Woman with a laptop

Photo by Petr Kratochvil

Results of a large study indicate that women who spend their leisure time sitting for prolonged periods—6 or more hours a day—have an increased risk of developing certain cancers.

These women had a significant increase in the risk of overall cancer, multiple myeloma, breast cancer, and ovarian cancer.

The increased risks were present even after taking into account a woman’s body mass index (BMI), frequency of physical activity, and other factors.

For men, there was no association between leisure time spent sitting and any type of cancer.

Alpa Patel, PhD, of the American Cancer Society in Atlanta, Georgia, and her colleagues conducted this research and reported the results in Cancer Epidemiology, Biomarkers & Prevention.

The researchers analyzed data on 69,260 men and 77,462 women who were initially cancer-free and enrolled in the American Cancer Society Cancer Prevention Study II Nutrition Cohort.

In addition to evaluating the amount of leisure time subjects spent sitting, the researchers assessed factors such as age, race, BMI, alcohol use, smoking status, diabetes status, diet, and frequency and type of physical activity.

At baseline, the men enrolled in this study were slightly older, leaner, and more likely to have ever smoked cigarettes compared to the women. Men and women who spent the most leisure time sitting were more likely than their peers to be obese, have type II diabetes mellitus or other chronic diseases, have a higher caloric intake, eat more red/processed meat, and have ever smoked.

Between 1992 and 2009, 18,555 men and 12,236 women were diagnosed with cancer.

In women, longer leisure time spent sitting was associated with a significantly increased risk of cancer overall, even after the researchers adjusted for potential confounders such as overall physical activity and BMI.

The relative risk (RR) of cancer was 1.10 for women who spent an average of 6 or more hours a day sitting, compared to those who spent less than 3 hours a day sitting.

Women who sat for 6 or more hours a day also had a significantly increased risk of multiple myeloma (RR=1.65), invasive breast cancer (RR=1.10), and ovarian cancer (RR=1.43).

Initially, there was a significant association between prolonged sitting and endometrial cancer, but this was attenuated after the researchers adjusted for BMI. The researchers also found positive, but not significant, associations between sitting time and esophageal, head and neck, and gallbladder cancers.

For men, there was no significant association between time spent sitting and overall cancer risk or the risk of individual cancers. The researchers said further study is warranted to better understand this difference between the sexes.

The team also noted that American Cancer Society guidelines for cancer prevention recommend reducing sitting time when possible. And, given the high rate of time spent sitting in the US, even a modest positive association with cancer could have broad public health implications.

Woman with a laptop

Photo by Petr Kratochvil

Results of a large study indicate that women who spend their leisure time sitting for prolonged periods—6 or more hours a day—have an increased risk of developing certain cancers.

These women had a significant increase in the risk of overall cancer, multiple myeloma, breast cancer, and ovarian cancer.

The increased risks were present even after taking into account a woman’s body mass index (BMI), frequency of physical activity, and other factors.

For men, there was no association between leisure time spent sitting and any type of cancer.

Alpa Patel, PhD, of the American Cancer Society in Atlanta, Georgia, and her colleagues conducted this research and reported the results in Cancer Epidemiology, Biomarkers & Prevention.

The researchers analyzed data on 69,260 men and 77,462 women who were initially cancer-free and enrolled in the American Cancer Society Cancer Prevention Study II Nutrition Cohort.

In addition to evaluating the amount of leisure time subjects spent sitting, the researchers assessed factors such as age, race, BMI, alcohol use, smoking status, diabetes status, diet, and frequency and type of physical activity.

At baseline, the men enrolled in this study were slightly older, leaner, and more likely to have ever smoked cigarettes compared to the women. Men and women who spent the most leisure time sitting were more likely than their peers to be obese, have type II diabetes mellitus or other chronic diseases, have a higher caloric intake, eat more red/processed meat, and have ever smoked.

Between 1992 and 2009, 18,555 men and 12,236 women were diagnosed with cancer.

In women, longer leisure time spent sitting was associated with a significantly increased risk of cancer overall, even after the researchers adjusted for potential confounders such as overall physical activity and BMI.

The relative risk (RR) of cancer was 1.10 for women who spent an average of 6 or more hours a day sitting, compared to those who spent less than 3 hours a day sitting.

Women who sat for 6 or more hours a day also had a significantly increased risk of multiple myeloma (RR=1.65), invasive breast cancer (RR=1.10), and ovarian cancer (RR=1.43).

Initially, there was a significant association between prolonged sitting and endometrial cancer, but this was attenuated after the researchers adjusted for BMI. The researchers also found positive, but not significant, associations between sitting time and esophageal, head and neck, and gallbladder cancers.

For men, there was no significant association between time spent sitting and overall cancer risk or the risk of individual cancers. The researchers said further study is warranted to better understand this difference between the sexes.

The team also noted that American Cancer Society guidelines for cancer prevention recommend reducing sitting time when possible. And, given the high rate of time spent sitting in the US, even a modest positive association with cancer could have broad public health implications.

Woman with a laptop

Photo by Petr Kratochvil

Results of a large study indicate that women who spend their leisure time sitting for prolonged periods—6 or more hours a day—have an increased risk of developing certain cancers.

These women had a significant increase in the risk of overall cancer, multiple myeloma, breast cancer, and ovarian cancer.

The increased risks were present even after taking into account a woman’s body mass index (BMI), frequency of physical activity, and other factors.

For men, there was no association between leisure time spent sitting and any type of cancer.

Alpa Patel, PhD, of the American Cancer Society in Atlanta, Georgia, and her colleagues conducted this research and reported the results in Cancer Epidemiology, Biomarkers & Prevention.

The researchers analyzed data on 69,260 men and 77,462 women who were initially cancer-free and enrolled in the American Cancer Society Cancer Prevention Study II Nutrition Cohort.

In addition to evaluating the amount of leisure time subjects spent sitting, the researchers assessed factors such as age, race, BMI, alcohol use, smoking status, diabetes status, diet, and frequency and type of physical activity.

At baseline, the men enrolled in this study were slightly older, leaner, and more likely to have ever smoked cigarettes compared to the women. Men and women who spent the most leisure time sitting were more likely than their peers to be obese, have type II diabetes mellitus or other chronic diseases, have a higher caloric intake, eat more red/processed meat, and have ever smoked.

Between 1992 and 2009, 18,555 men and 12,236 women were diagnosed with cancer.

In women, longer leisure time spent sitting was associated with a significantly increased risk of cancer overall, even after the researchers adjusted for potential confounders such as overall physical activity and BMI.

The relative risk (RR) of cancer was 1.10 for women who spent an average of 6 or more hours a day sitting, compared to those who spent less than 3 hours a day sitting.

Women who sat for 6 or more hours a day also had a significantly increased risk of multiple myeloma (RR=1.65), invasive breast cancer (RR=1.10), and ovarian cancer (RR=1.43).

Initially, there was a significant association between prolonged sitting and endometrial cancer, but this was attenuated after the researchers adjusted for BMI. The researchers also found positive, but not significant, associations between sitting time and esophageal, head and neck, and gallbladder cancers.

For men, there was no significant association between time spent sitting and overall cancer risk or the risk of individual cancers. The researchers said further study is warranted to better understand this difference between the sexes.

The team also noted that American Cancer Society guidelines for cancer prevention recommend reducing sitting time when possible. And, given the high rate of time spent sitting in the US, even a modest positive association with cancer could have broad public health implications.

Thrombus

Image by Keven MacKenzie

The UK’s National Institute for Health and Care Excellence (NICE) has issued a draft guidance recommending the oral anticoagulant edoxaban tosylate (Lixiana) as an option for treating and preventing the recurrence of venous thromboembolism (VTE).

A committee advising NICE concluded that edoxaban is clinically effective, and the drug will be a cost-effective use of National Health Service resources.

“The newer oral anticoagulants like edoxaban tosylate are an alternative to warfarin as the mainstay of treatment to prevent recurrent blood clots,” said Carole Longson, NICE Health Technology Evaluation Centre Director.

“The committee concluded that patients value newer oral anticoagulants such as edoxaban tosylate, which cause less disruption to their day-to-day lives than warfarin. We are pleased, therefore, to be able to recommend edoxaban tosylate as a further cost-effective option for treating [VTE] and preventing further episodes in adults.”

Clinical effectiveness

Edoxaban was recently approved in the European Union to treat and prevent deep vein thrombosis (DVT) and pulmonary embolism (PE). This approval was based on results of the Hokusai-VTE trial. The committee advising NICE analyzed data from this trial when considering the clinical effectiveness of edoxaban.

For Hokusai-VTE, researchers evaluated edoxaban in 4921 patients with DVT and 3319 with PE. Patients received initial treatment with low-molecular-weight heparin and were then randomized to receive edoxaban or warfarin daily for 3 to 12 months.

Overall, edoxaban proved as effective as warfarin. Recurrent, symptomatic VTE occurred in 3.2% and 3.5% of patients, respectively (P<0.001 for non-inferiority).

In addition, the incidence of clinically relevant bleeding was significantly lower in the edoxaban arm than the warfarin arm—8.5% and 10.3%, respectively (P=0.004 for superiority).

Cost-effectiveness

The recommended dose of edoxaban is 60 mg once daily, or 30 mg once daily in specific patient groups—those with renal impairment, low body weight (60 kg or less), or concomitant use of potent permeability glycoprotein inhibitors—following treatment with a parenteral anticoagulant for at least 5 days.

Edoxaban costs £2.10 per 15 mg, 30 mg, or 60 mg tablet (excluding value-added tax). Costs may vary in different settings because of negotiated procurement discounts.

Taking into account the lack of any clear evidence that edoxaban is significantly different from the other new oral anticoagulants, as well as the testimony of experts, the committee advising NICE concluded that the most plausible incremental cost-effectiveness ratio for edoxaban was likely to be in line with the other oral anticoagulants already recommended by NICE.

The draft guidance for edoxaban is now with consultees, who have the opportunity to appeal against it. Once NICE issues its final guidance on a technology, it replaces local recommendations.

Thrombus

Image by Keven MacKenzie

The UK’s National Institute for Health and Care Excellence (NICE) has issued a draft guidance recommending the oral anticoagulant edoxaban tosylate (Lixiana) as an option for treating and preventing the recurrence of venous thromboembolism (VTE).

A committee advising NICE concluded that edoxaban is clinically effective, and the drug will be a cost-effective use of National Health Service resources.

“The newer oral anticoagulants like edoxaban tosylate are an alternative to warfarin as the mainstay of treatment to prevent recurrent blood clots,” said Carole Longson, NICE Health Technology Evaluation Centre Director.

“The committee concluded that patients value newer oral anticoagulants such as edoxaban tosylate, which cause less disruption to their day-to-day lives than warfarin. We are pleased, therefore, to be able to recommend edoxaban tosylate as a further cost-effective option for treating [VTE] and preventing further episodes in adults.”

Clinical effectiveness

Edoxaban was recently approved in the European Union to treat and prevent deep vein thrombosis (DVT) and pulmonary embolism (PE). This approval was based on results of the Hokusai-VTE trial. The committee advising NICE analyzed data from this trial when considering the clinical effectiveness of edoxaban.

For Hokusai-VTE, researchers evaluated edoxaban in 4921 patients with DVT and 3319 with PE. Patients received initial treatment with low-molecular-weight heparin and were then randomized to receive edoxaban or warfarin daily for 3 to 12 months.

Overall, edoxaban proved as effective as warfarin. Recurrent, symptomatic VTE occurred in 3.2% and 3.5% of patients, respectively (P<0.001 for non-inferiority).

In addition, the incidence of clinically relevant bleeding was significantly lower in the edoxaban arm than the warfarin arm—8.5% and 10.3%, respectively (P=0.004 for superiority).

Cost-effectiveness

The recommended dose of edoxaban is 60 mg once daily, or 30 mg once daily in specific patient groups—those with renal impairment, low body weight (60 kg or less), or concomitant use of potent permeability glycoprotein inhibitors—following treatment with a parenteral anticoagulant for at least 5 days.

Edoxaban costs £2.10 per 15 mg, 30 mg, or 60 mg tablet (excluding value-added tax). Costs may vary in different settings because of negotiated procurement discounts.

Taking into account the lack of any clear evidence that edoxaban is significantly different from the other new oral anticoagulants, as well as the testimony of experts, the committee advising NICE concluded that the most plausible incremental cost-effectiveness ratio for edoxaban was likely to be in line with the other oral anticoagulants already recommended by NICE.

The draft guidance for edoxaban is now with consultees, who have the opportunity to appeal against it. Once NICE issues its final guidance on a technology, it replaces local recommendations.

Thrombus

Image by Keven MacKenzie

The UK’s National Institute for Health and Care Excellence (NICE) has issued a draft guidance recommending the oral anticoagulant edoxaban tosylate (Lixiana) as an option for treating and preventing the recurrence of venous thromboembolism (VTE).

A committee advising NICE concluded that edoxaban is clinically effective, and the drug will be a cost-effective use of National Health Service resources.

“The newer oral anticoagulants like edoxaban tosylate are an alternative to warfarin as the mainstay of treatment to prevent recurrent blood clots,” said Carole Longson, NICE Health Technology Evaluation Centre Director.

“The committee concluded that patients value newer oral anticoagulants such as edoxaban tosylate, which cause less disruption to their day-to-day lives than warfarin. We are pleased, therefore, to be able to recommend edoxaban tosylate as a further cost-effective option for treating [VTE] and preventing further episodes in adults.”

Clinical effectiveness

Edoxaban was recently approved in the European Union to treat and prevent deep vein thrombosis (DVT) and pulmonary embolism (PE). This approval was based on results of the Hokusai-VTE trial. The committee advising NICE analyzed data from this trial when considering the clinical effectiveness of edoxaban.

For Hokusai-VTE, researchers evaluated edoxaban in 4921 patients with DVT and 3319 with PE. Patients received initial treatment with low-molecular-weight heparin and were then randomized to receive edoxaban or warfarin daily for 3 to 12 months.

Overall, edoxaban proved as effective as warfarin. Recurrent, symptomatic VTE occurred in 3.2% and 3.5% of patients, respectively (P<0.001 for non-inferiority).

In addition, the incidence of clinically relevant bleeding was significantly lower in the edoxaban arm than the warfarin arm—8.5% and 10.3%, respectively (P=0.004 for superiority).

Cost-effectiveness

The recommended dose of edoxaban is 60 mg once daily, or 30 mg once daily in specific patient groups—those with renal impairment, low body weight (60 kg or less), or concomitant use of potent permeability glycoprotein inhibitors—following treatment with a parenteral anticoagulant for at least 5 days.

Edoxaban costs £2.10 per 15 mg, 30 mg, or 60 mg tablet (excluding value-added tax). Costs may vary in different settings because of negotiated procurement discounts.

Taking into account the lack of any clear evidence that edoxaban is significantly different from the other new oral anticoagulants, as well as the testimony of experts, the committee advising NICE concluded that the most plausible incremental cost-effectiveness ratio for edoxaban was likely to be in line with the other oral anticoagulants already recommended by NICE.

The draft guidance for edoxaban is now with consultees, who have the opportunity to appeal against it. Once NICE issues its final guidance on a technology, it replaces local recommendations.

 

 

Pregnant woman

Photo by Nina Matthews

 

Researchers have again found evidence to suggest that tests used to identify chromosomal fetal disorders can detect occult malignancies in pregnant women.

In a study made public last month, non-invasive prenatal tests (NIPTs) revealed 2 cases of lymphoma and a case of ovarian cancer in expectant mothers.

In the new study, researchers showed that positive NIPT results were due to leukemia, lymphoma, or solid tumors in 10 expectant mothers.

The research was published in JAMA and presented at the 19th International Conference on Prenatal Diagnosis and Therapy in Washington, DC. Funding for the study was provided by Illumina, and company employees were involved in the research.

“We did this study because noninvasive prenatal testing using sequencing of cell-free DNA in the mother’s plasma is the fastest-growing area of prenatal testing and, indeed, of genomic medicine,” said study author Diana W. Bianchi, MD, of Tufts Medical Center in Boston, Massachusetts.

“As the volume of tests has expanded, we’ve become increasingly aware of the so-called “false-positive” cases. [A]pproximately 0.2% of the time, there is a discrepancy between the results of the prenatal test—in which an aneuploidy is reported—and the result from the diagnostic fetal procedure, the amniocentesis or the chorionic villus sampling.”

“So we’re interested in the situation where the fetal chromosomes are normal, but the prenatal test shows that there’s an aneuploidy detected. We’re interested in the possible explanations for that discrepancy.”

To gain some insight, Dr Bianchi and her colleagues evaluated 125,426 samples from asymptomatic pregnant women who underwent plasma cell-free DNA sequencing for clinical prenatal aneuploidy screening using Illumina’s verifi Prenatal Test.

In all, 3757 samples (3%) were positive for 1 or more aneuploidies involving chromosomes 13, 18, 21, X, or Y. These were reported to the ordering physician with recommendations for further evaluation.

“In a small minority of women, [subsequent tests analyzing only fetal DNA] showed that the fetal chromosomes were normal, and that disagreed with [results of the NIPT],” Dr Bianchi said. “We were examining whether cancer could explain the discrepancy between these two test results.”

The researchers found that 10 of the women with discordant test results were subsequently diagnosed with cancer. There were 3 cases of B-cell lymphoma and 1 case each of T-cell leukemia, Hodgkin lymphoma, unspecified adenocarcinoma, leiomyosarcoma, and neuroendocrine, colorectal, and anal carcinomas.

Dr Bianchi and her colleagues were able to obtain detailed clinical and sequencing data for 8 of these cases. In the other 2 cases (leiomyosarcoma and unspecified adenocarcinoma), the women were critically ill and were not approached about participating in the study.

The researchers found that maternal cancers most frequently occurred when the NIPT detected more than 1 aneuploidy. There were 7 known cancers among 39 cases of multiple aneuploidies by NIPT. In 1 case, blood was sampled after the patient completed treatment for colorectal cancer, and the abnormal pattern was no longer evident.

When the researchers examined additional genetic information for the women with cancer, they found unique patterns of nonspecific copy-number gains and losses across multiple chromosomes.

“[These women] had DNA imbalances all across the genome,” Dr Bianchi said. “The [NIPT] normally is only looking at DNA material from the chromosomes of clinical interest—chromosomes 13, 18, 21, X, and Y.”

“When we opened up their results to look at all of the chromosomes, there were multiple abnormalities in other places, such as chromosome 8, chromosome 6, etc. Each woman had a unique pattern that was abnormal in many places. This suggested that it was the tumor DNA that was being shed into her blood and was contributing to the abnormal pattern.”

Dr Bianchi stressed that the tumor DNA did not affect the babies. She said all were born healthy, although labor was induced early in one mother to facilitate her cancer treatment.

 

 

Pregnant woman

Photo by Nina Matthews

 

Researchers have again found evidence to suggest that tests used to identify chromosomal fetal disorders can detect occult malignancies in pregnant women.

In a study made public last month, non-invasive prenatal tests (NIPTs) revealed 2 cases of lymphoma and a case of ovarian cancer in expectant mothers.

In the new study, researchers showed that positive NIPT results were due to leukemia, lymphoma, or solid tumors in 10 expectant mothers.

The research was published in JAMA and presented at the 19th International Conference on Prenatal Diagnosis and Therapy in Washington, DC. Funding for the study was provided by Illumina, and company employees were involved in the research.

“We did this study because noninvasive prenatal testing using sequencing of cell-free DNA in the mother’s plasma is the fastest-growing area of prenatal testing and, indeed, of genomic medicine,” said study author Diana W. Bianchi, MD, of Tufts Medical Center in Boston, Massachusetts.

“As the volume of tests has expanded, we’ve become increasingly aware of the so-called “false-positive” cases. [A]pproximately 0.2% of the time, there is a discrepancy between the results of the prenatal test—in which an aneuploidy is reported—and the result from the diagnostic fetal procedure, the amniocentesis or the chorionic villus sampling.”

“So we’re interested in the situation where the fetal chromosomes are normal, but the prenatal test shows that there’s an aneuploidy detected. We’re interested in the possible explanations for that discrepancy.”

To gain some insight, Dr Bianchi and her colleagues evaluated 125,426 samples from asymptomatic pregnant women who underwent plasma cell-free DNA sequencing for clinical prenatal aneuploidy screening using Illumina’s verifi Prenatal Test.

In all, 3757 samples (3%) were positive for 1 or more aneuploidies involving chromosomes 13, 18, 21, X, or Y. These were reported to the ordering physician with recommendations for further evaluation.

“In a small minority of women, [subsequent tests analyzing only fetal DNA] showed that the fetal chromosomes were normal, and that disagreed with [results of the NIPT],” Dr Bianchi said. “We were examining whether cancer could explain the discrepancy between these two test results.”

The researchers found that 10 of the women with discordant test results were subsequently diagnosed with cancer. There were 3 cases of B-cell lymphoma and 1 case each of T-cell leukemia, Hodgkin lymphoma, unspecified adenocarcinoma, leiomyosarcoma, and neuroendocrine, colorectal, and anal carcinomas.

Dr Bianchi and her colleagues were able to obtain detailed clinical and sequencing data for 8 of these cases. In the other 2 cases (leiomyosarcoma and unspecified adenocarcinoma), the women were critically ill and were not approached about participating in the study.

The researchers found that maternal cancers most frequently occurred when the NIPT detected more than 1 aneuploidy. There were 7 known cancers among 39 cases of multiple aneuploidies by NIPT. In 1 case, blood was sampled after the patient completed treatment for colorectal cancer, and the abnormal pattern was no longer evident.

When the researchers examined additional genetic information for the women with cancer, they found unique patterns of nonspecific copy-number gains and losses across multiple chromosomes.

“[These women] had DNA imbalances all across the genome,” Dr Bianchi said. “The [NIPT] normally is only looking at DNA material from the chromosomes of clinical interest—chromosomes 13, 18, 21, X, and Y.”

“When we opened up their results to look at all of the chromosomes, there were multiple abnormalities in other places, such as chromosome 8, chromosome 6, etc. Each woman had a unique pattern that was abnormal in many places. This suggested that it was the tumor DNA that was being shed into her blood and was contributing to the abnormal pattern.”

Dr Bianchi stressed that the tumor DNA did not affect the babies. She said all were born healthy, although labor was induced early in one mother to facilitate her cancer treatment.

 

 

Pregnant woman

Photo by Nina Matthews

 

Researchers have again found evidence to suggest that tests used to identify chromosomal fetal disorders can detect occult malignancies in pregnant women.

In a study made public last month, non-invasive prenatal tests (NIPTs) revealed 2 cases of lymphoma and a case of ovarian cancer in expectant mothers.

In the new study, researchers showed that positive NIPT results were due to leukemia, lymphoma, or solid tumors in 10 expectant mothers.

The research was published in JAMA and presented at the 19th International Conference on Prenatal Diagnosis and Therapy in Washington, DC. Funding for the study was provided by Illumina, and company employees were involved in the research.

“We did this study because noninvasive prenatal testing using sequencing of cell-free DNA in the mother’s plasma is the fastest-growing area of prenatal testing and, indeed, of genomic medicine,” said study author Diana W. Bianchi, MD, of Tufts Medical Center in Boston, Massachusetts.

“As the volume of tests has expanded, we’ve become increasingly aware of the so-called “false-positive” cases. [A]pproximately 0.2% of the time, there is a discrepancy between the results of the prenatal test—in which an aneuploidy is reported—and the result from the diagnostic fetal procedure, the amniocentesis or the chorionic villus sampling.”

“So we’re interested in the situation where the fetal chromosomes are normal, but the prenatal test shows that there’s an aneuploidy detected. We’re interested in the possible explanations for that discrepancy.”

To gain some insight, Dr Bianchi and her colleagues evaluated 125,426 samples from asymptomatic pregnant women who underwent plasma cell-free DNA sequencing for clinical prenatal aneuploidy screening using Illumina’s verifi Prenatal Test.

In all, 3757 samples (3%) were positive for 1 or more aneuploidies involving chromosomes 13, 18, 21, X, or Y. These were reported to the ordering physician with recommendations for further evaluation.

“In a small minority of women, [subsequent tests analyzing only fetal DNA] showed that the fetal chromosomes were normal, and that disagreed with [results of the NIPT],” Dr Bianchi said. “We were examining whether cancer could explain the discrepancy between these two test results.”

The researchers found that 10 of the women with discordant test results were subsequently diagnosed with cancer. There were 3 cases of B-cell lymphoma and 1 case each of T-cell leukemia, Hodgkin lymphoma, unspecified adenocarcinoma, leiomyosarcoma, and neuroendocrine, colorectal, and anal carcinomas.

Dr Bianchi and her colleagues were able to obtain detailed clinical and sequencing data for 8 of these cases. In the other 2 cases (leiomyosarcoma and unspecified adenocarcinoma), the women were critically ill and were not approached about participating in the study.

The researchers found that maternal cancers most frequently occurred when the NIPT detected more than 1 aneuploidy. There were 7 known cancers among 39 cases of multiple aneuploidies by NIPT. In 1 case, blood was sampled after the patient completed treatment for colorectal cancer, and the abnormal pattern was no longer evident.

When the researchers examined additional genetic information for the women with cancer, they found unique patterns of nonspecific copy-number gains and losses across multiple chromosomes.

“[These women] had DNA imbalances all across the genome,” Dr Bianchi said. “The [NIPT] normally is only looking at DNA material from the chromosomes of clinical interest—chromosomes 13, 18, 21, X, and Y.”

“When we opened up their results to look at all of the chromosomes, there were multiple abnormalities in other places, such as chromosome 8, chromosome 6, etc. Each woman had a unique pattern that was abnormal in many places. This suggested that it was the tumor DNA that was being shed into her blood and was contributing to the abnormal pattern.”

Dr Bianchi stressed that the tumor DNA did not affect the babies. She said all were born healthy, although labor was induced early in one mother to facilitate her cancer treatment.

Nancy Baxter, MD, PhD

Photo courtesy of

St. Michael’s Hospital

Up to 20 years after they are declared cancer-free, young adult (YA) cancer survivors are still hospitalized more often than the general population, according to research published in the Journal of Clinical Oncology.

Overall, the cancer survivors, who were ages 20 to 44 at diagnosis, were hospitalized about 1.5 times as often as control subjects.

“Even when young adults survive cancer, the cancer still has an impact on their lives and their long-term health, and this age group still has a lot of life to live,” said study author Nancy Baxter, MD, PhD, of St. Michael’s Hospital in Toronto, Ontario, Canada.

To conduct this study, Dr Baxter and her colleagues examined data from the Ontario Cancer Registry spanning the period from 1992 to 1999.

This included 20,275 patients who had their first cancer diagnosis between the ages of 20 and 44 and had lived for 5 years cancer-free. The researchers compared hospitalizations among these patients to hospitalizations in 101,344 non-cancer controls.

During the study period, 34.3% of cancer survivors (n=6948) were admitted to the hospital. The adjusted relative rate (ARR) of hospitalizations in survivors compared to controls was 1.51.

There was a significant decrease in hospitalizations among cancer survivors from the first time point the researchers analyzed to the last time point (P<0.0001).

But hospitalizations were more common among cancer survivors regardless of the time point. The ARR was 1.67 at 5 to 8 years after cancer diagnosis and 1.22 at 18 to 20 years after diagnosis.

When the researchers looked at individual malignancies, they found that survivors of melanoma or testicular cancer did not have higher rates of hospitalization than the control population. The ARRs were 0.97 and 1.07, respectively.

However, the rate of hospitalization was at least twice as high as the control population for survivors of leukemia (ARR=2.23) and lymphoma (ARR=2.02), as well as gastrointestinal (ARR=2.49), urologic (ARR=2.20), colorectal (ARR=2.10), and brain cancers (ARR=2.04).

Dr Baxter said having a better understanding of healthcare utilization and late effects in the YA cancer population may help healthcare providers counsel YA survivors on their future quality of life, identify areas where preventative strategies could be employed, and highlight the need to consider treatments that are not associated with long-term health consequences.

Nancy Baxter, MD, PhD

Photo courtesy of

St. Michael’s Hospital

Up to 20 years after they are declared cancer-free, young adult (YA) cancer survivors are still hospitalized more often than the general population, according to research published in the Journal of Clinical Oncology.

Overall, the cancer survivors, who were ages 20 to 44 at diagnosis, were hospitalized about 1.5 times as often as control subjects.

“Even when young adults survive cancer, the cancer still has an impact on their lives and their long-term health, and this age group still has a lot of life to live,” said study author Nancy Baxter, MD, PhD, of St. Michael’s Hospital in Toronto, Ontario, Canada.

To conduct this study, Dr Baxter and her colleagues examined data from the Ontario Cancer Registry spanning the period from 1992 to 1999.

This included 20,275 patients who had their first cancer diagnosis between the ages of 20 and 44 and had lived for 5 years cancer-free. The researchers compared hospitalizations among these patients to hospitalizations in 101,344 non-cancer controls.

During the study period, 34.3% of cancer survivors (n=6948) were admitted to the hospital. The adjusted relative rate (ARR) of hospitalizations in survivors compared to controls was 1.51.

There was a significant decrease in hospitalizations among cancer survivors from the first time point the researchers analyzed to the last time point (P<0.0001).

But hospitalizations were more common among cancer survivors regardless of the time point. The ARR was 1.67 at 5 to 8 years after cancer diagnosis and 1.22 at 18 to 20 years after diagnosis.

When the researchers looked at individual malignancies, they found that survivors of melanoma or testicular cancer did not have higher rates of hospitalization than the control population. The ARRs were 0.97 and 1.07, respectively.

However, the rate of hospitalization was at least twice as high as the control population for survivors of leukemia (ARR=2.23) and lymphoma (ARR=2.02), as well as gastrointestinal (ARR=2.49), urologic (ARR=2.20), colorectal (ARR=2.10), and brain cancers (ARR=2.04).

Dr Baxter said having a better understanding of healthcare utilization and late effects in the YA cancer population may help healthcare providers counsel YA survivors on their future quality of life, identify areas where preventative strategies could be employed, and highlight the need to consider treatments that are not associated with long-term health consequences.

Nancy Baxter, MD, PhD

Photo courtesy of

St. Michael’s Hospital

Up to 20 years after they are declared cancer-free, young adult (YA) cancer survivors are still hospitalized more often than the general population, according to research published in the Journal of Clinical Oncology.

Overall, the cancer survivors, who were ages 20 to 44 at diagnosis, were hospitalized about 1.5 times as often as control subjects.

“Even when young adults survive cancer, the cancer still has an impact on their lives and their long-term health, and this age group still has a lot of life to live,” said study author Nancy Baxter, MD, PhD, of St. Michael’s Hospital in Toronto, Ontario, Canada.

To conduct this study, Dr Baxter and her colleagues examined data from the Ontario Cancer Registry spanning the period from 1992 to 1999.

This included 20,275 patients who had their first cancer diagnosis between the ages of 20 and 44 and had lived for 5 years cancer-free. The researchers compared hospitalizations among these patients to hospitalizations in 101,344 non-cancer controls.

During the study period, 34.3% of cancer survivors (n=6948) were admitted to the hospital. The adjusted relative rate (ARR) of hospitalizations in survivors compared to controls was 1.51.

There was a significant decrease in hospitalizations among cancer survivors from the first time point the researchers analyzed to the last time point (P<0.0001).

But hospitalizations were more common among cancer survivors regardless of the time point. The ARR was 1.67 at 5 to 8 years after cancer diagnosis and 1.22 at 18 to 20 years after diagnosis.

When the researchers looked at individual malignancies, they found that survivors of melanoma or testicular cancer did not have higher rates of hospitalization than the control population. The ARRs were 0.97 and 1.07, respectively.

However, the rate of hospitalization was at least twice as high as the control population for survivors of leukemia (ARR=2.23) and lymphoma (ARR=2.02), as well as gastrointestinal (ARR=2.49), urologic (ARR=2.20), colorectal (ARR=2.10), and brain cancers (ARR=2.04).

Dr Baxter said having a better understanding of healthcare utilization and late effects in the YA cancer population may help healthcare providers counsel YA survivors on their future quality of life, identify areas where preventative strategies could be employed, and highlight the need to consider treatments that are not associated with long-term health consequences.

Of all the comorbidities associated with psoriasis, psoriatic arthritis (PsA) is the most common and one of the most problematic. Early recognition, diagnosis, and treatment of PsA can help prevent or limit extensive joint damage that occurs in later stages of the disease. Because cutaneous psoriasis precedes the onset of PsA in 84% of patients with psoriasis, it is incumbent upon dermatologists to be the first line of defense in the screening for joint problems. However, the efficacy of PsA screening remains unknown.

In a recent article published online on June 5 in the Journal of the American Academy of Dermatology, Villani et al performed an analysis to determine the point prevalence of undiagnosed PsA in patients with psoriasis, utilizing a systematic search of the literature and meta-analysis. Searching PubMed, Cochrane, and Embase databases, the authors identified 394 studies for review. None of the studies sought to determine the prevalence of undiagnosed PsA in patients with psoriasis.

The investigators made the assumption that the prevalence of newly diagnosed PsA in patients with psoriasis at the time they sought medical care could be a reasonable estimate of this value. Seven epidemiological studies and 5 studies on PsA screening questionnaires were selected for review and were used to clearly identify patients with newly diagnosed PsA.

The authors found that the prevalence of undiagnosed PsA was 15.5% when all studies were analyzed and 10.1% when only epidemiological studies were included. The high prevalence of undiagnosed PsA in patients with psoriasis reinforces the recommendation that dermatologists need to screen all patients with psoriasis for PsA.

What’s the issue?

The findings of this study are not surprising. Therefore, it is important that we double our efforts to screen patients for PsA to address this comorbidity as early as possible. Improved algorithms for screening of patients for PsA would be a welcome advancement. How will you improve your screening methods for PsA?

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

Of all the comorbidities associated with psoriasis, psoriatic arthritis (PsA) is the most common and one of the most problematic. Early recognition, diagnosis, and treatment of PsA can help prevent or limit extensive joint damage that occurs in later stages of the disease. Because cutaneous psoriasis precedes the onset of PsA in 84% of patients with psoriasis, it is incumbent upon dermatologists to be the first line of defense in the screening for joint problems. However, the efficacy of PsA screening remains unknown.

In a recent article published online on June 5 in the Journal of the American Academy of Dermatology, Villani et al performed an analysis to determine the point prevalence of undiagnosed PsA in patients with psoriasis, utilizing a systematic search of the literature and meta-analysis. Searching PubMed, Cochrane, and Embase databases, the authors identified 394 studies for review. None of the studies sought to determine the prevalence of undiagnosed PsA in patients with psoriasis.

The investigators made the assumption that the prevalence of newly diagnosed PsA in patients with psoriasis at the time they sought medical care could be a reasonable estimate of this value. Seven epidemiological studies and 5 studies on PsA screening questionnaires were selected for review and were used to clearly identify patients with newly diagnosed PsA.

The authors found that the prevalence of undiagnosed PsA was 15.5% when all studies were analyzed and 10.1% when only epidemiological studies were included. The high prevalence of undiagnosed PsA in patients with psoriasis reinforces the recommendation that dermatologists need to screen all patients with psoriasis for PsA.

What’s the issue?

The findings of this study are not surprising. Therefore, it is important that we double our efforts to screen patients for PsA to address this comorbidity as early as possible. Improved algorithms for screening of patients for PsA would be a welcome advancement. How will you improve your screening methods for PsA?

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

Of all the comorbidities associated with psoriasis, psoriatic arthritis (PsA) is the most common and one of the most problematic. Early recognition, diagnosis, and treatment of PsA can help prevent or limit extensive joint damage that occurs in later stages of the disease. Because cutaneous psoriasis precedes the onset of PsA in 84% of patients with psoriasis, it is incumbent upon dermatologists to be the first line of defense in the screening for joint problems. However, the efficacy of PsA screening remains unknown.

In a recent article published online on June 5 in the Journal of the American Academy of Dermatology, Villani et al performed an analysis to determine the point prevalence of undiagnosed PsA in patients with psoriasis, utilizing a systematic search of the literature and meta-analysis. Searching PubMed, Cochrane, and Embase databases, the authors identified 394 studies for review. None of the studies sought to determine the prevalence of undiagnosed PsA in patients with psoriasis.

The investigators made the assumption that the prevalence of newly diagnosed PsA in patients with psoriasis at the time they sought medical care could be a reasonable estimate of this value. Seven epidemiological studies and 5 studies on PsA screening questionnaires were selected for review and were used to clearly identify patients with newly diagnosed PsA.

The authors found that the prevalence of undiagnosed PsA was 15.5% when all studies were analyzed and 10.1% when only epidemiological studies were included. The high prevalence of undiagnosed PsA in patients with psoriasis reinforces the recommendation that dermatologists need to screen all patients with psoriasis for PsA.

What’s the issue?

The findings of this study are not surprising. Therefore, it is important that we double our efforts to screen patients for PsA to address this comorbidity as early as possible. Improved algorithms for screening of patients for PsA would be a welcome advancement. How will you improve your screening methods for PsA?

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

We are so lucky to be part of a field of medicine where advances in patient treatment options continue to occur. Having been involved in the Kybella clinical trials, it is exciting and satisfactory to see a new successful aesthetic treatment come to fruition. Kybella is the first and only Food and Drug Administration–approved injectable drug to reduce the appearance of “double chin” (submental fullness associated with submental fat) in adult patients. It is a synthetic form of naturally occurring deoxycholic acid (DCA), which lyses adipocytes when properly injected into subcutaneous fat. The safe and effective use of Kybella for the treatment of subcutaneous fat outside of the submental region has not been established and is not recommended.

The drug received unanimous support from an FDA advisory panel in March based on two placebo-controlled phase III trials involving more than 1,000 adults. In over 1,600 patients treated, 79% saw great improvement. In the studies, safety and efficacy were demonstrated with treatment of up to 50 injections of 0.2 mL each of the 1% DCA solution administered in a single treatment. Up to six treatments were administered at least 1 month apart.

Serious side effects associated with injection of DCA may include injury to the marginal mandibular nerve and dysphagia, but the most common side effects are swelling, bruising, pain, numbness, redness, and areas of hardness in the treatment area. Other potential side effects include: tingling, nodule, itching, skin tightness, headache, alopecia, and skin ulceration. In the studies, all cases of marginal mandibular nerve injury, manifesting as an asymmetric smile or facial muscle weakness, resolved spontaneously (range 1-298 days, median 44 days). Dysphagia occurred in the clinical trials as a result of administration site reactions (for example, pain, swelling, and induration in the submental area). Cases of dysphagia resolved spontaneously (range 1-81 days, median 3 days).

Caution should be taken in patients with a history of medical conditions in the neck area, difficulty swallowing, bleeding problems, or who take blood thinners. Likewise, caution should be used in patients who are or plan to become pregnant or breastfeed as Kybella has not been studied in pregnant or breastfeeding patients. Injection is contraindicated in the presence of infection at injection sites. Kybella only should be administered by a trained health care professional.

In addition to assessing whether not the patient is an ideal candidate, setting realistic expectations, and counseling about potential side effects, consultation also should include preprocedure photographs in the Frankfurt plane. Patients with moderate to severe convexity or fullness of the submental area are ideal candidates for the procedure. Those with little submental fat and excessive skin laxity may not be good candidates for this procedure and should consider a neck lift surgery as an alternative. Patients with prominent platysmal bands prior to procedure still may notice these bands after the procedure and may consider botulinum toxin injections or platysmal banding to treat these. While the active ingredient targets fat, some beneficial skin tightening may occur as a result of inflammation and fibrosis.

After photographs are taken, it is highly recommended to mark out specific anatomic landmarks on the patient, to avoid injury to the marginal mandibular nerve, salivary glands, lymph nodes, and the subhyoid region.

The procedure takes about 15-20 minutes with a short preparation time involved. Antihistamines and anti-inflammatory medications such as loratadine and ibuprofen may be given before the procedure to help reduce risk of discomfort and edema often experienced after injection. Preprocedure injection with local anesthetic also is recommended.

Once the treatment area is demarcated with a grid placed on the patient’s skin, injections of 0.2 mL of DCA are performed with a 30-gauge ½ inch needle. The product is supplied in a box with four 2-mL vials (10 mg/mL). No refrigeration is required. Once a vial is opened, it should only be used on one patient. A maximum of up to 10 mL may be injected in one patient in one session. Ice may applied after treatment. Postprocedure swelling and throbbing can be expected for several days and may rarely last up to 1 month. Patients may require two to six treatments spaced at least 1 month apart.

Dr. Wesley and Dr. Talakoub are cocontributors to a monthly Aesthetic Dermatology column in Dermatology News. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Wesley. Dr. Wesley was an investigator in the phase III Kybella clinical trials. E-mail her at [email protected].

We are so lucky to be part of a field of medicine where advances in patient treatment options continue to occur. Having been involved in the Kybella clinical trials, it is exciting and satisfactory to see a new successful aesthetic treatment come to fruition. Kybella is the first and only Food and Drug Administration–approved injectable drug to reduce the appearance of “double chin” (submental fullness associated with submental fat) in adult patients. It is a synthetic form of naturally occurring deoxycholic acid (DCA), which lyses adipocytes when properly injected into subcutaneous fat. The safe and effective use of Kybella for the treatment of subcutaneous fat outside of the submental region has not been established and is not recommended.

The drug received unanimous support from an FDA advisory panel in March based on two placebo-controlled phase III trials involving more than 1,000 adults. In over 1,600 patients treated, 79% saw great improvement. In the studies, safety and efficacy were demonstrated with treatment of up to 50 injections of 0.2 mL each of the 1% DCA solution administered in a single treatment. Up to six treatments were administered at least 1 month apart.

Serious side effects associated with injection of DCA may include injury to the marginal mandibular nerve and dysphagia, but the most common side effects are swelling, bruising, pain, numbness, redness, and areas of hardness in the treatment area. Other potential side effects include: tingling, nodule, itching, skin tightness, headache, alopecia, and skin ulceration. In the studies, all cases of marginal mandibular nerve injury, manifesting as an asymmetric smile or facial muscle weakness, resolved spontaneously (range 1-298 days, median 44 days). Dysphagia occurred in the clinical trials as a result of administration site reactions (for example, pain, swelling, and induration in the submental area). Cases of dysphagia resolved spontaneously (range 1-81 days, median 3 days).

Caution should be taken in patients with a history of medical conditions in the neck area, difficulty swallowing, bleeding problems, or who take blood thinners. Likewise, caution should be used in patients who are or plan to become pregnant or breastfeed as Kybella has not been studied in pregnant or breastfeeding patients. Injection is contraindicated in the presence of infection at injection sites. Kybella only should be administered by a trained health care professional.

In addition to assessing whether not the patient is an ideal candidate, setting realistic expectations, and counseling about potential side effects, consultation also should include preprocedure photographs in the Frankfurt plane. Patients with moderate to severe convexity or fullness of the submental area are ideal candidates for the procedure. Those with little submental fat and excessive skin laxity may not be good candidates for this procedure and should consider a neck lift surgery as an alternative. Patients with prominent platysmal bands prior to procedure still may notice these bands after the procedure and may consider botulinum toxin injections or platysmal banding to treat these. While the active ingredient targets fat, some beneficial skin tightening may occur as a result of inflammation and fibrosis.

After photographs are taken, it is highly recommended to mark out specific anatomic landmarks on the patient, to avoid injury to the marginal mandibular nerve, salivary glands, lymph nodes, and the subhyoid region.

The procedure takes about 15-20 minutes with a short preparation time involved. Antihistamines and anti-inflammatory medications such as loratadine and ibuprofen may be given before the procedure to help reduce risk of discomfort and edema often experienced after injection. Preprocedure injection with local anesthetic also is recommended.

Once the treatment area is demarcated with a grid placed on the patient’s skin, injections of 0.2 mL of DCA are performed with a 30-gauge ½ inch needle. The product is supplied in a box with four 2-mL vials (10 mg/mL). No refrigeration is required. Once a vial is opened, it should only be used on one patient. A maximum of up to 10 mL may be injected in one patient in one session. Ice may applied after treatment. Postprocedure swelling and throbbing can be expected for several days and may rarely last up to 1 month. Patients may require two to six treatments spaced at least 1 month apart.

Dr. Wesley and Dr. Talakoub are cocontributors to a monthly Aesthetic Dermatology column in Dermatology News. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Wesley. Dr. Wesley was an investigator in the phase III Kybella clinical trials. E-mail her at [email protected].

We are so lucky to be part of a field of medicine where advances in patient treatment options continue to occur. Having been involved in the Kybella clinical trials, it is exciting and satisfactory to see a new successful aesthetic treatment come to fruition. Kybella is the first and only Food and Drug Administration–approved injectable drug to reduce the appearance of “double chin” (submental fullness associated with submental fat) in adult patients. It is a synthetic form of naturally occurring deoxycholic acid (DCA), which lyses adipocytes when properly injected into subcutaneous fat. The safe and effective use of Kybella for the treatment of subcutaneous fat outside of the submental region has not been established and is not recommended.

The drug received unanimous support from an FDA advisory panel in March based on two placebo-controlled phase III trials involving more than 1,000 adults. In over 1,600 patients treated, 79% saw great improvement. In the studies, safety and efficacy were demonstrated with treatment of up to 50 injections of 0.2 mL each of the 1% DCA solution administered in a single treatment. Up to six treatments were administered at least 1 month apart.

Serious side effects associated with injection of DCA may include injury to the marginal mandibular nerve and dysphagia, but the most common side effects are swelling, bruising, pain, numbness, redness, and areas of hardness in the treatment area. Other potential side effects include: tingling, nodule, itching, skin tightness, headache, alopecia, and skin ulceration. In the studies, all cases of marginal mandibular nerve injury, manifesting as an asymmetric smile or facial muscle weakness, resolved spontaneously (range 1-298 days, median 44 days). Dysphagia occurred in the clinical trials as a result of administration site reactions (for example, pain, swelling, and induration in the submental area). Cases of dysphagia resolved spontaneously (range 1-81 days, median 3 days).

Caution should be taken in patients with a history of medical conditions in the neck area, difficulty swallowing, bleeding problems, or who take blood thinners. Likewise, caution should be used in patients who are or plan to become pregnant or breastfeed as Kybella has not been studied in pregnant or breastfeeding patients. Injection is contraindicated in the presence of infection at injection sites. Kybella only should be administered by a trained health care professional.

In addition to assessing whether not the patient is an ideal candidate, setting realistic expectations, and counseling about potential side effects, consultation also should include preprocedure photographs in the Frankfurt plane. Patients with moderate to severe convexity or fullness of the submental area are ideal candidates for the procedure. Those with little submental fat and excessive skin laxity may not be good candidates for this procedure and should consider a neck lift surgery as an alternative. Patients with prominent platysmal bands prior to procedure still may notice these bands after the procedure and may consider botulinum toxin injections or platysmal banding to treat these. While the active ingredient targets fat, some beneficial skin tightening may occur as a result of inflammation and fibrosis.

After photographs are taken, it is highly recommended to mark out specific anatomic landmarks on the patient, to avoid injury to the marginal mandibular nerve, salivary glands, lymph nodes, and the subhyoid region.

The procedure takes about 15-20 minutes with a short preparation time involved. Antihistamines and anti-inflammatory medications such as loratadine and ibuprofen may be given before the procedure to help reduce risk of discomfort and edema often experienced after injection. Preprocedure injection with local anesthetic also is recommended.

Once the treatment area is demarcated with a grid placed on the patient’s skin, injections of 0.2 mL of DCA are performed with a 30-gauge ½ inch needle. The product is supplied in a box with four 2-mL vials (10 mg/mL). No refrigeration is required. Once a vial is opened, it should only be used on one patient. A maximum of up to 10 mL may be injected in one patient in one session. Ice may applied after treatment. Postprocedure swelling and throbbing can be expected for several days and may rarely last up to 1 month. Patients may require two to six treatments spaced at least 1 month apart.

Dr. Wesley and Dr. Talakoub are cocontributors to a monthly Aesthetic Dermatology column in Dermatology News. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Wesley. Dr. Wesley was an investigator in the phase III Kybella clinical trials. E-mail her at [email protected].

I’m not a zebra hunter by nature. I see them here and there, but in a general practice the odds of finding them are pretty low. If I can’t solve the case, I refer to the more accomplished zebrologists at the tertiary centers.

That’s not to say I don’t look for them as best I can. Sometimes you get the vaguest hint you’re dealing with the unusual. Maybe because you’ve seen it before, or something the patient said triggered a distant memory from training.

One problem (among many) in diagnosing a zebra is time. It takes time to draw out a complex history and do an exam. There’s also time needed for the first, second, third … and later rounds of tests to come back, as well as time at appointments to note new symptoms, ask further questions, and discuss a diagnosis and plan. And, sometimes, you need time just to follow patients and see how their symptoms change.

Unfortunately, in medicine these days time is usually what you don’t have. Doctors are always under pressure to see a lot of patients and don’t have time to sort through the complex ones. This gets even worse for those employed by a health care system, when they may be working under quota requirements. After all, you can see four to five horses in the time needed for one zebra. And they pay about the same.

In solo practice, I don’t have quite the time constraints of an employed doctor meeting set numbers, but I still have the financial ones. I get the luxury of setting the schedule to give me more minutes when I know they’ll be needed, but at the back end it still comes with a financial penalty.

All of this makes it harder to find the zebras. They’re difficult enough to see as it is, and the financial pressure to shorten visits can keep even thorough docs from getting the whole story or turning over the case mentally. As one of my residency teachers (not Yogi Berra) said of differential diagnoses, “If you don’t think of it, you don’t think of it.”

Sadly, the nature of modern medicine is that it limits your ability to think of it, making it harder than ever to find the zebras in the herd.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

I’m not a zebra hunter by nature. I see them here and there, but in a general practice the odds of finding them are pretty low. If I can’t solve the case, I refer to the more accomplished zebrologists at the tertiary centers.

That’s not to say I don’t look for them as best I can. Sometimes you get the vaguest hint you’re dealing with the unusual. Maybe because you’ve seen it before, or something the patient said triggered a distant memory from training.

One problem (among many) in diagnosing a zebra is time. It takes time to draw out a complex history and do an exam. There’s also time needed for the first, second, third … and later rounds of tests to come back, as well as time at appointments to note new symptoms, ask further questions, and discuss a diagnosis and plan. And, sometimes, you need time just to follow patients and see how their symptoms change.

Unfortunately, in medicine these days time is usually what you don’t have. Doctors are always under pressure to see a lot of patients and don’t have time to sort through the complex ones. This gets even worse for those employed by a health care system, when they may be working under quota requirements. After all, you can see four to five horses in the time needed for one zebra. And they pay about the same.

In solo practice, I don’t have quite the time constraints of an employed doctor meeting set numbers, but I still have the financial ones. I get the luxury of setting the schedule to give me more minutes when I know they’ll be needed, but at the back end it still comes with a financial penalty.

All of this makes it harder to find the zebras. They’re difficult enough to see as it is, and the financial pressure to shorten visits can keep even thorough docs from getting the whole story or turning over the case mentally. As one of my residency teachers (not Yogi Berra) said of differential diagnoses, “If you don’t think of it, you don’t think of it.”

Sadly, the nature of modern medicine is that it limits your ability to think of it, making it harder than ever to find the zebras in the herd.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

I’m not a zebra hunter by nature. I see them here and there, but in a general practice the odds of finding them are pretty low. If I can’t solve the case, I refer to the more accomplished zebrologists at the tertiary centers.

That’s not to say I don’t look for them as best I can. Sometimes you get the vaguest hint you’re dealing with the unusual. Maybe because you’ve seen it before, or something the patient said triggered a distant memory from training.

One problem (among many) in diagnosing a zebra is time. It takes time to draw out a complex history and do an exam. There’s also time needed for the first, second, third … and later rounds of tests to come back, as well as time at appointments to note new symptoms, ask further questions, and discuss a diagnosis and plan. And, sometimes, you need time just to follow patients and see how their symptoms change.

Unfortunately, in medicine these days time is usually what you don’t have. Doctors are always under pressure to see a lot of patients and don’t have time to sort through the complex ones. This gets even worse for those employed by a health care system, when they may be working under quota requirements. After all, you can see four to five horses in the time needed for one zebra. And they pay about the same.

In solo practice, I don’t have quite the time constraints of an employed doctor meeting set numbers, but I still have the financial ones. I get the luxury of setting the schedule to give me more minutes when I know they’ll be needed, but at the back end it still comes with a financial penalty.

All of this makes it harder to find the zebras. They’re difficult enough to see as it is, and the financial pressure to shorten visits can keep even thorough docs from getting the whole story or turning over the case mentally. As one of my residency teachers (not Yogi Berra) said of differential diagnoses, “If you don’t think of it, you don’t think of it.”

Sadly, the nature of modern medicine is that it limits your ability to think of it, making it harder than ever to find the zebras in the herd.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

The flavanone naringenin (5,7,4-trihydroxyflavanone) is known to exhibit anticarcinogenic, antioxidative, antiatherogenic, estrogenic, and immunomodulatory activity (Nutr. Cancer. 2012;64:714-24; J. Nutr. 2001;131:235-41; Life Sci. 2013;93:516-24). Naringenin can be found in high concentrations in grapefruits, oranges, and other citrus fruits as well as tomatoes (skin), with grapefruit juice found to yield much higher levels in plasma than orange juice (J. Nutr. 2001;131:235-41; Am. J. Physiol. Gastrointest. Liver Physiol. 2000;279:G1148-54; Nutr. Cancer 2012;64:714-24). Naringenin has been shown, along with other flavanones such as hesperetin and ponciretin, to strongly inhibit IgE-induced beta-hexosaminidase release from RBL-2H3 cells. Sung-Hwan Park and associates have suggested that the glycosides of these substances have potential as agents for treating IgE-induced atopic allergies (Planta Med. 2005;71:24-7).

In 2012, Kushi Anand and associates also showed that the combination of curcumin and naringenin exerted antiangiogenic and antitumor effects in Swiss albino mice, adding that neither compound has been associated with reports of toxicity in animals or humans (Nutr. Cancer 2012;64:714-24).

Potential cutaneous benefits

Tae-Ho Kim and colleagues studied the effects of naringenin on 2,4-dinitrofluorobenzene (DNFB)-induced atomic dermatitis in NC/Nga mice in 2013. After repetitive skin contact with DNFB, mice received intraperitoneal injections of naringenin for 1 week, with the treatment with the fruit flavonoid significantly diminishing ear swelling and back skin lesions. The flavonoid also significantly inhibited interferon (IFN)-alpha production by activated CD4+ T cells and lowered serum IgE levels as well as DNFB-induced infiltration of eosinophils, mast cells, CD4+ T cells, and CD8+ T cells in skin lesions (Life Sci. 2013;93:516-24).

Also that year, a naringenin glucoside (naringenin-7-O-glucoside) was found in an industrial blanch water extract, a byproduct of almond processing, and believed to play a role in exerting or contributing to a photoprotective effect in a small in vivo study with 12 volunteers (Molecules 2013;18:12426-40).

©Ls9907/Thinkstockphotos.com

In 2014, K. Murata and associates screened several Prunus species in a search for skin-whitening compounds. Using an antityrosinase assay, the investigators determined that P. persica exhibited the greatest inhibitory activity and, in additional evaluation, it was found to hinder melanogenesis in B16 rat melanoma cells. Further, they identified afzelin (3-O-alpha-L-rhamnosylkaempferol) and the flavanone naringenin as the active ingredients responsible for inhibition of tyrosinase and melanogenesis and concluded that these substances warrant attention as potential skin-whitening agents (Nat. Prod. Commun. 2014;9:185-8).

A 2014 study in the ophthalmologic literature may also shed light on the photoprotective properties of naringenin. Jun-Li Lin and colleagues, studying the effects of the flavanone in eye drops used to treat N-methyl-N-nitrosourea (MNU)-induced photoreceptor cell death in rats, found that topical naringenin dose-dependently shielded the outer nuclear layer, outer retina, and whole retina, and prevented structural and functional damages to retinal neurons (Int. J. Ophthalmol. 2014;7:391-6).

Conclusion

The antioxidative, antiatherogenic, anticarcinogenic, antiproliferative, antimutagenic, estrogenic, and immunomodulatory properties of naringenin have been established in the laboratory. It remains to be seen whether such activity can be harnessed for medical applications, particularly in the dermatologic arena. Nevertheless, this flavanone warrants watching as research into its potential cutaneous applications proceeds. Currently, there is a dearth of research, though, regarding the use of naringenin in topical products.

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

The flavanone naringenin (5,7,4-trihydroxyflavanone) is known to exhibit anticarcinogenic, antioxidative, antiatherogenic, estrogenic, and immunomodulatory activity (Nutr. Cancer. 2012;64:714-24; J. Nutr. 2001;131:235-41; Life Sci. 2013;93:516-24). Naringenin can be found in high concentrations in grapefruits, oranges, and other citrus fruits as well as tomatoes (skin), with grapefruit juice found to yield much higher levels in plasma than orange juice (J. Nutr. 2001;131:235-41; Am. J. Physiol. Gastrointest. Liver Physiol. 2000;279:G1148-54; Nutr. Cancer 2012;64:714-24). Naringenin has been shown, along with other flavanones such as hesperetin and ponciretin, to strongly inhibit IgE-induced beta-hexosaminidase release from RBL-2H3 cells. Sung-Hwan Park and associates have suggested that the glycosides of these substances have potential as agents for treating IgE-induced atopic allergies (Planta Med. 2005;71:24-7).

In 2012, Kushi Anand and associates also showed that the combination of curcumin and naringenin exerted antiangiogenic and antitumor effects in Swiss albino mice, adding that neither compound has been associated with reports of toxicity in animals or humans (Nutr. Cancer 2012;64:714-24).

Potential cutaneous benefits

Tae-Ho Kim and colleagues studied the effects of naringenin on 2,4-dinitrofluorobenzene (DNFB)-induced atomic dermatitis in NC/Nga mice in 2013. After repetitive skin contact with DNFB, mice received intraperitoneal injections of naringenin for 1 week, with the treatment with the fruit flavonoid significantly diminishing ear swelling and back skin lesions. The flavonoid also significantly inhibited interferon (IFN)-alpha production by activated CD4+ T cells and lowered serum IgE levels as well as DNFB-induced infiltration of eosinophils, mast cells, CD4+ T cells, and CD8+ T cells in skin lesions (Life Sci. 2013;93:516-24).

Also that year, a naringenin glucoside (naringenin-7-O-glucoside) was found in an industrial blanch water extract, a byproduct of almond processing, and believed to play a role in exerting or contributing to a photoprotective effect in a small in vivo study with 12 volunteers (Molecules 2013;18:12426-40).

©Ls9907/Thinkstockphotos.com

In 2014, K. Murata and associates screened several Prunus species in a search for skin-whitening compounds. Using an antityrosinase assay, the investigators determined that P. persica exhibited the greatest inhibitory activity and, in additional evaluation, it was found to hinder melanogenesis in B16 rat melanoma cells. Further, they identified afzelin (3-O-alpha-L-rhamnosylkaempferol) and the flavanone naringenin as the active ingredients responsible for inhibition of tyrosinase and melanogenesis and concluded that these substances warrant attention as potential skin-whitening agents (Nat. Prod. Commun. 2014;9:185-8).

A 2014 study in the ophthalmologic literature may also shed light on the photoprotective properties of naringenin. Jun-Li Lin and colleagues, studying the effects of the flavanone in eye drops used to treat N-methyl-N-nitrosourea (MNU)-induced photoreceptor cell death in rats, found that topical naringenin dose-dependently shielded the outer nuclear layer, outer retina, and whole retina, and prevented structural and functional damages to retinal neurons (Int. J. Ophthalmol. 2014;7:391-6).

Conclusion

The antioxidative, antiatherogenic, anticarcinogenic, antiproliferative, antimutagenic, estrogenic, and immunomodulatory properties of naringenin have been established in the laboratory. It remains to be seen whether such activity can be harnessed for medical applications, particularly in the dermatologic arena. Nevertheless, this flavanone warrants watching as research into its potential cutaneous applications proceeds. Currently, there is a dearth of research, though, regarding the use of naringenin in topical products.

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

The flavanone naringenin (5,7,4-trihydroxyflavanone) is known to exhibit anticarcinogenic, antioxidative, antiatherogenic, estrogenic, and immunomodulatory activity (Nutr. Cancer. 2012;64:714-24; J. Nutr. 2001;131:235-41; Life Sci. 2013;93:516-24). Naringenin can be found in high concentrations in grapefruits, oranges, and other citrus fruits as well as tomatoes (skin), with grapefruit juice found to yield much higher levels in plasma than orange juice (J. Nutr. 2001;131:235-41; Am. J. Physiol. Gastrointest. Liver Physiol. 2000;279:G1148-54; Nutr. Cancer 2012;64:714-24). Naringenin has been shown, along with other flavanones such as hesperetin and ponciretin, to strongly inhibit IgE-induced beta-hexosaminidase release from RBL-2H3 cells. Sung-Hwan Park and associates have suggested that the glycosides of these substances have potential as agents for treating IgE-induced atopic allergies (Planta Med. 2005;71:24-7).

In 2012, Kushi Anand and associates also showed that the combination of curcumin and naringenin exerted antiangiogenic and antitumor effects in Swiss albino mice, adding that neither compound has been associated with reports of toxicity in animals or humans (Nutr. Cancer 2012;64:714-24).

Potential cutaneous benefits

Tae-Ho Kim and colleagues studied the effects of naringenin on 2,4-dinitrofluorobenzene (DNFB)-induced atomic dermatitis in NC/Nga mice in 2013. After repetitive skin contact with DNFB, mice received intraperitoneal injections of naringenin for 1 week, with the treatment with the fruit flavonoid significantly diminishing ear swelling and back skin lesions. The flavonoid also significantly inhibited interferon (IFN)-alpha production by activated CD4+ T cells and lowered serum IgE levels as well as DNFB-induced infiltration of eosinophils, mast cells, CD4+ T cells, and CD8+ T cells in skin lesions (Life Sci. 2013;93:516-24).

Also that year, a naringenin glucoside (naringenin-7-O-glucoside) was found in an industrial blanch water extract, a byproduct of almond processing, and believed to play a role in exerting or contributing to a photoprotective effect in a small in vivo study with 12 volunteers (Molecules 2013;18:12426-40).

©Ls9907/Thinkstockphotos.com

In 2014, K. Murata and associates screened several Prunus species in a search for skin-whitening compounds. Using an antityrosinase assay, the investigators determined that P. persica exhibited the greatest inhibitory activity and, in additional evaluation, it was found to hinder melanogenesis in B16 rat melanoma cells. Further, they identified afzelin (3-O-alpha-L-rhamnosylkaempferol) and the flavanone naringenin as the active ingredients responsible for inhibition of tyrosinase and melanogenesis and concluded that these substances warrant attention as potential skin-whitening agents (Nat. Prod. Commun. 2014;9:185-8).

A 2014 study in the ophthalmologic literature may also shed light on the photoprotective properties of naringenin. Jun-Li Lin and colleagues, studying the effects of the flavanone in eye drops used to treat N-methyl-N-nitrosourea (MNU)-induced photoreceptor cell death in rats, found that topical naringenin dose-dependently shielded the outer nuclear layer, outer retina, and whole retina, and prevented structural and functional damages to retinal neurons (Int. J. Ophthalmol. 2014;7:391-6).

Conclusion

The antioxidative, antiatherogenic, anticarcinogenic, antiproliferative, antimutagenic, estrogenic, and immunomodulatory properties of naringenin have been established in the laboratory. It remains to be seen whether such activity can be harnessed for medical applications, particularly in the dermatologic arena. Nevertheless, this flavanone warrants watching as research into its potential cutaneous applications proceeds. Currently, there is a dearth of research, though, regarding the use of naringenin in topical products.

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

Clinical question: Does fecal microbiotia transplantation (FMT) effectively treat patients with recurrent Clostridium difficile infection (CDI)?

Background: Patients with initial CDI have increased rates of recurrence (15%–30%), with variable success noted in treatment of recurrent disease. Increased interest in the use of FMT as a treatment strategy for CDI has led to various studies evaluating its efficacy.

Study design: Systematic review.

Setting: Multiple settings from studies obtained from MEDLINE, Cochrane Library, and ClinicalTrials.gov.

Synopsis: Literature search and review yielded a total of 35 included articles for analysis, mostly case-series studies (28), with only two randomized controlled trials (RCTs). Primary outcome was defined as symptom resolution, with a secondary outcome of recurrence. Although studies included assessed FMT as treatment for initial, recurrent, and refractory CDI, the majority of the evidence was focused on recurrent CDI. Among the studies analyzed, FMT was found to have a substantial effect on primary outcome of symptom resolution (85% of cases) among all pooled studies for recurrent CDI.

Although this review provided evidence suggestive of the efficacy of FMT in recurrent CDI, the paucity of RCT data was well documented and noted as a limitation in providing high-quality recommendations on FMT as a treatment option. Further high-quality research is recommended, and hospitalists caring for patients with recurrent CDI should be wary of treatment with FMT based on these data alone.

Bottom line: Studies evaluating FMT as a treatment option for recurrent CDI demonstrate significant benefit in symptom resolution, but further high-quality research is needed.

Citation: Drekonja D, Reich J, Gezahegn S, et al. Fecal microbiota transplantation for Clostridium difficile infection: a systematic review of the evidence. Ann Intern Med. 2015;162:630-638. doi:10.7326/M14-2693.

Visit our website for more hospitalist-focused literature reviews.

Clinical question: Does fecal microbiotia transplantation (FMT) effectively treat patients with recurrent Clostridium difficile infection (CDI)?

Background: Patients with initial CDI have increased rates of recurrence (15%–30%), with variable success noted in treatment of recurrent disease. Increased interest in the use of FMT as a treatment strategy for CDI has led to various studies evaluating its efficacy.

Study design: Systematic review.

Setting: Multiple settings from studies obtained from MEDLINE, Cochrane Library, and ClinicalTrials.gov.

Synopsis: Literature search and review yielded a total of 35 included articles for analysis, mostly case-series studies (28), with only two randomized controlled trials (RCTs). Primary outcome was defined as symptom resolution, with a secondary outcome of recurrence. Although studies included assessed FMT as treatment for initial, recurrent, and refractory CDI, the majority of the evidence was focused on recurrent CDI. Among the studies analyzed, FMT was found to have a substantial effect on primary outcome of symptom resolution (85% of cases) among all pooled studies for recurrent CDI.

Although this review provided evidence suggestive of the efficacy of FMT in recurrent CDI, the paucity of RCT data was well documented and noted as a limitation in providing high-quality recommendations on FMT as a treatment option. Further high-quality research is recommended, and hospitalists caring for patients with recurrent CDI should be wary of treatment with FMT based on these data alone.

Bottom line: Studies evaluating FMT as a treatment option for recurrent CDI demonstrate significant benefit in symptom resolution, but further high-quality research is needed.

Citation: Drekonja D, Reich J, Gezahegn S, et al. Fecal microbiota transplantation for Clostridium difficile infection: a systematic review of the evidence. Ann Intern Med. 2015;162:630-638. doi:10.7326/M14-2693.

Visit our website for more hospitalist-focused literature reviews.

Clinical question: Does fecal microbiotia transplantation (FMT) effectively treat patients with recurrent Clostridium difficile infection (CDI)?

Background: Patients with initial CDI have increased rates of recurrence (15%–30%), with variable success noted in treatment of recurrent disease. Increased interest in the use of FMT as a treatment strategy for CDI has led to various studies evaluating its efficacy.

Study design: Systematic review.

Setting: Multiple settings from studies obtained from MEDLINE, Cochrane Library, and ClinicalTrials.gov.

Synopsis: Literature search and review yielded a total of 35 included articles for analysis, mostly case-series studies (28), with only two randomized controlled trials (RCTs). Primary outcome was defined as symptom resolution, with a secondary outcome of recurrence. Although studies included assessed FMT as treatment for initial, recurrent, and refractory CDI, the majority of the evidence was focused on recurrent CDI. Among the studies analyzed, FMT was found to have a substantial effect on primary outcome of symptom resolution (85% of cases) among all pooled studies for recurrent CDI.

Although this review provided evidence suggestive of the efficacy of FMT in recurrent CDI, the paucity of RCT data was well documented and noted as a limitation in providing high-quality recommendations on FMT as a treatment option. Further high-quality research is recommended, and hospitalists caring for patients with recurrent CDI should be wary of treatment with FMT based on these data alone.

Bottom line: Studies evaluating FMT as a treatment option for recurrent CDI demonstrate significant benefit in symptom resolution, but further high-quality research is needed.

Citation: Drekonja D, Reich J, Gezahegn S, et al. Fecal microbiota transplantation for Clostridium difficile infection: a systematic review of the evidence. Ann Intern Med. 2015;162:630-638. doi:10.7326/M14-2693.

Visit our website for more hospitalist-focused literature reviews.