One of the most apparent and difficult-to-treat aspects of the aging eye is the descent of the eyebrow. The change in the orbital bone structure as well as fat loss and fat redistribution along the upper and lower eyelids and loss of skin elasticity contribute to the skeletonization of the periorbital area and a “drooping” of the eyebrow. Patients either have loss of volume across the entire brow, or primarily across the lateral and central brow creating what is known as an “a-frame” deformity.

Nonsurgical techniques that help lift the brow include a combination of relaxation of the orbicularis oculi muscle with neurotoxins, in addition to the injection of hyaluronic acid fillers along the brow margin and upper third of the face.

Small amounts of hyaluronic acid fillers injected with a 22- to 25-gauge cannula both above and below the eyebrow along the orbital rim provide an instantaneous lifting effect with long-lasting results. Hyaluronic acid and poly-L-lactic acid in dilute concentrations can also be injected with a cannula in the forehead, which creates a repletion of the volume in the upper face that is often lost with aging to create a lift of the eyebrows. Temple hollows can also be filled with calcium hydroxylapatite, poly-L-lactic acid and less often with hyaluronic acid to revolumize and create a lift of the lateral brow. Care should be taken as fillers used in these areas are off-label and need to be done by trained, expert injectors. The periorbital area is a danger zone with many vessels and nerves, and proper injection technique is crucial to avoid arterial blockage, nerve damage, and long-term complications.

Nonablative skin tightening with radiofrequency energy or ultrasound can be used for achieving a brow-lift. Although these techniques do provide collagen remodeling, multiple procedures are often necessary, and results are not always substantial. In a study of 36 patients undergoing ultrasound tightening of the face and neck, 86% showed a clinically significant brow-lift 90 days after treatment. The average brow elevation in this study was 1.7 mm.

In practice, however, patients are often more satisfied with the brow elevation they achieve with neurotoxins and fillers. Injectables provide a faster onset of results, fewer treatments, and minimal discomfort. Combination treatments provide the best overall results and although injectables in the periorbital area are technically difficult, patients are often very satisfied and return for repeat treatments.

References Aesthet Surg J. 2009;May-Jun;29(3):174-9.

J Am Acad Dermatol. 2010;Feb;62(2):262-9.

Dr. Wesley and Dr. Talakoub are cocontributors to this column. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Talakoub.

One of the most apparent and difficult-to-treat aspects of the aging eye is the descent of the eyebrow. The change in the orbital bone structure as well as fat loss and fat redistribution along the upper and lower eyelids and loss of skin elasticity contribute to the skeletonization of the periorbital area and a “drooping” of the eyebrow. Patients either have loss of volume across the entire brow, or primarily across the lateral and central brow creating what is known as an “a-frame” deformity.

Nonsurgical techniques that help lift the brow include a combination of relaxation of the orbicularis oculi muscle with neurotoxins, in addition to the injection of hyaluronic acid fillers along the brow margin and upper third of the face.

Small amounts of hyaluronic acid fillers injected with a 22- to 25-gauge cannula both above and below the eyebrow along the orbital rim provide an instantaneous lifting effect with long-lasting results. Hyaluronic acid and poly-L-lactic acid in dilute concentrations can also be injected with a cannula in the forehead, which creates a repletion of the volume in the upper face that is often lost with aging to create a lift of the eyebrows. Temple hollows can also be filled with calcium hydroxylapatite, poly-L-lactic acid and less often with hyaluronic acid to revolumize and create a lift of the lateral brow. Care should be taken as fillers used in these areas are off-label and need to be done by trained, expert injectors. The periorbital area is a danger zone with many vessels and nerves, and proper injection technique is crucial to avoid arterial blockage, nerve damage, and long-term complications.

Nonablative skin tightening with radiofrequency energy or ultrasound can be used for achieving a brow-lift. Although these techniques do provide collagen remodeling, multiple procedures are often necessary, and results are not always substantial. In a study of 36 patients undergoing ultrasound tightening of the face and neck, 86% showed a clinically significant brow-lift 90 days after treatment. The average brow elevation in this study was 1.7 mm.

In practice, however, patients are often more satisfied with the brow elevation they achieve with neurotoxins and fillers. Injectables provide a faster onset of results, fewer treatments, and minimal discomfort. Combination treatments provide the best overall results and although injectables in the periorbital area are technically difficult, patients are often very satisfied and return for repeat treatments.

References Aesthet Surg J. 2009;May-Jun;29(3):174-9.

J Am Acad Dermatol. 2010;Feb;62(2):262-9.

Dr. Wesley and Dr. Talakoub are cocontributors to this column. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Talakoub.

One of the most apparent and difficult-to-treat aspects of the aging eye is the descent of the eyebrow. The change in the orbital bone structure as well as fat loss and fat redistribution along the upper and lower eyelids and loss of skin elasticity contribute to the skeletonization of the periorbital area and a “drooping” of the eyebrow. Patients either have loss of volume across the entire brow, or primarily across the lateral and central brow creating what is known as an “a-frame” deformity.

Nonsurgical techniques that help lift the brow include a combination of relaxation of the orbicularis oculi muscle with neurotoxins, in addition to the injection of hyaluronic acid fillers along the brow margin and upper third of the face.

Small amounts of hyaluronic acid fillers injected with a 22- to 25-gauge cannula both above and below the eyebrow along the orbital rim provide an instantaneous lifting effect with long-lasting results. Hyaluronic acid and poly-L-lactic acid in dilute concentrations can also be injected with a cannula in the forehead, which creates a repletion of the volume in the upper face that is often lost with aging to create a lift of the eyebrows. Temple hollows can also be filled with calcium hydroxylapatite, poly-L-lactic acid and less often with hyaluronic acid to revolumize and create a lift of the lateral brow. Care should be taken as fillers used in these areas are off-label and need to be done by trained, expert injectors. The periorbital area is a danger zone with many vessels and nerves, and proper injection technique is crucial to avoid arterial blockage, nerve damage, and long-term complications.

Nonablative skin tightening with radiofrequency energy or ultrasound can be used for achieving a brow-lift. Although these techniques do provide collagen remodeling, multiple procedures are often necessary, and results are not always substantial. In a study of 36 patients undergoing ultrasound tightening of the face and neck, 86% showed a clinically significant brow-lift 90 days after treatment. The average brow elevation in this study was 1.7 mm.

In practice, however, patients are often more satisfied with the brow elevation they achieve with neurotoxins and fillers. Injectables provide a faster onset of results, fewer treatments, and minimal discomfort. Combination treatments provide the best overall results and although injectables in the periorbital area are technically difficult, patients are often very satisfied and return for repeat treatments.

References Aesthet Surg J. 2009;May-Jun;29(3):174-9.

J Am Acad Dermatol. 2010;Feb;62(2):262-9.

Dr. Wesley and Dr. Talakoub are cocontributors to this column. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Talakoub.

SAN DIEGO – Among incident hemodialysis patients, high-density lipoprotein cholesterol levels remained stable over time in men but mildly decreased over time in women, regardless of age.

In addition, larger deviations in HDL cholesterol in the first 6 months of incident hemodialysis were associated with a higher risk of 5-year all-cause mortality.

Those are key findings from a large analysis of patients who received hemodialysis care over a 4-year period, which was presented at the meeting sponsored by the American Society of Nephrology.

“Elevated high-density lipoprotein cholesterol levels, although protective in the general population, can be associated with higher mortality in hemodialysis patients,” Dr. Kamyar Kalantar-Zadeh and his colleagues wrote in an abstract of the study. “Association of HDL change over time with mortality has yet to be examined.”

Dr. Kalantar-Zadeh of the division of nephrology and hypertension at the University of California, Irvine, and his associates examined changes in HDL cholesterol levels over time in 24,400 incident hemodialysis patients who received care from facilities affiliated with DaVita HealthCare Partners between 2007 and 2011.

They examined the association of delta HDL (HDL cholesterol change between the first and second 91-day interval from dialysis start) and HDL cholesterol trajectory with all-cause mortality, using mixed effect and Cox regression models and adjusted for demographics, comorbidities, and baseline HDL cholesterol. Delta HDL was treated both as a continuous variable using restricted cubic splines and in five categories ranging from less than –6 mg/dL to 6 mg/dL or greater.

The mean age of patients was 65 years, 44% were female, 31% were black, and 66% had diabetes.

Mean baseline HDL cholesterol was 40.5 mg/dL, with an HDL cholesterol change of 1.7 mg/dL. The researchers found that while male patients had no significant change in HDL cholesterol over time, females had a significant decrease in HDL cholesterol (a mean of –0.6mg/dL per year). At the same time, a 6 mg/dL or greater increase or decrease in delta HDL was associated with a 7% and 37% increase in all-cause mortality, respectively, compared with the reference group. Delta HDL mortality associations did not differ across gender.

“Patients who have a greater than 6 mg/dL change in HDL between the first and second patient [tests] have a higher risk of 5-year all-cause mortality,” the researchers concluded. “Change in HDL exhibits a reverse J-shaped association with mortality in hemodialysis patients. Further studies are needed to examine the underlying causes of these HDL changes and pathophysiology leading to higher risk of all-cause mortality.”

The study was supported by funding from the National Institute of Diabetes and Digestive and Kidney Diseases. The researchers reported having no financial disclosures.

[email protected]

SAN DIEGO – Among incident hemodialysis patients, high-density lipoprotein cholesterol levels remained stable over time in men but mildly decreased over time in women, regardless of age.

In addition, larger deviations in HDL cholesterol in the first 6 months of incident hemodialysis were associated with a higher risk of 5-year all-cause mortality.

Those are key findings from a large analysis of patients who received hemodialysis care over a 4-year period, which was presented at the meeting sponsored by the American Society of Nephrology.

“Elevated high-density lipoprotein cholesterol levels, although protective in the general population, can be associated with higher mortality in hemodialysis patients,” Dr. Kamyar Kalantar-Zadeh and his colleagues wrote in an abstract of the study. “Association of HDL change over time with mortality has yet to be examined.”

Dr. Kalantar-Zadeh of the division of nephrology and hypertension at the University of California, Irvine, and his associates examined changes in HDL cholesterol levels over time in 24,400 incident hemodialysis patients who received care from facilities affiliated with DaVita HealthCare Partners between 2007 and 2011.

They examined the association of delta HDL (HDL cholesterol change between the first and second 91-day interval from dialysis start) and HDL cholesterol trajectory with all-cause mortality, using mixed effect and Cox regression models and adjusted for demographics, comorbidities, and baseline HDL cholesterol. Delta HDL was treated both as a continuous variable using restricted cubic splines and in five categories ranging from less than –6 mg/dL to 6 mg/dL or greater.

The mean age of patients was 65 years, 44% were female, 31% were black, and 66% had diabetes.

Mean baseline HDL cholesterol was 40.5 mg/dL, with an HDL cholesterol change of 1.7 mg/dL. The researchers found that while male patients had no significant change in HDL cholesterol over time, females had a significant decrease in HDL cholesterol (a mean of –0.6mg/dL per year). At the same time, a 6 mg/dL or greater increase or decrease in delta HDL was associated with a 7% and 37% increase in all-cause mortality, respectively, compared with the reference group. Delta HDL mortality associations did not differ across gender.

“Patients who have a greater than 6 mg/dL change in HDL between the first and second patient [tests] have a higher risk of 5-year all-cause mortality,” the researchers concluded. “Change in HDL exhibits a reverse J-shaped association with mortality in hemodialysis patients. Further studies are needed to examine the underlying causes of these HDL changes and pathophysiology leading to higher risk of all-cause mortality.”

The study was supported by funding from the National Institute of Diabetes and Digestive and Kidney Diseases. The researchers reported having no financial disclosures.

[email protected]

SAN DIEGO – Among incident hemodialysis patients, high-density lipoprotein cholesterol levels remained stable over time in men but mildly decreased over time in women, regardless of age.

In addition, larger deviations in HDL cholesterol in the first 6 months of incident hemodialysis were associated with a higher risk of 5-year all-cause mortality.

Those are key findings from a large analysis of patients who received hemodialysis care over a 4-year period, which was presented at the meeting sponsored by the American Society of Nephrology.

“Elevated high-density lipoprotein cholesterol levels, although protective in the general population, can be associated with higher mortality in hemodialysis patients,” Dr. Kamyar Kalantar-Zadeh and his colleagues wrote in an abstract of the study. “Association of HDL change over time with mortality has yet to be examined.”

Dr. Kalantar-Zadeh of the division of nephrology and hypertension at the University of California, Irvine, and his associates examined changes in HDL cholesterol levels over time in 24,400 incident hemodialysis patients who received care from facilities affiliated with DaVita HealthCare Partners between 2007 and 2011.

They examined the association of delta HDL (HDL cholesterol change between the first and second 91-day interval from dialysis start) and HDL cholesterol trajectory with all-cause mortality, using mixed effect and Cox regression models and adjusted for demographics, comorbidities, and baseline HDL cholesterol. Delta HDL was treated both as a continuous variable using restricted cubic splines and in five categories ranging from less than –6 mg/dL to 6 mg/dL or greater.

The mean age of patients was 65 years, 44% were female, 31% were black, and 66% had diabetes.

Mean baseline HDL cholesterol was 40.5 mg/dL, with an HDL cholesterol change of 1.7 mg/dL. The researchers found that while male patients had no significant change in HDL cholesterol over time, females had a significant decrease in HDL cholesterol (a mean of –0.6mg/dL per year). At the same time, a 6 mg/dL or greater increase or decrease in delta HDL was associated with a 7% and 37% increase in all-cause mortality, respectively, compared with the reference group. Delta HDL mortality associations did not differ across gender.

“Patients who have a greater than 6 mg/dL change in HDL between the first and second patient [tests] have a higher risk of 5-year all-cause mortality,” the researchers concluded. “Change in HDL exhibits a reverse J-shaped association with mortality in hemodialysis patients. Further studies are needed to examine the underlying causes of these HDL changes and pathophysiology leading to higher risk of all-cause mortality.”

The study was supported by funding from the National Institute of Diabetes and Digestive and Kidney Diseases. The researchers reported having no financial disclosures.

[email protected]

Concerns with delayed right ventricle dysfunction have offset the early survival advantages after Norwood procedure with right ventricle to pulmonary artery conduit (NW-RVPA) over the Norwood with Blalock-Taussig shunt (NW-BT) in newborns with left ventricular outflow tract obstruction, but a recent report provides evidence that RV function between the two procedures is comparable for up to six years.

Reporting in the January issue of the Journal of Thoracic and Cardiovascular Surgery (J Thorac Cardiovasc Surg. 2015 Dec;150:1440–52), investigators for the Congenital Heart Surgeons’ Society (CHSS) trial found that NW-RVPA has better overall six-year survival and superior right ventricle function in the short term after surgery than NW-BT. The study involved 454 newborns with critical left ventricular outflow tract obstruction (LVOTO) in the CHSS database who had Norwood stage-1 from 2005 to 2014. Propensity matching paired 169 NW-RVPA patients with the same number of NW-BT patients for comparison. CHSS along with the Hospital for Sick Children in Toronto provided funding for the study.

“For neonates with critical LVOTO and similar baseline characteristics undergoing a Norwood stage-1 operation, the six-year overall survival and transplant-free survival were significantly better after NW-RVPA vs. NW-BT,” said Dr. Travis J. Wilder and his colleagues from the Hospital for Sick Children in Toronto.

Key questions the study sought to answer involved the clinical implications of the small variations in RV function between the two procedures, as well as the association between Norwood procedures and tricuspid valve regurgitation (TR) and overall survival.

Overall six-year survival was 70% for the NW-RVPA group vs. 55% for the NW-BT group. Right ventricle dysfunction rates three months after the procedure were lower for the NW-RVPA group, 6% vs. 16%, but rates of late RV dysfunction were less than 5% for both groups. Likewise, rates of moderate or greater TR at two years were lower in the NW-RVPA group: 11% vs. 16%.

Rates of Fontan operation after six years were higher among the NW-RVPA group (54% vs. 49%), as were transplantation rates (6% vs. 2%). Overall, 2% converted to a biventricular repair, but only after NW-RVPA; and seven patients who had NW-RVPA underwent a tricuspid valve repair, compared with four in the NW-BT group.

“For all survivors not undergoing transplantation or biventricular repair, the prevalence of late moderate or greater RV dysfunction and TR were similar between NW-BT and NW-RVPA at six years, without evidence of increased RV dysfunction for patients who underwent NW-RVPA,” Dr. Wilder and his colleagues said.

Consistent with previous studies, the CHSS study showed an early risk of death after a Norwood stage-1 operation, which may be due to a greater prevalence of significant RV dysfunction as the operation transitions from stage 1 to stage 2, Dr. Wilder and his coauthors said. “Although causation between these two time-related events cannot directly be made, it suggests that poor RV function contributes to early hazard for death,” they said.

The authors acknowledge a number of limitations with their study: the variation in the quality of echocardiogram reports from the multiple institutions involved, the inability of propensity matching to account for unmeasured factors and the influence of center and surgeon volume among participating sites. They also said that the ventriculotomy the NW-RVPA involves can lead to late aneurysm, arrhythmias, and ventricular failure. The adverse effects of ventriculotomy on long-term RV function “may not become apparent for years,” Dr. Wilder and his coauthors said.

Dr. Wilder presented a report of the original results at the 2015 American Association for Thoracic Surgery Annual meeting.

The authors had no relationships to disclose.

Concerns with delayed right ventricle dysfunction have offset the early survival advantages after Norwood procedure with right ventricle to pulmonary artery conduit (NW-RVPA) over the Norwood with Blalock-Taussig shunt (NW-BT) in newborns with left ventricular outflow tract obstruction, but a recent report provides evidence that RV function between the two procedures is comparable for up to six years.

Reporting in the January issue of the Journal of Thoracic and Cardiovascular Surgery (J Thorac Cardiovasc Surg. 2015 Dec;150:1440–52), investigators for the Congenital Heart Surgeons’ Society (CHSS) trial found that NW-RVPA has better overall six-year survival and superior right ventricle function in the short term after surgery than NW-BT. The study involved 454 newborns with critical left ventricular outflow tract obstruction (LVOTO) in the CHSS database who had Norwood stage-1 from 2005 to 2014. Propensity matching paired 169 NW-RVPA patients with the same number of NW-BT patients for comparison. CHSS along with the Hospital for Sick Children in Toronto provided funding for the study.

“For neonates with critical LVOTO and similar baseline characteristics undergoing a Norwood stage-1 operation, the six-year overall survival and transplant-free survival were significantly better after NW-RVPA vs. NW-BT,” said Dr. Travis J. Wilder and his colleagues from the Hospital for Sick Children in Toronto.

Key questions the study sought to answer involved the clinical implications of the small variations in RV function between the two procedures, as well as the association between Norwood procedures and tricuspid valve regurgitation (TR) and overall survival.

Overall six-year survival was 70% for the NW-RVPA group vs. 55% for the NW-BT group. Right ventricle dysfunction rates three months after the procedure were lower for the NW-RVPA group, 6% vs. 16%, but rates of late RV dysfunction were less than 5% for both groups. Likewise, rates of moderate or greater TR at two years were lower in the NW-RVPA group: 11% vs. 16%.

Rates of Fontan operation after six years were higher among the NW-RVPA group (54% vs. 49%), as were transplantation rates (6% vs. 2%). Overall, 2% converted to a biventricular repair, but only after NW-RVPA; and seven patients who had NW-RVPA underwent a tricuspid valve repair, compared with four in the NW-BT group.

“For all survivors not undergoing transplantation or biventricular repair, the prevalence of late moderate or greater RV dysfunction and TR were similar between NW-BT and NW-RVPA at six years, without evidence of increased RV dysfunction for patients who underwent NW-RVPA,” Dr. Wilder and his colleagues said.

Consistent with previous studies, the CHSS study showed an early risk of death after a Norwood stage-1 operation, which may be due to a greater prevalence of significant RV dysfunction as the operation transitions from stage 1 to stage 2, Dr. Wilder and his coauthors said. “Although causation between these two time-related events cannot directly be made, it suggests that poor RV function contributes to early hazard for death,” they said.

The authors acknowledge a number of limitations with their study: the variation in the quality of echocardiogram reports from the multiple institutions involved, the inability of propensity matching to account for unmeasured factors and the influence of center and surgeon volume among participating sites. They also said that the ventriculotomy the NW-RVPA involves can lead to late aneurysm, arrhythmias, and ventricular failure. The adverse effects of ventriculotomy on long-term RV function “may not become apparent for years,” Dr. Wilder and his coauthors said.

Dr. Wilder presented a report of the original results at the 2015 American Association for Thoracic Surgery Annual meeting.

The authors had no relationships to disclose.

Concerns with delayed right ventricle dysfunction have offset the early survival advantages after Norwood procedure with right ventricle to pulmonary artery conduit (NW-RVPA) over the Norwood with Blalock-Taussig shunt (NW-BT) in newborns with left ventricular outflow tract obstruction, but a recent report provides evidence that RV function between the two procedures is comparable for up to six years.

Reporting in the January issue of the Journal of Thoracic and Cardiovascular Surgery (J Thorac Cardiovasc Surg. 2015 Dec;150:1440–52), investigators for the Congenital Heart Surgeons’ Society (CHSS) trial found that NW-RVPA has better overall six-year survival and superior right ventricle function in the short term after surgery than NW-BT. The study involved 454 newborns with critical left ventricular outflow tract obstruction (LVOTO) in the CHSS database who had Norwood stage-1 from 2005 to 2014. Propensity matching paired 169 NW-RVPA patients with the same number of NW-BT patients for comparison. CHSS along with the Hospital for Sick Children in Toronto provided funding for the study.

“For neonates with critical LVOTO and similar baseline characteristics undergoing a Norwood stage-1 operation, the six-year overall survival and transplant-free survival were significantly better after NW-RVPA vs. NW-BT,” said Dr. Travis J. Wilder and his colleagues from the Hospital for Sick Children in Toronto.

Key questions the study sought to answer involved the clinical implications of the small variations in RV function between the two procedures, as well as the association between Norwood procedures and tricuspid valve regurgitation (TR) and overall survival.

Overall six-year survival was 70% for the NW-RVPA group vs. 55% for the NW-BT group. Right ventricle dysfunction rates three months after the procedure were lower for the NW-RVPA group, 6% vs. 16%, but rates of late RV dysfunction were less than 5% for both groups. Likewise, rates of moderate or greater TR at two years were lower in the NW-RVPA group: 11% vs. 16%.

Rates of Fontan operation after six years were higher among the NW-RVPA group (54% vs. 49%), as were transplantation rates (6% vs. 2%). Overall, 2% converted to a biventricular repair, but only after NW-RVPA; and seven patients who had NW-RVPA underwent a tricuspid valve repair, compared with four in the NW-BT group.

“For all survivors not undergoing transplantation or biventricular repair, the prevalence of late moderate or greater RV dysfunction and TR were similar between NW-BT and NW-RVPA at six years, without evidence of increased RV dysfunction for patients who underwent NW-RVPA,” Dr. Wilder and his colleagues said.

Consistent with previous studies, the CHSS study showed an early risk of death after a Norwood stage-1 operation, which may be due to a greater prevalence of significant RV dysfunction as the operation transitions from stage 1 to stage 2, Dr. Wilder and his coauthors said. “Although causation between these two time-related events cannot directly be made, it suggests that poor RV function contributes to early hazard for death,” they said.

The authors acknowledge a number of limitations with their study: the variation in the quality of echocardiogram reports from the multiple institutions involved, the inability of propensity matching to account for unmeasured factors and the influence of center and surgeon volume among participating sites. They also said that the ventriculotomy the NW-RVPA involves can lead to late aneurysm, arrhythmias, and ventricular failure. The adverse effects of ventriculotomy on long-term RV function “may not become apparent for years,” Dr. Wilder and his coauthors said.

Dr. Wilder presented a report of the original results at the 2015 American Association for Thoracic Surgery Annual meeting.

The authors had no relationships to disclose.

SAN DIEGO – Among patients with chronic kidney disease, LDL cholesterol level was positively associated with risk of atherosclerotic vascular events, regardless of baseline inflammation, according to a large, randomized study.

In addition, lowering LDL cholesterol with ezetimibe/simvastatin was similarly effective in the presence or absence of inflammation.

“There has been substantial interest in the relationship between LDL cholesterol and outcomes in the general population, and in particular among people with kidney disease,” study author Dr. Richard Haynes of the Nuffield Department of Population Health at the University of Oxford (England) said in an interview in advance of the meeting.

“Previous studies have found a paradoxical increased risk of death at low cholesterol levels, which may be due to another disease process – such as inflammation – both lowering cholesterol and increasing the risk of death, thereby creating a false association,” he explained.

Dr. Haynes and his associates set out to determine the relevance of LDL cholesterol and C-reactive protein (CRP) to cardiovascular risk among 9,270 patients with chronic kidney disease who were enrolled in the Study of Heart and Renal Protection (SHARP), in which they received either ezetimibe/simvastatin or placebo.

The researchers used Cox regression to analyze the hazard ratio for all atherosclerotic vascular events over a period of 4.9 years. The effect of ezetimibe/simvastatin on major atherosclerotic events was estimated in the presence and absence of inflammation, which was defined as a CRP of 3 mg/L. The mean age of SHARP participants was 62 years, and 63% were men.

Dr. Ben Storey, a colleague of Dr. Haynes at Oxford, reported the study results at the meeting sponsored by the American Society of Nephrology.

Among all patients, usual LDL was positively associated with the risk of atherosclerotic vascular events (hazard ratio, 1.34). Compared with patients who had low CRP, those with high CRP were at higher risk, but the relationship between LDL-C and atherosclerotic vascular event risk was similar in both groups (HR, 1.32 and 1.41, respectively).

Ezetimibe/simvastatin was similarly effective at reducing major atherosclerotic events in patients with low and high CRP (risk ratio, 0.84 and 0.83, respectively). Sensitivity analyses yielded similar results.

“The observational data from SHARP show that LDL cholesterol is positively associated with the risk of atherosclerotic vascular events, irrespective of baseline inflammation,” Dr. Storey concluded. “The randomized evidence showed that lowering LDL cholesterol was similarly effective in the presence or absence of inflammation, but CRP is associated with vascular risk in [chronic kidney disease].”

The findings’ clinical implications are that inflammation, “while it is relevant to patients’ outcomes, does not modify the beneficial effects of lowering LDL cholesterol,” according to Dr. Haynes, “So, clinicians should not be put off from prescribing statin-based, cholesterol-lowering therapy by the presence – or absence – of inflammation.”

Merck funded SHARP, but the University of Oxford conducted and analyzed the study independently. The Australian National Health and Medical Research Council, the British Heart Foundation, Cancer Research UK, and the UK Medical Research Council provided additional support.

[email protected]

SAN DIEGO – Among patients with chronic kidney disease, LDL cholesterol level was positively associated with risk of atherosclerotic vascular events, regardless of baseline inflammation, according to a large, randomized study.

In addition, lowering LDL cholesterol with ezetimibe/simvastatin was similarly effective in the presence or absence of inflammation.

“There has been substantial interest in the relationship between LDL cholesterol and outcomes in the general population, and in particular among people with kidney disease,” study author Dr. Richard Haynes of the Nuffield Department of Population Health at the University of Oxford (England) said in an interview in advance of the meeting.

“Previous studies have found a paradoxical increased risk of death at low cholesterol levels, which may be due to another disease process – such as inflammation – both lowering cholesterol and increasing the risk of death, thereby creating a false association,” he explained.

Dr. Haynes and his associates set out to determine the relevance of LDL cholesterol and C-reactive protein (CRP) to cardiovascular risk among 9,270 patients with chronic kidney disease who were enrolled in the Study of Heart and Renal Protection (SHARP), in which they received either ezetimibe/simvastatin or placebo.

The researchers used Cox regression to analyze the hazard ratio for all atherosclerotic vascular events over a period of 4.9 years. The effect of ezetimibe/simvastatin on major atherosclerotic events was estimated in the presence and absence of inflammation, which was defined as a CRP of 3 mg/L. The mean age of SHARP participants was 62 years, and 63% were men.

Dr. Ben Storey, a colleague of Dr. Haynes at Oxford, reported the study results at the meeting sponsored by the American Society of Nephrology.

Among all patients, usual LDL was positively associated with the risk of atherosclerotic vascular events (hazard ratio, 1.34). Compared with patients who had low CRP, those with high CRP were at higher risk, but the relationship between LDL-C and atherosclerotic vascular event risk was similar in both groups (HR, 1.32 and 1.41, respectively).

Ezetimibe/simvastatin was similarly effective at reducing major atherosclerotic events in patients with low and high CRP (risk ratio, 0.84 and 0.83, respectively). Sensitivity analyses yielded similar results.

“The observational data from SHARP show that LDL cholesterol is positively associated with the risk of atherosclerotic vascular events, irrespective of baseline inflammation,” Dr. Storey concluded. “The randomized evidence showed that lowering LDL cholesterol was similarly effective in the presence or absence of inflammation, but CRP is associated with vascular risk in [chronic kidney disease].”

The findings’ clinical implications are that inflammation, “while it is relevant to patients’ outcomes, does not modify the beneficial effects of lowering LDL cholesterol,” according to Dr. Haynes, “So, clinicians should not be put off from prescribing statin-based, cholesterol-lowering therapy by the presence – or absence – of inflammation.”

Merck funded SHARP, but the University of Oxford conducted and analyzed the study independently. The Australian National Health and Medical Research Council, the British Heart Foundation, Cancer Research UK, and the UK Medical Research Council provided additional support.

[email protected]

SAN DIEGO – Among patients with chronic kidney disease, LDL cholesterol level was positively associated with risk of atherosclerotic vascular events, regardless of baseline inflammation, according to a large, randomized study.

In addition, lowering LDL cholesterol with ezetimibe/simvastatin was similarly effective in the presence or absence of inflammation.

“There has been substantial interest in the relationship between LDL cholesterol and outcomes in the general population, and in particular among people with kidney disease,” study author Dr. Richard Haynes of the Nuffield Department of Population Health at the University of Oxford (England) said in an interview in advance of the meeting.

“Previous studies have found a paradoxical increased risk of death at low cholesterol levels, which may be due to another disease process – such as inflammation – both lowering cholesterol and increasing the risk of death, thereby creating a false association,” he explained.

Dr. Haynes and his associates set out to determine the relevance of LDL cholesterol and C-reactive protein (CRP) to cardiovascular risk among 9,270 patients with chronic kidney disease who were enrolled in the Study of Heart and Renal Protection (SHARP), in which they received either ezetimibe/simvastatin or placebo.

The researchers used Cox regression to analyze the hazard ratio for all atherosclerotic vascular events over a period of 4.9 years. The effect of ezetimibe/simvastatin on major atherosclerotic events was estimated in the presence and absence of inflammation, which was defined as a CRP of 3 mg/L. The mean age of SHARP participants was 62 years, and 63% were men.

Dr. Ben Storey, a colleague of Dr. Haynes at Oxford, reported the study results at the meeting sponsored by the American Society of Nephrology.

Among all patients, usual LDL was positively associated with the risk of atherosclerotic vascular events (hazard ratio, 1.34). Compared with patients who had low CRP, those with high CRP were at higher risk, but the relationship between LDL-C and atherosclerotic vascular event risk was similar in both groups (HR, 1.32 and 1.41, respectively).

Ezetimibe/simvastatin was similarly effective at reducing major atherosclerotic events in patients with low and high CRP (risk ratio, 0.84 and 0.83, respectively). Sensitivity analyses yielded similar results.

“The observational data from SHARP show that LDL cholesterol is positively associated with the risk of atherosclerotic vascular events, irrespective of baseline inflammation,” Dr. Storey concluded. “The randomized evidence showed that lowering LDL cholesterol was similarly effective in the presence or absence of inflammation, but CRP is associated with vascular risk in [chronic kidney disease].”

The findings’ clinical implications are that inflammation, “while it is relevant to patients’ outcomes, does not modify the beneficial effects of lowering LDL cholesterol,” according to Dr. Haynes, “So, clinicians should not be put off from prescribing statin-based, cholesterol-lowering therapy by the presence – or absence – of inflammation.”

Merck funded SHARP, but the University of Oxford conducted and analyzed the study independently. The Australian National Health and Medical Research Council, the British Heart Foundation, Cancer Research UK, and the UK Medical Research Council provided additional support.

[email protected]

ORLANDO – Patients with acute myeloid leukemia (AML) initially treated at an academic center lived significantly longer than those treated at nonacademic centers, a database analysis shows.

Median overall survival increased from 7 months at a nonacademic center to 12.6 months at an academic center (P less than .001).

One-year overall survival rates were also significantly better at 51% vs. 39% (P less than .001).

Patrice Wendling/Frontline Medical News

The difference remained significant even after controlling for important confounders including age, comorbidity burden, receipt of chemotherapy, transplant, and delay between diagnosis and treatment, Mr. Smith Giri reported at the annual meeting of the American Society of Hematology.

“From a policy perspective, it may be useful to know whether these results are due to higher volume of cases, more advanced technology, expanded role of specialists, or greater, round-the-clock availability of resident physicians,” said Mr. Giri of the University of Tennessee Health Science Center in Memphis.

Prior studies in cancer have suggested better overall survival among breast cancer patients treated at academic centers, but this is the first study looking at outcomes in AML, the most common acute leukemia in adults.

Using the National Cancer Database Participant User File, the investigators identified 7,823 patients with AML who received their initial therapy at the reporting facility from 1998 to 2011. The database collects information from more than 1,500 Commission on Cancer (CoC)–accredited facilities. Of the 7,823 patients, 4,681 (60%) were treated at an AC (academic/research program) and 3,142 at a non-AC (community cancer program/comprehensive community cancer program).

Patients treated at an AC were significantly younger than those treated at a non-AC (median 62 years vs. 67 years), tended to be of nonwhite race, less educated, have a lower income, and more comorbidities.

Receipt of chemotherapy (97.4% vs. 94.5%) and transplant (9% vs. 2.4%) were significantly higher at an AC than a non-AC (both P less than .001).

Kaplan Meier survival curves suggested disparate survival curves between the two groups, mainly within the first 5 years of follow-up (P less than .001), Mr. Giri said.

In multivariate model analysis, the non-AC group had significantly worse risk adjusted 30-day mortality than the AC group (odds ratio, 1.52; 95% confidence interval 1.33-1.74; P less than .001) and worse overall survival (hazard ratio, 1.13; 95% CI 1.07-1.19; P less than .001).

The study (Ab. 533) findings should be interpreted with caution because of its limitations, including the lack of information on AML risk type in the database, the fact that administrative datasets are prone to coding errors, and because the analysis did not adjust for hospital volume, which has been shown to affect survival, he said. Also, because there are more than 3,500 non–Coc approved hospitals, the sample may not be representative of overall U.S. hospitals.

During a discussion of the results, Mr. Giri acknowledged that patients treated at academic centers may have greater access to clinical trials and experimental agents. Future analyses should also distinguish patients with a diagnosis of acute promyelocytic leukemia, a distinct subset of AML.

[email protected]

ORLANDO – Patients with acute myeloid leukemia (AML) initially treated at an academic center lived significantly longer than those treated at nonacademic centers, a database analysis shows.

Median overall survival increased from 7 months at a nonacademic center to 12.6 months at an academic center (P less than .001).

One-year overall survival rates were also significantly better at 51% vs. 39% (P less than .001).

Patrice Wendling/Frontline Medical News

The difference remained significant even after controlling for important confounders including age, comorbidity burden, receipt of chemotherapy, transplant, and delay between diagnosis and treatment, Mr. Smith Giri reported at the annual meeting of the American Society of Hematology.

“From a policy perspective, it may be useful to know whether these results are due to higher volume of cases, more advanced technology, expanded role of specialists, or greater, round-the-clock availability of resident physicians,” said Mr. Giri of the University of Tennessee Health Science Center in Memphis.

Prior studies in cancer have suggested better overall survival among breast cancer patients treated at academic centers, but this is the first study looking at outcomes in AML, the most common acute leukemia in adults.

Using the National Cancer Database Participant User File, the investigators identified 7,823 patients with AML who received their initial therapy at the reporting facility from 1998 to 2011. The database collects information from more than 1,500 Commission on Cancer (CoC)–accredited facilities. Of the 7,823 patients, 4,681 (60%) were treated at an AC (academic/research program) and 3,142 at a non-AC (community cancer program/comprehensive community cancer program).

Patients treated at an AC were significantly younger than those treated at a non-AC (median 62 years vs. 67 years), tended to be of nonwhite race, less educated, have a lower income, and more comorbidities.

Receipt of chemotherapy (97.4% vs. 94.5%) and transplant (9% vs. 2.4%) were significantly higher at an AC than a non-AC (both P less than .001).

Kaplan Meier survival curves suggested disparate survival curves between the two groups, mainly within the first 5 years of follow-up (P less than .001), Mr. Giri said.

In multivariate model analysis, the non-AC group had significantly worse risk adjusted 30-day mortality than the AC group (odds ratio, 1.52; 95% confidence interval 1.33-1.74; P less than .001) and worse overall survival (hazard ratio, 1.13; 95% CI 1.07-1.19; P less than .001).

The study (Ab. 533) findings should be interpreted with caution because of its limitations, including the lack of information on AML risk type in the database, the fact that administrative datasets are prone to coding errors, and because the analysis did not adjust for hospital volume, which has been shown to affect survival, he said. Also, because there are more than 3,500 non–Coc approved hospitals, the sample may not be representative of overall U.S. hospitals.

During a discussion of the results, Mr. Giri acknowledged that patients treated at academic centers may have greater access to clinical trials and experimental agents. Future analyses should also distinguish patients with a diagnosis of acute promyelocytic leukemia, a distinct subset of AML.

[email protected]

ORLANDO – Patients with acute myeloid leukemia (AML) initially treated at an academic center lived significantly longer than those treated at nonacademic centers, a database analysis shows.

Median overall survival increased from 7 months at a nonacademic center to 12.6 months at an academic center (P less than .001).

One-year overall survival rates were also significantly better at 51% vs. 39% (P less than .001).

Patrice Wendling/Frontline Medical News

The difference remained significant even after controlling for important confounders including age, comorbidity burden, receipt of chemotherapy, transplant, and delay between diagnosis and treatment, Mr. Smith Giri reported at the annual meeting of the American Society of Hematology.

“From a policy perspective, it may be useful to know whether these results are due to higher volume of cases, more advanced technology, expanded role of specialists, or greater, round-the-clock availability of resident physicians,” said Mr. Giri of the University of Tennessee Health Science Center in Memphis.

Prior studies in cancer have suggested better overall survival among breast cancer patients treated at academic centers, but this is the first study looking at outcomes in AML, the most common acute leukemia in adults.

Using the National Cancer Database Participant User File, the investigators identified 7,823 patients with AML who received their initial therapy at the reporting facility from 1998 to 2011. The database collects information from more than 1,500 Commission on Cancer (CoC)–accredited facilities. Of the 7,823 patients, 4,681 (60%) were treated at an AC (academic/research program) and 3,142 at a non-AC (community cancer program/comprehensive community cancer program).

Patients treated at an AC were significantly younger than those treated at a non-AC (median 62 years vs. 67 years), tended to be of nonwhite race, less educated, have a lower income, and more comorbidities.

Receipt of chemotherapy (97.4% vs. 94.5%) and transplant (9% vs. 2.4%) were significantly higher at an AC than a non-AC (both P less than .001).

Kaplan Meier survival curves suggested disparate survival curves between the two groups, mainly within the first 5 years of follow-up (P less than .001), Mr. Giri said.

In multivariate model analysis, the non-AC group had significantly worse risk adjusted 30-day mortality than the AC group (odds ratio, 1.52; 95% confidence interval 1.33-1.74; P less than .001) and worse overall survival (hazard ratio, 1.13; 95% CI 1.07-1.19; P less than .001).

The study (Ab. 533) findings should be interpreted with caution because of its limitations, including the lack of information on AML risk type in the database, the fact that administrative datasets are prone to coding errors, and because the analysis did not adjust for hospital volume, which has been shown to affect survival, he said. Also, because there are more than 3,500 non–Coc approved hospitals, the sample may not be representative of overall U.S. hospitals.

During a discussion of the results, Mr. Giri acknowledged that patients treated at academic centers may have greater access to clinical trials and experimental agents. Future analyses should also distinguish patients with a diagnosis of acute promyelocytic leukemia, a distinct subset of AML.

[email protected]

Most children and young adult patients with congenital heart disease can and should engage in some form of physical activity and should avoid a sedentary lifestyle, according to a task force scientific statement from the American Heart Association and the American College of Cardiology (AHA/ACC).

This recommendation comes despite the fears of sudden cardiac death (SCD) in young athletes, which formed the initial impetus of the entire series of task force reports.

The recommended level of sports participation for patients with treated or untreated congenital heart defect, however, should consider the training and the competitive aspects of the sport itself and must be individualized to the patient. This means taking into account the patient’s current functional status, history of surgery, and the presence of implanted cardiac devices, according to the report by Dr. George F. Van Hare of Washington University, St. Louis, and his colleagues, which was published online in the Journal of the American College of Cardiology.

© Jody Dingle/Fotolia.com

The report breaks down its specific recommendations based upon the various types of congenital heart defect (CHD). Full details and nuances of the recommendations and their specific levels of evidence for each individual condition and the many variants can be found in the online publication. Below is a brief and selected summary for some of the most common defects and some of those most pertinent to sudden cardiac death in young athletes.

Simple shunting lesions (atrial septal defect, ventricular septal defect, patent ductus arteriosus): Treated and untreated

In addressing the three most common subtypes of CHD – ventricular septal defect (VSD, 34%), atrial septal defect (ASD, 13%), and patent ductus arteriosus (PDA, 10%) – the committee found no data that children with these lesions are related to acknowledged episodes of sudden cardiac death (SCD). This applied whether the defects were closed or remained open. “With rare exceptions, patients with hemodynamically insignificant CHD such as VSD, ASD, and PDA may participate competitively in all sports,” it concluded. These recommendations fall under class I; level of evidence C for almost all of these patients, according to the writing committee.

Congenital coronary anomalies: Treated and untreated

Anomalies of coronary arteries are the second-most commonly identified structural causes of SCD in competitive athletes, accounting for about 17% of such deaths in the United States, according to the report. The vast majority of sudden deaths associated with coronary anomalies occur during or shortly after exercise. Despite being less commonly represented in patients, among athletes who have died suddenly, anomalous origin of the left main or left anterior descending coronary artery from the right sinus of Valsalva is far more prevalent. In addition, SCDs are most strongly associated with the pattern in which the anomalous left coronary artery passes between the aorta and main pulmonary artery. Recommended return to intense athletic activities is only to be permitted at least 3 months after surgery, and with a demonstration of the absence of ischemia on postoperative stress testing, with evidence levels depending on the type of anomaly. Of note, in contrast, the committee indicated that athletes with an anomalous origin of a right coronary artery from the left sinus of Valsalva should simply be evaluated by an exercise stress test, and for those without symptoms or a positive exercise stress test, permission to compete can be considered after adequate counseling (class IIa; level of evidence C).

Pulmonary valve stenosis: Treated and untreated

The committee determined that athletes with mild pulmonary stenosis (PS) and normal right ventricular (RV) function can participate in all competitive sports, although annual reevaluation also is recommended (class I; level of evidence B). In addition, athletes treated by operation or balloon valvuloplasty who have achieved adequate relief of PS (gradient less than 40 mm Hg by Doppler) can participate in all competitive sports (class I; level of evidence B). Other patients should be restricted to low-intensity sports, according to the committee.

Aortic valve stenosis: Treated and untreated

Children and adolescents with aortic stenosis (AS) are differentiated between those with mild, moderate, and severe AS by physical examination, ECG, and Doppler echocardiography. In all cases, regardless of the degree of stenosis, patients with a history of fatigue, light-headedness, dizziness, syncope, chest pain, or pallor on exercise deserve a full evaluation. Annual re-evaluation is required for all patients with AS because the disease can progress. Patients with severe AS are at risk of sudden death, particularly with exercise. The committee determined that athletes with mild AS can participate in all competitive sports (class I; level of evidence B), but that athletes with severe AS should be restricted from all competitive sports, with the possible exception of low-intensity sports (class III; level of evidence B).

Coarctation of the aorta: Treated and untreated

Before a decision is made regarding exercise participation, a detailed evaluation should be conducted, including a physical examination, ECG, chest radiograph, exercise testing, transthoracic echocardiographic evaluation of the aortic valve and aorta, and either magnetic resonance imaging or computed tomography angiography, according to the committee. The determination as to the level of sports participation permitted requires a complex assessment of these various test results and can range from full participation in the case of the least affected to restrictions to low-intensity sports in those more severely affected.

Cyanotic CHD, including tetralogy of Fallot

Full clinical assessment, including laboratory and exercise testing, should be considered before any physical activity because this population is at very high risk of sudden death, according to the committee. Recommendations are complex and depend on the level of repair and its success, but, in general, significant restrictions are recommended for all but the most effectively treated patients.

Transposition of the great arteries after atrial switch (Mustard or Senning operation)

This is a population highly at risk, according to the committee. They appear to have a unique response to exercise with reports that a high proportion of sudden death events occur during exertion. In addition, evidence of exercise-induced arrhythmias on routine clinical testing has not been shown to reliably predict exercise-induced SCD events. Although recommendations vary, including strong restrictions for many, at best the most successful of these patients should only be considered for low- to moderate-intensity competitive sports, according to the committee.

Other conditions assessed and evaluated by the committee included congenitally corrected TGA, TGA after the arterial switch, Fontan procedure, elevated pulmonary vascular resistence in CHD, ventricular dysfunction after CHD surgery, and Ebstein anomaly of the tricuspid valve.

In all cases, complete physical assessment of these patients is recommended, especially due to the often highly individualized nature of the patient’s presentation of these conditions and the variety and variability of interventions that may have been performed. Such differentials make recommendations regarding sports participation a complex calculus, which the committee attempts to provide, listing whatever evidence is available.

The majority of these patients, however, will not be considered for the highest levels of competitive sports participation. Although, in almost all cases, the need for physical activity as a contributor to patient health and well-being is stressed at whatever level of performance is possible.

The report ”Eligibility and disqualification recommendations for competitive athletes with cardiovascular abnormalities: Task Force 4: congenital heart disease: a scientific statement from the American Heart Association and American College of Cardiology,” was prepared by Dr. Van Hare and his colleagues on behalf of the American Heart Association Electrocardiography and Arrhythmias Committee of the Council on Clinical Cardiology, Council on Cardiovascular Disease in the Young, Council on Cardiovascular and Stroke Nursing, Council on Functional Genomics and Translational Biology, and the American College of Cardiology (doi: 10.1016/j.jacc.2015.09.032).

This report is one of the assessments and recommendations of 15 task forces on eligibility and disqualification recommendations for young athletes, nine of which are disease or multidisease related. The other six task forces focus on a variety of relevant topics and issues regarding the risks of young athletes on the field, including screening, the use of automated external defibrillators on the field, the use of dietary supplements and performance-enhancing drugs, sudden death, and the medical-legal perspectives involved.

All 15 task force reports were simultaneously published online in the Journal of the American College of Cardiology and the journal Circulation.

Dr. Van Hare and all but one member of the writing group had no disclosures. One member disclosed consultant/advisory committee associations with a variety of medical device companies.

[email protected]

Most children and young adult patients with congenital heart disease can and should engage in some form of physical activity and should avoid a sedentary lifestyle, according to a task force scientific statement from the American Heart Association and the American College of Cardiology (AHA/ACC).

This recommendation comes despite the fears of sudden cardiac death (SCD) in young athletes, which formed the initial impetus of the entire series of task force reports.

The recommended level of sports participation for patients with treated or untreated congenital heart defect, however, should consider the training and the competitive aspects of the sport itself and must be individualized to the patient. This means taking into account the patient’s current functional status, history of surgery, and the presence of implanted cardiac devices, according to the report by Dr. George F. Van Hare of Washington University, St. Louis, and his colleagues, which was published online in the Journal of the American College of Cardiology.

© Jody Dingle/Fotolia.com

The report breaks down its specific recommendations based upon the various types of congenital heart defect (CHD). Full details and nuances of the recommendations and their specific levels of evidence for each individual condition and the many variants can be found in the online publication. Below is a brief and selected summary for some of the most common defects and some of those most pertinent to sudden cardiac death in young athletes.

Simple shunting lesions (atrial septal defect, ventricular septal defect, patent ductus arteriosus): Treated and untreated

In addressing the three most common subtypes of CHD – ventricular septal defect (VSD, 34%), atrial septal defect (ASD, 13%), and patent ductus arteriosus (PDA, 10%) – the committee found no data that children with these lesions are related to acknowledged episodes of sudden cardiac death (SCD). This applied whether the defects were closed or remained open. “With rare exceptions, patients with hemodynamically insignificant CHD such as VSD, ASD, and PDA may participate competitively in all sports,” it concluded. These recommendations fall under class I; level of evidence C for almost all of these patients, according to the writing committee.

Congenital coronary anomalies: Treated and untreated

Anomalies of coronary arteries are the second-most commonly identified structural causes of SCD in competitive athletes, accounting for about 17% of such deaths in the United States, according to the report. The vast majority of sudden deaths associated with coronary anomalies occur during or shortly after exercise. Despite being less commonly represented in patients, among athletes who have died suddenly, anomalous origin of the left main or left anterior descending coronary artery from the right sinus of Valsalva is far more prevalent. In addition, SCDs are most strongly associated with the pattern in which the anomalous left coronary artery passes between the aorta and main pulmonary artery. Recommended return to intense athletic activities is only to be permitted at least 3 months after surgery, and with a demonstration of the absence of ischemia on postoperative stress testing, with evidence levels depending on the type of anomaly. Of note, in contrast, the committee indicated that athletes with an anomalous origin of a right coronary artery from the left sinus of Valsalva should simply be evaluated by an exercise stress test, and for those without symptoms or a positive exercise stress test, permission to compete can be considered after adequate counseling (class IIa; level of evidence C).

Pulmonary valve stenosis: Treated and untreated

The committee determined that athletes with mild pulmonary stenosis (PS) and normal right ventricular (RV) function can participate in all competitive sports, although annual reevaluation also is recommended (class I; level of evidence B). In addition, athletes treated by operation or balloon valvuloplasty who have achieved adequate relief of PS (gradient less than 40 mm Hg by Doppler) can participate in all competitive sports (class I; level of evidence B). Other patients should be restricted to low-intensity sports, according to the committee.

Aortic valve stenosis: Treated and untreated

Children and adolescents with aortic stenosis (AS) are differentiated between those with mild, moderate, and severe AS by physical examination, ECG, and Doppler echocardiography. In all cases, regardless of the degree of stenosis, patients with a history of fatigue, light-headedness, dizziness, syncope, chest pain, or pallor on exercise deserve a full evaluation. Annual re-evaluation is required for all patients with AS because the disease can progress. Patients with severe AS are at risk of sudden death, particularly with exercise. The committee determined that athletes with mild AS can participate in all competitive sports (class I; level of evidence B), but that athletes with severe AS should be restricted from all competitive sports, with the possible exception of low-intensity sports (class III; level of evidence B).

Coarctation of the aorta: Treated and untreated

Before a decision is made regarding exercise participation, a detailed evaluation should be conducted, including a physical examination, ECG, chest radiograph, exercise testing, transthoracic echocardiographic evaluation of the aortic valve and aorta, and either magnetic resonance imaging or computed tomography angiography, according to the committee. The determination as to the level of sports participation permitted requires a complex assessment of these various test results and can range from full participation in the case of the least affected to restrictions to low-intensity sports in those more severely affected.

Cyanotic CHD, including tetralogy of Fallot

Full clinical assessment, including laboratory and exercise testing, should be considered before any physical activity because this population is at very high risk of sudden death, according to the committee. Recommendations are complex and depend on the level of repair and its success, but, in general, significant restrictions are recommended for all but the most effectively treated patients.

Transposition of the great arteries after atrial switch (Mustard or Senning operation)

This is a population highly at risk, according to the committee. They appear to have a unique response to exercise with reports that a high proportion of sudden death events occur during exertion. In addition, evidence of exercise-induced arrhythmias on routine clinical testing has not been shown to reliably predict exercise-induced SCD events. Although recommendations vary, including strong restrictions for many, at best the most successful of these patients should only be considered for low- to moderate-intensity competitive sports, according to the committee.

Other conditions assessed and evaluated by the committee included congenitally corrected TGA, TGA after the arterial switch, Fontan procedure, elevated pulmonary vascular resistence in CHD, ventricular dysfunction after CHD surgery, and Ebstein anomaly of the tricuspid valve.

In all cases, complete physical assessment of these patients is recommended, especially due to the often highly individualized nature of the patient’s presentation of these conditions and the variety and variability of interventions that may have been performed. Such differentials make recommendations regarding sports participation a complex calculus, which the committee attempts to provide, listing whatever evidence is available.

The majority of these patients, however, will not be considered for the highest levels of competitive sports participation. Although, in almost all cases, the need for physical activity as a contributor to patient health and well-being is stressed at whatever level of performance is possible.

The report ”Eligibility and disqualification recommendations for competitive athletes with cardiovascular abnormalities: Task Force 4: congenital heart disease: a scientific statement from the American Heart Association and American College of Cardiology,” was prepared by Dr. Van Hare and his colleagues on behalf of the American Heart Association Electrocardiography and Arrhythmias Committee of the Council on Clinical Cardiology, Council on Cardiovascular Disease in the Young, Council on Cardiovascular and Stroke Nursing, Council on Functional Genomics and Translational Biology, and the American College of Cardiology (doi: 10.1016/j.jacc.2015.09.032).

This report is one of the assessments and recommendations of 15 task forces on eligibility and disqualification recommendations for young athletes, nine of which are disease or multidisease related. The other six task forces focus on a variety of relevant topics and issues regarding the risks of young athletes on the field, including screening, the use of automated external defibrillators on the field, the use of dietary supplements and performance-enhancing drugs, sudden death, and the medical-legal perspectives involved.

All 15 task force reports were simultaneously published online in the Journal of the American College of Cardiology and the journal Circulation.

Dr. Van Hare and all but one member of the writing group had no disclosures. One member disclosed consultant/advisory committee associations with a variety of medical device companies.

[email protected]

Most children and young adult patients with congenital heart disease can and should engage in some form of physical activity and should avoid a sedentary lifestyle, according to a task force scientific statement from the American Heart Association and the American College of Cardiology (AHA/ACC).

This recommendation comes despite the fears of sudden cardiac death (SCD) in young athletes, which formed the initial impetus of the entire series of task force reports.

The recommended level of sports participation for patients with treated or untreated congenital heart defect, however, should consider the training and the competitive aspects of the sport itself and must be individualized to the patient. This means taking into account the patient’s current functional status, history of surgery, and the presence of implanted cardiac devices, according to the report by Dr. George F. Van Hare of Washington University, St. Louis, and his colleagues, which was published online in the Journal of the American College of Cardiology.

© Jody Dingle/Fotolia.com

The report breaks down its specific recommendations based upon the various types of congenital heart defect (CHD). Full details and nuances of the recommendations and their specific levels of evidence for each individual condition and the many variants can be found in the online publication. Below is a brief and selected summary for some of the most common defects and some of those most pertinent to sudden cardiac death in young athletes.

Simple shunting lesions (atrial septal defect, ventricular septal defect, patent ductus arteriosus): Treated and untreated

In addressing the three most common subtypes of CHD – ventricular septal defect (VSD, 34%), atrial septal defect (ASD, 13%), and patent ductus arteriosus (PDA, 10%) – the committee found no data that children with these lesions are related to acknowledged episodes of sudden cardiac death (SCD). This applied whether the defects were closed or remained open. “With rare exceptions, patients with hemodynamically insignificant CHD such as VSD, ASD, and PDA may participate competitively in all sports,” it concluded. These recommendations fall under class I; level of evidence C for almost all of these patients, according to the writing committee.

Congenital coronary anomalies: Treated and untreated

Anomalies of coronary arteries are the second-most commonly identified structural causes of SCD in competitive athletes, accounting for about 17% of such deaths in the United States, according to the report. The vast majority of sudden deaths associated with coronary anomalies occur during or shortly after exercise. Despite being less commonly represented in patients, among athletes who have died suddenly, anomalous origin of the left main or left anterior descending coronary artery from the right sinus of Valsalva is far more prevalent. In addition, SCDs are most strongly associated with the pattern in which the anomalous left coronary artery passes between the aorta and main pulmonary artery. Recommended return to intense athletic activities is only to be permitted at least 3 months after surgery, and with a demonstration of the absence of ischemia on postoperative stress testing, with evidence levels depending on the type of anomaly. Of note, in contrast, the committee indicated that athletes with an anomalous origin of a right coronary artery from the left sinus of Valsalva should simply be evaluated by an exercise stress test, and for those without symptoms or a positive exercise stress test, permission to compete can be considered after adequate counseling (class IIa; level of evidence C).

Pulmonary valve stenosis: Treated and untreated

The committee determined that athletes with mild pulmonary stenosis (PS) and normal right ventricular (RV) function can participate in all competitive sports, although annual reevaluation also is recommended (class I; level of evidence B). In addition, athletes treated by operation or balloon valvuloplasty who have achieved adequate relief of PS (gradient less than 40 mm Hg by Doppler) can participate in all competitive sports (class I; level of evidence B). Other patients should be restricted to low-intensity sports, according to the committee.

Aortic valve stenosis: Treated and untreated

Children and adolescents with aortic stenosis (AS) are differentiated between those with mild, moderate, and severe AS by physical examination, ECG, and Doppler echocardiography. In all cases, regardless of the degree of stenosis, patients with a history of fatigue, light-headedness, dizziness, syncope, chest pain, or pallor on exercise deserve a full evaluation. Annual re-evaluation is required for all patients with AS because the disease can progress. Patients with severe AS are at risk of sudden death, particularly with exercise. The committee determined that athletes with mild AS can participate in all competitive sports (class I; level of evidence B), but that athletes with severe AS should be restricted from all competitive sports, with the possible exception of low-intensity sports (class III; level of evidence B).

Coarctation of the aorta: Treated and untreated

Before a decision is made regarding exercise participation, a detailed evaluation should be conducted, including a physical examination, ECG, chest radiograph, exercise testing, transthoracic echocardiographic evaluation of the aortic valve and aorta, and either magnetic resonance imaging or computed tomography angiography, according to the committee. The determination as to the level of sports participation permitted requires a complex assessment of these various test results and can range from full participation in the case of the least affected to restrictions to low-intensity sports in those more severely affected.

Cyanotic CHD, including tetralogy of Fallot

Full clinical assessment, including laboratory and exercise testing, should be considered before any physical activity because this population is at very high risk of sudden death, according to the committee. Recommendations are complex and depend on the level of repair and its success, but, in general, significant restrictions are recommended for all but the most effectively treated patients.

Transposition of the great arteries after atrial switch (Mustard or Senning operation)

This is a population highly at risk, according to the committee. They appear to have a unique response to exercise with reports that a high proportion of sudden death events occur during exertion. In addition, evidence of exercise-induced arrhythmias on routine clinical testing has not been shown to reliably predict exercise-induced SCD events. Although recommendations vary, including strong restrictions for many, at best the most successful of these patients should only be considered for low- to moderate-intensity competitive sports, according to the committee.

Other conditions assessed and evaluated by the committee included congenitally corrected TGA, TGA after the arterial switch, Fontan procedure, elevated pulmonary vascular resistence in CHD, ventricular dysfunction after CHD surgery, and Ebstein anomaly of the tricuspid valve.

In all cases, complete physical assessment of these patients is recommended, especially due to the often highly individualized nature of the patient’s presentation of these conditions and the variety and variability of interventions that may have been performed. Such differentials make recommendations regarding sports participation a complex calculus, which the committee attempts to provide, listing whatever evidence is available.

The majority of these patients, however, will not be considered for the highest levels of competitive sports participation. Although, in almost all cases, the need for physical activity as a contributor to patient health and well-being is stressed at whatever level of performance is possible.

The report ”Eligibility and disqualification recommendations for competitive athletes with cardiovascular abnormalities: Task Force 4: congenital heart disease: a scientific statement from the American Heart Association and American College of Cardiology,” was prepared by Dr. Van Hare and his colleagues on behalf of the American Heart Association Electrocardiography and Arrhythmias Committee of the Council on Clinical Cardiology, Council on Cardiovascular Disease in the Young, Council on Cardiovascular and Stroke Nursing, Council on Functional Genomics and Translational Biology, and the American College of Cardiology (doi: 10.1016/j.jacc.2015.09.032).

This report is one of the assessments and recommendations of 15 task forces on eligibility and disqualification recommendations for young athletes, nine of which are disease or multidisease related. The other six task forces focus on a variety of relevant topics and issues regarding the risks of young athletes on the field, including screening, the use of automated external defibrillators on the field, the use of dietary supplements and performance-enhancing drugs, sudden death, and the medical-legal perspectives involved.

All 15 task force reports were simultaneously published online in the Journal of the American College of Cardiology and the journal Circulation.

Dr. Van Hare and all but one member of the writing group had no disclosures. One member disclosed consultant/advisory committee associations with a variety of medical device companies.

[email protected]

Three biotypes surpass traditional diagnostic categories when it comes to identifying subgroups of psychosis, a study showed.

“Classification and treatment of brain diseases subsumed by psychiatry rely on clinical phenomenology, despite the call for alternatives,” wrote Brett A. Clementz, Ph.D., of the University of Georgia, Athens, and his coinvestigators. “There is overlap in susceptibility genes and phenotypes across bipolar disorder with psychosis and schizophrenia, and considerable similarity between different psychotic disorders on symptoms, illness course, cognition, psychophysiology, and neurobiology [while] drug treatments for these conditions overlap extensively” (Am J Psychiatry. 2015. doi: 10.1176/appi.ajp.2015.14091200).

The researchers recruited 711 people from Bipolar-Schizophrenia Network on Intermediate Phenotypes (B-SNIP) consortium sites (probands). All subjects had diagnoses of schizophrenia, schizoaffective disorder, or bipolar disorder with psychosis, and underwent interviews and laboratory data collection at the time of enrollment. In addition, 883 first-degree relatives of the 711 initial enrollees also were clinically evaluated, along with a cohort of 278 people deemed “demographically comparable [and] healthy” by investigators.

Biotypes for all individuals enrolled in the study were determined through laboratory tasks designed to “assess brain function at the neurocogntive/perceptual level.” These tasks consisted of the Brief Assessment of Cognition in Schizophrenia (BACS), pro- and antisaccade tasks, stop signal tasks, auditory paired stimuli and oddball evoked brain responses, and MRI acquisition and voxel-based morphometry.

The Structured Clinical Interview for DSM-IV and the Structured Interview for DSM-IV Personality Disorders were used for interviewing enrollees. Data compiled from these tests underwent multivariate taxometric analyses to compare biomarker variance across the three cohorts, in order to determine what, if any, heterogeneity exists in psychosis biotypes.

According to the results, diagnoses made with the clinical DSM guidelines yielded a single-severity continuum showing schizophrenia to be the most severe, followed by schizoaffective disorder and bipolar psychosis. However, biotypes showed significant variation, with investigators noting that “the three biotypes had distinctive patterns of abnormality across biomarkers that were neither entirely nor efficiently captured by a severity continuum.”

Larger separations were seen in biotype cohorts than in the DSM, specifically among probands. Among probands, group separation from healthy subjects was –2.58, –1.94, and –0.35 for biotype 1, 2, and 3 respectively for the BACS. Separation was –0.99, –0.78, and –0.05 for the stop signal task, and 3.32, 1.90, and 1.19 for the antisaccade errors. On the other hand, DSM diagnostics revealed group differences of –1.01, –1.51, and –1.83 for bipolar disorder psychosis, schizoaffective disorders, and schizophrenia, respectively, for the BACS test. Separation was –0.41, –0.61, and –0.55 for the stop signal task, and 1.36, 1.66, and 2.45 for antisaccade errors.

“Each biotype included all DSM psychosis categories, but probands diagnosed with schizophrenia were more numerous in biotype 1 (although 20% had bipolar disorder with psychosis), and probands diagnosed with bipolar disorder with psychosis were more numerous in biotype 3 (although 32% had schizophrenia), respectively,” the investigators noted.

The authors added that “when considered across proband and relative data, the biotype subgroups were superior to DSM diagnostic classes in between-group separations on external validating measures, illustrating the former scheme’s superiority for capturing neurobiological distinctiveness.”

Investigators noted that their approach did not use social functioning, brain structure, and characteristics of biological relatives in the creation of biotypes, which could have led to stronger results. Also, trial participants were mostly already on medication, classified as chronically psychotic, and tested at least once previously. The trial also had no replication sample for this sample population.

The study was supported by grants from the National Institute of Mental Health. Dr. Clementz did not report any relevant financial disclosures. Dr. Matcheri S. Keshavan reported receiving a grant from Sunovion and serving as a consultant to Forum Pharmaceuticals. Dr. Carol A. Tamminga also reported potential conflicts.

[email protected]

Three biotypes surpass traditional diagnostic categories when it comes to identifying subgroups of psychosis, a study showed.

“Classification and treatment of brain diseases subsumed by psychiatry rely on clinical phenomenology, despite the call for alternatives,” wrote Brett A. Clementz, Ph.D., of the University of Georgia, Athens, and his coinvestigators. “There is overlap in susceptibility genes and phenotypes across bipolar disorder with psychosis and schizophrenia, and considerable similarity between different psychotic disorders on symptoms, illness course, cognition, psychophysiology, and neurobiology [while] drug treatments for these conditions overlap extensively” (Am J Psychiatry. 2015. doi: 10.1176/appi.ajp.2015.14091200).

The researchers recruited 711 people from Bipolar-Schizophrenia Network on Intermediate Phenotypes (B-SNIP) consortium sites (probands). All subjects had diagnoses of schizophrenia, schizoaffective disorder, or bipolar disorder with psychosis, and underwent interviews and laboratory data collection at the time of enrollment. In addition, 883 first-degree relatives of the 711 initial enrollees also were clinically evaluated, along with a cohort of 278 people deemed “demographically comparable [and] healthy” by investigators.

Biotypes for all individuals enrolled in the study were determined through laboratory tasks designed to “assess brain function at the neurocogntive/perceptual level.” These tasks consisted of the Brief Assessment of Cognition in Schizophrenia (BACS), pro- and antisaccade tasks, stop signal tasks, auditory paired stimuli and oddball evoked brain responses, and MRI acquisition and voxel-based morphometry.

The Structured Clinical Interview for DSM-IV and the Structured Interview for DSM-IV Personality Disorders were used for interviewing enrollees. Data compiled from these tests underwent multivariate taxometric analyses to compare biomarker variance across the three cohorts, in order to determine what, if any, heterogeneity exists in psychosis biotypes.

According to the results, diagnoses made with the clinical DSM guidelines yielded a single-severity continuum showing schizophrenia to be the most severe, followed by schizoaffective disorder and bipolar psychosis. However, biotypes showed significant variation, with investigators noting that “the three biotypes had distinctive patterns of abnormality across biomarkers that were neither entirely nor efficiently captured by a severity continuum.”

Larger separations were seen in biotype cohorts than in the DSM, specifically among probands. Among probands, group separation from healthy subjects was –2.58, –1.94, and –0.35 for biotype 1, 2, and 3 respectively for the BACS. Separation was –0.99, –0.78, and –0.05 for the stop signal task, and 3.32, 1.90, and 1.19 for the antisaccade errors. On the other hand, DSM diagnostics revealed group differences of –1.01, –1.51, and –1.83 for bipolar disorder psychosis, schizoaffective disorders, and schizophrenia, respectively, for the BACS test. Separation was –0.41, –0.61, and –0.55 for the stop signal task, and 1.36, 1.66, and 2.45 for antisaccade errors.

“Each biotype included all DSM psychosis categories, but probands diagnosed with schizophrenia were more numerous in biotype 1 (although 20% had bipolar disorder with psychosis), and probands diagnosed with bipolar disorder with psychosis were more numerous in biotype 3 (although 32% had schizophrenia), respectively,” the investigators noted.

The authors added that “when considered across proband and relative data, the biotype subgroups were superior to DSM diagnostic classes in between-group separations on external validating measures, illustrating the former scheme’s superiority for capturing neurobiological distinctiveness.”

Investigators noted that their approach did not use social functioning, brain structure, and characteristics of biological relatives in the creation of biotypes, which could have led to stronger results. Also, trial participants were mostly already on medication, classified as chronically psychotic, and tested at least once previously. The trial also had no replication sample for this sample population.

The study was supported by grants from the National Institute of Mental Health. Dr. Clementz did not report any relevant financial disclosures. Dr. Matcheri S. Keshavan reported receiving a grant from Sunovion and serving as a consultant to Forum Pharmaceuticals. Dr. Carol A. Tamminga also reported potential conflicts.

[email protected]

Three biotypes surpass traditional diagnostic categories when it comes to identifying subgroups of psychosis, a study showed.

“Classification and treatment of brain diseases subsumed by psychiatry rely on clinical phenomenology, despite the call for alternatives,” wrote Brett A. Clementz, Ph.D., of the University of Georgia, Athens, and his coinvestigators. “There is overlap in susceptibility genes and phenotypes across bipolar disorder with psychosis and schizophrenia, and considerable similarity between different psychotic disorders on symptoms, illness course, cognition, psychophysiology, and neurobiology [while] drug treatments for these conditions overlap extensively” (Am J Psychiatry. 2015. doi: 10.1176/appi.ajp.2015.14091200).

The researchers recruited 711 people from Bipolar-Schizophrenia Network on Intermediate Phenotypes (B-SNIP) consortium sites (probands). All subjects had diagnoses of schizophrenia, schizoaffective disorder, or bipolar disorder with psychosis, and underwent interviews and laboratory data collection at the time of enrollment. In addition, 883 first-degree relatives of the 711 initial enrollees also were clinically evaluated, along with a cohort of 278 people deemed “demographically comparable [and] healthy” by investigators.

Biotypes for all individuals enrolled in the study were determined through laboratory tasks designed to “assess brain function at the neurocogntive/perceptual level.” These tasks consisted of the Brief Assessment of Cognition in Schizophrenia (BACS), pro- and antisaccade tasks, stop signal tasks, auditory paired stimuli and oddball evoked brain responses, and MRI acquisition and voxel-based morphometry.

The Structured Clinical Interview for DSM-IV and the Structured Interview for DSM-IV Personality Disorders were used for interviewing enrollees. Data compiled from these tests underwent multivariate taxometric analyses to compare biomarker variance across the three cohorts, in order to determine what, if any, heterogeneity exists in psychosis biotypes.

According to the results, diagnoses made with the clinical DSM guidelines yielded a single-severity continuum showing schizophrenia to be the most severe, followed by schizoaffective disorder and bipolar psychosis. However, biotypes showed significant variation, with investigators noting that “the three biotypes had distinctive patterns of abnormality across biomarkers that were neither entirely nor efficiently captured by a severity continuum.”

Larger separations were seen in biotype cohorts than in the DSM, specifically among probands. Among probands, group separation from healthy subjects was –2.58, –1.94, and –0.35 for biotype 1, 2, and 3 respectively for the BACS. Separation was –0.99, –0.78, and –0.05 for the stop signal task, and 3.32, 1.90, and 1.19 for the antisaccade errors. On the other hand, DSM diagnostics revealed group differences of –1.01, –1.51, and –1.83 for bipolar disorder psychosis, schizoaffective disorders, and schizophrenia, respectively, for the BACS test. Separation was –0.41, –0.61, and –0.55 for the stop signal task, and 1.36, 1.66, and 2.45 for antisaccade errors.

“Each biotype included all DSM psychosis categories, but probands diagnosed with schizophrenia were more numerous in biotype 1 (although 20% had bipolar disorder with psychosis), and probands diagnosed with bipolar disorder with psychosis were more numerous in biotype 3 (although 32% had schizophrenia), respectively,” the investigators noted.

The authors added that “when considered across proband and relative data, the biotype subgroups were superior to DSM diagnostic classes in between-group separations on external validating measures, illustrating the former scheme’s superiority for capturing neurobiological distinctiveness.”

Investigators noted that their approach did not use social functioning, brain structure, and characteristics of biological relatives in the creation of biotypes, which could have led to stronger results. Also, trial participants were mostly already on medication, classified as chronically psychotic, and tested at least once previously. The trial also had no replication sample for this sample population.

The study was supported by grants from the National Institute of Mental Health. Dr. Clementz did not report any relevant financial disclosures. Dr. Matcheri S. Keshavan reported receiving a grant from Sunovion and serving as a consultant to Forum Pharmaceuticals. Dr. Carol A. Tamminga also reported potential conflicts.

[email protected]

CHICAGO – A high neutrophil to lymphocyte ratio on days 2 and 5 of surgical ICU hospitalization independently predicts increased mortality in critically ill trauma patients, an award-winning study showed.

The risk of death was two times higher for patients with a neutrophil to lymphocyte ratio (NLR) of at least 10.45 on day 2 (adjusted hazard ratio, 2.07; 95% confidence interval, 1.38-3.13; P = .001) and 5.7 times higher for those with an NLR of at least 7.91 on day 5 (adjusted HR, 5.79; 95% CI, 2.93-11.44; P less than .001) in a multivariate analysis, after adjustment for age 65 years or older, male sex, a systolic blood pressure of 90 mm Hg or less, a Glasgow Coma Scale (GCS) score of 8 or less, an Injury Severity Score (ISS) of at least 25, and operation on admission.

Patrice Wendling/Frontline Medical News

“The neutrophil to lymphocyte ratio is easily accessible, the calculation is simple, it adds no additional costs, and virtually all critically ill patients will have these labs,” study author Dr. Evren Dilektasli said at the American College of Surgeons annual clinical congress.

The simple calculation has been shown to be useful in the diagnosis of appendicitis and to be associated with overall survivalin metastatic colorectal cancer, but its association with mortality in trauma patients is not known, he said.

The retrospective cohort comprised 1,356 trauma patients, at least 16 years old, admitted to the Los Angeles County–University of Southern California Medical Center surgical ICU between January 2013 and January 2014. The median NLR was calculated for each day of the surgical ICU stay. At baseline, 16% of patients had an ISS of at least 25, 16.5% had a GCS of 8 or less, 4.5% had a systolic BP of 90 mm Hg or less, 74.3% were male, 23.7% were aged 65 or older, and 86% had a blunt injury. The most common operations on admission were laparotomy (39.6%) and craniectomy/craniotomy (20.7%).

In receiver operating characteristic (ROC) analysis for the first 10 days of hospitalization, the area under the curve (AUC) values for predicting mortality were between 0.55 on day 1 and a high of 0.79 on day 5, Dr. Dilektasli reported.

Starting from day 2 to day 10, the AUCs were statistically significant for predicting mortality.

The NLRs on day 2 (AUC, 0.73; P less than .001) and day 5 (AUC, 0.79; P less than .001) were selected in order to adjust for the clinical probability of early and late complications, he said.

Subsequent ROC curve analysis revealed an NLR cutoff of 10.45 on day 2 (AUC, 0.73; sensitivity, 73.2%; specificity, 61.8%) and a cutoff of 7.91 on day 5 (AUC, 0.79; sensitivity, 82.8%; specificity, 65.2%).

A high NLR on day 2 (at least 10.45) versus a low NLR (less than 10.45) was associated with significantly more ventilator days (5 days vs. 3 days), a longer surgical ICU length of stay (5 days vs. 3 days), a longer hospital stay (11 days vs. 8 days), and greater mortality (18.3% vs. 4.8%; all P values less than .001), reported Dr. Dilektasli, who was a research fellow at USC at the time of the study and has returned to Turkey to continue his training.

On day 5, a high NLR (at least 7.91) versus a low NLR (less than 7.91) was associated with significantly more ventilator days (7 days vs. 4 days; P less than .001), a longer surgical ICU stay (9 days vs. 5 days; P less than .001), and increased mortality (20.4% vs. 2.8%; P less than .001), but not a longer hospital stay (17 days vs. 14 days; P = .119).

In Kaplan-Meier analysis, a significant difference was observed between the high and low NLR groups on day 2 (log rank P less than .001) and day 5 (log rank P less than .001), he said.

“NLR may be a promising tool for assessing the risk of in-hospital mortality,” Dr. Dilektasli concluded. “Prospective external validation is warranted in a larger heterogeneous trauma population.”

During a discussion of the study, it was noted that the ROC curves were impressive, but that other biologic markers known to be associated with poor survival such as C-reactive protein level and class II major hepatitis C expression should have been included in the analysis.

When asked whether any patients with a low NLR on day 2 went on to have a high NLR on day 5, Dr. Dilektasli said there were such patients and that they also had an increased risk of death.

The findings of the study, which earned an excellence in research award, are only an “observation” at this point and are not being used in clinical practice, he added.

The authors reported having no relevant financial conflicts of interest.

[email protected]

CHICAGO – A high neutrophil to lymphocyte ratio on days 2 and 5 of surgical ICU hospitalization independently predicts increased mortality in critically ill trauma patients, an award-winning study showed.

The risk of death was two times higher for patients with a neutrophil to lymphocyte ratio (NLR) of at least 10.45 on day 2 (adjusted hazard ratio, 2.07; 95% confidence interval, 1.38-3.13; P = .001) and 5.7 times higher for those with an NLR of at least 7.91 on day 5 (adjusted HR, 5.79; 95% CI, 2.93-11.44; P less than .001) in a multivariate analysis, after adjustment for age 65 years or older, male sex, a systolic blood pressure of 90 mm Hg or less, a Glasgow Coma Scale (GCS) score of 8 or less, an Injury Severity Score (ISS) of at least 25, and operation on admission.

Patrice Wendling/Frontline Medical News

“The neutrophil to lymphocyte ratio is easily accessible, the calculation is simple, it adds no additional costs, and virtually all critically ill patients will have these labs,” study author Dr. Evren Dilektasli said at the American College of Surgeons annual clinical congress.

The simple calculation has been shown to be useful in the diagnosis of appendicitis and to be associated with overall survivalin metastatic colorectal cancer, but its association with mortality in trauma patients is not known, he said.

The retrospective cohort comprised 1,356 trauma patients, at least 16 years old, admitted to the Los Angeles County–University of Southern California Medical Center surgical ICU between January 2013 and January 2014. The median NLR was calculated for each day of the surgical ICU stay. At baseline, 16% of patients had an ISS of at least 25, 16.5% had a GCS of 8 or less, 4.5% had a systolic BP of 90 mm Hg or less, 74.3% were male, 23.7% were aged 65 or older, and 86% had a blunt injury. The most common operations on admission were laparotomy (39.6%) and craniectomy/craniotomy (20.7%).

In receiver operating characteristic (ROC) analysis for the first 10 days of hospitalization, the area under the curve (AUC) values for predicting mortality were between 0.55 on day 1 and a high of 0.79 on day 5, Dr. Dilektasli reported.

Starting from day 2 to day 10, the AUCs were statistically significant for predicting mortality.

The NLRs on day 2 (AUC, 0.73; P less than .001) and day 5 (AUC, 0.79; P less than .001) were selected in order to adjust for the clinical probability of early and late complications, he said.

Subsequent ROC curve analysis revealed an NLR cutoff of 10.45 on day 2 (AUC, 0.73; sensitivity, 73.2%; specificity, 61.8%) and a cutoff of 7.91 on day 5 (AUC, 0.79; sensitivity, 82.8%; specificity, 65.2%).

A high NLR on day 2 (at least 10.45) versus a low NLR (less than 10.45) was associated with significantly more ventilator days (5 days vs. 3 days), a longer surgical ICU length of stay (5 days vs. 3 days), a longer hospital stay (11 days vs. 8 days), and greater mortality (18.3% vs. 4.8%; all P values less than .001), reported Dr. Dilektasli, who was a research fellow at USC at the time of the study and has returned to Turkey to continue his training.

On day 5, a high NLR (at least 7.91) versus a low NLR (less than 7.91) was associated with significantly more ventilator days (7 days vs. 4 days; P less than .001), a longer surgical ICU stay (9 days vs. 5 days; P less than .001), and increased mortality (20.4% vs. 2.8%; P less than .001), but not a longer hospital stay (17 days vs. 14 days; P = .119).

In Kaplan-Meier analysis, a significant difference was observed between the high and low NLR groups on day 2 (log rank P less than .001) and day 5 (log rank P less than .001), he said.

“NLR may be a promising tool for assessing the risk of in-hospital mortality,” Dr. Dilektasli concluded. “Prospective external validation is warranted in a larger heterogeneous trauma population.”

During a discussion of the study, it was noted that the ROC curves were impressive, but that other biologic markers known to be associated with poor survival such as C-reactive protein level and class II major hepatitis C expression should have been included in the analysis.

When asked whether any patients with a low NLR on day 2 went on to have a high NLR on day 5, Dr. Dilektasli said there were such patients and that they also had an increased risk of death.

The findings of the study, which earned an excellence in research award, are only an “observation” at this point and are not being used in clinical practice, he added.

The authors reported having no relevant financial conflicts of interest.

[email protected]

CHICAGO – A high neutrophil to lymphocyte ratio on days 2 and 5 of surgical ICU hospitalization independently predicts increased mortality in critically ill trauma patients, an award-winning study showed.

The risk of death was two times higher for patients with a neutrophil to lymphocyte ratio (NLR) of at least 10.45 on day 2 (adjusted hazard ratio, 2.07; 95% confidence interval, 1.38-3.13; P = .001) and 5.7 times higher for those with an NLR of at least 7.91 on day 5 (adjusted HR, 5.79; 95% CI, 2.93-11.44; P less than .001) in a multivariate analysis, after adjustment for age 65 years or older, male sex, a systolic blood pressure of 90 mm Hg or less, a Glasgow Coma Scale (GCS) score of 8 or less, an Injury Severity Score (ISS) of at least 25, and operation on admission.

Patrice Wendling/Frontline Medical News

“The neutrophil to lymphocyte ratio is easily accessible, the calculation is simple, it adds no additional costs, and virtually all critically ill patients will have these labs,” study author Dr. Evren Dilektasli said at the American College of Surgeons annual clinical congress.

The simple calculation has been shown to be useful in the diagnosis of appendicitis and to be associated with overall survivalin metastatic colorectal cancer, but its association with mortality in trauma patients is not known, he said.

The retrospective cohort comprised 1,356 trauma patients, at least 16 years old, admitted to the Los Angeles County–University of Southern California Medical Center surgical ICU between January 2013 and January 2014. The median NLR was calculated for each day of the surgical ICU stay. At baseline, 16% of patients had an ISS of at least 25, 16.5% had a GCS of 8 or less, 4.5% had a systolic BP of 90 mm Hg or less, 74.3% were male, 23.7% were aged 65 or older, and 86% had a blunt injury. The most common operations on admission were laparotomy (39.6%) and craniectomy/craniotomy (20.7%).

In receiver operating characteristic (ROC) analysis for the first 10 days of hospitalization, the area under the curve (AUC) values for predicting mortality were between 0.55 on day 1 and a high of 0.79 on day 5, Dr. Dilektasli reported.

Starting from day 2 to day 10, the AUCs were statistically significant for predicting mortality.

The NLRs on day 2 (AUC, 0.73; P less than .001) and day 5 (AUC, 0.79; P less than .001) were selected in order to adjust for the clinical probability of early and late complications, he said.

Subsequent ROC curve analysis revealed an NLR cutoff of 10.45 on day 2 (AUC, 0.73; sensitivity, 73.2%; specificity, 61.8%) and a cutoff of 7.91 on day 5 (AUC, 0.79; sensitivity, 82.8%; specificity, 65.2%).

A high NLR on day 2 (at least 10.45) versus a low NLR (less than 10.45) was associated with significantly more ventilator days (5 days vs. 3 days), a longer surgical ICU length of stay (5 days vs. 3 days), a longer hospital stay (11 days vs. 8 days), and greater mortality (18.3% vs. 4.8%; all P values less than .001), reported Dr. Dilektasli, who was a research fellow at USC at the time of the study and has returned to Turkey to continue his training.

On day 5, a high NLR (at least 7.91) versus a low NLR (less than 7.91) was associated with significantly more ventilator days (7 days vs. 4 days; P less than .001), a longer surgical ICU stay (9 days vs. 5 days; P less than .001), and increased mortality (20.4% vs. 2.8%; P less than .001), but not a longer hospital stay (17 days vs. 14 days; P = .119).

In Kaplan-Meier analysis, a significant difference was observed between the high and low NLR groups on day 2 (log rank P less than .001) and day 5 (log rank P less than .001), he said.

“NLR may be a promising tool for assessing the risk of in-hospital mortality,” Dr. Dilektasli concluded. “Prospective external validation is warranted in a larger heterogeneous trauma population.”

During a discussion of the study, it was noted that the ROC curves were impressive, but that other biologic markers known to be associated with poor survival such as C-reactive protein level and class II major hepatitis C expression should have been included in the analysis.

When asked whether any patients with a low NLR on day 2 went on to have a high NLR on day 5, Dr. Dilektasli said there were such patients and that they also had an increased risk of death.

The findings of the study, which earned an excellence in research award, are only an “observation” at this point and are not being used in clinical practice, he added.

The authors reported having no relevant financial conflicts of interest.

[email protected]

In the thick of a job search for this coming July, I fondly remember my first experience at the 47th Annual STS meeting in San Diego in 2011. The presidential address was delivered by Dr. Mathisen and focused nearly an entire hour on encouraging and mentoring young trainees to pursue a career in cardiothoracic surgery. Citing concerns about job availability and security, declining compensation, and increasing scrutiny on outcome measures, the president attempted to individually address these.

Most vividly I remember the emphasis on baby boomers getting older, median CT surgeon age approaching the retirement point, and the overall increased need for young, motivated, and highly skilled junior attendings. Until this year, the number of STS and CTSnet job posts was abysmally low. This led many new graduates to consider advanced fellowships or alternative avenues. Half a decade after Dr. Mathisen’s prediction at STS, the proverbial flood gates have opened.

This past year, I’ve seen at least a dozen quality academic positions looking for new graduates in thoracic surgery. Additionally, at least another dozen hybrid practice or private/community practice groups are looking to hire junior attendings. What is also interesting is the direction that many practices are headed: thoracic service lines, where volume is accrued from surrounding community practices and brought to centralized, multidisciplinary tertiary care institutions.

In many models, mentorship has been built in with involved senior partners, especially now that expertise in advanced techniques in bronchoscopy (EBUS, navigational bronchoscopy), endoscopy (RFA, EMR, and other ablative strategies) and minimally invasive surgery (VATS, MIS esophagectomy, robotic) are commonly expected by patients. These skills are initially learned in training and, with the right support structure, are perfected early in practice.

With more precise earlier stage screening and detection of esophageal and lung malignancies and the general stability or increase in the year-to-year incidence of these cancers, I expect the job market will continue to accommodate a growing need for thoracic surgeons in the United States. This should greatly help recruitment of the best young medical talent into what is truly an exciting and blossoming field of surgery.

Reference

Mathisen DJ. “It’s Not the Destination, It’s the Journey: Lessons Learned”. 47th Annual STS Presidential Address. San Diego, CA. January 2011. www.sts.org/news/mathisen-delivers-presidential-address.

Dr. Shersher is at Rush University Medical Center, Chicago.

In the thick of a job search for this coming July, I fondly remember my first experience at the 47th Annual STS meeting in San Diego in 2011. The presidential address was delivered by Dr. Mathisen and focused nearly an entire hour on encouraging and mentoring young trainees to pursue a career in cardiothoracic surgery. Citing concerns about job availability and security, declining compensation, and increasing scrutiny on outcome measures, the president attempted to individually address these.

Most vividly I remember the emphasis on baby boomers getting older, median CT surgeon age approaching the retirement point, and the overall increased need for young, motivated, and highly skilled junior attendings. Until this year, the number of STS and CTSnet job posts was abysmally low. This led many new graduates to consider advanced fellowships or alternative avenues. Half a decade after Dr. Mathisen’s prediction at STS, the proverbial flood gates have opened.

This past year, I’ve seen at least a dozen quality academic positions looking for new graduates in thoracic surgery. Additionally, at least another dozen hybrid practice or private/community practice groups are looking to hire junior attendings. What is also interesting is the direction that many practices are headed: thoracic service lines, where volume is accrued from surrounding community practices and brought to centralized, multidisciplinary tertiary care institutions.

In many models, mentorship has been built in with involved senior partners, especially now that expertise in advanced techniques in bronchoscopy (EBUS, navigational bronchoscopy), endoscopy (RFA, EMR, and other ablative strategies) and minimally invasive surgery (VATS, MIS esophagectomy, robotic) are commonly expected by patients. These skills are initially learned in training and, with the right support structure, are perfected early in practice.

With more precise earlier stage screening and detection of esophageal and lung malignancies and the general stability or increase in the year-to-year incidence of these cancers, I expect the job market will continue to accommodate a growing need for thoracic surgeons in the United States. This should greatly help recruitment of the best young medical talent into what is truly an exciting and blossoming field of surgery.

Reference

Mathisen DJ. “It’s Not the Destination, It’s the Journey: Lessons Learned”. 47th Annual STS Presidential Address. San Diego, CA. January 2011. www.sts.org/news/mathisen-delivers-presidential-address.

Dr. Shersher is at Rush University Medical Center, Chicago.

In the thick of a job search for this coming July, I fondly remember my first experience at the 47th Annual STS meeting in San Diego in 2011. The presidential address was delivered by Dr. Mathisen and focused nearly an entire hour on encouraging and mentoring young trainees to pursue a career in cardiothoracic surgery. Citing concerns about job availability and security, declining compensation, and increasing scrutiny on outcome measures, the president attempted to individually address these.

Most vividly I remember the emphasis on baby boomers getting older, median CT surgeon age approaching the retirement point, and the overall increased need for young, motivated, and highly skilled junior attendings. Until this year, the number of STS and CTSnet job posts was abysmally low. This led many new graduates to consider advanced fellowships or alternative avenues. Half a decade after Dr. Mathisen’s prediction at STS, the proverbial flood gates have opened.

This past year, I’ve seen at least a dozen quality academic positions looking for new graduates in thoracic surgery. Additionally, at least another dozen hybrid practice or private/community practice groups are looking to hire junior attendings. What is also interesting is the direction that many practices are headed: thoracic service lines, where volume is accrued from surrounding community practices and brought to centralized, multidisciplinary tertiary care institutions.

In many models, mentorship has been built in with involved senior partners, especially now that expertise in advanced techniques in bronchoscopy (EBUS, navigational bronchoscopy), endoscopy (RFA, EMR, and other ablative strategies) and minimally invasive surgery (VATS, MIS esophagectomy, robotic) are commonly expected by patients. These skills are initially learned in training and, with the right support structure, are perfected early in practice.

With more precise earlier stage screening and detection of esophageal and lung malignancies and the general stability or increase in the year-to-year incidence of these cancers, I expect the job market will continue to accommodate a growing need for thoracic surgeons in the United States. This should greatly help recruitment of the best young medical talent into what is truly an exciting and blossoming field of surgery.

Reference

Mathisen DJ. “It’s Not the Destination, It’s the Journey: Lessons Learned”. 47th Annual STS Presidential Address. San Diego, CA. January 2011. www.sts.org/news/mathisen-delivers-presidential-address.

Dr. Shersher is at Rush University Medical Center, Chicago.

The article “What Is Your Diagnosis? Tinea Corporis” (Cutis. 2015;96:297, 326) contained an error in the author affiliations. The text should have stated:

Ms. Gyurjyan is from the University of Virginia School of Medicine, Charlottesville. Dr. Wilson is from the Department of Dermatology, University of Virginia Health System, Charlottesville.

The staff of Cutis^® makes every possible effort to ensure accuracy in its articles and apologizes for the mistake.

The article “What Is Your Diagnosis? Tinea Corporis” (Cutis. 2015;96:297, 326) contained an error in the author affiliations. The text should have stated:

Ms. Gyurjyan is from the University of Virginia School of Medicine, Charlottesville. Dr. Wilson is from the Department of Dermatology, University of Virginia Health System, Charlottesville.

The staff of Cutis^® makes every possible effort to ensure accuracy in its articles and apologizes for the mistake.

The article “What Is Your Diagnosis? Tinea Corporis” (Cutis. 2015;96:297, 326) contained an error in the author affiliations. The text should have stated:

Ms. Gyurjyan is from the University of Virginia School of Medicine, Charlottesville. Dr. Wilson is from the Department of Dermatology, University of Virginia Health System, Charlottesville.

The staff of Cutis^® makes every possible effort to ensure accuracy in its articles and apologizes for the mistake.