Used for centuries by humans for its health-promoting qualities, royal jelly is a yellowish, viscous secretion from the hypopharyngeal and mandibular glands of worker bees that nourishes bee larvae of all kinds (i.e., drones, workers, queens) after which it becomes the exclusive nourishment for queens throughout their development.^1-3 A wide range of biologic activity has been attributed to royal jelly, including antitumor, antibacterial, anti-inflammatory, antioxidant, collagen production-promoting, immunomodulatory, and wound healing.^3-8 Royal jelly is used in cosmetics, health tonics (particularly in Asia), dietary supplements, and beverages.^2,9

Produced from pollen, royal jelly contains water, proteins (82%-90% of which are known as the major royal jelly proteins, with five primary members), lipids – including its primary unsaturated fatty acid, 10-hydroxy-2-decenoic acid (10-HDA) – sugars, carbohydrates, free amino acids, vitamins, and minerals.^4,7,10 Many of the benefits to human health linked to royal jelly can be partly attributed to the activity of its lipids, particularly 10-HDA, which render the royal jelly emulsion highly acidic and impart antimicrobial properties.¹⁰ These and other constituents of royal jelly operate in ways that are thought to yield broad protection against skin aging and cancer development, modulation of the immune system, induction of neurogenesis, and alleviation of menopausal symptoms.¹ This column will focus on recent studies pertaining to the topical use of royal jelly.

Wound healing

In 2008, Abdelatif et al. conducted a pilot study to determine the safety and effectiveness of a then-new ointment combining royal jelly and panthenol (Pedyphar) in 60 patients with limb-threatening diabetic foot infections. After 9 weeks of treatment and through 6 months of follow-up, 96% of subjects with full-thickness skin ulcers (Wagner grades 1 and 2) or deep tissue infection and suspected osteomyelitis (grade 3) responded well, with all grade 1 and 2 ulcers healing and 92% of grade 3 ulcers healing. All patients with gangrenous lesions (grades 4 and 5) healed after surgical excision, debridement, and conservative treatment with the royal jelly/panthenol product. The researchers called for more double-blind, randomized controlled studies to confirm their promising findings of the safety and efficacy of the royal jelly/panthenol combination.¹¹

Two years later, Kim et al. treated freshly scratched normal human dermal fibroblasts with different concentrations of royal jelly (0.1 mg/mL, 1.0 mg/mL, or 5 mg/mL) for up to 48 hours. Fibroblast migration was found to have peaked at 24 hours after wound induction, with royal jelly significantly and dose-dependently accelerating the migration at the 8-hour mark. Royal jelly also influenced several fibroblast lipids involved in the wound healing process, with a decrease in cholesterol level and an increase in sphinganines.¹²

A small study with eight subjects was done in 2011 by Siavash et al. to evaluate the efficacy of topically applied royal jelly for diabetic foot ulcers. Seven of the eight ulcers treated healed, with a mean healing time of 41 days. The eighth ulcer improved, diminishing significantly in size. The researchers concluded that a royal jelly dressing is an effective alternative for treatment of diabetic foot ulcers.¹³ However, the same team conducted a double-blind, placebo-controlled clinical trial of topical royal jelly on diabetic foot ulcers in 25 patients (6 females, 19 males) and found no significant differences between 5% sterile topical royal jelly or placebo.⁶

Collagen production

shootthebreeze/thinkstockphotos.com

A decade ago, Koya-Miyata et al. showed that royal jelly promotes collagen synthesis by skin fibroblasts in the presence of ascorbic acid-2-O-alpha-glucoside. They also showed that its primary fatty acid constituent, 10-HDA, facilitates the collagen production by fibroblasts treated with ascorbic acid-2-O-alpha-glucoside through activation of transforming growth factor-beta 1 production.₅

Photoprotection

Park et al. measured the 10-HDA content of royal jelly in 2011 and studied its effects on UVB-induced skin photoaging in normal human dermal fibroblasts. The introduction of royal jelly (0.211% 10-HDA) promoted the production of procollagen type I and transforming growth factor (TGF)-beta-1 without affecting matrix metalloproteinase (MMP)-1 levels. The investigators concluded that the impact of royal jelly on collagen production positioned the bee product as a potential photoprotectant against UVB-induced photoaging.¹⁴ The next year, Park et al. observed that the production of type I collagen in the dorsal skin of ovariectomized Sprague-Dawley rats was enhanced by the dietary supplementation of 1% royal jelly extract. Although MMP-1 levels were unaffected, the investigators speculated that the effects on collagen synthesis alone were sufficient for royal jelly to provide anti-aging activity.⁴

In 2013, Zheng et al. found that 10-HDA significantly protected fibroblasts from UVA-induced cytotoxicity, reactive oxygen species, and cellular senescence. They also noted that 10-HDA inhibited the UVA-generated expression of MMP-1 and -3, and stimulated collagen production. Treatment with 10-HDA also reduced the activation of the c-Jun N-terminal kinase (JNK) and p38 mitogen-activated protein kinase (MAPK) pathways. The researchers concluded that this royal jelly fatty acid appears to be a promising agent for the prevention and treatment of cutaneous photoaging.⁸

Skin whitening

In 2011, Han et al. reported that royal jelly dose-dependently inhibited melanin biosynthesis in the B16F1 mouse melanocyte cell line by reducing tyrosinase activity. Royal jelly also lowered mRNA levels of tyrosinase. The investigators concluded that royal jelly may be a viable option in the skin-lightening arsenal.³

Safety

There are some reports of contact dermatitis from the use of topical royal jelly.¹⁵ Far more significant, while rare, adverse reactions have been linked to oral use of royal jelly, including acute asthma, anaphylaxis, and even death.^2,16,17

Conclusion

Royal jelly is one of several bee products found to have beneficial health effects in humans. Various dermatologic applications of royal jelly have been employed in recent decades. More research is necessary, though, to determine just how useful this bee product may be for a range of cutaneous conditions.

References

1. J Med Food. 2013;16(2):96-102.

2. Biosci Biotechnol Biochem. 2013;77(4):789-95.

3. Am J Chin Med. 2011;39(6):1253-60.

4. J Med Food. 2012;15(6):568-75.

5. Biosci Biotechnol Biochem. 2004 Apr;68(4):767-73.

6. Int Wound J. 2015;12(2):137-42.

7. J Food Sci. 2008 Nov;73(9):R117-24.

8. J Eur Acad Dermatol. Venereol. 2013;27(10):1269-77.

9. Pharmacogn Mag. 2013;9(33):9-13.

10. Ayu. 2012;33(2):178-82.

11. J Wound Care. 2008;17(3):108-10.

12. Nutr Res Pract. 2010;4(5):362-8.

13. J Res Med Sci. 2011;16(7):904-9.

14. J Med Food. 2011;14(9):899-906.

15. Contact Dermatitis. 1983;9(6):452-5.

16. Trop Biomed. 2008;25(3):243-51.

17. J Dermatol. 2011;38(11):1079-81.

Dr. Baumann is chief executive officer of the Baumann Cosmetic & Research Institute in the Design District in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann wrote the textbook, “Cosmetic Dermatology: Principles and Practice” (New York: McGraw-Hill, 2002), and a book for consumers, “The Skin Type Solution” (New York: Bantam Dell, 2006). She has contributed to the Cosmeceutical Critique column in Dermatology News since January 2001. Her latest book, “Cosmeceuticals and Cosmetic Ingredients,” was published in November 2014. Dr. Baumann has received funding for clinical grants from Allergan, Aveeno, Avon Products, Evolus, Galderma, GlaxoSmithKline, Kythera Biopharmaceuticals, Mary Kay, Medicis Pharmaceuticals, Neutrogena, Philosophy, Topix Pharmaceuticals, and Unilever.

Used for centuries by humans for its health-promoting qualities, royal jelly is a yellowish, viscous secretion from the hypopharyngeal and mandibular glands of worker bees that nourishes bee larvae of all kinds (i.e., drones, workers, queens) after which it becomes the exclusive nourishment for queens throughout their development.^1-3 A wide range of biologic activity has been attributed to royal jelly, including antitumor, antibacterial, anti-inflammatory, antioxidant, collagen production-promoting, immunomodulatory, and wound healing.^3-8 Royal jelly is used in cosmetics, health tonics (particularly in Asia), dietary supplements, and beverages.^2,9

Produced from pollen, royal jelly contains water, proteins (82%-90% of which are known as the major royal jelly proteins, with five primary members), lipids – including its primary unsaturated fatty acid, 10-hydroxy-2-decenoic acid (10-HDA) – sugars, carbohydrates, free amino acids, vitamins, and minerals.^4,7,10 Many of the benefits to human health linked to royal jelly can be partly attributed to the activity of its lipids, particularly 10-HDA, which render the royal jelly emulsion highly acidic and impart antimicrobial properties.¹⁰ These and other constituents of royal jelly operate in ways that are thought to yield broad protection against skin aging and cancer development, modulation of the immune system, induction of neurogenesis, and alleviation of menopausal symptoms.¹ This column will focus on recent studies pertaining to the topical use of royal jelly.

Wound healing

In 2008, Abdelatif et al. conducted a pilot study to determine the safety and effectiveness of a then-new ointment combining royal jelly and panthenol (Pedyphar) in 60 patients with limb-threatening diabetic foot infections. After 9 weeks of treatment and through 6 months of follow-up, 96% of subjects with full-thickness skin ulcers (Wagner grades 1 and 2) or deep tissue infection and suspected osteomyelitis (grade 3) responded well, with all grade 1 and 2 ulcers healing and 92% of grade 3 ulcers healing. All patients with gangrenous lesions (grades 4 and 5) healed after surgical excision, debridement, and conservative treatment with the royal jelly/panthenol product. The researchers called for more double-blind, randomized controlled studies to confirm their promising findings of the safety and efficacy of the royal jelly/panthenol combination.¹¹

Two years later, Kim et al. treated freshly scratched normal human dermal fibroblasts with different concentrations of royal jelly (0.1 mg/mL, 1.0 mg/mL, or 5 mg/mL) for up to 48 hours. Fibroblast migration was found to have peaked at 24 hours after wound induction, with royal jelly significantly and dose-dependently accelerating the migration at the 8-hour mark. Royal jelly also influenced several fibroblast lipids involved in the wound healing process, with a decrease in cholesterol level and an increase in sphinganines.¹²

A small study with eight subjects was done in 2011 by Siavash et al. to evaluate the efficacy of topically applied royal jelly for diabetic foot ulcers. Seven of the eight ulcers treated healed, with a mean healing time of 41 days. The eighth ulcer improved, diminishing significantly in size. The researchers concluded that a royal jelly dressing is an effective alternative for treatment of diabetic foot ulcers.¹³ However, the same team conducted a double-blind, placebo-controlled clinical trial of topical royal jelly on diabetic foot ulcers in 25 patients (6 females, 19 males) and found no significant differences between 5% sterile topical royal jelly or placebo.⁶

Collagen production

shootthebreeze/thinkstockphotos.com

A decade ago, Koya-Miyata et al. showed that royal jelly promotes collagen synthesis by skin fibroblasts in the presence of ascorbic acid-2-O-alpha-glucoside. They also showed that its primary fatty acid constituent, 10-HDA, facilitates the collagen production by fibroblasts treated with ascorbic acid-2-O-alpha-glucoside through activation of transforming growth factor-beta 1 production.₅

Photoprotection

Park et al. measured the 10-HDA content of royal jelly in 2011 and studied its effects on UVB-induced skin photoaging in normal human dermal fibroblasts. The introduction of royal jelly (0.211% 10-HDA) promoted the production of procollagen type I and transforming growth factor (TGF)-beta-1 without affecting matrix metalloproteinase (MMP)-1 levels. The investigators concluded that the impact of royal jelly on collagen production positioned the bee product as a potential photoprotectant against UVB-induced photoaging.¹⁴ The next year, Park et al. observed that the production of type I collagen in the dorsal skin of ovariectomized Sprague-Dawley rats was enhanced by the dietary supplementation of 1% royal jelly extract. Although MMP-1 levels were unaffected, the investigators speculated that the effects on collagen synthesis alone were sufficient for royal jelly to provide anti-aging activity.⁴

In 2013, Zheng et al. found that 10-HDA significantly protected fibroblasts from UVA-induced cytotoxicity, reactive oxygen species, and cellular senescence. They also noted that 10-HDA inhibited the UVA-generated expression of MMP-1 and -3, and stimulated collagen production. Treatment with 10-HDA also reduced the activation of the c-Jun N-terminal kinase (JNK) and p38 mitogen-activated protein kinase (MAPK) pathways. The researchers concluded that this royal jelly fatty acid appears to be a promising agent for the prevention and treatment of cutaneous photoaging.⁸

Skin whitening

In 2011, Han et al. reported that royal jelly dose-dependently inhibited melanin biosynthesis in the B16F1 mouse melanocyte cell line by reducing tyrosinase activity. Royal jelly also lowered mRNA levels of tyrosinase. The investigators concluded that royal jelly may be a viable option in the skin-lightening arsenal.³

Safety

There are some reports of contact dermatitis from the use of topical royal jelly.¹⁵ Far more significant, while rare, adverse reactions have been linked to oral use of royal jelly, including acute asthma, anaphylaxis, and even death.^2,16,17

Conclusion

Royal jelly is one of several bee products found to have beneficial health effects in humans. Various dermatologic applications of royal jelly have been employed in recent decades. More research is necessary, though, to determine just how useful this bee product may be for a range of cutaneous conditions.

References

1. J Med Food. 2013;16(2):96-102.

2. Biosci Biotechnol Biochem. 2013;77(4):789-95.

3. Am J Chin Med. 2011;39(6):1253-60.

4. J Med Food. 2012;15(6):568-75.

5. Biosci Biotechnol Biochem. 2004 Apr;68(4):767-73.

6. Int Wound J. 2015;12(2):137-42.

7. J Food Sci. 2008 Nov;73(9):R117-24.

8. J Eur Acad Dermatol. Venereol. 2013;27(10):1269-77.

9. Pharmacogn Mag. 2013;9(33):9-13.

10. Ayu. 2012;33(2):178-82.

11. J Wound Care. 2008;17(3):108-10.

12. Nutr Res Pract. 2010;4(5):362-8.

13. J Res Med Sci. 2011;16(7):904-9.

14. J Med Food. 2011;14(9):899-906.

15. Contact Dermatitis. 1983;9(6):452-5.

16. Trop Biomed. 2008;25(3):243-51.

17. J Dermatol. 2011;38(11):1079-81.

Dr. Baumann is chief executive officer of the Baumann Cosmetic & Research Institute in the Design District in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann wrote the textbook, “Cosmetic Dermatology: Principles and Practice” (New York: McGraw-Hill, 2002), and a book for consumers, “The Skin Type Solution” (New York: Bantam Dell, 2006). She has contributed to the Cosmeceutical Critique column in Dermatology News since January 2001. Her latest book, “Cosmeceuticals and Cosmetic Ingredients,” was published in November 2014. Dr. Baumann has received funding for clinical grants from Allergan, Aveeno, Avon Products, Evolus, Galderma, GlaxoSmithKline, Kythera Biopharmaceuticals, Mary Kay, Medicis Pharmaceuticals, Neutrogena, Philosophy, Topix Pharmaceuticals, and Unilever.

Used for centuries by humans for its health-promoting qualities, royal jelly is a yellowish, viscous secretion from the hypopharyngeal and mandibular glands of worker bees that nourishes bee larvae of all kinds (i.e., drones, workers, queens) after which it becomes the exclusive nourishment for queens throughout their development.^1-3 A wide range of biologic activity has been attributed to royal jelly, including antitumor, antibacterial, anti-inflammatory, antioxidant, collagen production-promoting, immunomodulatory, and wound healing.^3-8 Royal jelly is used in cosmetics, health tonics (particularly in Asia), dietary supplements, and beverages.^2,9

Produced from pollen, royal jelly contains water, proteins (82%-90% of which are known as the major royal jelly proteins, with five primary members), lipids – including its primary unsaturated fatty acid, 10-hydroxy-2-decenoic acid (10-HDA) – sugars, carbohydrates, free amino acids, vitamins, and minerals.^4,7,10 Many of the benefits to human health linked to royal jelly can be partly attributed to the activity of its lipids, particularly 10-HDA, which render the royal jelly emulsion highly acidic and impart antimicrobial properties.¹⁰ These and other constituents of royal jelly operate in ways that are thought to yield broad protection against skin aging and cancer development, modulation of the immune system, induction of neurogenesis, and alleviation of menopausal symptoms.¹ This column will focus on recent studies pertaining to the topical use of royal jelly.

Wound healing

In 2008, Abdelatif et al. conducted a pilot study to determine the safety and effectiveness of a then-new ointment combining royal jelly and panthenol (Pedyphar) in 60 patients with limb-threatening diabetic foot infections. After 9 weeks of treatment and through 6 months of follow-up, 96% of subjects with full-thickness skin ulcers (Wagner grades 1 and 2) or deep tissue infection and suspected osteomyelitis (grade 3) responded well, with all grade 1 and 2 ulcers healing and 92% of grade 3 ulcers healing. All patients with gangrenous lesions (grades 4 and 5) healed after surgical excision, debridement, and conservative treatment with the royal jelly/panthenol product. The researchers called for more double-blind, randomized controlled studies to confirm their promising findings of the safety and efficacy of the royal jelly/panthenol combination.¹¹

Two years later, Kim et al. treated freshly scratched normal human dermal fibroblasts with different concentrations of royal jelly (0.1 mg/mL, 1.0 mg/mL, or 5 mg/mL) for up to 48 hours. Fibroblast migration was found to have peaked at 24 hours after wound induction, with royal jelly significantly and dose-dependently accelerating the migration at the 8-hour mark. Royal jelly also influenced several fibroblast lipids involved in the wound healing process, with a decrease in cholesterol level and an increase in sphinganines.¹²

A small study with eight subjects was done in 2011 by Siavash et al. to evaluate the efficacy of topically applied royal jelly for diabetic foot ulcers. Seven of the eight ulcers treated healed, with a mean healing time of 41 days. The eighth ulcer improved, diminishing significantly in size. The researchers concluded that a royal jelly dressing is an effective alternative for treatment of diabetic foot ulcers.¹³ However, the same team conducted a double-blind, placebo-controlled clinical trial of topical royal jelly on diabetic foot ulcers in 25 patients (6 females, 19 males) and found no significant differences between 5% sterile topical royal jelly or placebo.⁶

Collagen production

shootthebreeze/thinkstockphotos.com

A decade ago, Koya-Miyata et al. showed that royal jelly promotes collagen synthesis by skin fibroblasts in the presence of ascorbic acid-2-O-alpha-glucoside. They also showed that its primary fatty acid constituent, 10-HDA, facilitates the collagen production by fibroblasts treated with ascorbic acid-2-O-alpha-glucoside through activation of transforming growth factor-beta 1 production.₅

Photoprotection

Park et al. measured the 10-HDA content of royal jelly in 2011 and studied its effects on UVB-induced skin photoaging in normal human dermal fibroblasts. The introduction of royal jelly (0.211% 10-HDA) promoted the production of procollagen type I and transforming growth factor (TGF)-beta-1 without affecting matrix metalloproteinase (MMP)-1 levels. The investigators concluded that the impact of royal jelly on collagen production positioned the bee product as a potential photoprotectant against UVB-induced photoaging.¹⁴ The next year, Park et al. observed that the production of type I collagen in the dorsal skin of ovariectomized Sprague-Dawley rats was enhanced by the dietary supplementation of 1% royal jelly extract. Although MMP-1 levels were unaffected, the investigators speculated that the effects on collagen synthesis alone were sufficient for royal jelly to provide anti-aging activity.⁴

In 2013, Zheng et al. found that 10-HDA significantly protected fibroblasts from UVA-induced cytotoxicity, reactive oxygen species, and cellular senescence. They also noted that 10-HDA inhibited the UVA-generated expression of MMP-1 and -3, and stimulated collagen production. Treatment with 10-HDA also reduced the activation of the c-Jun N-terminal kinase (JNK) and p38 mitogen-activated protein kinase (MAPK) pathways. The researchers concluded that this royal jelly fatty acid appears to be a promising agent for the prevention and treatment of cutaneous photoaging.⁸

Skin whitening

In 2011, Han et al. reported that royal jelly dose-dependently inhibited melanin biosynthesis in the B16F1 mouse melanocyte cell line by reducing tyrosinase activity. Royal jelly also lowered mRNA levels of tyrosinase. The investigators concluded that royal jelly may be a viable option in the skin-lightening arsenal.³

Safety

There are some reports of contact dermatitis from the use of topical royal jelly.¹⁵ Far more significant, while rare, adverse reactions have been linked to oral use of royal jelly, including acute asthma, anaphylaxis, and even death.^2,16,17

Conclusion

Royal jelly is one of several bee products found to have beneficial health effects in humans. Various dermatologic applications of royal jelly have been employed in recent decades. More research is necessary, though, to determine just how useful this bee product may be for a range of cutaneous conditions.

References

1. J Med Food. 2013;16(2):96-102.

2. Biosci Biotechnol Biochem. 2013;77(4):789-95.

3. Am J Chin Med. 2011;39(6):1253-60.

4. J Med Food. 2012;15(6):568-75.

5. Biosci Biotechnol Biochem. 2004 Apr;68(4):767-73.

6. Int Wound J. 2015;12(2):137-42.

7. J Food Sci. 2008 Nov;73(9):R117-24.

8. J Eur Acad Dermatol. Venereol. 2013;27(10):1269-77.

9. Pharmacogn Mag. 2013;9(33):9-13.

10. Ayu. 2012;33(2):178-82.

11. J Wound Care. 2008;17(3):108-10.

12. Nutr Res Pract. 2010;4(5):362-8.

13. J Res Med Sci. 2011;16(7):904-9.

14. J Med Food. 2011;14(9):899-906.

15. Contact Dermatitis. 1983;9(6):452-5.

16. Trop Biomed. 2008;25(3):243-51.

17. J Dermatol. 2011;38(11):1079-81.

Dr. Baumann is chief executive officer of the Baumann Cosmetic & Research Institute in the Design District in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann wrote the textbook, “Cosmetic Dermatology: Principles and Practice” (New York: McGraw-Hill, 2002), and a book for consumers, “The Skin Type Solution” (New York: Bantam Dell, 2006). She has contributed to the Cosmeceutical Critique column in Dermatology News since January 2001. Her latest book, “Cosmeceuticals and Cosmetic Ingredients,” was published in November 2014. Dr. Baumann has received funding for clinical grants from Allergan, Aveeno, Avon Products, Evolus, Galderma, GlaxoSmithKline, Kythera Biopharmaceuticals, Mary Kay, Medicis Pharmaceuticals, Neutrogena, Philosophy, Topix Pharmaceuticals, and Unilever.

A mentor—now in his 60s—related his experiences as a resident. On call as a second-year resident, he would often be alone at a busy trauma center with no backup. When a case came in, he would quickly read about it in the library, then manage it in the emergency department (ED) if possible, or, if necessary, take the patient to the operating room (OR).

In the era of improved patient care, increased supervision, and decreased autonomy, this is not the reality anymore.¹ In theory, more reliable patient care is the result; however, the pendulum may have swung too far.

There are a number of injuries that are amenable to definitive fixation in the ED, but not as limited an array of injuries as we have perhaps grown accustomed to. Hand injuries are among the most common orthopedic injuries seen in the ED, with fractures of the metacarpals and phalanges constituting nearly one-half of all hand injuries.² The authors recently attended an excellent instructional course lecture on “The Lost and Found Art of Percutaneous Pinning in the Hand and Wrist” at the annual conference of the American Academy of Orthopaedic Surgeons.³ The presenters itemized a comprehensive list of fractures and simple dislocations of the hand, which could be simply, safely, effectively, and definitively managed through percutaneous pinning techniques. A significant number of unstable fractures of the phalanges and metacarpals can be treated in the ED under mini–C-arm fluoroscopy without an admission and trip to the OR.^3,4 Most phalangeal and metacarpal fractures are nondisplaced or minimally displaced and stable, and can often be handled with a combination of closed reduction, buddy-taping, and splinting.⁵ The indications for percutaneous versus internal fixation depend on a number of factors, including bone quality, degree of comminution, quality of the soft-tissue envelope, articular involvement, acuity of presentation, and goals for motion.^6,7

Many simple injury patterns involving unstable fractures or dislocations may be definitively managed in the ED with percutaneous pinning (eg, injuries that are unstable with closed reduction alone but that do not necessitate soft-tissue dissection). These include but are not limited to bony mallet injuries, unstable transverse or oblique fractures or fracture-dislocations of the phalanges and metacarpals, carpometacarpal fracture- dislocations, and underlying fractures that need protection of nail-bed repairs, soft-tissue flaps, or extensor tendon injuries (Figures 1, 2).^7,8 The techniques for specific fracture types are beyond the scope of this article but are readily available.^5,6

There are certain situations that undoubtedly warrant surgery in the OR, such as neurovascular injury necessitating microvascular repair, flexor tendon laceration, severely comminuted or segmental fractures, irreducible dislocations, and fractures with severe soft-tissue injury or contamination not amenable to primary irrigation, débridement, and closure at bedside.^4,7,8

You might ask, “Why would one treat an operative injury in the ED and not formally in the OR?,” and we submit that there are a number of reasons.

First, and most important, with increasing health care costs and decreasing reimbursements, physicians are faced with providing safe but economical care. Percutaneous Kirschner wire (K-wire) fixation is dramatically more cost-effective when performed in the ED than in the OR. The cost of a procedure performed in either setting is similarly dependent on a variety of factors, generally including complexity of the patient or procedure, costs of supplies and pharmacologic agents, fixed versus variable overhead costs, and the professional fees of providers and ancillary personnel.^9,10

While the patient is not charged per hour in the ED, it is estimated that ORs in the United States cost, on average, $62 per minute, ranging from as low as $22 to as high as $133 per minute.⁹ Additionally, the number of personnel involved in running an OR exceeds those for a similar procedure performed in the ED, considering (at a minimum) the orthopedic surgeon, anesthesiologist, scrub and radiology technicians, and nursing personnel required before, during, and after an operation.

While analgesia and procedural sedation can be performed similarly in either setting, it is our experience that patients are managed much more often in the ED with local anesthesia under direct care of only the orthopedic provider, whereas intravenous sedation and general anesthesia are far more commonly implemented in the OR. There are exceptions for pediatric patients or those who are unable to tolerate the procedure under only local anesthesia. Local anesthesia or even intravenous conscious sedation entails less risk as well as lower associated drug costs.¹¹

The difference in risk is especially true for sicker patients undergoing minimally invasive procedures.¹¹ Although administration of adequate procedural analgesia grows increasingly difficult the more proximal the injury, the hand and the fingers are easily and reliably anesthetized with well-placed wrist or digital blocks, with infrequent complications.¹² Application of a lidocaine/bupivacaine mixture provides up to 6 to 8 hours of analgesia. A small tourniquet alternative, such as the finger of a sterile glove or phlebotomy tourniquet, applied to the base of the finger or the wrist additionally provides a relatively bloodless field and effectively acts as a Bier block.

Percutaneous pins are much more forgiving than rigid internal fixation. If the initial placement of a pin is unsatisfactory, the pin can be reinserted at little cost.¹² Conversely, it may not be possible to reposition a misplaced screw or screw with inadequate purchase and still maintain adequate fixation. While percutaneous pin fixation is not as rigid as screw fixation, the degree of stability provided is adequate for the small forces affecting the hand in most cases. Accordingly, there is a very low incidence of fibrous union or nonunion.^13,14 With an increasing appreciation of soft-tissue handling over the past few decades, another significant advantage of K-wire fixation is the obviation of soft-tissue dissection, preserving the biology to maximize healing and minimize adverse sequelae.¹² Percutaneous fixation has been shown to achieve functional outcomes comparable to open reduction with internal fixation of operative phalangeal and metacarpal fractures, without soft-tissue disruption, scarring, or implant irritation, and with minimal risk of infection.^3,13,15,16 Ultimate range of motion after percutaneous fixation is comparable, if not superior, to that of internal fixation, despite the initial advantage of rigid internal fixation secondary to decreased scarring and lack of indwelling hardware.^16,17

While the risk of infection, perhaps the primary concern with percutaneous fixation, has been cited as high as 7%, osteomyelitis is exceedingly rare (<0.5%).^3,13,14 Furthermore, pins are often left in place for 3 to 6 weeks, and infection has been found to occur most often at a mean of 10 weeks.^7,13 Infection can also be mitigated by intelligent pin placement, relief of residual tension, and splint immobilization.^4,15 Pin loosening has similarly been reported in up to 4% of cases in large retrospective studies, occurring at an average of 8 weeks, by which time most pins would have been extricated.¹³ Other complications related to impaling adjacent neurovascular or tendinous structures have also been cited but are rare.¹³ A 12-month prospective study of 75 patients specifically evaluating the outcomes after closed reduction with percutaneous fixation of unstable hand fractures in the ED reported only 6 complications at final follow-up.⁴ Complications were all minor, with no cases of nonunion, delayed union, malunion, pin-tract infection, pyarthrosis, or cellulitis, even in the setting of open fractures. Three patients required revision in the OR for pin migration, initial malreduction, and bone loss in the setting of comminution, respectively. The authors credited their low complication rate to supplementary immobilization.

In conclusion, many unstable simple fractures and dislocations of the hand and wrist can be safely and effectively treated in the ED. While it may seem daunting for a junior resident who is unfamiliar with percutaneous techniques, the authors advocate learning from a more senior mentor. The only additional training required is an understanding of how to apply this skill set in a different setting.

A mentor—now in his 60s—related his experiences as a resident. On call as a second-year resident, he would often be alone at a busy trauma center with no backup. When a case came in, he would quickly read about it in the library, then manage it in the emergency department (ED) if possible, or, if necessary, take the patient to the operating room (OR).

In the era of improved patient care, increased supervision, and decreased autonomy, this is not the reality anymore.¹ In theory, more reliable patient care is the result; however, the pendulum may have swung too far.

There are a number of injuries that are amenable to definitive fixation in the ED, but not as limited an array of injuries as we have perhaps grown accustomed to. Hand injuries are among the most common orthopedic injuries seen in the ED, with fractures of the metacarpals and phalanges constituting nearly one-half of all hand injuries.² The authors recently attended an excellent instructional course lecture on “The Lost and Found Art of Percutaneous Pinning in the Hand and Wrist” at the annual conference of the American Academy of Orthopaedic Surgeons.³ The presenters itemized a comprehensive list of fractures and simple dislocations of the hand, which could be simply, safely, effectively, and definitively managed through percutaneous pinning techniques. A significant number of unstable fractures of the phalanges and metacarpals can be treated in the ED under mini–C-arm fluoroscopy without an admission and trip to the OR.^3,4 Most phalangeal and metacarpal fractures are nondisplaced or minimally displaced and stable, and can often be handled with a combination of closed reduction, buddy-taping, and splinting.⁵ The indications for percutaneous versus internal fixation depend on a number of factors, including bone quality, degree of comminution, quality of the soft-tissue envelope, articular involvement, acuity of presentation, and goals for motion.^6,7

Many simple injury patterns involving unstable fractures or dislocations may be definitively managed in the ED with percutaneous pinning (eg, injuries that are unstable with closed reduction alone but that do not necessitate soft-tissue dissection). These include but are not limited to bony mallet injuries, unstable transverse or oblique fractures or fracture-dislocations of the phalanges and metacarpals, carpometacarpal fracture- dislocations, and underlying fractures that need protection of nail-bed repairs, soft-tissue flaps, or extensor tendon injuries (Figures 1, 2).^7,8 The techniques for specific fracture types are beyond the scope of this article but are readily available.^5,6

There are certain situations that undoubtedly warrant surgery in the OR, such as neurovascular injury necessitating microvascular repair, flexor tendon laceration, severely comminuted or segmental fractures, irreducible dislocations, and fractures with severe soft-tissue injury or contamination not amenable to primary irrigation, débridement, and closure at bedside.^4,7,8

You might ask, “Why would one treat an operative injury in the ED and not formally in the OR?,” and we submit that there are a number of reasons.

First, and most important, with increasing health care costs and decreasing reimbursements, physicians are faced with providing safe but economical care. Percutaneous Kirschner wire (K-wire) fixation is dramatically more cost-effective when performed in the ED than in the OR. The cost of a procedure performed in either setting is similarly dependent on a variety of factors, generally including complexity of the patient or procedure, costs of supplies and pharmacologic agents, fixed versus variable overhead costs, and the professional fees of providers and ancillary personnel.^9,10

While the patient is not charged per hour in the ED, it is estimated that ORs in the United States cost, on average, $62 per minute, ranging from as low as $22 to as high as $133 per minute.⁹ Additionally, the number of personnel involved in running an OR exceeds those for a similar procedure performed in the ED, considering (at a minimum) the orthopedic surgeon, anesthesiologist, scrub and radiology technicians, and nursing personnel required before, during, and after an operation.

While analgesia and procedural sedation can be performed similarly in either setting, it is our experience that patients are managed much more often in the ED with local anesthesia under direct care of only the orthopedic provider, whereas intravenous sedation and general anesthesia are far more commonly implemented in the OR. There are exceptions for pediatric patients or those who are unable to tolerate the procedure under only local anesthesia. Local anesthesia or even intravenous conscious sedation entails less risk as well as lower associated drug costs.¹¹

The difference in risk is especially true for sicker patients undergoing minimally invasive procedures.¹¹ Although administration of adequate procedural analgesia grows increasingly difficult the more proximal the injury, the hand and the fingers are easily and reliably anesthetized with well-placed wrist or digital blocks, with infrequent complications.¹² Application of a lidocaine/bupivacaine mixture provides up to 6 to 8 hours of analgesia. A small tourniquet alternative, such as the finger of a sterile glove or phlebotomy tourniquet, applied to the base of the finger or the wrist additionally provides a relatively bloodless field and effectively acts as a Bier block.

Percutaneous pins are much more forgiving than rigid internal fixation. If the initial placement of a pin is unsatisfactory, the pin can be reinserted at little cost.¹² Conversely, it may not be possible to reposition a misplaced screw or screw with inadequate purchase and still maintain adequate fixation. While percutaneous pin fixation is not as rigid as screw fixation, the degree of stability provided is adequate for the small forces affecting the hand in most cases. Accordingly, there is a very low incidence of fibrous union or nonunion.^13,14 With an increasing appreciation of soft-tissue handling over the past few decades, another significant advantage of K-wire fixation is the obviation of soft-tissue dissection, preserving the biology to maximize healing and minimize adverse sequelae.¹² Percutaneous fixation has been shown to achieve functional outcomes comparable to open reduction with internal fixation of operative phalangeal and metacarpal fractures, without soft-tissue disruption, scarring, or implant irritation, and with minimal risk of infection.^3,13,15,16 Ultimate range of motion after percutaneous fixation is comparable, if not superior, to that of internal fixation, despite the initial advantage of rigid internal fixation secondary to decreased scarring and lack of indwelling hardware.^16,17

While the risk of infection, perhaps the primary concern with percutaneous fixation, has been cited as high as 7%, osteomyelitis is exceedingly rare (<0.5%).^3,13,14 Furthermore, pins are often left in place for 3 to 6 weeks, and infection has been found to occur most often at a mean of 10 weeks.^7,13 Infection can also be mitigated by intelligent pin placement, relief of residual tension, and splint immobilization.^4,15 Pin loosening has similarly been reported in up to 4% of cases in large retrospective studies, occurring at an average of 8 weeks, by which time most pins would have been extricated.¹³ Other complications related to impaling adjacent neurovascular or tendinous structures have also been cited but are rare.¹³ A 12-month prospective study of 75 patients specifically evaluating the outcomes after closed reduction with percutaneous fixation of unstable hand fractures in the ED reported only 6 complications at final follow-up.⁴ Complications were all minor, with no cases of nonunion, delayed union, malunion, pin-tract infection, pyarthrosis, or cellulitis, even in the setting of open fractures. Three patients required revision in the OR for pin migration, initial malreduction, and bone loss in the setting of comminution, respectively. The authors credited their low complication rate to supplementary immobilization.

In conclusion, many unstable simple fractures and dislocations of the hand and wrist can be safely and effectively treated in the ED. While it may seem daunting for a junior resident who is unfamiliar with percutaneous techniques, the authors advocate learning from a more senior mentor. The only additional training required is an understanding of how to apply this skill set in a different setting.

A mentor—now in his 60s—related his experiences as a resident. On call as a second-year resident, he would often be alone at a busy trauma center with no backup. When a case came in, he would quickly read about it in the library, then manage it in the emergency department (ED) if possible, or, if necessary, take the patient to the operating room (OR).

In the era of improved patient care, increased supervision, and decreased autonomy, this is not the reality anymore.¹ In theory, more reliable patient care is the result; however, the pendulum may have swung too far.

There are a number of injuries that are amenable to definitive fixation in the ED, but not as limited an array of injuries as we have perhaps grown accustomed to. Hand injuries are among the most common orthopedic injuries seen in the ED, with fractures of the metacarpals and phalanges constituting nearly one-half of all hand injuries.² The authors recently attended an excellent instructional course lecture on “The Lost and Found Art of Percutaneous Pinning in the Hand and Wrist” at the annual conference of the American Academy of Orthopaedic Surgeons.³ The presenters itemized a comprehensive list of fractures and simple dislocations of the hand, which could be simply, safely, effectively, and definitively managed through percutaneous pinning techniques. A significant number of unstable fractures of the phalanges and metacarpals can be treated in the ED under mini–C-arm fluoroscopy without an admission and trip to the OR.^3,4 Most phalangeal and metacarpal fractures are nondisplaced or minimally displaced and stable, and can often be handled with a combination of closed reduction, buddy-taping, and splinting.⁵ The indications for percutaneous versus internal fixation depend on a number of factors, including bone quality, degree of comminution, quality of the soft-tissue envelope, articular involvement, acuity of presentation, and goals for motion.^6,7

Many simple injury patterns involving unstable fractures or dislocations may be definitively managed in the ED with percutaneous pinning (eg, injuries that are unstable with closed reduction alone but that do not necessitate soft-tissue dissection). These include but are not limited to bony mallet injuries, unstable transverse or oblique fractures or fracture-dislocations of the phalanges and metacarpals, carpometacarpal fracture- dislocations, and underlying fractures that need protection of nail-bed repairs, soft-tissue flaps, or extensor tendon injuries (Figures 1, 2).^7,8 The techniques for specific fracture types are beyond the scope of this article but are readily available.^5,6

There are certain situations that undoubtedly warrant surgery in the OR, such as neurovascular injury necessitating microvascular repair, flexor tendon laceration, severely comminuted or segmental fractures, irreducible dislocations, and fractures with severe soft-tissue injury or contamination not amenable to primary irrigation, débridement, and closure at bedside.^4,7,8

You might ask, “Why would one treat an operative injury in the ED and not formally in the OR?,” and we submit that there are a number of reasons.

First, and most important, with increasing health care costs and decreasing reimbursements, physicians are faced with providing safe but economical care. Percutaneous Kirschner wire (K-wire) fixation is dramatically more cost-effective when performed in the ED than in the OR. The cost of a procedure performed in either setting is similarly dependent on a variety of factors, generally including complexity of the patient or procedure, costs of supplies and pharmacologic agents, fixed versus variable overhead costs, and the professional fees of providers and ancillary personnel.^9,10

While the patient is not charged per hour in the ED, it is estimated that ORs in the United States cost, on average, $62 per minute, ranging from as low as $22 to as high as $133 per minute.⁹ Additionally, the number of personnel involved in running an OR exceeds those for a similar procedure performed in the ED, considering (at a minimum) the orthopedic surgeon, anesthesiologist, scrub and radiology technicians, and nursing personnel required before, during, and after an operation.

While analgesia and procedural sedation can be performed similarly in either setting, it is our experience that patients are managed much more often in the ED with local anesthesia under direct care of only the orthopedic provider, whereas intravenous sedation and general anesthesia are far more commonly implemented in the OR. There are exceptions for pediatric patients or those who are unable to tolerate the procedure under only local anesthesia. Local anesthesia or even intravenous conscious sedation entails less risk as well as lower associated drug costs.¹¹

The difference in risk is especially true for sicker patients undergoing minimally invasive procedures.¹¹ Although administration of adequate procedural analgesia grows increasingly difficult the more proximal the injury, the hand and the fingers are easily and reliably anesthetized with well-placed wrist or digital blocks, with infrequent complications.¹² Application of a lidocaine/bupivacaine mixture provides up to 6 to 8 hours of analgesia. A small tourniquet alternative, such as the finger of a sterile glove or phlebotomy tourniquet, applied to the base of the finger or the wrist additionally provides a relatively bloodless field and effectively acts as a Bier block.

Percutaneous pins are much more forgiving than rigid internal fixation. If the initial placement of a pin is unsatisfactory, the pin can be reinserted at little cost.¹² Conversely, it may not be possible to reposition a misplaced screw or screw with inadequate purchase and still maintain adequate fixation. While percutaneous pin fixation is not as rigid as screw fixation, the degree of stability provided is adequate for the small forces affecting the hand in most cases. Accordingly, there is a very low incidence of fibrous union or nonunion.^13,14 With an increasing appreciation of soft-tissue handling over the past few decades, another significant advantage of K-wire fixation is the obviation of soft-tissue dissection, preserving the biology to maximize healing and minimize adverse sequelae.¹² Percutaneous fixation has been shown to achieve functional outcomes comparable to open reduction with internal fixation of operative phalangeal and metacarpal fractures, without soft-tissue disruption, scarring, or implant irritation, and with minimal risk of infection.^3,13,15,16 Ultimate range of motion after percutaneous fixation is comparable, if not superior, to that of internal fixation, despite the initial advantage of rigid internal fixation secondary to decreased scarring and lack of indwelling hardware.^16,17

While the risk of infection, perhaps the primary concern with percutaneous fixation, has been cited as high as 7%, osteomyelitis is exceedingly rare (<0.5%).^3,13,14 Furthermore, pins are often left in place for 3 to 6 weeks, and infection has been found to occur most often at a mean of 10 weeks.^7,13 Infection can also be mitigated by intelligent pin placement, relief of residual tension, and splint immobilization.^4,15 Pin loosening has similarly been reported in up to 4% of cases in large retrospective studies, occurring at an average of 8 weeks, by which time most pins would have been extricated.¹³ Other complications related to impaling adjacent neurovascular or tendinous structures have also been cited but are rare.¹³ A 12-month prospective study of 75 patients specifically evaluating the outcomes after closed reduction with percutaneous fixation of unstable hand fractures in the ED reported only 6 complications at final follow-up.⁴ Complications were all minor, with no cases of nonunion, delayed union, malunion, pin-tract infection, pyarthrosis, or cellulitis, even in the setting of open fractures. Three patients required revision in the OR for pin migration, initial malreduction, and bone loss in the setting of comminution, respectively. The authors credited their low complication rate to supplementary immobilization.

In conclusion, many unstable simple fractures and dislocations of the hand and wrist can be safely and effectively treated in the ED. While it may seem daunting for a junior resident who is unfamiliar with percutaneous techniques, the authors advocate learning from a more senior mentor. The only additional training required is an understanding of how to apply this skill set in a different setting.

The apparent increase in the prevalence of incidental pancreatic cysts in recent years may be tied to improvements in MRI scanning technology, results of a study suggest.

Researchers conducted a retrospective analysis of data from 500 patients who underwent an MRI for nonpancreatic indications at a single center between 2005 and 2014; 50 were sampled from each year in chronological order.

© parisvas/Thinkstockphotos.com

A total of 208 patients (41.6%) were found to have an incidental cyst, of which less than a quarter were described in the original MRI report, according to a paper published online in Clinical Gastroenterology and Hepatology.

Analysis showed a very strong association between the type of imaging hardware and software, and the presence of cysts; older hardware found pancreatic cysts in 30.3% of patients and the newest hardware found cysts in 56.3% of patients.

However, MRI field strength was not associated with the frequency of lesion discovery (Clin Gastro Hepatol. 2015 Sep 11. doi: 10.1016/j.cgh.2015.08.038).

Most cysts were relatively small, with a median size of 4 mm. Nearly half of the patients with a cyst only had one described.

Nearly two-thirds of these cysts (62%) had an uncertain diagnosis, but 35% of patients were diagnosed with an intraductal papillary mucinous neoplasm, and one patient showed radiologic evidence of subacute pancreatitis.

When compared to the rest of the cohort, individuals with pancreatic cysts were more likely to be older, have diabetes mellitus, or have a personal history of cancer, particularly nonmelanoma skin cancer and hepatocellular carcinoma.

“Our study demonstrates the relationship between the higher trend of incidental pancreatic cysts observed in the recent years and the improvements in the technical features of MRIs,” wrote Dr. Maria Moris and colleagues from the Mayo Clinic, Jacksonville.

The authors said the real prevalence of pancreatic cystic lesions is estimated to range from 0.2% to 44.7%.

Their finding of a prevalence of 41.6% was higher than that found in similar imaging studies, but the authors suggested some of this may be due to the lack of a size cutoff in their study, as opposed to a 5-mm cutoff used in one earlier study that found a prevalence of 10%.

“Moreover, we believe that we may have even underestimated the real prevalence because of the absence of magnetic resonance cholangiopancreatography sequences (only 19% of the examinations), and the lack of 3-T studies (6% of the MRIs),” they wrote.

The median size of the lesions was lower than those found in previous studies.

“This smaller size was unexpected because, as a result of the exclusion criteria applied, the technical features of the MRIs were not the most specific for [pancreatic cystic lesion] PCL visualization,” the authors wrote, suggesting that this may have been due to the radiologist’s experience in this field.

The study was funded by the Joyce E. Baker Foundation for Research at Mayo Clinic in Jacksonville. One author disclosed grants or travel support from Olympus, Boston Scientific, and Cosmo Pharmaceuticals. There were no other conflicts of interest declared.

AGA Resource

Review the AGA guideline on the management of asymptomatic pancreatic neoplastic cysts at http://www.gastro.org/guidelines/2015/5/29/pancreatic-cysts.

The apparent increase in the prevalence of incidental pancreatic cysts in recent years may be tied to improvements in MRI scanning technology, results of a study suggest.

Researchers conducted a retrospective analysis of data from 500 patients who underwent an MRI for nonpancreatic indications at a single center between 2005 and 2014; 50 were sampled from each year in chronological order.

© parisvas/Thinkstockphotos.com

A total of 208 patients (41.6%) were found to have an incidental cyst, of which less than a quarter were described in the original MRI report, according to a paper published online in Clinical Gastroenterology and Hepatology.

Analysis showed a very strong association between the type of imaging hardware and software, and the presence of cysts; older hardware found pancreatic cysts in 30.3% of patients and the newest hardware found cysts in 56.3% of patients.

However, MRI field strength was not associated with the frequency of lesion discovery (Clin Gastro Hepatol. 2015 Sep 11. doi: 10.1016/j.cgh.2015.08.038).

Most cysts were relatively small, with a median size of 4 mm. Nearly half of the patients with a cyst only had one described.

Nearly two-thirds of these cysts (62%) had an uncertain diagnosis, but 35% of patients were diagnosed with an intraductal papillary mucinous neoplasm, and one patient showed radiologic evidence of subacute pancreatitis.

When compared to the rest of the cohort, individuals with pancreatic cysts were more likely to be older, have diabetes mellitus, or have a personal history of cancer, particularly nonmelanoma skin cancer and hepatocellular carcinoma.

“Our study demonstrates the relationship between the higher trend of incidental pancreatic cysts observed in the recent years and the improvements in the technical features of MRIs,” wrote Dr. Maria Moris and colleagues from the Mayo Clinic, Jacksonville.

The authors said the real prevalence of pancreatic cystic lesions is estimated to range from 0.2% to 44.7%.

Their finding of a prevalence of 41.6% was higher than that found in similar imaging studies, but the authors suggested some of this may be due to the lack of a size cutoff in their study, as opposed to a 5-mm cutoff used in one earlier study that found a prevalence of 10%.

“Moreover, we believe that we may have even underestimated the real prevalence because of the absence of magnetic resonance cholangiopancreatography sequences (only 19% of the examinations), and the lack of 3-T studies (6% of the MRIs),” they wrote.

The median size of the lesions was lower than those found in previous studies.

“This smaller size was unexpected because, as a result of the exclusion criteria applied, the technical features of the MRIs were not the most specific for [pancreatic cystic lesion] PCL visualization,” the authors wrote, suggesting that this may have been due to the radiologist’s experience in this field.

The study was funded by the Joyce E. Baker Foundation for Research at Mayo Clinic in Jacksonville. One author disclosed grants or travel support from Olympus, Boston Scientific, and Cosmo Pharmaceuticals. There were no other conflicts of interest declared.

AGA Resource

Review the AGA guideline on the management of asymptomatic pancreatic neoplastic cysts at http://www.gastro.org/guidelines/2015/5/29/pancreatic-cysts.

The apparent increase in the prevalence of incidental pancreatic cysts in recent years may be tied to improvements in MRI scanning technology, results of a study suggest.

Researchers conducted a retrospective analysis of data from 500 patients who underwent an MRI for nonpancreatic indications at a single center between 2005 and 2014; 50 were sampled from each year in chronological order.

© parisvas/Thinkstockphotos.com

A total of 208 patients (41.6%) were found to have an incidental cyst, of which less than a quarter were described in the original MRI report, according to a paper published online in Clinical Gastroenterology and Hepatology.

Analysis showed a very strong association between the type of imaging hardware and software, and the presence of cysts; older hardware found pancreatic cysts in 30.3% of patients and the newest hardware found cysts in 56.3% of patients.

However, MRI field strength was not associated with the frequency of lesion discovery (Clin Gastro Hepatol. 2015 Sep 11. doi: 10.1016/j.cgh.2015.08.038).

Most cysts were relatively small, with a median size of 4 mm. Nearly half of the patients with a cyst only had one described.

Nearly two-thirds of these cysts (62%) had an uncertain diagnosis, but 35% of patients were diagnosed with an intraductal papillary mucinous neoplasm, and one patient showed radiologic evidence of subacute pancreatitis.

When compared to the rest of the cohort, individuals with pancreatic cysts were more likely to be older, have diabetes mellitus, or have a personal history of cancer, particularly nonmelanoma skin cancer and hepatocellular carcinoma.

“Our study demonstrates the relationship between the higher trend of incidental pancreatic cysts observed in the recent years and the improvements in the technical features of MRIs,” wrote Dr. Maria Moris and colleagues from the Mayo Clinic, Jacksonville.

The authors said the real prevalence of pancreatic cystic lesions is estimated to range from 0.2% to 44.7%.

Their finding of a prevalence of 41.6% was higher than that found in similar imaging studies, but the authors suggested some of this may be due to the lack of a size cutoff in their study, as opposed to a 5-mm cutoff used in one earlier study that found a prevalence of 10%.

“Moreover, we believe that we may have even underestimated the real prevalence because of the absence of magnetic resonance cholangiopancreatography sequences (only 19% of the examinations), and the lack of 3-T studies (6% of the MRIs),” they wrote.

The median size of the lesions was lower than those found in previous studies.

“This smaller size was unexpected because, as a result of the exclusion criteria applied, the technical features of the MRIs were not the most specific for [pancreatic cystic lesion] PCL visualization,” the authors wrote, suggesting that this may have been due to the radiologist’s experience in this field.

The study was funded by the Joyce E. Baker Foundation for Research at Mayo Clinic in Jacksonville. One author disclosed grants or travel support from Olympus, Boston Scientific, and Cosmo Pharmaceuticals. There were no other conflicts of interest declared.

AGA Resource

Review the AGA guideline on the management of asymptomatic pancreatic neoplastic cysts at http://www.gastro.org/guidelines/2015/5/29/pancreatic-cysts.

Results of a new study provide information on the trajectories of prescription drug use before and after total hip arthroplasty (THA). The study was published online ahead of print November 14 in Pain.

Researchers merged Norwegian national joint replacement and prescription databases to analyze the medication use of nearly 40,000 patients undergoing THA from 2005 to 2011. The patients’ average age was 68.5 and about three-fourths of patients underwent THA because of primary osteoarthritis.

The investigators analyzed trends in prescription drug use over 2 years: 4 quarters before and 4 quarters after hip-replacement surgery. The study focused on analgesics and hypnotics as well as drugs to treat anxiety and depression.

Overall, about half of patients filled a prescription for an analgesic in the year before surgery. Analgesic use included nonsteroidal anti-inflammatory drugs (NSAIDs) in 38% of patients, opioids in 16%, and other non-opioid analgesics in 12%.

Use of pain medications continued to increase during the last quarter before THA and then increased dramatically in the first quarter after surgery. The sharpest increases were for opioids, which increased to 28% in the last quarter before THA, then to 65% in the first quarter afterward; non-opioid analgesics increased to 21% and then to 60.5%.

The percentage of patients who filled prescriptions for hypnotics also increased from the quarter before to the quarter after surgery—from 14% to 25%. Analysis of the dosage showed a similar pattern.

With continued follow-up after THA, medication use decreased. By 1 year after THA, opioid use had decreased to 14%, NSAID use had decreased to 18%, and non-opioid analgesic use had decreased to 13%. Use of hypnotic drugs also decreased, along with medications to treat anxiety. There was little or no change in the use of antidepressants.

“Patients with chronic pain are frequent users of analgesic and psychotropic drugs and thereby risk adverse drug events,” said Tone Blågestad, a PhD candidate from the Department of Clinical Psychology at the University of Bergen in Norway, and coauthors. They cited special concern about the potential for serious adverse effects of opioids, including drug overdose.

The results suggest that use of pain medications increases in the year before THA, with a further increase immediately afterward, followed by a long-term decrease. That pattern is consistent with previous studies on pain scores in the period before and after THA.

Hypnotic drug use shows a similar trend, suggesting that sleep problems get worse, then improve with long-term pain relief after THA. The lack of change in antidepressant use suggests that depression in patients undergoing hip replacement isn’t necessarily related to hip pain.

“Overall, the present results extend the positive effects of THA to include reduced reliance on medication to alleviate symptoms,” said Ms. Blågestad and colleagues. The finding that hypnotics follow the same prescription trajectory as analgesics highlights the link between pain and sleep. The researchers add, “Our results warrant attention to the increased risk of adverse medication effects occurring with the increased use of both opioids and hypnotics in the recovery phase.”

Results of a new study provide information on the trajectories of prescription drug use before and after total hip arthroplasty (THA). The study was published online ahead of print November 14 in Pain.

Researchers merged Norwegian national joint replacement and prescription databases to analyze the medication use of nearly 40,000 patients undergoing THA from 2005 to 2011. The patients’ average age was 68.5 and about three-fourths of patients underwent THA because of primary osteoarthritis.

The investigators analyzed trends in prescription drug use over 2 years: 4 quarters before and 4 quarters after hip-replacement surgery. The study focused on analgesics and hypnotics as well as drugs to treat anxiety and depression.

Overall, about half of patients filled a prescription for an analgesic in the year before surgery. Analgesic use included nonsteroidal anti-inflammatory drugs (NSAIDs) in 38% of patients, opioids in 16%, and other non-opioid analgesics in 12%.

Use of pain medications continued to increase during the last quarter before THA and then increased dramatically in the first quarter after surgery. The sharpest increases were for opioids, which increased to 28% in the last quarter before THA, then to 65% in the first quarter afterward; non-opioid analgesics increased to 21% and then to 60.5%.

The percentage of patients who filled prescriptions for hypnotics also increased from the quarter before to the quarter after surgery—from 14% to 25%. Analysis of the dosage showed a similar pattern.

With continued follow-up after THA, medication use decreased. By 1 year after THA, opioid use had decreased to 14%, NSAID use had decreased to 18%, and non-opioid analgesic use had decreased to 13%. Use of hypnotic drugs also decreased, along with medications to treat anxiety. There was little or no change in the use of antidepressants.

“Patients with chronic pain are frequent users of analgesic and psychotropic drugs and thereby risk adverse drug events,” said Tone Blågestad, a PhD candidate from the Department of Clinical Psychology at the University of Bergen in Norway, and coauthors. They cited special concern about the potential for serious adverse effects of opioids, including drug overdose.

The results suggest that use of pain medications increases in the year before THA, with a further increase immediately afterward, followed by a long-term decrease. That pattern is consistent with previous studies on pain scores in the period before and after THA.

Hypnotic drug use shows a similar trend, suggesting that sleep problems get worse, then improve with long-term pain relief after THA. The lack of change in antidepressant use suggests that depression in patients undergoing hip replacement isn’t necessarily related to hip pain.

“Overall, the present results extend the positive effects of THA to include reduced reliance on medication to alleviate symptoms,” said Ms. Blågestad and colleagues. The finding that hypnotics follow the same prescription trajectory as analgesics highlights the link between pain and sleep. The researchers add, “Our results warrant attention to the increased risk of adverse medication effects occurring with the increased use of both opioids and hypnotics in the recovery phase.”

Results of a new study provide information on the trajectories of prescription drug use before and after total hip arthroplasty (THA). The study was published online ahead of print November 14 in Pain.

Researchers merged Norwegian national joint replacement and prescription databases to analyze the medication use of nearly 40,000 patients undergoing THA from 2005 to 2011. The patients’ average age was 68.5 and about three-fourths of patients underwent THA because of primary osteoarthritis.

The investigators analyzed trends in prescription drug use over 2 years: 4 quarters before and 4 quarters after hip-replacement surgery. The study focused on analgesics and hypnotics as well as drugs to treat anxiety and depression.

Overall, about half of patients filled a prescription for an analgesic in the year before surgery. Analgesic use included nonsteroidal anti-inflammatory drugs (NSAIDs) in 38% of patients, opioids in 16%, and other non-opioid analgesics in 12%.

Use of pain medications continued to increase during the last quarter before THA and then increased dramatically in the first quarter after surgery. The sharpest increases were for opioids, which increased to 28% in the last quarter before THA, then to 65% in the first quarter afterward; non-opioid analgesics increased to 21% and then to 60.5%.

The percentage of patients who filled prescriptions for hypnotics also increased from the quarter before to the quarter after surgery—from 14% to 25%. Analysis of the dosage showed a similar pattern.

With continued follow-up after THA, medication use decreased. By 1 year after THA, opioid use had decreased to 14%, NSAID use had decreased to 18%, and non-opioid analgesic use had decreased to 13%. Use of hypnotic drugs also decreased, along with medications to treat anxiety. There was little or no change in the use of antidepressants.

“Patients with chronic pain are frequent users of analgesic and psychotropic drugs and thereby risk adverse drug events,” said Tone Blågestad, a PhD candidate from the Department of Clinical Psychology at the University of Bergen in Norway, and coauthors. They cited special concern about the potential for serious adverse effects of opioids, including drug overdose.

The results suggest that use of pain medications increases in the year before THA, with a further increase immediately afterward, followed by a long-term decrease. That pattern is consistent with previous studies on pain scores in the period before and after THA.

Hypnotic drug use shows a similar trend, suggesting that sleep problems get worse, then improve with long-term pain relief after THA. The lack of change in antidepressant use suggests that depression in patients undergoing hip replacement isn’t necessarily related to hip pain.

“Overall, the present results extend the positive effects of THA to include reduced reliance on medication to alleviate symptoms,” said Ms. Blågestad and colleagues. The finding that hypnotics follow the same prescription trajectory as analgesics highlights the link between pain and sleep. The researchers add, “Our results warrant attention to the increased risk of adverse medication effects occurring with the increased use of both opioids and hypnotics in the recovery phase.”

The presence of KIR2DL5B was associated with lower rates of major molecular response (MMR), transformation-free survival, and event-free survival (but not overall survival) in patients with chronic phase–chronic myeloid leukemia (CP-CML) treated with sequential imatinib/nilotinib, according to researchers.

Univariate analysis demonstrated a significant association between KIR2DL5B and achievement of a major molecular response, with hazard ratio 0.423 (95% CI, 0.262-0.682; P less than .001). Other KIR genotypes, KIR2DL2pos and KIR2DS3pos, were also associated with inferior achievement of MMR, probably because of their association with KIR2DL5B due to linkage disequilibrium among KIR genes, according to the investigators.

“Our findings suggest that even with the potent second-generation TKI [tyrosine kinase inhibitor] nilotinib, KIR genotypes, a predetermined genetic host factor, may still be one of the most discriminatory prognostic markers available at baseline,” wrote Dr. David T. Yeung of the department of genetics and molecular pathology, Centre for Cancer Biology and the University of Adelaide, South Australia, and colleagues (Blood 2015 Dec 17. doi:10.1182/blood-2015-07-655589).

Killer immunoglobulin-like receptors (KIRs) contribute to natural killer (NK) cell–mediated killing of tumor cells, in both activating and inhibitory roles. Normal cells are spared through actions of inhibitory KIRs. Although the mechanism underlying the association between KIR2DL5B and CP-CML treatment outcomes is still unclear, the gene encodes an inhibitory KIR receptor, the absence of which may increase efficiency of NK-mediated killing of leukemic stem cells, researchers suggested.

The Therapeutic Intensification in De Novo Leukaemia (TIDEL-II) study included 210 patients with CP-CML who were treated with imatinib initially, and nilotinib subsequently if predetermined molecular targets were not met. The KIR substudy included 148 patients with samples available for genotyping.

KIR genotype frequencies observed in this study were similar to other white populations reported in the Allele Frequency Database.

Early molecular response was also significantly associated with treatment outcomes, independent of KIR prognostic significance, and may add additional prognostic information, available 3 months after treatment commences.

“In contrast, KIR2DL5B can identify, at baseline, the 20% of patients with a transformation risk of [about] 10% over 2 years versus the 80% of patients with a transformation risk of less than 3%,” the authors wrote. They suggest that KIR2DL5B, combined with other predictive markers, may enable targeted early interventions to improve outcomes.

The presence of KIR2DL5B was associated with lower rates of major molecular response (MMR), transformation-free survival, and event-free survival (but not overall survival) in patients with chronic phase–chronic myeloid leukemia (CP-CML) treated with sequential imatinib/nilotinib, according to researchers.

Univariate analysis demonstrated a significant association between KIR2DL5B and achievement of a major molecular response, with hazard ratio 0.423 (95% CI, 0.262-0.682; P less than .001). Other KIR genotypes, KIR2DL2pos and KIR2DS3pos, were also associated with inferior achievement of MMR, probably because of their association with KIR2DL5B due to linkage disequilibrium among KIR genes, according to the investigators.

“Our findings suggest that even with the potent second-generation TKI [tyrosine kinase inhibitor] nilotinib, KIR genotypes, a predetermined genetic host factor, may still be one of the most discriminatory prognostic markers available at baseline,” wrote Dr. David T. Yeung of the department of genetics and molecular pathology, Centre for Cancer Biology and the University of Adelaide, South Australia, and colleagues (Blood 2015 Dec 17. doi:10.1182/blood-2015-07-655589).

Killer immunoglobulin-like receptors (KIRs) contribute to natural killer (NK) cell–mediated killing of tumor cells, in both activating and inhibitory roles. Normal cells are spared through actions of inhibitory KIRs. Although the mechanism underlying the association between KIR2DL5B and CP-CML treatment outcomes is still unclear, the gene encodes an inhibitory KIR receptor, the absence of which may increase efficiency of NK-mediated killing of leukemic stem cells, researchers suggested.

The Therapeutic Intensification in De Novo Leukaemia (TIDEL-II) study included 210 patients with CP-CML who were treated with imatinib initially, and nilotinib subsequently if predetermined molecular targets were not met. The KIR substudy included 148 patients with samples available for genotyping.

KIR genotype frequencies observed in this study were similar to other white populations reported in the Allele Frequency Database.

Early molecular response was also significantly associated with treatment outcomes, independent of KIR prognostic significance, and may add additional prognostic information, available 3 months after treatment commences.

“In contrast, KIR2DL5B can identify, at baseline, the 20% of patients with a transformation risk of [about] 10% over 2 years versus the 80% of patients with a transformation risk of less than 3%,” the authors wrote. They suggest that KIR2DL5B, combined with other predictive markers, may enable targeted early interventions to improve outcomes.

The presence of KIR2DL5B was associated with lower rates of major molecular response (MMR), transformation-free survival, and event-free survival (but not overall survival) in patients with chronic phase–chronic myeloid leukemia (CP-CML) treated with sequential imatinib/nilotinib, according to researchers.

Univariate analysis demonstrated a significant association between KIR2DL5B and achievement of a major molecular response, with hazard ratio 0.423 (95% CI, 0.262-0.682; P less than .001). Other KIR genotypes, KIR2DL2pos and KIR2DS3pos, were also associated with inferior achievement of MMR, probably because of their association with KIR2DL5B due to linkage disequilibrium among KIR genes, according to the investigators.

“Our findings suggest that even with the potent second-generation TKI [tyrosine kinase inhibitor] nilotinib, KIR genotypes, a predetermined genetic host factor, may still be one of the most discriminatory prognostic markers available at baseline,” wrote Dr. David T. Yeung of the department of genetics and molecular pathology, Centre for Cancer Biology and the University of Adelaide, South Australia, and colleagues (Blood 2015 Dec 17. doi:10.1182/blood-2015-07-655589).

Killer immunoglobulin-like receptors (KIRs) contribute to natural killer (NK) cell–mediated killing of tumor cells, in both activating and inhibitory roles. Normal cells are spared through actions of inhibitory KIRs. Although the mechanism underlying the association between KIR2DL5B and CP-CML treatment outcomes is still unclear, the gene encodes an inhibitory KIR receptor, the absence of which may increase efficiency of NK-mediated killing of leukemic stem cells, researchers suggested.

The Therapeutic Intensification in De Novo Leukaemia (TIDEL-II) study included 210 patients with CP-CML who were treated with imatinib initially, and nilotinib subsequently if predetermined molecular targets were not met. The KIR substudy included 148 patients with samples available for genotyping.

KIR genotype frequencies observed in this study were similar to other white populations reported in the Allele Frequency Database.

Early molecular response was also significantly associated with treatment outcomes, independent of KIR prognostic significance, and may add additional prognostic information, available 3 months after treatment commences.

“In contrast, KIR2DL5B can identify, at baseline, the 20% of patients with a transformation risk of [about] 10% over 2 years versus the 80% of patients with a transformation risk of less than 3%,” the authors wrote. They suggest that KIR2DL5B, combined with other predictive markers, may enable targeted early interventions to improve outcomes.

SAN FRANCISCO – The most common fear of rheumatoid arthritis (RA) and axial spondyloarthritis (axSpA) patients is that their future suffering will be as bad as their past suffering, according to a French survey of 474 patients.

Overall, 182 of the 303 RA patients (60%) and 122 of the 171 axSpA patients (71%) in the study ranked that fear as at least a 7 on a 10-point scale, and it remained a serious and common concern even among the roughly half of patients who were in remission.

Majorities in both groups were highly concerned about deformity, wheel chair dependence, burdening loved ones, losing autonomy, and disease spread to other joints. Less common fears, but still ranked at least a 7 by about one-third to well over half of patients, were more frequent flares, inability to care for others, losing friends, loss of treatment effectiveness, fear of treatment side effects, and not finding help if independence is lost.

In general, axSpA was perceived as the more frightening disease, with patients more likely than those with RA to give fears presented on the survey a score of 7 or higher; axSpA patients also were more likely to fear the impact of disease on pregnancy and work, and more worried about passing disease onto their children. Fears about joints seizing up, bone and spine fusion, and increased flare activity were far more prevalent in the axSpA group.

The findings are from a test run of a new questionnaire being developed in France to capture the psychological burden of chronic inflammatory disease. The idea is to make patients’ fears and convictions explicit so that providers know what they are and can help patients cope.

“We’ve had this idea for a long time. Patients have fears and beliefs that” are difficult to express, and they get in the way of effective office communication. The questionnaire might break down the walls, so “patients know their doctors understand and are concerned” about their overall well-being, said senior investigator Dr. Francis Berenbaum, chief of rheumatology at Saint Antoine Hospital in Paris.

It’s hoped that the efforts will improve trust and dialogue between patients and doctors and lead to better treatment adherence and follow-up, more effective counseling, and perhaps even new patient-related outcomes for clinical trials, he said at the annual meeting of the American College of Rheumatology.

To create the survey, the team conducted semi-structured patient interviews at rheumatology practices across France. They whittled the responses down to identify 23 common fears and 19 disease-related beliefs in RA and axSpA. The resulting 44-item survey – there are two additional items about pregnancy and work-related concerns – asks patients to rate each one on a scale of 1-10. The team hopes to have data soon to show whether or not the efforts improve outcomes.

Common beliefs in both groups were that fatigue, over-exertion, stress, and weather changes trigger flares, but that moderate physical activity reduces them.

Almost half of RA patients, versus about a quarter of axSpA patients, believed that their disease was triggered by an emotional shock or stressful event, and small minorities in both groups attributed their disease to pollution, vaccines, or passive or active smoking. About 70% of patients in both groups were on biologics, and about one-third in each were very worried that their treatments would cause cancer.

Some “disease perceptions may not be accurate” and “provide a basis for discussion … to dispel misconceptions, align treatment expectations, and provide reassurance,” the investigators noted,

The RA patients were 60 years old on average, and about three-quarters were women. The median disease duration was 10 years, and mean Disease Activity Score (DAS28) was 2.7; axSpA patients were a mean age of 47 years, 43% were women, and the median disease duration was 12 years. Their mean Bath Ankylosing Spondylitis Disease Activity Index score was 3.2.

Foundation Arthritis Jacques Courtin and UCB Pharma funded the work. Dr. Berenbaum has no relevant disclosures. Two investigators are UCB employees.

[email protected]

SAN FRANCISCO – The most common fear of rheumatoid arthritis (RA) and axial spondyloarthritis (axSpA) patients is that their future suffering will be as bad as their past suffering, according to a French survey of 474 patients.

Overall, 182 of the 303 RA patients (60%) and 122 of the 171 axSpA patients (71%) in the study ranked that fear as at least a 7 on a 10-point scale, and it remained a serious and common concern even among the roughly half of patients who were in remission.

Majorities in both groups were highly concerned about deformity, wheel chair dependence, burdening loved ones, losing autonomy, and disease spread to other joints. Less common fears, but still ranked at least a 7 by about one-third to well over half of patients, were more frequent flares, inability to care for others, losing friends, loss of treatment effectiveness, fear of treatment side effects, and not finding help if independence is lost.

In general, axSpA was perceived as the more frightening disease, with patients more likely than those with RA to give fears presented on the survey a score of 7 or higher; axSpA patients also were more likely to fear the impact of disease on pregnancy and work, and more worried about passing disease onto their children. Fears about joints seizing up, bone and spine fusion, and increased flare activity were far more prevalent in the axSpA group.

The findings are from a test run of a new questionnaire being developed in France to capture the psychological burden of chronic inflammatory disease. The idea is to make patients’ fears and convictions explicit so that providers know what they are and can help patients cope.

“We’ve had this idea for a long time. Patients have fears and beliefs that” are difficult to express, and they get in the way of effective office communication. The questionnaire might break down the walls, so “patients know their doctors understand and are concerned” about their overall well-being, said senior investigator Dr. Francis Berenbaum, chief of rheumatology at Saint Antoine Hospital in Paris.

It’s hoped that the efforts will improve trust and dialogue between patients and doctors and lead to better treatment adherence and follow-up, more effective counseling, and perhaps even new patient-related outcomes for clinical trials, he said at the annual meeting of the American College of Rheumatology.

To create the survey, the team conducted semi-structured patient interviews at rheumatology practices across France. They whittled the responses down to identify 23 common fears and 19 disease-related beliefs in RA and axSpA. The resulting 44-item survey – there are two additional items about pregnancy and work-related concerns – asks patients to rate each one on a scale of 1-10. The team hopes to have data soon to show whether or not the efforts improve outcomes.

Common beliefs in both groups were that fatigue, over-exertion, stress, and weather changes trigger flares, but that moderate physical activity reduces them.

Almost half of RA patients, versus about a quarter of axSpA patients, believed that their disease was triggered by an emotional shock or stressful event, and small minorities in both groups attributed their disease to pollution, vaccines, or passive or active smoking. About 70% of patients in both groups were on biologics, and about one-third in each were very worried that their treatments would cause cancer.

Some “disease perceptions may not be accurate” and “provide a basis for discussion … to dispel misconceptions, align treatment expectations, and provide reassurance,” the investigators noted,

The RA patients were 60 years old on average, and about three-quarters were women. The median disease duration was 10 years, and mean Disease Activity Score (DAS28) was 2.7; axSpA patients were a mean age of 47 years, 43% were women, and the median disease duration was 12 years. Their mean Bath Ankylosing Spondylitis Disease Activity Index score was 3.2.

Foundation Arthritis Jacques Courtin and UCB Pharma funded the work. Dr. Berenbaum has no relevant disclosures. Two investigators are UCB employees.

[email protected]

SAN FRANCISCO – The most common fear of rheumatoid arthritis (RA) and axial spondyloarthritis (axSpA) patients is that their future suffering will be as bad as their past suffering, according to a French survey of 474 patients.

Overall, 182 of the 303 RA patients (60%) and 122 of the 171 axSpA patients (71%) in the study ranked that fear as at least a 7 on a 10-point scale, and it remained a serious and common concern even among the roughly half of patients who were in remission.

Majorities in both groups were highly concerned about deformity, wheel chair dependence, burdening loved ones, losing autonomy, and disease spread to other joints. Less common fears, but still ranked at least a 7 by about one-third to well over half of patients, were more frequent flares, inability to care for others, losing friends, loss of treatment effectiveness, fear of treatment side effects, and not finding help if independence is lost.

In general, axSpA was perceived as the more frightening disease, with patients more likely than those with RA to give fears presented on the survey a score of 7 or higher; axSpA patients also were more likely to fear the impact of disease on pregnancy and work, and more worried about passing disease onto their children. Fears about joints seizing up, bone and spine fusion, and increased flare activity were far more prevalent in the axSpA group.

The findings are from a test run of a new questionnaire being developed in France to capture the psychological burden of chronic inflammatory disease. The idea is to make patients’ fears and convictions explicit so that providers know what they are and can help patients cope.

“We’ve had this idea for a long time. Patients have fears and beliefs that” are difficult to express, and they get in the way of effective office communication. The questionnaire might break down the walls, so “patients know their doctors understand and are concerned” about their overall well-being, said senior investigator Dr. Francis Berenbaum, chief of rheumatology at Saint Antoine Hospital in Paris.

It’s hoped that the efforts will improve trust and dialogue between patients and doctors and lead to better treatment adherence and follow-up, more effective counseling, and perhaps even new patient-related outcomes for clinical trials, he said at the annual meeting of the American College of Rheumatology.

To create the survey, the team conducted semi-structured patient interviews at rheumatology practices across France. They whittled the responses down to identify 23 common fears and 19 disease-related beliefs in RA and axSpA. The resulting 44-item survey – there are two additional items about pregnancy and work-related concerns – asks patients to rate each one on a scale of 1-10. The team hopes to have data soon to show whether or not the efforts improve outcomes.

Common beliefs in both groups were that fatigue, over-exertion, stress, and weather changes trigger flares, but that moderate physical activity reduces them.

Almost half of RA patients, versus about a quarter of axSpA patients, believed that their disease was triggered by an emotional shock or stressful event, and small minorities in both groups attributed their disease to pollution, vaccines, or passive or active smoking. About 70% of patients in both groups were on biologics, and about one-third in each were very worried that their treatments would cause cancer.

Some “disease perceptions may not be accurate” and “provide a basis for discussion … to dispel misconceptions, align treatment expectations, and provide reassurance,” the investigators noted,

The RA patients were 60 years old on average, and about three-quarters were women. The median disease duration was 10 years, and mean Disease Activity Score (DAS28) was 2.7; axSpA patients were a mean age of 47 years, 43% were women, and the median disease duration was 12 years. Their mean Bath Ankylosing Spondylitis Disease Activity Index score was 3.2.

Foundation Arthritis Jacques Courtin and UCB Pharma funded the work. Dr. Berenbaum has no relevant disclosures. Two investigators are UCB employees.

[email protected]

SAN DIEGO – The overall rate of hospital-acquired pneumonia following cervical spinal cord injury is about 20%, results from a study of national data demonstrated.

“Cervical spinal cord injury patients are at an increased risk for the development of hospital-acquired pneumonia,” lead study author Dr. Pablo J. Diaz-Collado said in an interview after the annual meeting of the Cervical Spine Research Society.

“Complete cord injuries, longer length of stay, ICU stay and ventilation time lead to significantly increased risk of HAP, which then leads to poor inpatient outcomes,” he said. “It is of crucial importance to keep these risk factors in mind when treating patients with cervical spinal cord injuries. There is a need to optimize the management protocols for these patients to help prevent the development of HAPs.”

Dr. Diaz-Collado, an orthopedic surgery resident at Yale–New Haven (Conn.) Hospital, and his associates identified 5,198 cervical spinal cord injury patients in the 2011 and 2012 National Trauma Data Bank (NTDB) to analyze risk factors for the development of HAP and inpatient outcomes in this population. They used multivariate logistic regression to identify independent associations of various risk factors with the occurrence of HAP.

The researchers found that the overall incidence of HAP among cervical spinal cord injury patients was 20.5%, which amounted to 1,065 patients. Factors independently associated with HAP were complete spinal cord injuries (compared to central cord injuries; OR 1.44; P = .009); longer inpatient length of stay (OR 3.08 for a stay that lasted 7-13 days, OR 10.21 for 21-27 days, and OR 14.89 for 35 days or more; P = .001 or less for all associations); longer ICU stay (OR 2.86 for a stay that lasted 9-11 days, OR 3.05 for 12-14 days, and OR 2.94 for 15 days or more; P less than .001 for all associations), and longer time on mechanical ventilation (OR 2.68 for ventilation that lasted 3-6 days, OR 3.76 for 7-13 days, OR 3.98 for 14-20 days, and OR 3.99 for 21 days or more; P less than .001 for all associations).

After the researchers controlled for all other risk factors, including patient comorbidities, Injury Severity Score, and other inpatient complications, HAP was associated with increased odds of death (OR 1.60; P = .005), inpatient adverse events (OR 1.65; P less than .001), discharge to an extended-care facility (OR 1.93; P = .001), and longer length of stay (a mean of an additional 10.93 days; P less than .001).

Dr. Diaz-Collado acknowledged that the study is “limited by the quality of the data entry. In addition, the database does not include classifications of fractures, and thus stratification of the analysis in terms of the different kinds of fractures in the cervical spine is not possible. Finally, procedural codes are less accurate and thus including whether or not patients underwent a surgical intervention is less reliable.”

Dr. Diaz-Collado reported having no financial disclosures.

[email protected]

SAN DIEGO – The overall rate of hospital-acquired pneumonia following cervical spinal cord injury is about 20%, results from a study of national data demonstrated.

“Cervical spinal cord injury patients are at an increased risk for the development of hospital-acquired pneumonia,” lead study author Dr. Pablo J. Diaz-Collado said in an interview after the annual meeting of the Cervical Spine Research Society.

“Complete cord injuries, longer length of stay, ICU stay and ventilation time lead to significantly increased risk of HAP, which then leads to poor inpatient outcomes,” he said. “It is of crucial importance to keep these risk factors in mind when treating patients with cervical spinal cord injuries. There is a need to optimize the management protocols for these patients to help prevent the development of HAPs.”

Dr. Diaz-Collado, an orthopedic surgery resident at Yale–New Haven (Conn.) Hospital, and his associates identified 5,198 cervical spinal cord injury patients in the 2011 and 2012 National Trauma Data Bank (NTDB) to analyze risk factors for the development of HAP and inpatient outcomes in this population. They used multivariate logistic regression to identify independent associations of various risk factors with the occurrence of HAP.

The researchers found that the overall incidence of HAP among cervical spinal cord injury patients was 20.5%, which amounted to 1,065 patients. Factors independently associated with HAP were complete spinal cord injuries (compared to central cord injuries; OR 1.44; P = .009); longer inpatient length of stay (OR 3.08 for a stay that lasted 7-13 days, OR 10.21 for 21-27 days, and OR 14.89 for 35 days or more; P = .001 or less for all associations); longer ICU stay (OR 2.86 for a stay that lasted 9-11 days, OR 3.05 for 12-14 days, and OR 2.94 for 15 days or more; P less than .001 for all associations), and longer time on mechanical ventilation (OR 2.68 for ventilation that lasted 3-6 days, OR 3.76 for 7-13 days, OR 3.98 for 14-20 days, and OR 3.99 for 21 days or more; P less than .001 for all associations).

After the researchers controlled for all other risk factors, including patient comorbidities, Injury Severity Score, and other inpatient complications, HAP was associated with increased odds of death (OR 1.60; P = .005), inpatient adverse events (OR 1.65; P less than .001), discharge to an extended-care facility (OR 1.93; P = .001), and longer length of stay (a mean of an additional 10.93 days; P less than .001).

Dr. Diaz-Collado acknowledged that the study is “limited by the quality of the data entry. In addition, the database does not include classifications of fractures, and thus stratification of the analysis in terms of the different kinds of fractures in the cervical spine is not possible. Finally, procedural codes are less accurate and thus including whether or not patients underwent a surgical intervention is less reliable.”

Dr. Diaz-Collado reported having no financial disclosures.

[email protected]

SAN DIEGO – The overall rate of hospital-acquired pneumonia following cervical spinal cord injury is about 20%, results from a study of national data demonstrated.

“Cervical spinal cord injury patients are at an increased risk for the development of hospital-acquired pneumonia,” lead study author Dr. Pablo J. Diaz-Collado said in an interview after the annual meeting of the Cervical Spine Research Society.

“Complete cord injuries, longer length of stay, ICU stay and ventilation time lead to significantly increased risk of HAP, which then leads to poor inpatient outcomes,” he said. “It is of crucial importance to keep these risk factors in mind when treating patients with cervical spinal cord injuries. There is a need to optimize the management protocols for these patients to help prevent the development of HAPs.”

Dr. Diaz-Collado, an orthopedic surgery resident at Yale–New Haven (Conn.) Hospital, and his associates identified 5,198 cervical spinal cord injury patients in the 2011 and 2012 National Trauma Data Bank (NTDB) to analyze risk factors for the development of HAP and inpatient outcomes in this population. They used multivariate logistic regression to identify independent associations of various risk factors with the occurrence of HAP.

The researchers found that the overall incidence of HAP among cervical spinal cord injury patients was 20.5%, which amounted to 1,065 patients. Factors independently associated with HAP were complete spinal cord injuries (compared to central cord injuries; OR 1.44; P = .009); longer inpatient length of stay (OR 3.08 for a stay that lasted 7-13 days, OR 10.21 for 21-27 days, and OR 14.89 for 35 days or more; P = .001 or less for all associations); longer ICU stay (OR 2.86 for a stay that lasted 9-11 days, OR 3.05 for 12-14 days, and OR 2.94 for 15 days or more; P less than .001 for all associations), and longer time on mechanical ventilation (OR 2.68 for ventilation that lasted 3-6 days, OR 3.76 for 7-13 days, OR 3.98 for 14-20 days, and OR 3.99 for 21 days or more; P less than .001 for all associations).

After the researchers controlled for all other risk factors, including patient comorbidities, Injury Severity Score, and other inpatient complications, HAP was associated with increased odds of death (OR 1.60; P = .005), inpatient adverse events (OR 1.65; P less than .001), discharge to an extended-care facility (OR 1.93; P = .001), and longer length of stay (a mean of an additional 10.93 days; P less than .001).

Dr. Diaz-Collado acknowledged that the study is “limited by the quality of the data entry. In addition, the database does not include classifications of fractures, and thus stratification of the analysis in terms of the different kinds of fractures in the cervical spine is not possible. Finally, procedural codes are less accurate and thus including whether or not patients underwent a surgical intervention is less reliable.”

Dr. Diaz-Collado reported having no financial disclosures.

[email protected]

Sagar Lonial, MD

© ASCO/Todd Buchanan

Single-agent daratumumab has exhibited “encouraging efficacy” and a “favorable safety profile” in patients with heavily pretreated and refractory multiple myeloma (MM), according to investigators from the phase 2 SIRIUS trial.

The drug produced an overall response rate of 30% in MM patients who had received 3 or more prior lines of therapy. The median progression-free survival was close to 4 months, and the median overall survival was nearly 18 months.

Thirty percent of patients had treatment-emergent serious adverse events (AEs), and 23% had grade 3 or 4 treatment-emergent serious AEs.

“This represents the first single-agent activity we have for a monoclonal antibody in treating multiple myeloma,” said study author Sagar Lonial, MD, of Emory University School of Medicine in Atlanta, Georgia.

“The future hope for daratumumab is in our ability to bring this active agent to earlier lines of therapy and combine it with drugs where you may get synergy.”

Dr Lonial and his colleagues reported results from the ongoing SIRIUS trial in The Lancet. Results from the trial were previously presented at the 2015 ASCO Annual Meeting. The research was funded by Janssen Research & Development, the company developing daratumumab.

In part 1 of the trial, 34 MM patients were randomized to receive either 8 mg/kg of daratumumab once every 4 weeks or 16 mg/kg once a week for 8 weeks, then once every 2 weeks for 16 weeks and once every 4 weeks after that, until disease progression or unacceptable toxicity.

In part 2, an additional 90 MM patients were enrolled and received 16 mg/kg of daratumumab on the same dosing schedule as in part 1.

Dr Lonial and his colleagues reported results for all patients who received 16 mg/kg of daratumumab. At the first interim analysis, the 8 mg/kg arm did not meet the criteria for expansion because the overall response rate was 11.1%.

The 106 patients who received the 16 mg/kg dose of daratumumab had received a median of 5 prior lines of therapy, including a proteasome inhibitor and an immunomodulatory drug. Ninety-seven percent of these patients were refractory to their last line of therapy, and 95% were refractory to both a proteasome inhibitor and an immunomodulatory drug.

Response and survival

According to an independent review committee, 29.2% of patients responded to daratumumab. Eighteen patients had a partial response, 10 had a very good partial response, and 3 had a stringent complete response.

The median duration of response was 7.4 months, and the median time to first response was 1 month.

The median overall survival was 17.5 months, and the 12-month overall survival was 64.8%. The median progression-free survival was 3.7 months.

Safety

The most common AEs were fatigue (40%), anemia (33%), nausea (29%), thrombocytopenia (25%), neutropenia (23%), back pain (22%), and cough (21%). Thirty percent of patients experienced serious AEs, and 23% had serious grade 3/4 AEs.

Infusion-related reactions were reported in 42% of patients and were predominantly grade 1 or 2 (5% grade 3; no grade 4). The most common infusion-related reactions were nasal congestion (12%), throat irritation (7%), cough (6%), dyspnea (6%), chills (6%), and vomiting (6%)—all of which were treated with standard of care and slower infusion rates.

None of the patients discontinued daratumumab because of drug-related treatment-emergent AEs, infusion-related reactions, or death. However, 5% of patients discontinued treatment because of treatment-emergent AEs—2 cases of progressive disease and 1 case each of H1N1 influenza, hypercalcemia, and spinal cord compression.

Twenty-nine percent of patients died after treatment—27% due to progressive disease and 2% due to AEs. The 2 AEs were cardiorespiratory failure secondary to H1N1 influenza complications and general health deterioration secondary to complications of aspiration pneumonia.

Sagar Lonial, MD

© ASCO/Todd Buchanan

Single-agent daratumumab has exhibited “encouraging efficacy” and a “favorable safety profile” in patients with heavily pretreated and refractory multiple myeloma (MM), according to investigators from the phase 2 SIRIUS trial.

The drug produced an overall response rate of 30% in MM patients who had received 3 or more prior lines of therapy. The median progression-free survival was close to 4 months, and the median overall survival was nearly 18 months.

Thirty percent of patients had treatment-emergent serious adverse events (AEs), and 23% had grade 3 or 4 treatment-emergent serious AEs.

“This represents the first single-agent activity we have for a monoclonal antibody in treating multiple myeloma,” said study author Sagar Lonial, MD, of Emory University School of Medicine in Atlanta, Georgia.

“The future hope for daratumumab is in our ability to bring this active agent to earlier lines of therapy and combine it with drugs where you may get synergy.”

Dr Lonial and his colleagues reported results from the ongoing SIRIUS trial in The Lancet. Results from the trial were previously presented at the 2015 ASCO Annual Meeting. The research was funded by Janssen Research & Development, the company developing daratumumab.

In part 1 of the trial, 34 MM patients were randomized to receive either 8 mg/kg of daratumumab once every 4 weeks or 16 mg/kg once a week for 8 weeks, then once every 2 weeks for 16 weeks and once every 4 weeks after that, until disease progression or unacceptable toxicity.

In part 2, an additional 90 MM patients were enrolled and received 16 mg/kg of daratumumab on the same dosing schedule as in part 1.

Dr Lonial and his colleagues reported results for all patients who received 16 mg/kg of daratumumab. At the first interim analysis, the 8 mg/kg arm did not meet the criteria for expansion because the overall response rate was 11.1%.

The 106 patients who received the 16 mg/kg dose of daratumumab had received a median of 5 prior lines of therapy, including a proteasome inhibitor and an immunomodulatory drug. Ninety-seven percent of these patients were refractory to their last line of therapy, and 95% were refractory to both a proteasome inhibitor and an immunomodulatory drug.

Response and survival

According to an independent review committee, 29.2% of patients responded to daratumumab. Eighteen patients had a partial response, 10 had a very good partial response, and 3 had a stringent complete response.

The median duration of response was 7.4 months, and the median time to first response was 1 month.

The median overall survival was 17.5 months, and the 12-month overall survival was 64.8%. The median progression-free survival was 3.7 months.

Safety

The most common AEs were fatigue (40%), anemia (33%), nausea (29%), thrombocytopenia (25%), neutropenia (23%), back pain (22%), and cough (21%). Thirty percent of patients experienced serious AEs, and 23% had serious grade 3/4 AEs.

Infusion-related reactions were reported in 42% of patients and were predominantly grade 1 or 2 (5% grade 3; no grade 4). The most common infusion-related reactions were nasal congestion (12%), throat irritation (7%), cough (6%), dyspnea (6%), chills (6%), and vomiting (6%)—all of which were treated with standard of care and slower infusion rates.

None of the patients discontinued daratumumab because of drug-related treatment-emergent AEs, infusion-related reactions, or death. However, 5% of patients discontinued treatment because of treatment-emergent AEs—2 cases of progressive disease and 1 case each of H1N1 influenza, hypercalcemia, and spinal cord compression.

Twenty-nine percent of patients died after treatment—27% due to progressive disease and 2% due to AEs. The 2 AEs were cardiorespiratory failure secondary to H1N1 influenza complications and general health deterioration secondary to complications of aspiration pneumonia.

Sagar Lonial, MD

© ASCO/Todd Buchanan

Single-agent daratumumab has exhibited “encouraging efficacy” and a “favorable safety profile” in patients with heavily pretreated and refractory multiple myeloma (MM), according to investigators from the phase 2 SIRIUS trial.

The drug produced an overall response rate of 30% in MM patients who had received 3 or more prior lines of therapy. The median progression-free survival was close to 4 months, and the median overall survival was nearly 18 months.

Thirty percent of patients had treatment-emergent serious adverse events (AEs), and 23% had grade 3 or 4 treatment-emergent serious AEs.

“This represents the first single-agent activity we have for a monoclonal antibody in treating multiple myeloma,” said study author Sagar Lonial, MD, of Emory University School of Medicine in Atlanta, Georgia.

“The future hope for daratumumab is in our ability to bring this active agent to earlier lines of therapy and combine it with drugs where you may get synergy.”

Dr Lonial and his colleagues reported results from the ongoing SIRIUS trial in The Lancet. Results from the trial were previously presented at the 2015 ASCO Annual Meeting. The research was funded by Janssen Research & Development, the company developing daratumumab.

In part 1 of the trial, 34 MM patients were randomized to receive either 8 mg/kg of daratumumab once every 4 weeks or 16 mg/kg once a week for 8 weeks, then once every 2 weeks for 16 weeks and once every 4 weeks after that, until disease progression or unacceptable toxicity.

In part 2, an additional 90 MM patients were enrolled and received 16 mg/kg of daratumumab on the same dosing schedule as in part 1.

Dr Lonial and his colleagues reported results for all patients who received 16 mg/kg of daratumumab. At the first interim analysis, the 8 mg/kg arm did not meet the criteria for expansion because the overall response rate was 11.1%.

The 106 patients who received the 16 mg/kg dose of daratumumab had received a median of 5 prior lines of therapy, including a proteasome inhibitor and an immunomodulatory drug. Ninety-seven percent of these patients were refractory to their last line of therapy, and 95% were refractory to both a proteasome inhibitor and an immunomodulatory drug.

Response and survival

According to an independent review committee, 29.2% of patients responded to daratumumab. Eighteen patients had a partial response, 10 had a very good partial response, and 3 had a stringent complete response.

The median duration of response was 7.4 months, and the median time to first response was 1 month.

The median overall survival was 17.5 months, and the 12-month overall survival was 64.8%. The median progression-free survival was 3.7 months.

Safety

The most common AEs were fatigue (40%), anemia (33%), nausea (29%), thrombocytopenia (25%), neutropenia (23%), back pain (22%), and cough (21%). Thirty percent of patients experienced serious AEs, and 23% had serious grade 3/4 AEs.

Infusion-related reactions were reported in 42% of patients and were predominantly grade 1 or 2 (5% grade 3; no grade 4). The most common infusion-related reactions were nasal congestion (12%), throat irritation (7%), cough (6%), dyspnea (6%), chills (6%), and vomiting (6%)—all of which were treated with standard of care and slower infusion rates.

None of the patients discontinued daratumumab because of drug-related treatment-emergent AEs, infusion-related reactions, or death. However, 5% of patients discontinued treatment because of treatment-emergent AEs—2 cases of progressive disease and 1 case each of H1N1 influenza, hypercalcemia, and spinal cord compression.

Twenty-nine percent of patients died after treatment—27% due to progressive disease and 2% due to AEs. The 2 AEs were cardiorespiratory failure secondary to H1N1 influenza complications and general health deterioration secondary to complications of aspiration pneumonia.

Woman sunbathing

People residing at higher latitudes, with lower exposure to sunlight/ultraviolet B (UVB) rays, have at least a 2-fold greater risk of developing leukemia than equatorial populations, according to research published in PLOS ONE.

“These results suggest that much of the burden of leukemia worldwide is due to the epidemic of vitamin D deficiency we are experiencing in winter in populations distant from the equator,” said Cedric Garland, DrPH, of the University of California San Diego in La Jolla, California.

“People who live in areas with low solar ultraviolet B exposure tend to have low levels of vitamin D metabolites in their blood. These low levels place them at high risk of certain cancers, including leukemia.”

Dr Garland and his colleagues analyzed age-adjusted incidence rates of leukemia in 172 countries and compared that information with cloud cover data from the International Satellite Cloud Climatology Project.

The team found that leukemia rates were highest in countries relatively closer to the poles, such as Australia, New Zealand, Chile, Ireland, Canada, and the United States.

And leukemia rates were lowest in countries closer to the equator, such as Bolivia, Samoa, Madagascar, and Nigeria.

The researchers also discovered that leukemia incidence was inversely associated with cloud-adjusted UVB irradiance in males (P≤0.01) and females (P≤0.01) in both hemispheres.

The association persisted in males (P≤0.05) and females (P≤0.01) after the team controlled for elevation and life expectancy.

The researchers said it’s plausible that the association is due to vitamin D deficiency.

This study follows similar investigations by Dr Garland and his colleagues in which they looked at other cancers, including breast, colon, pancreas, bladder, and multiple myeloma. In each study, the team found that reduced UVB radiation exposure and lower vitamin D levels were associated with higher risks of cancer.

“These studies do not necessarily provide final evidence,” Dr Garland said, “but they have been helpful in the past in identifying associations that have helped minimize cancer risk.”

Woman sunbathing

People residing at higher latitudes, with lower exposure to sunlight/ultraviolet B (UVB) rays, have at least a 2-fold greater risk of developing leukemia than equatorial populations, according to research published in PLOS ONE.

“These results suggest that much of the burden of leukemia worldwide is due to the epidemic of vitamin D deficiency we are experiencing in winter in populations distant from the equator,” said Cedric Garland, DrPH, of the University of California San Diego in La Jolla, California.

“People who live in areas with low solar ultraviolet B exposure tend to have low levels of vitamin D metabolites in their blood. These low levels place them at high risk of certain cancers, including leukemia.”

Dr Garland and his colleagues analyzed age-adjusted incidence rates of leukemia in 172 countries and compared that information with cloud cover data from the International Satellite Cloud Climatology Project.

The team found that leukemia rates were highest in countries relatively closer to the poles, such as Australia, New Zealand, Chile, Ireland, Canada, and the United States.

And leukemia rates were lowest in countries closer to the equator, such as Bolivia, Samoa, Madagascar, and Nigeria.

The researchers also discovered that leukemia incidence was inversely associated with cloud-adjusted UVB irradiance in males (P≤0.01) and females (P≤0.01) in both hemispheres.

The association persisted in males (P≤0.05) and females (P≤0.01) after the team controlled for elevation and life expectancy.

The researchers said it’s plausible that the association is due to vitamin D deficiency.

This study follows similar investigations by Dr Garland and his colleagues in which they looked at other cancers, including breast, colon, pancreas, bladder, and multiple myeloma. In each study, the team found that reduced UVB radiation exposure and lower vitamin D levels were associated with higher risks of cancer.

“These studies do not necessarily provide final evidence,” Dr Garland said, “but they have been helpful in the past in identifying associations that have helped minimize cancer risk.”

Woman sunbathing

People residing at higher latitudes, with lower exposure to sunlight/ultraviolet B (UVB) rays, have at least a 2-fold greater risk of developing leukemia than equatorial populations, according to research published in PLOS ONE.

“These results suggest that much of the burden of leukemia worldwide is due to the epidemic of vitamin D deficiency we are experiencing in winter in populations distant from the equator,” said Cedric Garland, DrPH, of the University of California San Diego in La Jolla, California.

“People who live in areas with low solar ultraviolet B exposure tend to have low levels of vitamin D metabolites in their blood. These low levels place them at high risk of certain cancers, including leukemia.”

Dr Garland and his colleagues analyzed age-adjusted incidence rates of leukemia in 172 countries and compared that information with cloud cover data from the International Satellite Cloud Climatology Project.

The team found that leukemia rates were highest in countries relatively closer to the poles, such as Australia, New Zealand, Chile, Ireland, Canada, and the United States.

And leukemia rates were lowest in countries closer to the equator, such as Bolivia, Samoa, Madagascar, and Nigeria.

The researchers also discovered that leukemia incidence was inversely associated with cloud-adjusted UVB irradiance in males (P≤0.01) and females (P≤0.01) in both hemispheres.

The association persisted in males (P≤0.05) and females (P≤0.01) after the team controlled for elevation and life expectancy.

The researchers said it’s plausible that the association is due to vitamin D deficiency.

This study follows similar investigations by Dr Garland and his colleagues in which they looked at other cancers, including breast, colon, pancreas, bladder, and multiple myeloma. In each study, the team found that reduced UVB radiation exposure and lower vitamin D levels were associated with higher risks of cancer.

“These studies do not necessarily provide final evidence,” Dr Garland said, “but they have been helpful in the past in identifying associations that have helped minimize cancer risk.”

Micrograph showing CTCL

New research indicates that toxins in Staphylococcus bacteria help malignant cells gain control over healthy cells in patients with cutaneous T-cell lymphoma (CTCL).

Investigators found that staphylococcal enterotoxin-A (SEA) induces STAT3 activation and IL-17 expression in malignant T cells via engagement of non-malignant CD4 T cells.

As STAT3 activation has been implicated in CTCL pathogenesis, the discovery suggests bacterial toxins play a key role in activating an oncogenic pathway in CTCL.

“We have gained important insight into the processes that activate cancer cells and make them grow,” said Niels Oedum, MD, of the University of Copenhagen in Denmark.

“[CTCL] patients’ frequent bacterial infections might not be a mere side effect of the disease. On the contrary, toxins in the bacteria actually ‘benefit’ cancer cells. Our next step is examining whether combatting infections can slow down the growth of cancer cells and thus stop the disease.”

Dr Oedum and his colleagues described their research in Blood.

The investigators knew that, in CTCL, CD4 T cells become malignant and turn parasitic on the rest of the immune system. In addition to using healthy cells to do their work for them, the malignant cells slowly destroy the skin’s immune defense mechanism.

The team’s new discoveries indicate that bacterial toxins in some patients enable malignant cells to send off signals that obstruct and change the immune defense mechanism, which would otherwise fight the malignant cells. What was believed to be an overly active immune defense mechanism could, in other words, turn out to be a malignant infection brought on by bacteria, which only worsens the disease.

Dr Oedum and his colleagues found that SEA-positive bacteria isolatated from the skin of CTCL patients stimulated activation of STAT3 and upregulation of IL-17 in malignant and non-malignant T cells.

Malignant T cells expressing an SEA non-responsive T-cell receptor V beta chain did not respond to SEA when cultured alone but exhibited STAT3 activation and IL-17 expression in co-cultures with SEA-responsive, non-malignant T cells.

The investigators found evidence to suggest the response is induced via IL-2Rg cytokines and a JAK3-dependent pathway in malignant T cells. The JAK3 inhibitor tofacitinib inhibited SEA-induced IL-17 production in co-cultures of malignant and non-malignant T cells.

Dr Oedum and his colleagues plan to continue their work investigating how bacteria might affect the balance between the immune defense mechanism and the disease in patients with CTCL.

In the long-term, the investigators’ aim is to understand how bacteria and their toxins can worsen CTCL, knowledge that may be used to develop new targeted treatments.

As only some of the bacteria produce toxins, the team said it will also be important to develop methods to determine which patients may benefit from treatment with antibiotics.

Micrograph showing CTCL

New research indicates that toxins in Staphylococcus bacteria help malignant cells gain control over healthy cells in patients with cutaneous T-cell lymphoma (CTCL).

Investigators found that staphylococcal enterotoxin-A (SEA) induces STAT3 activation and IL-17 expression in malignant T cells via engagement of non-malignant CD4 T cells.

As STAT3 activation has been implicated in CTCL pathogenesis, the discovery suggests bacterial toxins play a key role in activating an oncogenic pathway in CTCL.

“We have gained important insight into the processes that activate cancer cells and make them grow,” said Niels Oedum, MD, of the University of Copenhagen in Denmark.

“[CTCL] patients’ frequent bacterial infections might not be a mere side effect of the disease. On the contrary, toxins in the bacteria actually ‘benefit’ cancer cells. Our next step is examining whether combatting infections can slow down the growth of cancer cells and thus stop the disease.”

Dr Oedum and his colleagues described their research in Blood.

The investigators knew that, in CTCL, CD4 T cells become malignant and turn parasitic on the rest of the immune system. In addition to using healthy cells to do their work for them, the malignant cells slowly destroy the skin’s immune defense mechanism.

The team’s new discoveries indicate that bacterial toxins in some patients enable malignant cells to send off signals that obstruct and change the immune defense mechanism, which would otherwise fight the malignant cells. What was believed to be an overly active immune defense mechanism could, in other words, turn out to be a malignant infection brought on by bacteria, which only worsens the disease.

Dr Oedum and his colleagues found that SEA-positive bacteria isolatated from the skin of CTCL patients stimulated activation of STAT3 and upregulation of IL-17 in malignant and non-malignant T cells.

Malignant T cells expressing an SEA non-responsive T-cell receptor V beta chain did not respond to SEA when cultured alone but exhibited STAT3 activation and IL-17 expression in co-cultures with SEA-responsive, non-malignant T cells.

The investigators found evidence to suggest the response is induced via IL-2Rg cytokines and a JAK3-dependent pathway in malignant T cells. The JAK3 inhibitor tofacitinib inhibited SEA-induced IL-17 production in co-cultures of malignant and non-malignant T cells.

Dr Oedum and his colleagues plan to continue their work investigating how bacteria might affect the balance between the immune defense mechanism and the disease in patients with CTCL.

In the long-term, the investigators’ aim is to understand how bacteria and their toxins can worsen CTCL, knowledge that may be used to develop new targeted treatments.

As only some of the bacteria produce toxins, the team said it will also be important to develop methods to determine which patients may benefit from treatment with antibiotics.

Micrograph showing CTCL

New research indicates that toxins in Staphylococcus bacteria help malignant cells gain control over healthy cells in patients with cutaneous T-cell lymphoma (CTCL).

Investigators found that staphylococcal enterotoxin-A (SEA) induces STAT3 activation and IL-17 expression in malignant T cells via engagement of non-malignant CD4 T cells.

As STAT3 activation has been implicated in CTCL pathogenesis, the discovery suggests bacterial toxins play a key role in activating an oncogenic pathway in CTCL.

“We have gained important insight into the processes that activate cancer cells and make them grow,” said Niels Oedum, MD, of the University of Copenhagen in Denmark.

“[CTCL] patients’ frequent bacterial infections might not be a mere side effect of the disease. On the contrary, toxins in the bacteria actually ‘benefit’ cancer cells. Our next step is examining whether combatting infections can slow down the growth of cancer cells and thus stop the disease.”

Dr Oedum and his colleagues described their research in Blood.

The investigators knew that, in CTCL, CD4 T cells become malignant and turn parasitic on the rest of the immune system. In addition to using healthy cells to do their work for them, the malignant cells slowly destroy the skin’s immune defense mechanism.

The team’s new discoveries indicate that bacterial toxins in some patients enable malignant cells to send off signals that obstruct and change the immune defense mechanism, which would otherwise fight the malignant cells. What was believed to be an overly active immune defense mechanism could, in other words, turn out to be a malignant infection brought on by bacteria, which only worsens the disease.

Dr Oedum and his colleagues found that SEA-positive bacteria isolatated from the skin of CTCL patients stimulated activation of STAT3 and upregulation of IL-17 in malignant and non-malignant T cells.

Malignant T cells expressing an SEA non-responsive T-cell receptor V beta chain did not respond to SEA when cultured alone but exhibited STAT3 activation and IL-17 expression in co-cultures with SEA-responsive, non-malignant T cells.

The investigators found evidence to suggest the response is induced via IL-2Rg cytokines and a JAK3-dependent pathway in malignant T cells. The JAK3 inhibitor tofacitinib inhibited SEA-induced IL-17 production in co-cultures of malignant and non-malignant T cells.

Dr Oedum and his colleagues plan to continue their work investigating how bacteria might affect the balance between the immune defense mechanism and the disease in patients with CTCL.

In the long-term, the investigators’ aim is to understand how bacteria and their toxins can worsen CTCL, knowledge that may be used to develop new targeted treatments.

As only some of the bacteria produce toxins, the team said it will also be important to develop methods to determine which patients may benefit from treatment with antibiotics.