organization for Women

In June, Betty Friedan, Pauli Murray, and several other women launched the National Organization for Women at a conference in Washington, D.C., with Ms. Friedan famously writing N-O-W on a paper napkin.

Medical ethics

Dr. Henry K. Beecher published an article on ethics in the New England Journal of Medicine that is credited with spurring the federal government to set rules on human experimentation and informed consent, including establishment of Institutional Review Boards.

A safety net is born

Photo courtesy of White House

On July 1, 1966, Medicare coverage began, with more than 19 million beneficiaries.

The AMA

Courtesy of the American Medical Association

The American Medical Association published the first edition of the Current Procedural Terminology (CPT) code book, creating a system of standardized terms for medical procedures used in documentation. Also in 1966, the AMA encouraged doctors to promote exercise to improve health.

Planned Parenthood

The Planned Parenthood Federation of America awarded its first Margaret Sanger Award. In 1966, four men received the award, including the Rev. Martin Luther King Jr. and President Lyndon B. Johnson.

Pregnancy testing

The first radioimmunoassay for hCG (human chorionic gonadotropin) was described by A.R. Midgley, but the test could not distinguish between hCG and luteinizing hormone. A home pregnancy test was still a decade away.

Throughout 2016, Ob.Gyn. News will celebrate its 50th anniversary with exclusive articles looking at the evolution of the specialty, including the history of contraception, changes in gynecologic surgery, and the transformation of the well-woman visit. Look for these articles and more special features in the pages of Ob.Gyn. News and online at obgynnews.com.

[email protected]

On Twitter @maryellenny

As Ob.Gyn. News celebrates 50 years of publication, we’re taking a look back at our first year – 1966.

Not surprisingly, medicine looked a lot different in the mid-1960s, largely driven by the culture and technology of the time. A review of the 1966 issues of Obstetrics and Gynecology (the Green Journal), offers a snapshot of the state of the science.

With scientists still struggling to develop a rapid test to detect pregnancy, researchers from the Brookdale Hospital Center in Brooklyn, N.Y., detailed the possibility of using elevated breast temperature to get faster results. They compared 50 pregnant and 50 nonpregnant women and found a consistent rise in breast temperature in all pregnant women as early as 1 week after the first missed period. In the March issue, they concluded that the use of temperature difference between the breast and a baseline area on the anterior chest wall could be a rapid, simple, and accurate pregnancy test (Obstet Gynecol. 1966 Mar;27[3]:378-80).

In August, researchers from Australia published promising data on the use of ultrasonic echoscopic examination of the uterus in late pregnancy. They found that the technology was useful in determining fetal position and possible abnormalities and could be repeated as often as necessary to observe changes and growth. The big advantage, they noted, would be the opportunity to avoid excessive fetal exposure to x-rays (Obstet Gynecol. 1966 Aug;28[2]:164-9).

Advertising directed at physicians – in both the Green Journal and in Ob.Gyn. News – provided a glimpse into the practice of medicine at the time. Ob.gyns. saw ads for products such as Eskatrol – a capsule that contained dextroamphetamine sulfate and prochlorperazine – promoted to help women control appetite and “relieve the emotional stress that causes overeating.” And doctors also saw ads for oral contraceptives, first approved by the Food and Drug Administration in 1960.

Ob.gyn. practice was different culturally as well. In a regular column titled “After Office Hours,” published in the Green Journal in January 1966, Dr. Malcolm S. Allan explored a relatively new idea – husband-attended deliveries. Dr. Allan, of Wesson Maternity Hospital in Springfield, Mass., explained that his hospital had conducted a nationwide survey of chiefs of obstetrics after they received a petition seeking to allow husbands into the delivery room, as well as more flexibility for fathers to room in with the mother and baby. The survey, which included responses from 267 hospitals, showed that 81% of hospitals did not allow husbands in the delivery room (Obstet Gynecol. 1966 Jan;27[1]:146-8).

After reviewing the survey results and talking to experts in the area, Dr. Allan and the leadership at Wesson decided not to allow husbands to witness deliveries. He concluded that “some patients in some of these ‘off-beat’ programs are being allowed to assume too much authority for determining the medical management of their pregnancies, while leaving the obstetrician with the responsibility for a healthy outcome.”

But in other ways, not much has changed since 1966. The March edition of “After Office Hours” bemoaned a looming manpower crisis in obstetrics (Obstet Gynecol. 1966 Mar;27[3]:449-52). Dr. Jan Schneider of the University of Michigan, Ann Arbor, wrote that even using conservative estimates of population growth, by 1970 there would be 20,000 obstetricians in the United States delivering on average of 225 babies each, a strain on the workforce. What were some of the factors? An uneven distribution of obstetricians throughout the country and increasing specialization.

In another familiar theme, Dr. Schneider urged physicians to consider team care as one part of the solution, allowing nurse midwives to provide prenatal care and perform normal deliveries under physician supervision.

Some of the clinical debates going on in 1966 are still unresolved. Consider the September 1966 issue of the Green Journal, which features an interim report on contraception with an intrauterine bow inserted immediately postpartum (Obstet Gynecol. 1966 Sep;28[3]:329-31). Five decades later, only about 12 state Medicaid programs cover the cost of insertion of an IUD immediately postpartum. And in the August 1966 issue of the Green Journal, Dr. Carl J. Pauerstein asked, “Once a Section, Always a Trial of Labor?” (Obstet Gynecol. 1966 Aug;28[2]:273-6). A look at the recent Master Class on vaginal birth after cesarean shows that those same questions are still being debated today.

So what will physicians and patients say about obstetrics and gynecology practice 50 years from now?

1966 at a glance

The Surgeon General

In a report to U.S. Surgeon General William H. Stewart titled “Protecting and Improving Health through the Radiological Sciences,” the National Advisory Committee on Radiation warned about emerging problems in the use of ionizing radiation in medicine.

Births

According to data provided by the Centers for Disease Control and Prevention, in 1966, there were 3.6 million births, for a birth rate of 18.4 and a fertility rate of 90.8; 8.4% of births were to unmarried women.

Women get organized

Courtesy of the National Organization for Women

In June, Betty Friedan, Pauli Murray, and several other women launched the National Organization for Women at a conference in Washington, D.C., with Ms. Friedan famously writing N-O-W on a paper napkin.

Medical ethics

Dr. Henry K. Beecher published an article on ethics in the New England Journal of Medicine that is credited with spurring the federal government to set rules on human experimentation and informed consent, including establishment of Institutional Review Boards.

A safety net is born

Photo courtesy of White House

On July 1, 1966, Medicare coverage began, with more than 19 million beneficiaries.

The AMA

Courtesy of the American Medical Association

The American Medical Association published the first edition of the Current Procedural Terminology (CPT) code book, creating a system of standardized terms for medical procedures used in documentation. Also in 1966, the AMA encouraged doctors to promote exercise to improve health.

Planned Parenthood

The Planned Parenthood Federation of America awarded its first Margaret Sanger Award. In 1966, four men received the award, including the Rev. Martin Luther King Jr. and President Lyndon B. Johnson.

Pregnancy testing

The first radioimmunoassay for hCG (human chorionic gonadotropin) was described by A.R. Midgley, but the test could not distinguish between hCG and luteinizing hormone. A home pregnancy test was still a decade away.

Throughout 2016, Ob.Gyn. News will celebrate its 50th anniversary with exclusive articles looking at the evolution of the specialty, including the history of contraception, changes in gynecologic surgery, and the transformation of the well-woman visit. Look for these articles and more special features in the pages of Ob.Gyn. News and online at obgynnews.com.

[email protected]

On Twitter @maryellenny

As Ob.Gyn. News celebrates 50 years of publication, we’re taking a look back at our first year – 1966.

Not surprisingly, medicine looked a lot different in the mid-1960s, largely driven by the culture and technology of the time. A review of the 1966 issues of Obstetrics and Gynecology (the Green Journal), offers a snapshot of the state of the science.

With scientists still struggling to develop a rapid test to detect pregnancy, researchers from the Brookdale Hospital Center in Brooklyn, N.Y., detailed the possibility of using elevated breast temperature to get faster results. They compared 50 pregnant and 50 nonpregnant women and found a consistent rise in breast temperature in all pregnant women as early as 1 week after the first missed period. In the March issue, they concluded that the use of temperature difference between the breast and a baseline area on the anterior chest wall could be a rapid, simple, and accurate pregnancy test (Obstet Gynecol. 1966 Mar;27[3]:378-80).

In August, researchers from Australia published promising data on the use of ultrasonic echoscopic examination of the uterus in late pregnancy. They found that the technology was useful in determining fetal position and possible abnormalities and could be repeated as often as necessary to observe changes and growth. The big advantage, they noted, would be the opportunity to avoid excessive fetal exposure to x-rays (Obstet Gynecol. 1966 Aug;28[2]:164-9).

Advertising directed at physicians – in both the Green Journal and in Ob.Gyn. News – provided a glimpse into the practice of medicine at the time. Ob.gyns. saw ads for products such as Eskatrol – a capsule that contained dextroamphetamine sulfate and prochlorperazine – promoted to help women control appetite and “relieve the emotional stress that causes overeating.” And doctors also saw ads for oral contraceptives, first approved by the Food and Drug Administration in 1960.

Ob.gyn. practice was different culturally as well. In a regular column titled “After Office Hours,” published in the Green Journal in January 1966, Dr. Malcolm S. Allan explored a relatively new idea – husband-attended deliveries. Dr. Allan, of Wesson Maternity Hospital in Springfield, Mass., explained that his hospital had conducted a nationwide survey of chiefs of obstetrics after they received a petition seeking to allow husbands into the delivery room, as well as more flexibility for fathers to room in with the mother and baby. The survey, which included responses from 267 hospitals, showed that 81% of hospitals did not allow husbands in the delivery room (Obstet Gynecol. 1966 Jan;27[1]:146-8).

After reviewing the survey results and talking to experts in the area, Dr. Allan and the leadership at Wesson decided not to allow husbands to witness deliveries. He concluded that “some patients in some of these ‘off-beat’ programs are being allowed to assume too much authority for determining the medical management of their pregnancies, while leaving the obstetrician with the responsibility for a healthy outcome.”

But in other ways, not much has changed since 1966. The March edition of “After Office Hours” bemoaned a looming manpower crisis in obstetrics (Obstet Gynecol. 1966 Mar;27[3]:449-52). Dr. Jan Schneider of the University of Michigan, Ann Arbor, wrote that even using conservative estimates of population growth, by 1970 there would be 20,000 obstetricians in the United States delivering on average of 225 babies each, a strain on the workforce. What were some of the factors? An uneven distribution of obstetricians throughout the country and increasing specialization.

In another familiar theme, Dr. Schneider urged physicians to consider team care as one part of the solution, allowing nurse midwives to provide prenatal care and perform normal deliveries under physician supervision.

Some of the clinical debates going on in 1966 are still unresolved. Consider the September 1966 issue of the Green Journal, which features an interim report on contraception with an intrauterine bow inserted immediately postpartum (Obstet Gynecol. 1966 Sep;28[3]:329-31). Five decades later, only about 12 state Medicaid programs cover the cost of insertion of an IUD immediately postpartum. And in the August 1966 issue of the Green Journal, Dr. Carl J. Pauerstein asked, “Once a Section, Always a Trial of Labor?” (Obstet Gynecol. 1966 Aug;28[2]:273-6). A look at the recent Master Class on vaginal birth after cesarean shows that those same questions are still being debated today.

So what will physicians and patients say about obstetrics and gynecology practice 50 years from now?

1966 at a glance

The Surgeon General

In a report to U.S. Surgeon General William H. Stewart titled “Protecting and Improving Health through the Radiological Sciences,” the National Advisory Committee on Radiation warned about emerging problems in the use of ionizing radiation in medicine.

Births

According to data provided by the Centers for Disease Control and Prevention, in 1966, there were 3.6 million births, for a birth rate of 18.4 and a fertility rate of 90.8; 8.4% of births were to unmarried women.

Women get organized

Courtesy of the National Organization for Women

In June, Betty Friedan, Pauli Murray, and several other women launched the National Organization for Women at a conference in Washington, D.C., with Ms. Friedan famously writing N-O-W on a paper napkin.

Medical ethics

Dr. Henry K. Beecher published an article on ethics in the New England Journal of Medicine that is credited with spurring the federal government to set rules on human experimentation and informed consent, including establishment of Institutional Review Boards.

A safety net is born

Photo courtesy of White House

On July 1, 1966, Medicare coverage began, with more than 19 million beneficiaries.

The AMA

Courtesy of the American Medical Association

The American Medical Association published the first edition of the Current Procedural Terminology (CPT) code book, creating a system of standardized terms for medical procedures used in documentation. Also in 1966, the AMA encouraged doctors to promote exercise to improve health.

Planned Parenthood

The Planned Parenthood Federation of America awarded its first Margaret Sanger Award. In 1966, four men received the award, including the Rev. Martin Luther King Jr. and President Lyndon B. Johnson.

Pregnancy testing

The first radioimmunoassay for hCG (human chorionic gonadotropin) was described by A.R. Midgley, but the test could not distinguish between hCG and luteinizing hormone. A home pregnancy test was still a decade away.

Throughout 2016, Ob.Gyn. News will celebrate its 50th anniversary with exclusive articles looking at the evolution of the specialty, including the history of contraception, changes in gynecologic surgery, and the transformation of the well-woman visit. Look for these articles and more special features in the pages of Ob.Gyn. News and online at obgynnews.com.

[email protected]

On Twitter @maryellenny

On October 14, 2015, the US Food and Drug Administration declined to approve tofacitinib citrate, an oral rheumatoid arthritis drug, for the treatment of moderate to severe chronic plaque psoriasis. The FDA communicated its decision to the manufacturer in the form of a complete response letter, which typically outlines concerns and conditions that must be addressed in order to gain FDA approval following initial review of an application.

A recent press release indicated that the manufacturer is committed to pursuing approval of the product based on the strength of the clinical data for its treatment of psoriasis. The FDA generally does not disclose the contents of its complete response letters, but the manufacturer reported it has been asked to provide additional safety analyses of the drug for psoriasis and that it will work closely with the agency to gain the additional approval for treatment of patients with chronic plaque psoriasis.

What’s the Issue?

With the increasing number of psoriasis drugs on the market and in the pipeline, the risk-benefit profile of all drugs needs to be evaluated very carefully. Therefore, safety is the focal issue in all new drug development. Hopefully these issues with the FDA approval of tofacitinib citrate will be worked out so that we may have another oral option for our psoriasis patients. How will this development influence your approach to new therapies?

We want to know your views! Tell us what you think.

On October 14, 2015, the US Food and Drug Administration declined to approve tofacitinib citrate, an oral rheumatoid arthritis drug, for the treatment of moderate to severe chronic plaque psoriasis. The FDA communicated its decision to the manufacturer in the form of a complete response letter, which typically outlines concerns and conditions that must be addressed in order to gain FDA approval following initial review of an application.

A recent press release indicated that the manufacturer is committed to pursuing approval of the product based on the strength of the clinical data for its treatment of psoriasis. The FDA generally does not disclose the contents of its complete response letters, but the manufacturer reported it has been asked to provide additional safety analyses of the drug for psoriasis and that it will work closely with the agency to gain the additional approval for treatment of patients with chronic plaque psoriasis.

What’s the Issue?

With the increasing number of psoriasis drugs on the market and in the pipeline, the risk-benefit profile of all drugs needs to be evaluated very carefully. Therefore, safety is the focal issue in all new drug development. Hopefully these issues with the FDA approval of tofacitinib citrate will be worked out so that we may have another oral option for our psoriasis patients. How will this development influence your approach to new therapies?

We want to know your views! Tell us what you think.

On October 14, 2015, the US Food and Drug Administration declined to approve tofacitinib citrate, an oral rheumatoid arthritis drug, for the treatment of moderate to severe chronic plaque psoriasis. The FDA communicated its decision to the manufacturer in the form of a complete response letter, which typically outlines concerns and conditions that must be addressed in order to gain FDA approval following initial review of an application.

A recent press release indicated that the manufacturer is committed to pursuing approval of the product based on the strength of the clinical data for its treatment of psoriasis. The FDA generally does not disclose the contents of its complete response letters, but the manufacturer reported it has been asked to provide additional safety analyses of the drug for psoriasis and that it will work closely with the agency to gain the additional approval for treatment of patients with chronic plaque psoriasis.

What’s the Issue?

With the increasing number of psoriasis drugs on the market and in the pipeline, the risk-benefit profile of all drugs needs to be evaluated very carefully. Therefore, safety is the focal issue in all new drug development. Hopefully these issues with the FDA approval of tofacitinib citrate will be worked out so that we may have another oral option for our psoriasis patients. How will this development influence your approach to new therapies?

We want to know your views! Tell us what you think.

More U.S. adults over the age of 65 visited an emergency department because of an infectious disease than for myocardial infarction and congestive heart failure combined, according to a new study.

Based on a nationwide ED sample, adults over 65 visited the ED just over 3.1 million times in 2012 due to infectious diseases (ID), more than three times the estimated amount for myocardial infarction and congestive heart failure. The most common diagnoses were lower respiratory infections (26.2%), urinary tract infections (25.3%), and septicemia (18.9%).

Of the 3.1 million cases brought to the ED, nearly 1.8 million cases were hospitalized, with septicemia the most common cause for hospitalization, accounting for 32.2% of ID-related hospitalizations, followed by lower respiratory infections. Septicemia was also the most common cause of mortality, accounting for 74.7% of the nearly 124,000 deaths.

“These observations underscore the importance of integrated strategies aimed at reducing ID-related morbidity and health care use of elderly adults as a national priority for research, health policy, and community action,” Dr. Tadahiro Goto of the University of Fukui (Japan) Hospital and his associates concluded.

Find the full study in the Journal of the American Geriatrics Society (2015 Dec 23. doi: 101111/jgs.13836).

[email protected]

More U.S. adults over the age of 65 visited an emergency department because of an infectious disease than for myocardial infarction and congestive heart failure combined, according to a new study.

Based on a nationwide ED sample, adults over 65 visited the ED just over 3.1 million times in 2012 due to infectious diseases (ID), more than three times the estimated amount for myocardial infarction and congestive heart failure. The most common diagnoses were lower respiratory infections (26.2%), urinary tract infections (25.3%), and septicemia (18.9%).

Of the 3.1 million cases brought to the ED, nearly 1.8 million cases were hospitalized, with septicemia the most common cause for hospitalization, accounting for 32.2% of ID-related hospitalizations, followed by lower respiratory infections. Septicemia was also the most common cause of mortality, accounting for 74.7% of the nearly 124,000 deaths.

“These observations underscore the importance of integrated strategies aimed at reducing ID-related morbidity and health care use of elderly adults as a national priority for research, health policy, and community action,” Dr. Tadahiro Goto of the University of Fukui (Japan) Hospital and his associates concluded.

Find the full study in the Journal of the American Geriatrics Society (2015 Dec 23. doi: 101111/jgs.13836).

[email protected]

More U.S. adults over the age of 65 visited an emergency department because of an infectious disease than for myocardial infarction and congestive heart failure combined, according to a new study.

Based on a nationwide ED sample, adults over 65 visited the ED just over 3.1 million times in 2012 due to infectious diseases (ID), more than three times the estimated amount for myocardial infarction and congestive heart failure. The most common diagnoses were lower respiratory infections (26.2%), urinary tract infections (25.3%), and septicemia (18.9%).

Of the 3.1 million cases brought to the ED, nearly 1.8 million cases were hospitalized, with septicemia the most common cause for hospitalization, accounting for 32.2% of ID-related hospitalizations, followed by lower respiratory infections. Septicemia was also the most common cause of mortality, accounting for 74.7% of the nearly 124,000 deaths.

“These observations underscore the importance of integrated strategies aimed at reducing ID-related morbidity and health care use of elderly adults as a national priority for research, health policy, and community action,” Dr. Tadahiro Goto of the University of Fukui (Japan) Hospital and his associates concluded.

Find the full study in the Journal of the American Geriatrics Society (2015 Dec 23. doi: 101111/jgs.13836).

[email protected]

LAS VEGAS – Though pyoderma gangrenosum and other neutrophilic skin disorders are rare, clinicians should include them in their differential, especially for nonhealing surgical wounds or skin “infections.”

Since these painful areas of ulceration need corticosteroid treatment, not antibiotics, for resolution, accurate diagnosis is critical for healing, Dr. J. Mark Jackson said at the Skin Disease Education Foundation’s annual Las Vegas dermatology seminar.

In a review of pyoderma gangrenosum (PG) and its cousins at the meeting, Dr. Jackson noted that the etiology of PG is unknown, but disordered neutrophilic chemotaxis is thought to be a factor. The many different manifestations of this disease are now collectively called the “neutrophilic dermatoses,” he said.

“Pyoderma gangrenosum is a very important diagnosis to consider in the differential diagnosis for nonhealing ulcerations, as suspicion and early recognition of this debilitating condition can prevent long-term sequelae such as pain, scarring, and long-term immunosuppressive medications,” said Dr. Jackson of the department of dermatology at the University of Louisville (Ky.).

The diagnosis should be suspected in the setting of a painful cutaneous ulcer with necrolysis. The border is typically irregular, violaceous, and undermined, he said, adding that this classic undermined border is caused by the sheets of neutrophils that characterize the disease.

Noting that half of patients with PG have underlying associated conditions such as Crohn’s disease, ulcerative colitis, rheumatoid arthritis, and hematologic malignancies, Dr. Jackson emphasized that systemic disease associated with PG should heighten suspicion. “Histopathologic findings may be consistent with but not diagnostic of PG,” and can include a sterile dermal neutrophilia, with or without mixed inflammation and a lymphocytic vasculitis.

“Where you biopsy is important,” he continued, emphasizing that the biopsy must capture the margin of ulceration, where the sheets of neutrophils characteristic of PG will be seen on pathology.

Courtesy Dr. J. Mark Jackson

Therapy consists of corticosteroids, with or without an immunosuppressive agent, and cessation of treatments that may continue to provoke pathergy.

Other diseases should also be considered in the differential diagnosis, including dangerous infectious causes, such as atypical mycobacteria, deep fungal infections, and staphylococcal and streptococcal infections. Squamous cell carcinoma, lymphoma, and leukemia may also present with similar lesions, as may metastatic Crohn’s disease, Dr. Jackson said. Several vasculitic and vasculopathic inflammatory conditions can also have similar appearances, including Wegener’s granulomatosis and vasoocclusive disorders such as peripheral vascular disease and cryoglobulinemia.

Classically, PG presents as painful ulcerated areas, most often on the lower extremities, that have a typical undermined border, caused by the sheets of neutrophils that characterize PG, he pointed out. PG may be mistaken for venous stasis ulcers, pressure ulcers, and cellulitis, but it doesn’t improve with antibiotics and mechanical manipulation from exfoliative dressings – and debridement may worsen the condition.

Courtesy Dr. J. Mark Jackson

For susceptible individuals, surgery may provoke a pathergic response and trigger PG at the site of the surgical wound, and dogged attempts at conventional wound care may cause continued pathergy and begin a vicious cycle, Dr. Jackson said.

Peristomal pyoderma gangrenosum is a disease subcategory that may be seen in patients whose inflammatory bowel disease has been surgically treated and who have a stoma. Patients will have ulcerating lesions around their stoma site that are often misdiagnosed and treated as infections. Some wound care therapies, such as debridement, may continue to provoke the pathergic response and worsen peristomal PG, he said.

Though associated disease is seen in up to 50% of individuals with PG, there’s no predictable timeline linking the development of PG with the course of the associated disorder. In classic PG, usually occurring on the legs, autoimmune diseases such as inflammatory bowel disease, rheumatoid arthritis or another inflammatory arthritis, and paraproteinemia may be seen. Atypical PG, occurring more commonly on the upper extremities and face, is associated with myelogenous leukemia and preleukemic states, Dr. Jackson said.

Pyoderma gangrenosum lesions improve with corticosteroid administration. Depending on disease severity and location, topical, intralesional, or systemic steroids may be used.

Adjunctive treatments for PG and other neutrophilic dermatoses can include antibiotics with anti-inflammatory properties, such as minocycline or doxycycline, dapsone, and metronidazole. Immunosuppressives such as cyclosporine, azathioprine, and mycophenolate mofetil may also help speed resolution. In some cases, skin grafts may be necessary.

Courtesy Dr. J. Mark Jackson

PG patients with Crohn’s disease or rheumatoid arthritis who are prescribed tumor necrosis factor–alpha (TNF-alpha) inhibitors for their systemic disease may also see improvement in PG lesions, Dr. Jackson said.

Other rare categories of neutrophilic dermatoses include Sweet’s syndrome, an acute febrile neutrophilic dermatosis, and neutrophilic dermatosis of the dorsum of the hand.

Neutrophilic invasion can also occur in other organs. “These extracutaneous lesions are also ‘sterile’ neutrophilic abscesses, which are often misdiagnosed as infections,” Dr. Jackson said. The most common site of extracutaneous neutrophilic infiltration is the lungs, though any organ system may be affected.

Dr. Jackson disclosed that he has received research support, honoraria, consulting fees, and other support from Abbvie, Amgen, Celgene, Dermira, Galderma, Genentech, Janssen, Lilly, Medimetriks, Merck, Novartis, Pfizer, Promius, and Top MD.

The Skin Disease Education Foundation and this news organization are owned by the same parent company.

[email protected]

On Twitter @karioakes

LAS VEGAS – Though pyoderma gangrenosum and other neutrophilic skin disorders are rare, clinicians should include them in their differential, especially for nonhealing surgical wounds or skin “infections.”

Since these painful areas of ulceration need corticosteroid treatment, not antibiotics, for resolution, accurate diagnosis is critical for healing, Dr. J. Mark Jackson said at the Skin Disease Education Foundation’s annual Las Vegas dermatology seminar.

In a review of pyoderma gangrenosum (PG) and its cousins at the meeting, Dr. Jackson noted that the etiology of PG is unknown, but disordered neutrophilic chemotaxis is thought to be a factor. The many different manifestations of this disease are now collectively called the “neutrophilic dermatoses,” he said.

“Pyoderma gangrenosum is a very important diagnosis to consider in the differential diagnosis for nonhealing ulcerations, as suspicion and early recognition of this debilitating condition can prevent long-term sequelae such as pain, scarring, and long-term immunosuppressive medications,” said Dr. Jackson of the department of dermatology at the University of Louisville (Ky.).

The diagnosis should be suspected in the setting of a painful cutaneous ulcer with necrolysis. The border is typically irregular, violaceous, and undermined, he said, adding that this classic undermined border is caused by the sheets of neutrophils that characterize the disease.

Noting that half of patients with PG have underlying associated conditions such as Crohn’s disease, ulcerative colitis, rheumatoid arthritis, and hematologic malignancies, Dr. Jackson emphasized that systemic disease associated with PG should heighten suspicion. “Histopathologic findings may be consistent with but not diagnostic of PG,” and can include a sterile dermal neutrophilia, with or without mixed inflammation and a lymphocytic vasculitis.

“Where you biopsy is important,” he continued, emphasizing that the biopsy must capture the margin of ulceration, where the sheets of neutrophils characteristic of PG will be seen on pathology.

Courtesy Dr. J. Mark Jackson

Therapy consists of corticosteroids, with or without an immunosuppressive agent, and cessation of treatments that may continue to provoke pathergy.

Other diseases should also be considered in the differential diagnosis, including dangerous infectious causes, such as atypical mycobacteria, deep fungal infections, and staphylococcal and streptococcal infections. Squamous cell carcinoma, lymphoma, and leukemia may also present with similar lesions, as may metastatic Crohn’s disease, Dr. Jackson said. Several vasculitic and vasculopathic inflammatory conditions can also have similar appearances, including Wegener’s granulomatosis and vasoocclusive disorders such as peripheral vascular disease and cryoglobulinemia.

Classically, PG presents as painful ulcerated areas, most often on the lower extremities, that have a typical undermined border, caused by the sheets of neutrophils that characterize PG, he pointed out. PG may be mistaken for venous stasis ulcers, pressure ulcers, and cellulitis, but it doesn’t improve with antibiotics and mechanical manipulation from exfoliative dressings – and debridement may worsen the condition.

Courtesy Dr. J. Mark Jackson

For susceptible individuals, surgery may provoke a pathergic response and trigger PG at the site of the surgical wound, and dogged attempts at conventional wound care may cause continued pathergy and begin a vicious cycle, Dr. Jackson said.

Peristomal pyoderma gangrenosum is a disease subcategory that may be seen in patients whose inflammatory bowel disease has been surgically treated and who have a stoma. Patients will have ulcerating lesions around their stoma site that are often misdiagnosed and treated as infections. Some wound care therapies, such as debridement, may continue to provoke the pathergic response and worsen peristomal PG, he said.

Though associated disease is seen in up to 50% of individuals with PG, there’s no predictable timeline linking the development of PG with the course of the associated disorder. In classic PG, usually occurring on the legs, autoimmune diseases such as inflammatory bowel disease, rheumatoid arthritis or another inflammatory arthritis, and paraproteinemia may be seen. Atypical PG, occurring more commonly on the upper extremities and face, is associated with myelogenous leukemia and preleukemic states, Dr. Jackson said.

Pyoderma gangrenosum lesions improve with corticosteroid administration. Depending on disease severity and location, topical, intralesional, or systemic steroids may be used.

Adjunctive treatments for PG and other neutrophilic dermatoses can include antibiotics with anti-inflammatory properties, such as minocycline or doxycycline, dapsone, and metronidazole. Immunosuppressives such as cyclosporine, azathioprine, and mycophenolate mofetil may also help speed resolution. In some cases, skin grafts may be necessary.

Courtesy Dr. J. Mark Jackson

PG patients with Crohn’s disease or rheumatoid arthritis who are prescribed tumor necrosis factor–alpha (TNF-alpha) inhibitors for their systemic disease may also see improvement in PG lesions, Dr. Jackson said.

Other rare categories of neutrophilic dermatoses include Sweet’s syndrome, an acute febrile neutrophilic dermatosis, and neutrophilic dermatosis of the dorsum of the hand.

Neutrophilic invasion can also occur in other organs. “These extracutaneous lesions are also ‘sterile’ neutrophilic abscesses, which are often misdiagnosed as infections,” Dr. Jackson said. The most common site of extracutaneous neutrophilic infiltration is the lungs, though any organ system may be affected.

Dr. Jackson disclosed that he has received research support, honoraria, consulting fees, and other support from Abbvie, Amgen, Celgene, Dermira, Galderma, Genentech, Janssen, Lilly, Medimetriks, Merck, Novartis, Pfizer, Promius, and Top MD.

The Skin Disease Education Foundation and this news organization are owned by the same parent company.

[email protected]

On Twitter @karioakes

LAS VEGAS – Though pyoderma gangrenosum and other neutrophilic skin disorders are rare, clinicians should include them in their differential, especially for nonhealing surgical wounds or skin “infections.”

Since these painful areas of ulceration need corticosteroid treatment, not antibiotics, for resolution, accurate diagnosis is critical for healing, Dr. J. Mark Jackson said at the Skin Disease Education Foundation’s annual Las Vegas dermatology seminar.

In a review of pyoderma gangrenosum (PG) and its cousins at the meeting, Dr. Jackson noted that the etiology of PG is unknown, but disordered neutrophilic chemotaxis is thought to be a factor. The many different manifestations of this disease are now collectively called the “neutrophilic dermatoses,” he said.

“Pyoderma gangrenosum is a very important diagnosis to consider in the differential diagnosis for nonhealing ulcerations, as suspicion and early recognition of this debilitating condition can prevent long-term sequelae such as pain, scarring, and long-term immunosuppressive medications,” said Dr. Jackson of the department of dermatology at the University of Louisville (Ky.).

The diagnosis should be suspected in the setting of a painful cutaneous ulcer with necrolysis. The border is typically irregular, violaceous, and undermined, he said, adding that this classic undermined border is caused by the sheets of neutrophils that characterize the disease.

Noting that half of patients with PG have underlying associated conditions such as Crohn’s disease, ulcerative colitis, rheumatoid arthritis, and hematologic malignancies, Dr. Jackson emphasized that systemic disease associated with PG should heighten suspicion. “Histopathologic findings may be consistent with but not diagnostic of PG,” and can include a sterile dermal neutrophilia, with or without mixed inflammation and a lymphocytic vasculitis.

“Where you biopsy is important,” he continued, emphasizing that the biopsy must capture the margin of ulceration, where the sheets of neutrophils characteristic of PG will be seen on pathology.

Courtesy Dr. J. Mark Jackson

Therapy consists of corticosteroids, with or without an immunosuppressive agent, and cessation of treatments that may continue to provoke pathergy.

Other diseases should also be considered in the differential diagnosis, including dangerous infectious causes, such as atypical mycobacteria, deep fungal infections, and staphylococcal and streptococcal infections. Squamous cell carcinoma, lymphoma, and leukemia may also present with similar lesions, as may metastatic Crohn’s disease, Dr. Jackson said. Several vasculitic and vasculopathic inflammatory conditions can also have similar appearances, including Wegener’s granulomatosis and vasoocclusive disorders such as peripheral vascular disease and cryoglobulinemia.

Classically, PG presents as painful ulcerated areas, most often on the lower extremities, that have a typical undermined border, caused by the sheets of neutrophils that characterize PG, he pointed out. PG may be mistaken for venous stasis ulcers, pressure ulcers, and cellulitis, but it doesn’t improve with antibiotics and mechanical manipulation from exfoliative dressings – and debridement may worsen the condition.

Courtesy Dr. J. Mark Jackson

For susceptible individuals, surgery may provoke a pathergic response and trigger PG at the site of the surgical wound, and dogged attempts at conventional wound care may cause continued pathergy and begin a vicious cycle, Dr. Jackson said.

Peristomal pyoderma gangrenosum is a disease subcategory that may be seen in patients whose inflammatory bowel disease has been surgically treated and who have a stoma. Patients will have ulcerating lesions around their stoma site that are often misdiagnosed and treated as infections. Some wound care therapies, such as debridement, may continue to provoke the pathergic response and worsen peristomal PG, he said.

Though associated disease is seen in up to 50% of individuals with PG, there’s no predictable timeline linking the development of PG with the course of the associated disorder. In classic PG, usually occurring on the legs, autoimmune diseases such as inflammatory bowel disease, rheumatoid arthritis or another inflammatory arthritis, and paraproteinemia may be seen. Atypical PG, occurring more commonly on the upper extremities and face, is associated with myelogenous leukemia and preleukemic states, Dr. Jackson said.

Pyoderma gangrenosum lesions improve with corticosteroid administration. Depending on disease severity and location, topical, intralesional, or systemic steroids may be used.

Adjunctive treatments for PG and other neutrophilic dermatoses can include antibiotics with anti-inflammatory properties, such as minocycline or doxycycline, dapsone, and metronidazole. Immunosuppressives such as cyclosporine, azathioprine, and mycophenolate mofetil may also help speed resolution. In some cases, skin grafts may be necessary.

Courtesy Dr. J. Mark Jackson

PG patients with Crohn’s disease or rheumatoid arthritis who are prescribed tumor necrosis factor–alpha (TNF-alpha) inhibitors for their systemic disease may also see improvement in PG lesions, Dr. Jackson said.

Other rare categories of neutrophilic dermatoses include Sweet’s syndrome, an acute febrile neutrophilic dermatosis, and neutrophilic dermatosis of the dorsum of the hand.

Neutrophilic invasion can also occur in other organs. “These extracutaneous lesions are also ‘sterile’ neutrophilic abscesses, which are often misdiagnosed as infections,” Dr. Jackson said. The most common site of extracutaneous neutrophilic infiltration is the lungs, though any organ system may be affected.

Dr. Jackson disclosed that he has received research support, honoraria, consulting fees, and other support from Abbvie, Amgen, Celgene, Dermira, Galderma, Genentech, Janssen, Lilly, Medimetriks, Merck, Novartis, Pfizer, Promius, and Top MD.

The Skin Disease Education Foundation and this news organization are owned by the same parent company.

[email protected]

On Twitter @karioakes

When vaccinating children against influenza, inactivated and live attenuated influenza vaccines show little significant difference in effectiveness against nearly all strains of the virus, according to a new study in Pediatrics.

However, the study – which examined the effectiveness of IIV and LAIV across four consecutive influenza seasons between 2010 and 2014 – cautions that the 2013-2014 season’s A/(H1N1)pdm09 showed an uncharacteristically large gap in effectiveness favoring IIV, a discrepancy likely due to a problem with a vaccine component in LAIV. (Pediatrics. 2016;137(2):e20153279)

“We found that lower LAIV effectiveness in 2013-2014 was specific to the A/(H1N1)pdm09 vaccine component and was consistent with a previously unexamined effect during the 2010-2011 influenza season,” Jessie R. Chung of the influenza division at the Centers for Disease Control and Prevention and associates wrote, adding that the impetus for the study was the lack of available data “from observational studies after the 2009 pandemic on relative effectiveness of LAIV and IIV in children and adolescents.”

Ms. Chung* and coinvestigators enrolled children aged 2-17 years from clinics and hospitals in Michigan, New York, Pennsylvania, Tennessee, Texas, Washington, and Wisconsin during the 2010-2011, 2011-2012, 2012-2013, and 2013-2014 influenza seasons. Children brought in with symptoms of acute respiratory illness – cough, fever, or feverishness – had nasal and throat swabs collected to test for presence and type of influenza.

In total, 7,718 subjects were evaluated across the four influenza seasons, but after excluding subjects for various reasons – unknown vaccine type, indeterminate vaccine status, and inconclusive reverse transcription polymerase chain reaction results, among others – 6,819 subjects were included for vaccine effectiveness analysis, of which 2,703 were ultimately matched age appropriately and placed into IIV and LAIV cohorts for comparison. The IIV cohort consisted of 2,066 individuals (76.4%), while the LAIV cohort had 637 (23.6%).

During the 2010-2011 season, 66 of the 477 IIV subjects contracted influenza, versus 21 of 116 who received LAIV (14% vs. 18%, respectively). In the 2011-2012 season, 51 of the 499 IIV subjects (10%) contracted influenza, compared with 12 of the 152 LAIV subjects (8%). In the 2012-2013 season, 198 of the 622 IIV subjects (32%) contracted influenza, versus 61 of the 205 LAIV subjects (30%). But, in the 2013-2014 season, 36 of the 468 IIV subjects (8%) contracted influenza, versus 34 of the 164 LAIV subjects (21%).

After adjustment for age and season, the odds ratio for the 2013-2014 season was significantly higher than those of the other seasons across the entire age spectrum of 2-17 years: 2.88, compared with 1.49 (2010-2011), 0.67 (2011-2012), and 0.92 (2012-2013).

When comparing influenza type/subtype, adjusted odds ratio was 5.53 for those with A/(H1N1)pdm09 in the 2010-2011 season, compared with 2.65 for those with the same in the 2013-2014 season. Those with A/H3N2 did not show as significant a difference across seasons (2010-2013), nor did those with influenza type B (2010-2011, 2012-2013).

“We found no statistically significant difference in LAIV effectiveness compared with IIV against medically attended, laboratory-confirmed influenza illness due to A/H3N2 or B viruses,” Ms. Chung and colleagues concluded. “We found significantly higher odds of influenza A/(H1N1)pdm09 among participants vaccinated with LAIV, compared with IIV, [but] reasons for lower effectiveness of LAIV against the A/(H1N1)pdm09 virus, compared with IIV are not fully understood.”

The investigators added that “the finding appears to be specific to the A/(H1N1)pdm09 vaccine component; we did not detect any statistically significant differences in effectiveness for the other components.” Three previous randomized controlled trials indicated that trivalent LAIV was just as effective, if not more so, than IIV, making the findings of this study surprising and “unexpected,” the authors noted.

This study was supported by the CDC through cooperative agreements with a variety of universities and foundations, and funded by the National Institutes of Health. Ms. Chung and associates reported no relevant financial disclosures.

*A previous version of this story misstated Jessie Chung’s academic title. Ms. Chung holds a Master’s in public health.

[email protected]

When vaccinating children against influenza, inactivated and live attenuated influenza vaccines show little significant difference in effectiveness against nearly all strains of the virus, according to a new study in Pediatrics.

However, the study – which examined the effectiveness of IIV and LAIV across four consecutive influenza seasons between 2010 and 2014 – cautions that the 2013-2014 season’s A/(H1N1)pdm09 showed an uncharacteristically large gap in effectiveness favoring IIV, a discrepancy likely due to a problem with a vaccine component in LAIV. (Pediatrics. 2016;137(2):e20153279)

“We found that lower LAIV effectiveness in 2013-2014 was specific to the A/(H1N1)pdm09 vaccine component and was consistent with a previously unexamined effect during the 2010-2011 influenza season,” Jessie R. Chung of the influenza division at the Centers for Disease Control and Prevention and associates wrote, adding that the impetus for the study was the lack of available data “from observational studies after the 2009 pandemic on relative effectiveness of LAIV and IIV in children and adolescents.”

Ms. Chung* and coinvestigators enrolled children aged 2-17 years from clinics and hospitals in Michigan, New York, Pennsylvania, Tennessee, Texas, Washington, and Wisconsin during the 2010-2011, 2011-2012, 2012-2013, and 2013-2014 influenza seasons. Children brought in with symptoms of acute respiratory illness – cough, fever, or feverishness – had nasal and throat swabs collected to test for presence and type of influenza.

In total, 7,718 subjects were evaluated across the four influenza seasons, but after excluding subjects for various reasons – unknown vaccine type, indeterminate vaccine status, and inconclusive reverse transcription polymerase chain reaction results, among others – 6,819 subjects were included for vaccine effectiveness analysis, of which 2,703 were ultimately matched age appropriately and placed into IIV and LAIV cohorts for comparison. The IIV cohort consisted of 2,066 individuals (76.4%), while the LAIV cohort had 637 (23.6%).

During the 2010-2011 season, 66 of the 477 IIV subjects contracted influenza, versus 21 of 116 who received LAIV (14% vs. 18%, respectively). In the 2011-2012 season, 51 of the 499 IIV subjects (10%) contracted influenza, compared with 12 of the 152 LAIV subjects (8%). In the 2012-2013 season, 198 of the 622 IIV subjects (32%) contracted influenza, versus 61 of the 205 LAIV subjects (30%). But, in the 2013-2014 season, 36 of the 468 IIV subjects (8%) contracted influenza, versus 34 of the 164 LAIV subjects (21%).

After adjustment for age and season, the odds ratio for the 2013-2014 season was significantly higher than those of the other seasons across the entire age spectrum of 2-17 years: 2.88, compared with 1.49 (2010-2011), 0.67 (2011-2012), and 0.92 (2012-2013).

When comparing influenza type/subtype, adjusted odds ratio was 5.53 for those with A/(H1N1)pdm09 in the 2010-2011 season, compared with 2.65 for those with the same in the 2013-2014 season. Those with A/H3N2 did not show as significant a difference across seasons (2010-2013), nor did those with influenza type B (2010-2011, 2012-2013).

“We found no statistically significant difference in LAIV effectiveness compared with IIV against medically attended, laboratory-confirmed influenza illness due to A/H3N2 or B viruses,” Ms. Chung and colleagues concluded. “We found significantly higher odds of influenza A/(H1N1)pdm09 among participants vaccinated with LAIV, compared with IIV, [but] reasons for lower effectiveness of LAIV against the A/(H1N1)pdm09 virus, compared with IIV are not fully understood.”

The investigators added that “the finding appears to be specific to the A/(H1N1)pdm09 vaccine component; we did not detect any statistically significant differences in effectiveness for the other components.” Three previous randomized controlled trials indicated that trivalent LAIV was just as effective, if not more so, than IIV, making the findings of this study surprising and “unexpected,” the authors noted.

This study was supported by the CDC through cooperative agreements with a variety of universities and foundations, and funded by the National Institutes of Health. Ms. Chung and associates reported no relevant financial disclosures.

*A previous version of this story misstated Jessie Chung’s academic title. Ms. Chung holds a Master’s in public health.

[email protected]

When vaccinating children against influenza, inactivated and live attenuated influenza vaccines show little significant difference in effectiveness against nearly all strains of the virus, according to a new study in Pediatrics.

However, the study – which examined the effectiveness of IIV and LAIV across four consecutive influenza seasons between 2010 and 2014 – cautions that the 2013-2014 season’s A/(H1N1)pdm09 showed an uncharacteristically large gap in effectiveness favoring IIV, a discrepancy likely due to a problem with a vaccine component in LAIV. (Pediatrics. 2016;137(2):e20153279)

“We found that lower LAIV effectiveness in 2013-2014 was specific to the A/(H1N1)pdm09 vaccine component and was consistent with a previously unexamined effect during the 2010-2011 influenza season,” Jessie R. Chung of the influenza division at the Centers for Disease Control and Prevention and associates wrote, adding that the impetus for the study was the lack of available data “from observational studies after the 2009 pandemic on relative effectiveness of LAIV and IIV in children and adolescents.”

Ms. Chung* and coinvestigators enrolled children aged 2-17 years from clinics and hospitals in Michigan, New York, Pennsylvania, Tennessee, Texas, Washington, and Wisconsin during the 2010-2011, 2011-2012, 2012-2013, and 2013-2014 influenza seasons. Children brought in with symptoms of acute respiratory illness – cough, fever, or feverishness – had nasal and throat swabs collected to test for presence and type of influenza.

In total, 7,718 subjects were evaluated across the four influenza seasons, but after excluding subjects for various reasons – unknown vaccine type, indeterminate vaccine status, and inconclusive reverse transcription polymerase chain reaction results, among others – 6,819 subjects were included for vaccine effectiveness analysis, of which 2,703 were ultimately matched age appropriately and placed into IIV and LAIV cohorts for comparison. The IIV cohort consisted of 2,066 individuals (76.4%), while the LAIV cohort had 637 (23.6%).

During the 2010-2011 season, 66 of the 477 IIV subjects contracted influenza, versus 21 of 116 who received LAIV (14% vs. 18%, respectively). In the 2011-2012 season, 51 of the 499 IIV subjects (10%) contracted influenza, compared with 12 of the 152 LAIV subjects (8%). In the 2012-2013 season, 198 of the 622 IIV subjects (32%) contracted influenza, versus 61 of the 205 LAIV subjects (30%). But, in the 2013-2014 season, 36 of the 468 IIV subjects (8%) contracted influenza, versus 34 of the 164 LAIV subjects (21%).

After adjustment for age and season, the odds ratio for the 2013-2014 season was significantly higher than those of the other seasons across the entire age spectrum of 2-17 years: 2.88, compared with 1.49 (2010-2011), 0.67 (2011-2012), and 0.92 (2012-2013).

When comparing influenza type/subtype, adjusted odds ratio was 5.53 for those with A/(H1N1)pdm09 in the 2010-2011 season, compared with 2.65 for those with the same in the 2013-2014 season. Those with A/H3N2 did not show as significant a difference across seasons (2010-2013), nor did those with influenza type B (2010-2011, 2012-2013).

“We found no statistically significant difference in LAIV effectiveness compared with IIV against medically attended, laboratory-confirmed influenza illness due to A/H3N2 or B viruses,” Ms. Chung and colleagues concluded. “We found significantly higher odds of influenza A/(H1N1)pdm09 among participants vaccinated with LAIV, compared with IIV, [but] reasons for lower effectiveness of LAIV against the A/(H1N1)pdm09 virus, compared with IIV are not fully understood.”

The investigators added that “the finding appears to be specific to the A/(H1N1)pdm09 vaccine component; we did not detect any statistically significant differences in effectiveness for the other components.” Three previous randomized controlled trials indicated that trivalent LAIV was just as effective, if not more so, than IIV, making the findings of this study surprising and “unexpected,” the authors noted.

This study was supported by the CDC through cooperative agreements with a variety of universities and foundations, and funded by the National Institutes of Health. Ms. Chung and associates reported no relevant financial disclosures.

*A previous version of this story misstated Jessie Chung’s academic title. Ms. Chung holds a Master’s in public health.

[email protected]

Use of a novel reversible albumin-binding human growth hormone (GH) derivative administered subcutaneously once weekly for 4 weeks was safe and effective in adults with growth hormone deficiency, according to a phase I, randomized, open-label trial.

Results from a recent clinical trial of the agent, known as NNC0195-0092 and being developed by Norvo Nordisk, indicated the feasibility of a once-weekly dosing regimen in healthy men (J Clin Endocrinol Metab. 2014;99:E1819-29). The purpose of the current study was to report the first data obtained from a multiple-dose trial of NNC0195-0092 conducted in men and women at three hospitals in Denmark and one in Sweden.

“GH is currently administered as daily subcutaneous injections; however, a long-acting GH formulation that decreases injection frequency may improve treatment adherence and reduce the inconvenience associated with daily injections,” researchers led by Dr. Michael Højby Rasmussen wrote in the article published online Jan. 4 in the Journal of Clinical Endocrinology and Metabolism (2016. doi: 10.1210/jc.2015-1991). They went on to note that the plasma half-life of therapeutic peptides such as GH can be extended through binding to serum albumin, which “has a high affinity and binding capacity for fatty acids, and acylation of fatty acids to therapeutic proteins has been used to facilitate binding of these molecules to circulating albumin. In NNC0195-0092, fatty acids with noncovalent albumin-binding properties have been attached by acylation.”

Dr. Rasmussen of Novo Nordisk, Denmark, and his associates reported results from 25 men and nine women with a mean age of 53 years who were assigned into four cohorts of eight subjects and randomized to receive once-weekly NNC0195-0092 for 4 weeks in doses that ranged from 0.02 to 0.12 mg/kg, or daily injections of Norditropin NordiFlex for 4 weeks with a dose replicating the pretrial dose of somatropin. They found that the number of adverse events was similar at the 0.02, 0.04, and 0.08 mg/kg doses of NNC0195-0092, compared with the daily injections of Norditropin NordiFlex, while the number of adverse events was greatest at the 0.12 mg/kg dose of NNC0195-0092.

“No clinically significant safety and tolerability signals causally related to NNC0195-0092 were identified, nor were any immunogenicity concerns revealed,” the investigators concluded. “The IGF-I profiles were consistent with a once-weekly treatment profile of NNC0195-0092 at a starting dose of 0.02-0.04 mg/kg/wk.”

The trial was supported by Novo Nordisk. Dr. Rasmussen disclosed that he is an employee of the company.

[email protected]

Use of a novel reversible albumin-binding human growth hormone (GH) derivative administered subcutaneously once weekly for 4 weeks was safe and effective in adults with growth hormone deficiency, according to a phase I, randomized, open-label trial.

Results from a recent clinical trial of the agent, known as NNC0195-0092 and being developed by Norvo Nordisk, indicated the feasibility of a once-weekly dosing regimen in healthy men (J Clin Endocrinol Metab. 2014;99:E1819-29). The purpose of the current study was to report the first data obtained from a multiple-dose trial of NNC0195-0092 conducted in men and women at three hospitals in Denmark and one in Sweden.

“GH is currently administered as daily subcutaneous injections; however, a long-acting GH formulation that decreases injection frequency may improve treatment adherence and reduce the inconvenience associated with daily injections,” researchers led by Dr. Michael Højby Rasmussen wrote in the article published online Jan. 4 in the Journal of Clinical Endocrinology and Metabolism (2016. doi: 10.1210/jc.2015-1991). They went on to note that the plasma half-life of therapeutic peptides such as GH can be extended through binding to serum albumin, which “has a high affinity and binding capacity for fatty acids, and acylation of fatty acids to therapeutic proteins has been used to facilitate binding of these molecules to circulating albumin. In NNC0195-0092, fatty acids with noncovalent albumin-binding properties have been attached by acylation.”

Dr. Rasmussen of Novo Nordisk, Denmark, and his associates reported results from 25 men and nine women with a mean age of 53 years who were assigned into four cohorts of eight subjects and randomized to receive once-weekly NNC0195-0092 for 4 weeks in doses that ranged from 0.02 to 0.12 mg/kg, or daily injections of Norditropin NordiFlex for 4 weeks with a dose replicating the pretrial dose of somatropin. They found that the number of adverse events was similar at the 0.02, 0.04, and 0.08 mg/kg doses of NNC0195-0092, compared with the daily injections of Norditropin NordiFlex, while the number of adverse events was greatest at the 0.12 mg/kg dose of NNC0195-0092.

“No clinically significant safety and tolerability signals causally related to NNC0195-0092 were identified, nor were any immunogenicity concerns revealed,” the investigators concluded. “The IGF-I profiles were consistent with a once-weekly treatment profile of NNC0195-0092 at a starting dose of 0.02-0.04 mg/kg/wk.”

The trial was supported by Novo Nordisk. Dr. Rasmussen disclosed that he is an employee of the company.

[email protected]

Use of a novel reversible albumin-binding human growth hormone (GH) derivative administered subcutaneously once weekly for 4 weeks was safe and effective in adults with growth hormone deficiency, according to a phase I, randomized, open-label trial.

Results from a recent clinical trial of the agent, known as NNC0195-0092 and being developed by Norvo Nordisk, indicated the feasibility of a once-weekly dosing regimen in healthy men (J Clin Endocrinol Metab. 2014;99:E1819-29). The purpose of the current study was to report the first data obtained from a multiple-dose trial of NNC0195-0092 conducted in men and women at three hospitals in Denmark and one in Sweden.

“GH is currently administered as daily subcutaneous injections; however, a long-acting GH formulation that decreases injection frequency may improve treatment adherence and reduce the inconvenience associated with daily injections,” researchers led by Dr. Michael Højby Rasmussen wrote in the article published online Jan. 4 in the Journal of Clinical Endocrinology and Metabolism (2016. doi: 10.1210/jc.2015-1991). They went on to note that the plasma half-life of therapeutic peptides such as GH can be extended through binding to serum albumin, which “has a high affinity and binding capacity for fatty acids, and acylation of fatty acids to therapeutic proteins has been used to facilitate binding of these molecules to circulating albumin. In NNC0195-0092, fatty acids with noncovalent albumin-binding properties have been attached by acylation.”

Dr. Rasmussen of Novo Nordisk, Denmark, and his associates reported results from 25 men and nine women with a mean age of 53 years who were assigned into four cohorts of eight subjects and randomized to receive once-weekly NNC0195-0092 for 4 weeks in doses that ranged from 0.02 to 0.12 mg/kg, or daily injections of Norditropin NordiFlex for 4 weeks with a dose replicating the pretrial dose of somatropin. They found that the number of adverse events was similar at the 0.02, 0.04, and 0.08 mg/kg doses of NNC0195-0092, compared with the daily injections of Norditropin NordiFlex, while the number of adverse events was greatest at the 0.12 mg/kg dose of NNC0195-0092.

“No clinically significant safety and tolerability signals causally related to NNC0195-0092 were identified, nor were any immunogenicity concerns revealed,” the investigators concluded. “The IGF-I profiles were consistent with a once-weekly treatment profile of NNC0195-0092 at a starting dose of 0.02-0.04 mg/kg/wk.”

The trial was supported by Novo Nordisk. Dr. Rasmussen disclosed that he is an employee of the company.

[email protected]

Fractures of the cuboid bone are uncommon, with an annual incidence of approximately 1.8 per 100,000.¹ This is largely attributed to the inherent stability provided by its anatomy and position in the foot’s lateral column, where it functions as a link between the lateral column and transverse plantar arch.² Regarding its anatomy, the cuboid is a pyramidal-shaped bone with 6 bony surfaces that provide tremendous stability—3 of these are articular, 3 nonarticular.

Although the cuboid bone is susceptible to low-energy avulsion injuries, injuries that occur in the setting of high-energy trauma are most concerning, as they often occur concurrently with other midfoot fractures and dislocations. These less common crush injuries are associated with comminution, articular disruption, and shortening of the lateral column.^3-5 Avulsion injuries occur via a twisting mechanism, while the more complex nutcracker fracture evolves via longitudinal compression of the lateral column, with the foot in a position of forced plantarflexion.⁶ Other comminuted fractures occur from direct impact on the lateral aspect of the foot.

Management of cuboid fractures varies according to etiology, fracture displacement, and articular involvement. Conservative management is reserved solely for stable, nondisplaced fractures.⁷ Unstable fracture-dislocations and those with associated lateral column shortening necessitate operative treatment, which attempts to restore anatomy, stability, and length of the foot’s lateral column.^7-9 However, with the exception of open injuries, fractures tenting the skin, and injuries with concomitant compartment syndrome, the high-energy nature of cuboid fractures often precludes early surgical intervention, as the foot’s soft-tissue envelope is too compromised. For this reason, operative intervention is often performed on a delayed basis only after recovery of the soft tissue.

In this case report and literature review, we describe a reconstructive shelf arthroplasty of the fifth tarsometatarsal (TMT) joint as a primary intervention for crush-type cuboid fractures with associated joint subsidence and lateral column shortening. The shelf arthroplasty, which was first credited to Konig in 1891, has historically been described as a remodeling operation using bone graft wedges for the treatment of nonconcentric acetabular dysplasia.¹⁰ Although bone grafting is recognized as an effective means of addressing osseous voids in the setting of comminuted cuboid fractures, its specific application in the form of a shelf arthroplasty has not been described.¹¹ The patient provided written informed consent for print and electronic publication of this case report.

Case Report

An otherwise healthy 45-year-old woman presented to our institution’s emergency department (ED) complaining of right foot pain after a motor vehicle accident. She was the restrained driver in a head-on collision. Primary survey revealed a swollen, ecchymotic, and tender right foot. Radiographs demonstrated fractures of her first, second, third, and fourth metatarsals, and a comminuted cuboid fracture with lateral column shortening and disruption of the fifth TMT joint (Figure 1).

Due to swelling, initial management consisted of soft-tissue management through the use of a well-padded splint. As this was her only injury, she was instructed to remain non-weight-bearing, ambulate with crutches, and return to our outpatient office for close follow-up. The need for delayed surgical intervention of her multiple foot injuries, due to her compromised soft-tissue envelope, was discussed prior to discharge.

Surgical intervention was performed 15 days after the injury, when the soft-tissue swelling had dissipated. The surgical plan included fixation of the multiple metatarsal fractures and lateral column reconstruction and stabilization. With regard to the lateral column, we obtained patient consent for several possible procedures, including fifth TMT joint closed reduction and percutaneous pinning, open reduction and internal fixation (ORIF), and TMT joint reconstruction with iliac crest bone graft (ICBG).

The metatarsals were addressed first via a dorsomedial incision, using a 5-hole 2.7-mm Limited Contact Dynamic Compression Plate (Synthes) to stabilize the first metatarsal and 2.0-mm Kirschner wires (K-wires) to maintain the length and alignment of the second, third, and fourth metatarsals (Figure 2). Closed reduction and percutaneous pinning of the fifth metatarsal was then attempted but abandoned because of persistent instability and subsidence of the cuboid in the proximal and plantar direction. ORIF was then attempted through a dorsolateral incision extending from just distal to the sinus tarsi to the base of the fourth metatarsal. However, the lateral cuboid was too comminuted to accommodate any fixation and prevent fifth TMT joint subluxation and lateral column shortening.

Autograft reconstruction of the lateral column was therefore performed, using radiographs of the patient’s uninjured, contralateral foot as a template for our lateral column shelf arthroplasty (Figure 3). Based on this template, the length and alignment of the lateral column were provisionally maintained with two 2.0-mm K-wires placed between the fifth metatarsal and intact cuboid (Figure 4). Tricortical ICBG was then harvested through an anterior approach to the iliac crest and contoured accordingly to fill the osseous void. To facilitate graft incorporation, comminuted fragments of cuboid bone were removed, with the remaining bone decorticated. The graft was then fixed to the remaining cuboid with two 4.0-mm partially threaded cannulated screws (Synthes; Figures 2, 4). This construct restored the length of the lateral column and effectively buttressed the fifth TMT joint, preventing subsidence and dislocation of the TMT joint.

After a 2-day postoperative course in the hospital, the patient was discharged. She remained non-weight-bearing in a splint with Robert Jones cotton bandage. At her 2-week postoperative visit, all hardware was intact and there was no evidence of infection. Her sutures were removed and she was placed in a new splint. At the patient’s 5-week postoperative visit, all K-wires were removed. At this time she remained non-weight-bearing but was transitioned into a controlled ankle movement (CAM) boot and was allowed to begin active and passive ankle exercises. At her 10-week follow-up, radiographs revealed appropriate interval healing and callus formation. The patient began weight-bearing as tolerated in the CAM boot at that time. At 12 weeks, she was transitioned into a hard-soled shoe for comfort and was allowed to ambulate in the footwear of her choice as tolerated. Her activity levels were slowly advanced, and, at her 12-month follow-up, the patient had returned to playing tennis in her recreational league with no residual sequelae (Figure 5).

Discussion

Although rare, cuboid fractures are critical to identify and can result in significant disability, as they are frequently associated with additional foot trauma, as demonstrated in this case.^1-4When isolated cuboid fractures are present, further imaging must be performed, including additional radiographic views and computed tomography, to search for other injuries, such as TMT joint complex disruption.

Only those cuboid fractures that are low-energy, stable, or nondisplaced can be effectively managed conservatively.¹²In the presence of instability, articular incongruity, or lateral column shortening, operative intervention is warranted. Arthritic degeneration, pain, and deformity result from residual incongruity at the calcaneocuboid or TMT joints, or when lateral column length is not restored.^4-6,13 The latter leads to forefoot abduction and lateral subluxation of the lesser metatarsals, with ensuing posttraumatic pes planus or planovalgus deformity, which often necessitates secondary reconstructive procedures or arthrodesis.^14,15 Stable reduction and restoration of lateral column length can be challenging, particularly in the setting of comminution and bone loss. Common methods of treatment involve lifting the dorsolateral cortex of the cuboid and buttressing the impacted articular surface with bone graft or bone graft substitutes. Fixation can be achieved with K-wires, small fragment plates and screws, and distraction external fixation.¹¹ The latter is a particularly beneficial technique, as it can be used independent of or in conjunction with ORIF.

In a study by Weber and Locher,¹¹ the short-term to midterm results of cuboid ORIF were assessed in 12 patients. Results were found to be good with respect to restoration of length, joint reconstruction, and overall return to function.¹¹ Admittedly, these authors at times employed a similar but conceptually different approach to our patient. In their 7 patients with severe comminution and lateral column shortening, corticocancellous ICBG was used. However, Weber and Locher¹¹did not describe this as a shelf arthroplasty, but instead as an adjunct to primary ORIF.

In our case, the tricortical ICBG shelf arthroplasty was used as it is in the hip, as a salvage procedure. Although little is known about outcomes following shelf arthroplasty for lateral column reconstruction in the foot, a 50% failure rate has been observed in the hip.¹⁶ As such, our preference was to perform an anatomic ORIF of the cuboid and lateral column, with the shelf arthroplasty only indicated if we were unable to achieve this. We believe that the need for tricortical ICBG in the treatment of cuboid fractures is indicative of a more severe injury and that it is a less optimal and more technically demanding intervention compared with primary ORIF. Furthermore, in other studies devoted to the treatment of cuboid fractures, patients requiring reconstruction with structural graft are not included in primary ORIF cohorts.¹⁷

As in the hip, suboptimal outcomes may occur when shelf arthroplasty is performed in the foot. There are additional considerations unique to the foot that surgeons must also contemplate when considering shelf arthroplasty. As demonstrated in the literature for adult-acquired flatfoot deformity, lateral column reconstruction is challenging and controversial and is associated with overload, pain, and the need to remove prominent hardware.¹⁸ These complications may also occur after shelf arthroplasty for cuboid fractures.

The work by Weber and Locher¹¹ did not elucidate such considerations, and outcomes of ORIF and ICBG reconstruction were not compared. This is a limitation of their study, as differences in functional outcomes between the 2 procedures remain unknown. Given the degree of comminution that precludes ORIF and necessitates a graft reconstruction, we believe that the description of the shelf arthroplasty as a salvage procedure more accurately reflects the severity of injury. This may have implications regarding outcomes and patient expectations that the orthopedic surgeon must address. Future studies must further evaluate the outcomes of this technique, independent of and in comparison with ORIF.

Conclusion

In this case, we describe shelf arthroplasty for cuboid fractures. It is a reconstructive salvage procedure that is indicated when ORIF cannot be achieved. This useful approach to a complex injury must remain in the armamentarium of orthopedic surgeons. As we have demonstrated, it can effectively restore a damaged lateral column, providing length and, in our case, enabling the patient to return to her pre-injury level of activity.

Fractures of the cuboid bone are uncommon, with an annual incidence of approximately 1.8 per 100,000.¹ This is largely attributed to the inherent stability provided by its anatomy and position in the foot’s lateral column, where it functions as a link between the lateral column and transverse plantar arch.² Regarding its anatomy, the cuboid is a pyramidal-shaped bone with 6 bony surfaces that provide tremendous stability—3 of these are articular, 3 nonarticular.

Although the cuboid bone is susceptible to low-energy avulsion injuries, injuries that occur in the setting of high-energy trauma are most concerning, as they often occur concurrently with other midfoot fractures and dislocations. These less common crush injuries are associated with comminution, articular disruption, and shortening of the lateral column.^3-5 Avulsion injuries occur via a twisting mechanism, while the more complex nutcracker fracture evolves via longitudinal compression of the lateral column, with the foot in a position of forced plantarflexion.⁶ Other comminuted fractures occur from direct impact on the lateral aspect of the foot.

Management of cuboid fractures varies according to etiology, fracture displacement, and articular involvement. Conservative management is reserved solely for stable, nondisplaced fractures.⁷ Unstable fracture-dislocations and those with associated lateral column shortening necessitate operative treatment, which attempts to restore anatomy, stability, and length of the foot’s lateral column.^7-9 However, with the exception of open injuries, fractures tenting the skin, and injuries with concomitant compartment syndrome, the high-energy nature of cuboid fractures often precludes early surgical intervention, as the foot’s soft-tissue envelope is too compromised. For this reason, operative intervention is often performed on a delayed basis only after recovery of the soft tissue.

In this case report and literature review, we describe a reconstructive shelf arthroplasty of the fifth tarsometatarsal (TMT) joint as a primary intervention for crush-type cuboid fractures with associated joint subsidence and lateral column shortening. The shelf arthroplasty, which was first credited to Konig in 1891, has historically been described as a remodeling operation using bone graft wedges for the treatment of nonconcentric acetabular dysplasia.¹⁰ Although bone grafting is recognized as an effective means of addressing osseous voids in the setting of comminuted cuboid fractures, its specific application in the form of a shelf arthroplasty has not been described.¹¹ The patient provided written informed consent for print and electronic publication of this case report.

Case Report

An otherwise healthy 45-year-old woman presented to our institution’s emergency department (ED) complaining of right foot pain after a motor vehicle accident. She was the restrained driver in a head-on collision. Primary survey revealed a swollen, ecchymotic, and tender right foot. Radiographs demonstrated fractures of her first, second, third, and fourth metatarsals, and a comminuted cuboid fracture with lateral column shortening and disruption of the fifth TMT joint (Figure 1).

Due to swelling, initial management consisted of soft-tissue management through the use of a well-padded splint. As this was her only injury, she was instructed to remain non-weight-bearing, ambulate with crutches, and return to our outpatient office for close follow-up. The need for delayed surgical intervention of her multiple foot injuries, due to her compromised soft-tissue envelope, was discussed prior to discharge.

Surgical intervention was performed 15 days after the injury, when the soft-tissue swelling had dissipated. The surgical plan included fixation of the multiple metatarsal fractures and lateral column reconstruction and stabilization. With regard to the lateral column, we obtained patient consent for several possible procedures, including fifth TMT joint closed reduction and percutaneous pinning, open reduction and internal fixation (ORIF), and TMT joint reconstruction with iliac crest bone graft (ICBG).

The metatarsals were addressed first via a dorsomedial incision, using a 5-hole 2.7-mm Limited Contact Dynamic Compression Plate (Synthes) to stabilize the first metatarsal and 2.0-mm Kirschner wires (K-wires) to maintain the length and alignment of the second, third, and fourth metatarsals (Figure 2). Closed reduction and percutaneous pinning of the fifth metatarsal was then attempted but abandoned because of persistent instability and subsidence of the cuboid in the proximal and plantar direction. ORIF was then attempted through a dorsolateral incision extending from just distal to the sinus tarsi to the base of the fourth metatarsal. However, the lateral cuboid was too comminuted to accommodate any fixation and prevent fifth TMT joint subluxation and lateral column shortening.

Autograft reconstruction of the lateral column was therefore performed, using radiographs of the patient’s uninjured, contralateral foot as a template for our lateral column shelf arthroplasty (Figure 3). Based on this template, the length and alignment of the lateral column were provisionally maintained with two 2.0-mm K-wires placed between the fifth metatarsal and intact cuboid (Figure 4). Tricortical ICBG was then harvested through an anterior approach to the iliac crest and contoured accordingly to fill the osseous void. To facilitate graft incorporation, comminuted fragments of cuboid bone were removed, with the remaining bone decorticated. The graft was then fixed to the remaining cuboid with two 4.0-mm partially threaded cannulated screws (Synthes; Figures 2, 4). This construct restored the length of the lateral column and effectively buttressed the fifth TMT joint, preventing subsidence and dislocation of the TMT joint.

After a 2-day postoperative course in the hospital, the patient was discharged. She remained non-weight-bearing in a splint with Robert Jones cotton bandage. At her 2-week postoperative visit, all hardware was intact and there was no evidence of infection. Her sutures were removed and she was placed in a new splint. At the patient’s 5-week postoperative visit, all K-wires were removed. At this time she remained non-weight-bearing but was transitioned into a controlled ankle movement (CAM) boot and was allowed to begin active and passive ankle exercises. At her 10-week follow-up, radiographs revealed appropriate interval healing and callus formation. The patient began weight-bearing as tolerated in the CAM boot at that time. At 12 weeks, she was transitioned into a hard-soled shoe for comfort and was allowed to ambulate in the footwear of her choice as tolerated. Her activity levels were slowly advanced, and, at her 12-month follow-up, the patient had returned to playing tennis in her recreational league with no residual sequelae (Figure 5).

Discussion

Although rare, cuboid fractures are critical to identify and can result in significant disability, as they are frequently associated with additional foot trauma, as demonstrated in this case.^1-4When isolated cuboid fractures are present, further imaging must be performed, including additional radiographic views and computed tomography, to search for other injuries, such as TMT joint complex disruption.

Only those cuboid fractures that are low-energy, stable, or nondisplaced can be effectively managed conservatively.¹²In the presence of instability, articular incongruity, or lateral column shortening, operative intervention is warranted. Arthritic degeneration, pain, and deformity result from residual incongruity at the calcaneocuboid or TMT joints, or when lateral column length is not restored.^4-6,13 The latter leads to forefoot abduction and lateral subluxation of the lesser metatarsals, with ensuing posttraumatic pes planus or planovalgus deformity, which often necessitates secondary reconstructive procedures or arthrodesis.^14,15 Stable reduction and restoration of lateral column length can be challenging, particularly in the setting of comminution and bone loss. Common methods of treatment involve lifting the dorsolateral cortex of the cuboid and buttressing the impacted articular surface with bone graft or bone graft substitutes. Fixation can be achieved with K-wires, small fragment plates and screws, and distraction external fixation.¹¹ The latter is a particularly beneficial technique, as it can be used independent of or in conjunction with ORIF.

In a study by Weber and Locher,¹¹ the short-term to midterm results of cuboid ORIF were assessed in 12 patients. Results were found to be good with respect to restoration of length, joint reconstruction, and overall return to function.¹¹ Admittedly, these authors at times employed a similar but conceptually different approach to our patient. In their 7 patients with severe comminution and lateral column shortening, corticocancellous ICBG was used. However, Weber and Locher¹¹did not describe this as a shelf arthroplasty, but instead as an adjunct to primary ORIF.

In our case, the tricortical ICBG shelf arthroplasty was used as it is in the hip, as a salvage procedure. Although little is known about outcomes following shelf arthroplasty for lateral column reconstruction in the foot, a 50% failure rate has been observed in the hip.¹⁶ As such, our preference was to perform an anatomic ORIF of the cuboid and lateral column, with the shelf arthroplasty only indicated if we were unable to achieve this. We believe that the need for tricortical ICBG in the treatment of cuboid fractures is indicative of a more severe injury and that it is a less optimal and more technically demanding intervention compared with primary ORIF. Furthermore, in other studies devoted to the treatment of cuboid fractures, patients requiring reconstruction with structural graft are not included in primary ORIF cohorts.¹⁷

As in the hip, suboptimal outcomes may occur when shelf arthroplasty is performed in the foot. There are additional considerations unique to the foot that surgeons must also contemplate when considering shelf arthroplasty. As demonstrated in the literature for adult-acquired flatfoot deformity, lateral column reconstruction is challenging and controversial and is associated with overload, pain, and the need to remove prominent hardware.¹⁸ These complications may also occur after shelf arthroplasty for cuboid fractures.

The work by Weber and Locher¹¹ did not elucidate such considerations, and outcomes of ORIF and ICBG reconstruction were not compared. This is a limitation of their study, as differences in functional outcomes between the 2 procedures remain unknown. Given the degree of comminution that precludes ORIF and necessitates a graft reconstruction, we believe that the description of the shelf arthroplasty as a salvage procedure more accurately reflects the severity of injury. This may have implications regarding outcomes and patient expectations that the orthopedic surgeon must address. Future studies must further evaluate the outcomes of this technique, independent of and in comparison with ORIF.

Conclusion

In this case, we describe shelf arthroplasty for cuboid fractures. It is a reconstructive salvage procedure that is indicated when ORIF cannot be achieved. This useful approach to a complex injury must remain in the armamentarium of orthopedic surgeons. As we have demonstrated, it can effectively restore a damaged lateral column, providing length and, in our case, enabling the patient to return to her pre-injury level of activity.

Fractures of the cuboid bone are uncommon, with an annual incidence of approximately 1.8 per 100,000.¹ This is largely attributed to the inherent stability provided by its anatomy and position in the foot’s lateral column, where it functions as a link between the lateral column and transverse plantar arch.² Regarding its anatomy, the cuboid is a pyramidal-shaped bone with 6 bony surfaces that provide tremendous stability—3 of these are articular, 3 nonarticular.

Although the cuboid bone is susceptible to low-energy avulsion injuries, injuries that occur in the setting of high-energy trauma are most concerning, as they often occur concurrently with other midfoot fractures and dislocations. These less common crush injuries are associated with comminution, articular disruption, and shortening of the lateral column.^3-5 Avulsion injuries occur via a twisting mechanism, while the more complex nutcracker fracture evolves via longitudinal compression of the lateral column, with the foot in a position of forced plantarflexion.⁶ Other comminuted fractures occur from direct impact on the lateral aspect of the foot.

Management of cuboid fractures varies according to etiology, fracture displacement, and articular involvement. Conservative management is reserved solely for stable, nondisplaced fractures.⁷ Unstable fracture-dislocations and those with associated lateral column shortening necessitate operative treatment, which attempts to restore anatomy, stability, and length of the foot’s lateral column.^7-9 However, with the exception of open injuries, fractures tenting the skin, and injuries with concomitant compartment syndrome, the high-energy nature of cuboid fractures often precludes early surgical intervention, as the foot’s soft-tissue envelope is too compromised. For this reason, operative intervention is often performed on a delayed basis only after recovery of the soft tissue.

In this case report and literature review, we describe a reconstructive shelf arthroplasty of the fifth tarsometatarsal (TMT) joint as a primary intervention for crush-type cuboid fractures with associated joint subsidence and lateral column shortening. The shelf arthroplasty, which was first credited to Konig in 1891, has historically been described as a remodeling operation using bone graft wedges for the treatment of nonconcentric acetabular dysplasia.¹⁰ Although bone grafting is recognized as an effective means of addressing osseous voids in the setting of comminuted cuboid fractures, its specific application in the form of a shelf arthroplasty has not been described.¹¹ The patient provided written informed consent for print and electronic publication of this case report.

Case Report

An otherwise healthy 45-year-old woman presented to our institution’s emergency department (ED) complaining of right foot pain after a motor vehicle accident. She was the restrained driver in a head-on collision. Primary survey revealed a swollen, ecchymotic, and tender right foot. Radiographs demonstrated fractures of her first, second, third, and fourth metatarsals, and a comminuted cuboid fracture with lateral column shortening and disruption of the fifth TMT joint (Figure 1).

Due to swelling, initial management consisted of soft-tissue management through the use of a well-padded splint. As this was her only injury, she was instructed to remain non-weight-bearing, ambulate with crutches, and return to our outpatient office for close follow-up. The need for delayed surgical intervention of her multiple foot injuries, due to her compromised soft-tissue envelope, was discussed prior to discharge.

Surgical intervention was performed 15 days after the injury, when the soft-tissue swelling had dissipated. The surgical plan included fixation of the multiple metatarsal fractures and lateral column reconstruction and stabilization. With regard to the lateral column, we obtained patient consent for several possible procedures, including fifth TMT joint closed reduction and percutaneous pinning, open reduction and internal fixation (ORIF), and TMT joint reconstruction with iliac crest bone graft (ICBG).

The metatarsals were addressed first via a dorsomedial incision, using a 5-hole 2.7-mm Limited Contact Dynamic Compression Plate (Synthes) to stabilize the first metatarsal and 2.0-mm Kirschner wires (K-wires) to maintain the length and alignment of the second, third, and fourth metatarsals (Figure 2). Closed reduction and percutaneous pinning of the fifth metatarsal was then attempted but abandoned because of persistent instability and subsidence of the cuboid in the proximal and plantar direction. ORIF was then attempted through a dorsolateral incision extending from just distal to the sinus tarsi to the base of the fourth metatarsal. However, the lateral cuboid was too comminuted to accommodate any fixation and prevent fifth TMT joint subluxation and lateral column shortening.

Autograft reconstruction of the lateral column was therefore performed, using radiographs of the patient’s uninjured, contralateral foot as a template for our lateral column shelf arthroplasty (Figure 3). Based on this template, the length and alignment of the lateral column were provisionally maintained with two 2.0-mm K-wires placed between the fifth metatarsal and intact cuboid (Figure 4). Tricortical ICBG was then harvested through an anterior approach to the iliac crest and contoured accordingly to fill the osseous void. To facilitate graft incorporation, comminuted fragments of cuboid bone were removed, with the remaining bone decorticated. The graft was then fixed to the remaining cuboid with two 4.0-mm partially threaded cannulated screws (Synthes; Figures 2, 4). This construct restored the length of the lateral column and effectively buttressed the fifth TMT joint, preventing subsidence and dislocation of the TMT joint.

After a 2-day postoperative course in the hospital, the patient was discharged. She remained non-weight-bearing in a splint with Robert Jones cotton bandage. At her 2-week postoperative visit, all hardware was intact and there was no evidence of infection. Her sutures were removed and she was placed in a new splint. At the patient’s 5-week postoperative visit, all K-wires were removed. At this time she remained non-weight-bearing but was transitioned into a controlled ankle movement (CAM) boot and was allowed to begin active and passive ankle exercises. At her 10-week follow-up, radiographs revealed appropriate interval healing and callus formation. The patient began weight-bearing as tolerated in the CAM boot at that time. At 12 weeks, she was transitioned into a hard-soled shoe for comfort and was allowed to ambulate in the footwear of her choice as tolerated. Her activity levels were slowly advanced, and, at her 12-month follow-up, the patient had returned to playing tennis in her recreational league with no residual sequelae (Figure 5).

Discussion

Although rare, cuboid fractures are critical to identify and can result in significant disability, as they are frequently associated with additional foot trauma, as demonstrated in this case.^1-4When isolated cuboid fractures are present, further imaging must be performed, including additional radiographic views and computed tomography, to search for other injuries, such as TMT joint complex disruption.

Only those cuboid fractures that are low-energy, stable, or nondisplaced can be effectively managed conservatively.¹²In the presence of instability, articular incongruity, or lateral column shortening, operative intervention is warranted. Arthritic degeneration, pain, and deformity result from residual incongruity at the calcaneocuboid or TMT joints, or when lateral column length is not restored.^4-6,13 The latter leads to forefoot abduction and lateral subluxation of the lesser metatarsals, with ensuing posttraumatic pes planus or planovalgus deformity, which often necessitates secondary reconstructive procedures or arthrodesis.^14,15 Stable reduction and restoration of lateral column length can be challenging, particularly in the setting of comminution and bone loss. Common methods of treatment involve lifting the dorsolateral cortex of the cuboid and buttressing the impacted articular surface with bone graft or bone graft substitutes. Fixation can be achieved with K-wires, small fragment plates and screws, and distraction external fixation.¹¹ The latter is a particularly beneficial technique, as it can be used independent of or in conjunction with ORIF.

In a study by Weber and Locher,¹¹ the short-term to midterm results of cuboid ORIF were assessed in 12 patients. Results were found to be good with respect to restoration of length, joint reconstruction, and overall return to function.¹¹ Admittedly, these authors at times employed a similar but conceptually different approach to our patient. In their 7 patients with severe comminution and lateral column shortening, corticocancellous ICBG was used. However, Weber and Locher¹¹did not describe this as a shelf arthroplasty, but instead as an adjunct to primary ORIF.

In our case, the tricortical ICBG shelf arthroplasty was used as it is in the hip, as a salvage procedure. Although little is known about outcomes following shelf arthroplasty for lateral column reconstruction in the foot, a 50% failure rate has been observed in the hip.¹⁶ As such, our preference was to perform an anatomic ORIF of the cuboid and lateral column, with the shelf arthroplasty only indicated if we were unable to achieve this. We believe that the need for tricortical ICBG in the treatment of cuboid fractures is indicative of a more severe injury and that it is a less optimal and more technically demanding intervention compared with primary ORIF. Furthermore, in other studies devoted to the treatment of cuboid fractures, patients requiring reconstruction with structural graft are not included in primary ORIF cohorts.¹⁷

As in the hip, suboptimal outcomes may occur when shelf arthroplasty is performed in the foot. There are additional considerations unique to the foot that surgeons must also contemplate when considering shelf arthroplasty. As demonstrated in the literature for adult-acquired flatfoot deformity, lateral column reconstruction is challenging and controversial and is associated with overload, pain, and the need to remove prominent hardware.¹⁸ These complications may also occur after shelf arthroplasty for cuboid fractures.

The work by Weber and Locher¹¹ did not elucidate such considerations, and outcomes of ORIF and ICBG reconstruction were not compared. This is a limitation of their study, as differences in functional outcomes between the 2 procedures remain unknown. Given the degree of comminution that precludes ORIF and necessitates a graft reconstruction, we believe that the description of the shelf arthroplasty as a salvage procedure more accurately reflects the severity of injury. This may have implications regarding outcomes and patient expectations that the orthopedic surgeon must address. Future studies must further evaluate the outcomes of this technique, independent of and in comparison with ORIF.

Conclusion

In this case, we describe shelf arthroplasty for cuboid fractures. It is a reconstructive salvage procedure that is indicated when ORIF cannot be achieved. This useful approach to a complex injury must remain in the armamentarium of orthopedic surgeons. As we have demonstrated, it can effectively restore a damaged lateral column, providing length and, in our case, enabling the patient to return to her pre-injury level of activity.