Pulmonary Health Hub

Home treatment with rivaroxaban for patients with a low-risk first deep vein thrombosis or pulmonary embolism is associated with low rates of thrombosis recurrence or major bleeding, according to data from a prospective observational study.

The study enrolled 71 patients with low-risk deep vein thrombosis (DVT), 30 with pulmonary embolism, and five with both, all of whom were discharged with prescriptions for 15mg of rivaroxaban twice a day for 21 days and then 20 mg once per day for a further month.

There were no cases of thrombosis recurrence within the treatment period – although three patients had a recurrent DVT after stopping treatment – and no incidents of major or clinically relevant bleeding while on the therapy, as was reported in the July edition of Academic Emergency Medicine.

“This preliminary report provides data to support the initial outpatient treatment of low-risk ED patients with deep vein thrombosis and pulmonary embolism,” wrote Dr. Daren M. Beam and colleagues from the Indiana University School of Medicine (Academic Emergency Medicine 2015, 22:789–795 [doi:10.1111/acem.12711]).

The study was partly supported by the Lilly Physician Scientist Award. One author declared consultancies with Stago Diagnostica, Janssen, and Pfizer.

Home treatment with rivaroxaban for patients with a low-risk first deep vein thrombosis or pulmonary embolism is associated with low rates of thrombosis recurrence or major bleeding, according to data from a prospective observational study.

The study enrolled 71 patients with low-risk deep vein thrombosis (DVT), 30 with pulmonary embolism, and five with both, all of whom were discharged with prescriptions for 15mg of rivaroxaban twice a day for 21 days and then 20 mg once per day for a further month.

There were no cases of thrombosis recurrence within the treatment period – although three patients had a recurrent DVT after stopping treatment – and no incidents of major or clinically relevant bleeding while on the therapy, as was reported in the July edition of Academic Emergency Medicine.

“This preliminary report provides data to support the initial outpatient treatment of low-risk ED patients with deep vein thrombosis and pulmonary embolism,” wrote Dr. Daren M. Beam and colleagues from the Indiana University School of Medicine (Academic Emergency Medicine 2015, 22:789–795 [doi:10.1111/acem.12711]).

The study was partly supported by the Lilly Physician Scientist Award. One author declared consultancies with Stago Diagnostica, Janssen, and Pfizer.

Home treatment with rivaroxaban for patients with a low-risk first deep vein thrombosis or pulmonary embolism is associated with low rates of thrombosis recurrence or major bleeding, according to data from a prospective observational study.

The study enrolled 71 patients with low-risk deep vein thrombosis (DVT), 30 with pulmonary embolism, and five with both, all of whom were discharged with prescriptions for 15mg of rivaroxaban twice a day for 21 days and then 20 mg once per day for a further month.

There were no cases of thrombosis recurrence within the treatment period – although three patients had a recurrent DVT after stopping treatment – and no incidents of major or clinically relevant bleeding while on the therapy, as was reported in the July edition of Academic Emergency Medicine.

“This preliminary report provides data to support the initial outpatient treatment of low-risk ED patients with deep vein thrombosis and pulmonary embolism,” wrote Dr. Daren M. Beam and colleagues from the Indiana University School of Medicine (Academic Emergency Medicine 2015, 22:789–795 [doi:10.1111/acem.12711]).

The study was partly supported by the Lilly Physician Scientist Award. One author declared consultancies with Stago Diagnostica, Janssen, and Pfizer.

To weary parents, the fact that their child does not want to go to bed at night is both puzzling and exasperating. No matter what age, it is important to have a healthy bedtime for the child’s well-being as well as their caregiver’s!

Sleep, like the “canary in the mine,” is vulnerable to disruption by anything from minor illness to changes in schedule, things viewed on media, or emotions in the home, to life changes such as a new sibling, toilet training, or a new school year. In patients on stimulant medicine resisting bedtime, consider the need to finally eat. Asking about these specifically will help you plan an appropriate time to successfully address bedtime conflicts.

Knowing some basic principles about falling asleep can help your counseling. “Sleep drive” builds up over the day like a coiled spring, making falling asleep easier initially than for wakings later in the night. It also means that a nap too close to bedtime reduces the drive. Avoiding any naps (after age 4 years) and naps lasting past 4 p.m. for children under 4, even in car rides, is crucial. Beware of teens “having trouble falling asleep” who have sneaked in a nap after school!

To optimize sleep drive, calculate age-related sleep needs and, ideally, ask parents to keep a sleep diary for 1-2 weeks, especially checking on naps at daycare. Updated sleep duration standards (preschool 10-13 hours; school age 9-11 hours; teens 8-10 hours (see sleepfoundation.org) show that ranges of total sleep are remarkably stable, but may not meet parents’ ideals for time “off duty.”

If placed in bed when not yet tired, anyone will have trouble falling asleep (phase shift). For a child, lying awake in the dark alone is time for active imaginations to conjure fear of separation (> 4-6 months), monsters (for preschoolers), burglars (for anxious school-aged children), or the next day’s social or academic stresses (for school-aged children to teens). Children with anxiety disorders even worry that they may not get enough sleep! A soothing routine with a story in their bed (not media), a spritzing of “monster spray” or a “bedtime ticket” to cash in for “one more thing” (for those who beg) will usually suffice for preschoolers. A “magic flashlight” lends the child some control to check for monsters, but an “exorcism ritual” by the all-powerful parent can be added if needed. Teens are never too old for a chance to talk or even a story read by the parent (but they won’t ask for this).

A secret to managing bedtime struggles is to start the routine at the time the child is now falling asleep to avoid resistance, and keeping wake-up time appropriate to the new schedule. Once falling asleep within 10 minutes, move bedtime 15 minutes earlier each night to reach the schedule, then maintain 7 days per week (or within 1 hour) to prevent resetting the biological clock. Sorry, no movie nights until 2 a.m. or “sleeping in” on weekends! Teens who resist bedtime may be napping, socializing at the “only time” peers are up, addicted to media, or avoiding family. Their cooperation must be engaged to make a change by staying up all night once, then setting a new schedule, or staying up 1 hour later each night until the desired bedtime is reached.

©deyangeorgiev/thinkstockphotos.com

Because sleep includes being paralyzed (REM stages), evolution encourages animals to sleep together to protect from predators. Sleeping alone requires a great deal of reassurance, such as from a friendly atmosphere, favorite stuffed toy, and familiar routine that implies safety. Children could use a toy, pet, or even a sibling to feel safe. While body contact is the most reassuring, children may not return to sleep from the many normal night wakings without it. Most can be weaned from this dependence by the parent sitting by the bed silently, moving one foot closer to the door each night. A promise to “check on you” in 5 minutes also helps.

Other factors making sleep easier include avoiding caffeine, stimulating medicines, or nicotine as well as exciting games, media, or exercise within 2 hours of bedtime. A quiet, dark, cool but not damp location used only for sleeping is helpful, but not always possible. A white noise generator, fan, or radio on static can help.

Many parents strangely expect their child to give up the pleasures of the day and take themselves to bed! As for other kinds of limit setting, parental company is typically needed for brushing teeth, pajamas, and a story. Ideally, it can be fun as a race or with songs, not a yelling match, which undermines the sense of safety. Setting rules about no electronics in the bedroom, even for charging, after a certain hour is often the only solution (even for adults) to the common struggle over ending media.

Often the bedtime complaint is “curtain calls” after being settled in bed. For children who call out, advise parents wait a few moments before responding, then reassure verbally without entering their room, waiting longer each time. For the child getting out of bed, one parent should lead them back without talking at all as many times as necessary. A reward for staying in bed without calling or coming out can be an extra story the next night and/or a morning reward. Alternatively, close the door and turn off the light if they come out or call out. After a few moments in the dark, give a “second chance” as long as they are quietly in bed. Gating the doorway works well for toddlers – sleeping on the floor is not dangerous!

Families often are ambivalent about asking for bedtime advice, thinking your solutions might be stressful, harmful to their relationship, or will take up their own precious sleep. For many, a prolonged bedtime is the best part of their day. Special Time earlier is often key to enforcing a healthy bedtime. Reassure them that these solutions usually take less than 3 weeks!

For the child, bedtime means giving up on fun but, more importantly, separation from the parent. This separation is harder if negative emotions are left from a day of behavior struggles or parents are even subtly angry at each other. For parents, bedtime means separating from their main pleasure in life. They also may be regretting their interactions during the day. Ambivalence about parting also may come from fears of being alone with their partner due to marital discord, intimate partner violence, chronic arguing, substance use, or simply depression. When simple advice fails, it is important to explore these meanings with families, encourage positive daytime behavior management methods, and avoid conflict in front of the children to resolve bedtime struggles.

Dr. Howard is assistant professor of pediatrics at the Johns Hopkins University School of Medicine, Baltimore, and creator of CHADIS (www.CHADIS.com). She has no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline. E-mail her at [email protected].

To weary parents, the fact that their child does not want to go to bed at night is both puzzling and exasperating. No matter what age, it is important to have a healthy bedtime for the child’s well-being as well as their caregiver’s!

Sleep, like the “canary in the mine,” is vulnerable to disruption by anything from minor illness to changes in schedule, things viewed on media, or emotions in the home, to life changes such as a new sibling, toilet training, or a new school year. In patients on stimulant medicine resisting bedtime, consider the need to finally eat. Asking about these specifically will help you plan an appropriate time to successfully address bedtime conflicts.

Knowing some basic principles about falling asleep can help your counseling. “Sleep drive” builds up over the day like a coiled spring, making falling asleep easier initially than for wakings later in the night. It also means that a nap too close to bedtime reduces the drive. Avoiding any naps (after age 4 years) and naps lasting past 4 p.m. for children under 4, even in car rides, is crucial. Beware of teens “having trouble falling asleep” who have sneaked in a nap after school!

To optimize sleep drive, calculate age-related sleep needs and, ideally, ask parents to keep a sleep diary for 1-2 weeks, especially checking on naps at daycare. Updated sleep duration standards (preschool 10-13 hours; school age 9-11 hours; teens 8-10 hours (see sleepfoundation.org) show that ranges of total sleep are remarkably stable, but may not meet parents’ ideals for time “off duty.”

If placed in bed when not yet tired, anyone will have trouble falling asleep (phase shift). For a child, lying awake in the dark alone is time for active imaginations to conjure fear of separation (> 4-6 months), monsters (for preschoolers), burglars (for anxious school-aged children), or the next day’s social or academic stresses (for school-aged children to teens). Children with anxiety disorders even worry that they may not get enough sleep! A soothing routine with a story in their bed (not media), a spritzing of “monster spray” or a “bedtime ticket” to cash in for “one more thing” (for those who beg) will usually suffice for preschoolers. A “magic flashlight” lends the child some control to check for monsters, but an “exorcism ritual” by the all-powerful parent can be added if needed. Teens are never too old for a chance to talk or even a story read by the parent (but they won’t ask for this).

A secret to managing bedtime struggles is to start the routine at the time the child is now falling asleep to avoid resistance, and keeping wake-up time appropriate to the new schedule. Once falling asleep within 10 minutes, move bedtime 15 minutes earlier each night to reach the schedule, then maintain 7 days per week (or within 1 hour) to prevent resetting the biological clock. Sorry, no movie nights until 2 a.m. or “sleeping in” on weekends! Teens who resist bedtime may be napping, socializing at the “only time” peers are up, addicted to media, or avoiding family. Their cooperation must be engaged to make a change by staying up all night once, then setting a new schedule, or staying up 1 hour later each night until the desired bedtime is reached.

©deyangeorgiev/thinkstockphotos.com

Because sleep includes being paralyzed (REM stages), evolution encourages animals to sleep together to protect from predators. Sleeping alone requires a great deal of reassurance, such as from a friendly atmosphere, favorite stuffed toy, and familiar routine that implies safety. Children could use a toy, pet, or even a sibling to feel safe. While body contact is the most reassuring, children may not return to sleep from the many normal night wakings without it. Most can be weaned from this dependence by the parent sitting by the bed silently, moving one foot closer to the door each night. A promise to “check on you” in 5 minutes also helps.

Other factors making sleep easier include avoiding caffeine, stimulating medicines, or nicotine as well as exciting games, media, or exercise within 2 hours of bedtime. A quiet, dark, cool but not damp location used only for sleeping is helpful, but not always possible. A white noise generator, fan, or radio on static can help.

Many parents strangely expect their child to give up the pleasures of the day and take themselves to bed! As for other kinds of limit setting, parental company is typically needed for brushing teeth, pajamas, and a story. Ideally, it can be fun as a race or with songs, not a yelling match, which undermines the sense of safety. Setting rules about no electronics in the bedroom, even for charging, after a certain hour is often the only solution (even for adults) to the common struggle over ending media.

Often the bedtime complaint is “curtain calls” after being settled in bed. For children who call out, advise parents wait a few moments before responding, then reassure verbally without entering their room, waiting longer each time. For the child getting out of bed, one parent should lead them back without talking at all as many times as necessary. A reward for staying in bed without calling or coming out can be an extra story the next night and/or a morning reward. Alternatively, close the door and turn off the light if they come out or call out. After a few moments in the dark, give a “second chance” as long as they are quietly in bed. Gating the doorway works well for toddlers – sleeping on the floor is not dangerous!

Families often are ambivalent about asking for bedtime advice, thinking your solutions might be stressful, harmful to their relationship, or will take up their own precious sleep. For many, a prolonged bedtime is the best part of their day. Special Time earlier is often key to enforcing a healthy bedtime. Reassure them that these solutions usually take less than 3 weeks!

For the child, bedtime means giving up on fun but, more importantly, separation from the parent. This separation is harder if negative emotions are left from a day of behavior struggles or parents are even subtly angry at each other. For parents, bedtime means separating from their main pleasure in life. They also may be regretting their interactions during the day. Ambivalence about parting also may come from fears of being alone with their partner due to marital discord, intimate partner violence, chronic arguing, substance use, or simply depression. When simple advice fails, it is important to explore these meanings with families, encourage positive daytime behavior management methods, and avoid conflict in front of the children to resolve bedtime struggles.

Dr. Howard is assistant professor of pediatrics at the Johns Hopkins University School of Medicine, Baltimore, and creator of CHADIS (www.CHADIS.com). She has no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline. E-mail her at [email protected].

To weary parents, the fact that their child does not want to go to bed at night is both puzzling and exasperating. No matter what age, it is important to have a healthy bedtime for the child’s well-being as well as their caregiver’s!

Sleep, like the “canary in the mine,” is vulnerable to disruption by anything from minor illness to changes in schedule, things viewed on media, or emotions in the home, to life changes such as a new sibling, toilet training, or a new school year. In patients on stimulant medicine resisting bedtime, consider the need to finally eat. Asking about these specifically will help you plan an appropriate time to successfully address bedtime conflicts.

Knowing some basic principles about falling asleep can help your counseling. “Sleep drive” builds up over the day like a coiled spring, making falling asleep easier initially than for wakings later in the night. It also means that a nap too close to bedtime reduces the drive. Avoiding any naps (after age 4 years) and naps lasting past 4 p.m. for children under 4, even in car rides, is crucial. Beware of teens “having trouble falling asleep” who have sneaked in a nap after school!

To optimize sleep drive, calculate age-related sleep needs and, ideally, ask parents to keep a sleep diary for 1-2 weeks, especially checking on naps at daycare. Updated sleep duration standards (preschool 10-13 hours; school age 9-11 hours; teens 8-10 hours (see sleepfoundation.org) show that ranges of total sleep are remarkably stable, but may not meet parents’ ideals for time “off duty.”

If placed in bed when not yet tired, anyone will have trouble falling asleep (phase shift). For a child, lying awake in the dark alone is time for active imaginations to conjure fear of separation (> 4-6 months), monsters (for preschoolers), burglars (for anxious school-aged children), or the next day’s social or academic stresses (for school-aged children to teens). Children with anxiety disorders even worry that they may not get enough sleep! A soothing routine with a story in their bed (not media), a spritzing of “monster spray” or a “bedtime ticket” to cash in for “one more thing” (for those who beg) will usually suffice for preschoolers. A “magic flashlight” lends the child some control to check for monsters, but an “exorcism ritual” by the all-powerful parent can be added if needed. Teens are never too old for a chance to talk or even a story read by the parent (but they won’t ask for this).

A secret to managing bedtime struggles is to start the routine at the time the child is now falling asleep to avoid resistance, and keeping wake-up time appropriate to the new schedule. Once falling asleep within 10 minutes, move bedtime 15 minutes earlier each night to reach the schedule, then maintain 7 days per week (or within 1 hour) to prevent resetting the biological clock. Sorry, no movie nights until 2 a.m. or “sleeping in” on weekends! Teens who resist bedtime may be napping, socializing at the “only time” peers are up, addicted to media, or avoiding family. Their cooperation must be engaged to make a change by staying up all night once, then setting a new schedule, or staying up 1 hour later each night until the desired bedtime is reached.

©deyangeorgiev/thinkstockphotos.com

Because sleep includes being paralyzed (REM stages), evolution encourages animals to sleep together to protect from predators. Sleeping alone requires a great deal of reassurance, such as from a friendly atmosphere, favorite stuffed toy, and familiar routine that implies safety. Children could use a toy, pet, or even a sibling to feel safe. While body contact is the most reassuring, children may not return to sleep from the many normal night wakings without it. Most can be weaned from this dependence by the parent sitting by the bed silently, moving one foot closer to the door each night. A promise to “check on you” in 5 minutes also helps.

Other factors making sleep easier include avoiding caffeine, stimulating medicines, or nicotine as well as exciting games, media, or exercise within 2 hours of bedtime. A quiet, dark, cool but not damp location used only for sleeping is helpful, but not always possible. A white noise generator, fan, or radio on static can help.

Many parents strangely expect their child to give up the pleasures of the day and take themselves to bed! As for other kinds of limit setting, parental company is typically needed for brushing teeth, pajamas, and a story. Ideally, it can be fun as a race or with songs, not a yelling match, which undermines the sense of safety. Setting rules about no electronics in the bedroom, even for charging, after a certain hour is often the only solution (even for adults) to the common struggle over ending media.

Often the bedtime complaint is “curtain calls” after being settled in bed. For children who call out, advise parents wait a few moments before responding, then reassure verbally without entering their room, waiting longer each time. For the child getting out of bed, one parent should lead them back without talking at all as many times as necessary. A reward for staying in bed without calling or coming out can be an extra story the next night and/or a morning reward. Alternatively, close the door and turn off the light if they come out or call out. After a few moments in the dark, give a “second chance” as long as they are quietly in bed. Gating the doorway works well for toddlers – sleeping on the floor is not dangerous!

Families often are ambivalent about asking for bedtime advice, thinking your solutions might be stressful, harmful to their relationship, or will take up their own precious sleep. For many, a prolonged bedtime is the best part of their day. Special Time earlier is often key to enforcing a healthy bedtime. Reassure them that these solutions usually take less than 3 weeks!

For the child, bedtime means giving up on fun but, more importantly, separation from the parent. This separation is harder if negative emotions are left from a day of behavior struggles or parents are even subtly angry at each other. For parents, bedtime means separating from their main pleasure in life. They also may be regretting their interactions during the day. Ambivalence about parting also may come from fears of being alone with their partner due to marital discord, intimate partner violence, chronic arguing, substance use, or simply depression. When simple advice fails, it is important to explore these meanings with families, encourage positive daytime behavior management methods, and avoid conflict in front of the children to resolve bedtime struggles.

Dr. Howard is assistant professor of pediatrics at the Johns Hopkins University School of Medicine, Baltimore, and creator of CHADIS (www.CHADIS.com). She has no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline. E-mail her at [email protected].

The antibiotic dicloxacillin appears to markedly decrease INR levels in patients taking warfarin, reducing the mean INR to subtherapeutic ranges in the majority who take both drugs concomitantly, according to a research letter to the editor published online July 20 in JAMA.

Adverse interactions between warfarin and other drugs are often suspected, but solid data are lacking. Case reports have suggested that the commonly used antibiotic dicloxacillin reduces warfarin’s anticoagulant effects, but no studies have examined the issue, said Anton Pottegård, Ph.D., of the department of clinical pharmacology, University of Southern Denmark, Odense, and his associates (JAMA 2015;314:296-7).

To further investigate that possibility, the investigators analyzed information in an anticoagulant database covering 7,400 patients treated by three outpatient clinics and 50 general practitioners during a 15-year period. They focused on weekly INR levels recorded for 236 patients (median age, 68 years), most of whom took warfarin because of atrial fibrillation or heart valve replacement.

The mean INR level before dicloxacillin exposure was 2.59, compared with 1.97 after dicloxacillin exposure (P < .001). A total of 144 patients (61%) had subtherapeutic INR levels (< 2.0) during the 2-4 weeks following a course of dicloxacillin, Dr. Pottegård and his associates said.

A similar but less drastic decrease was observed among the 64 patients taking a different anticoagulant, phenprocoumon, who were given dicloxacillin. Mean INR levels dropped from 2.61 before exposure to 2.30 afterward (P = .003), and 41% of the group had subtherapeutic INR levels after taking the antibiotic.

No sponsor was reported for this study. Dr. Pottegård and his associates reported having no relevant financial disclosures.

The antibiotic dicloxacillin appears to markedly decrease INR levels in patients taking warfarin, reducing the mean INR to subtherapeutic ranges in the majority who take both drugs concomitantly, according to a research letter to the editor published online July 20 in JAMA.

Adverse interactions between warfarin and other drugs are often suspected, but solid data are lacking. Case reports have suggested that the commonly used antibiotic dicloxacillin reduces warfarin’s anticoagulant effects, but no studies have examined the issue, said Anton Pottegård, Ph.D., of the department of clinical pharmacology, University of Southern Denmark, Odense, and his associates (JAMA 2015;314:296-7).

To further investigate that possibility, the investigators analyzed information in an anticoagulant database covering 7,400 patients treated by three outpatient clinics and 50 general practitioners during a 15-year period. They focused on weekly INR levels recorded for 236 patients (median age, 68 years), most of whom took warfarin because of atrial fibrillation or heart valve replacement.

The mean INR level before dicloxacillin exposure was 2.59, compared with 1.97 after dicloxacillin exposure (P < .001). A total of 144 patients (61%) had subtherapeutic INR levels (< 2.0) during the 2-4 weeks following a course of dicloxacillin, Dr. Pottegård and his associates said.

A similar but less drastic decrease was observed among the 64 patients taking a different anticoagulant, phenprocoumon, who were given dicloxacillin. Mean INR levels dropped from 2.61 before exposure to 2.30 afterward (P = .003), and 41% of the group had subtherapeutic INR levels after taking the antibiotic.

No sponsor was reported for this study. Dr. Pottegård and his associates reported having no relevant financial disclosures.

The antibiotic dicloxacillin appears to markedly decrease INR levels in patients taking warfarin, reducing the mean INR to subtherapeutic ranges in the majority who take both drugs concomitantly, according to a research letter to the editor published online July 20 in JAMA.

Adverse interactions between warfarin and other drugs are often suspected, but solid data are lacking. Case reports have suggested that the commonly used antibiotic dicloxacillin reduces warfarin’s anticoagulant effects, but no studies have examined the issue, said Anton Pottegård, Ph.D., of the department of clinical pharmacology, University of Southern Denmark, Odense, and his associates (JAMA 2015;314:296-7).

To further investigate that possibility, the investigators analyzed information in an anticoagulant database covering 7,400 patients treated by three outpatient clinics and 50 general practitioners during a 15-year period. They focused on weekly INR levels recorded for 236 patients (median age, 68 years), most of whom took warfarin because of atrial fibrillation or heart valve replacement.

The mean INR level before dicloxacillin exposure was 2.59, compared with 1.97 after dicloxacillin exposure (P < .001). A total of 144 patients (61%) had subtherapeutic INR levels (< 2.0) during the 2-4 weeks following a course of dicloxacillin, Dr. Pottegård and his associates said.

A similar but less drastic decrease was observed among the 64 patients taking a different anticoagulant, phenprocoumon, who were given dicloxacillin. Mean INR levels dropped from 2.61 before exposure to 2.30 afterward (P = .003), and 41% of the group had subtherapeutic INR levels after taking the antibiotic.

No sponsor was reported for this study. Dr. Pottegård and his associates reported having no relevant financial disclosures.

Most of our patients have been or will be exposed to water in a recreational setting this summer. As health care providers, we might not routinely consider illnesses associated with recreational water exposure or discuss preventive strategies; however, the Centers for Disease Control and Prevention has been actively promoting awareness about recreational water illnesses for years. May 18-24, 2015, was the 11th annual observance of Healthy and Safe Swimming Week, formerly known as Recreational Illness and Injury Prevention Week. The focus for 2015 was promoting the role of swimmers, residential pool owners, public health officials, and beach staff in the prevention of drownings, chemical injuries, and outbreaks of illness. One goal was for the swimmer to take a more active role in protecting themselves and preventing the spread of infections to others. For our colleagues, that means educating both parents and children.

To begin our discussion, let’s define recreational water illnesses (RWI). RWIs are caused by a variety of infectious pathogens transmitted by ingestion, inhalation of aerosols or mists, or having contact with contaminated water from both treated (swimming pools, hot tubs, water parks, and fountains) and untreated (lakes, rivers, and oceans) sources of water in recreational venues. RWIs also can be caused by chemicals that have evaporated from water leading to poor indoor air quality. However, I am focusing on the infectious etiologies.

A broad spectrum of infections are associated with RWIs, including infections of the gastrointestinal tract, ear, skin, eye, central nervous system, and wounds. Diarrhea is the most common infection. Implicated pathogens include Giardia, Shigella, norovirus, and Escherichia coli O157:H7, but it is Cryptosporidium that has emerged as the pathogen implicated most often in swimming pool–related outbreaks. Recently published data from the CDC revealed that in 2011-2012, there were 90 recreational-associated outbreaks reported from 32 states and Puerto Rico resulting in 1,788 infections, with 69 outbreaks occurring in treated water venues. Of these, 36 (51%) were caused by Cryptosporidium. Among 21 outbreaks occurring in untreated recreational water, E. coli was responsible for 7 (33%) (MMWR Morb. Mortal. Wkly Rep. 2015;64:668-72)

It’s no surprise diarrhea is the most common illness. Infection can easily occur after swallowing contaminated water. Many erroneously think chlorine kills all pathogens. Cryptosporidium is chlorine tolerant and can persist in treated water with the current recommended levels of chlorine for more than 10 days (J. Water Health 2008;6:513-20). For chlorine-sensitive pathogens, maintenance of the disinfection process must remain intact. What role do swimmers play? Most people have about 0.4 g of feces on their bottoms that can contaminate water when rinsed off. How many people enter a pool with a diarrheal illness? How many may go swimming after having recently recovered from a diarrheal illness and may have asymptomatic shedding? We all have cringed when we see a diapered child in the water. All of these are potential ways for the swimmer to contaminate an adequately treated pool. Additionally, while Cryptosporidium infections are usually self-limited, some individuals, including the immunocompromised host and especially those with advanced HIV and those who are solid organ transplant recipients, may have a protracted course of profuse diarrhea if infected.

While diarrhea maybe the most common RWI, it is not the only one. Acute otitis externa (AOE), more commonly known as “swimmer’s ear,” is one of the most frequent reasons for summer health care encounters. It has been estimated that in the United States in 2007, 2.4 million health care visits resulted in the diagnosis of AOE (MMWR Morb. Mortal. Wkly. Rep. 2011;60:605-9). Visits were highest among children aged 5-9 years; however, adults accounted for 53% of the encounters. Inflammation and infection of the external auditory canal is usually caused by bacteria. Pseudomonas aeruginosa or Staphylococcus aureus are the two most common etiologies. Water is easily introduced into the external auditory canal with recreational water activities, leading to maceration and subsequent infection of the canal. Simply reminding parents to thoroughly dry their child’s ears after water exposure can help prevent AOE.

© kali9/iStockphoto.com

P. aeruginosa also is the agent causing the self-limiting conditions hot tub folliculitis and hot-foot syndrome. Hot tub folliculitis is characterized by the development of tender, pruritic papules and papulopustules on the hips, buttocks, and axillae, usually developing 8-48 hours after exposure to water that has been contaminated because of inadequate chlorination. Hot-foot syndrome is characterized by painful planter nodules (N. Engl. J. Med. 2001;345:335).

Serious diseases are encountered infrequently, but there are some that require more urgent interventions. Primary amebic meningoencephalitis (PAM) is an extremely rare, progressive, and almost always fatal infection of the brain caused by Naegleria fowleri. The pathogen is found in warm freshwater including lakes, rivers, streams, and hot springs. It enters the body through the nose and travels via the olfactory nerve to the brain. Infection usually occurs when individuals swim or dive in warm freshwater. Most cases have been reported in children from Southern states. In 2010, the first case in a northern state was reported from Minnesota, and three additional cases have since been reported in Kansas and Indiana (J. Ped. Infect. Dis. 2014 [doi: 10.1093/jpids/piu103]). Cases also have been reported in two individuals who were regular users of neti pots for sinus irrigation because the irrigating solution was prepared with contaminated tap water (Clin. Infect. Dis. 2012;55:e79-85). Clinical presentation is similar to bacterial meningitis. Helpful diagnostic clues may come from obtaining a history of swimming in freshwater within the 2 weeks prior to presentation, especially during the summer, or the use of nasal or sinus irrigation with untreated tap water. Consultation with an infectious disease specialist is recommended.

Acanthamoeba keratitis is a potentially blinding infection of the cornea that primarily occurs in individuals who wear contact lenses. Risk factors for the infection include swimming, showering, and use of hot tubs while wearing contact lenses. Improper storage and cleansing contacts with tap water are other risk factors. Anyone with corneal trauma and similar water exposures also would be at risk. Clinically, the history combined with a foreign-body sensation, pain, and decreased visual acuity should make one include this infection in the differential diagnosis. Referral to an ophthalmologist is required.

Finally, swimming with an open wound is a portal of entry for Vibrio vulnificus. It usually is associated with consumption of contaminated seafood, especially oysters. In immunocompromised individuals, especially those with chronic liver disease, this bacteria can cause a life-threatening illness leading to bacteremia, septic shock, and development of blistering skin lesions. Infections are fatal in approximately 50% of cases.

The goal of this brief review was not to discourage swimming, but to make your patients and their families healthy swimmers. Here are a few things the CDC is recommending to help them achieve that goal:

• Shower prior to going swimming.

• Do not swallow or drink pool water.

• Take bathroom breaks every hour and rinse off before going back into the water.

• Do not swim if you have diarrhea.

• Wait at least 2 weeks to go swimming if you have had diarrhea.

• Change swim diapers frequently and away from the water.

• Suggest patients download the free CDC app Healthy Swimming for more detailed information and suggest they visit cdc.gov/healthywater/swimming.

Dr. Word is a pediatric infectious disease specialist and director of the Houston Travel Medicine Clinic. She had no relevant financial disclosures. Write to Dr. Word at [email protected].

Most of our patients have been or will be exposed to water in a recreational setting this summer. As health care providers, we might not routinely consider illnesses associated with recreational water exposure or discuss preventive strategies; however, the Centers for Disease Control and Prevention has been actively promoting awareness about recreational water illnesses for years. May 18-24, 2015, was the 11th annual observance of Healthy and Safe Swimming Week, formerly known as Recreational Illness and Injury Prevention Week. The focus for 2015 was promoting the role of swimmers, residential pool owners, public health officials, and beach staff in the prevention of drownings, chemical injuries, and outbreaks of illness. One goal was for the swimmer to take a more active role in protecting themselves and preventing the spread of infections to others. For our colleagues, that means educating both parents and children.

To begin our discussion, let’s define recreational water illnesses (RWI). RWIs are caused by a variety of infectious pathogens transmitted by ingestion, inhalation of aerosols or mists, or having contact with contaminated water from both treated (swimming pools, hot tubs, water parks, and fountains) and untreated (lakes, rivers, and oceans) sources of water in recreational venues. RWIs also can be caused by chemicals that have evaporated from water leading to poor indoor air quality. However, I am focusing on the infectious etiologies.

A broad spectrum of infections are associated with RWIs, including infections of the gastrointestinal tract, ear, skin, eye, central nervous system, and wounds. Diarrhea is the most common infection. Implicated pathogens include Giardia, Shigella, norovirus, and Escherichia coli O157:H7, but it is Cryptosporidium that has emerged as the pathogen implicated most often in swimming pool–related outbreaks. Recently published data from the CDC revealed that in 2011-2012, there were 90 recreational-associated outbreaks reported from 32 states and Puerto Rico resulting in 1,788 infections, with 69 outbreaks occurring in treated water venues. Of these, 36 (51%) were caused by Cryptosporidium. Among 21 outbreaks occurring in untreated recreational water, E. coli was responsible for 7 (33%) (MMWR Morb. Mortal. Wkly Rep. 2015;64:668-72)

It’s no surprise diarrhea is the most common illness. Infection can easily occur after swallowing contaminated water. Many erroneously think chlorine kills all pathogens. Cryptosporidium is chlorine tolerant and can persist in treated water with the current recommended levels of chlorine for more than 10 days (J. Water Health 2008;6:513-20). For chlorine-sensitive pathogens, maintenance of the disinfection process must remain intact. What role do swimmers play? Most people have about 0.4 g of feces on their bottoms that can contaminate water when rinsed off. How many people enter a pool with a diarrheal illness? How many may go swimming after having recently recovered from a diarrheal illness and may have asymptomatic shedding? We all have cringed when we see a diapered child in the water. All of these are potential ways for the swimmer to contaminate an adequately treated pool. Additionally, while Cryptosporidium infections are usually self-limited, some individuals, including the immunocompromised host and especially those with advanced HIV and those who are solid organ transplant recipients, may have a protracted course of profuse diarrhea if infected.

While diarrhea maybe the most common RWI, it is not the only one. Acute otitis externa (AOE), more commonly known as “swimmer’s ear,” is one of the most frequent reasons for summer health care encounters. It has been estimated that in the United States in 2007, 2.4 million health care visits resulted in the diagnosis of AOE (MMWR Morb. Mortal. Wkly. Rep. 2011;60:605-9). Visits were highest among children aged 5-9 years; however, adults accounted for 53% of the encounters. Inflammation and infection of the external auditory canal is usually caused by bacteria. Pseudomonas aeruginosa or Staphylococcus aureus are the two most common etiologies. Water is easily introduced into the external auditory canal with recreational water activities, leading to maceration and subsequent infection of the canal. Simply reminding parents to thoroughly dry their child’s ears after water exposure can help prevent AOE.

© kali9/iStockphoto.com

P. aeruginosa also is the agent causing the self-limiting conditions hot tub folliculitis and hot-foot syndrome. Hot tub folliculitis is characterized by the development of tender, pruritic papules and papulopustules on the hips, buttocks, and axillae, usually developing 8-48 hours after exposure to water that has been contaminated because of inadequate chlorination. Hot-foot syndrome is characterized by painful planter nodules (N. Engl. J. Med. 2001;345:335).

Serious diseases are encountered infrequently, but there are some that require more urgent interventions. Primary amebic meningoencephalitis (PAM) is an extremely rare, progressive, and almost always fatal infection of the brain caused by Naegleria fowleri. The pathogen is found in warm freshwater including lakes, rivers, streams, and hot springs. It enters the body through the nose and travels via the olfactory nerve to the brain. Infection usually occurs when individuals swim or dive in warm freshwater. Most cases have been reported in children from Southern states. In 2010, the first case in a northern state was reported from Minnesota, and three additional cases have since been reported in Kansas and Indiana (J. Ped. Infect. Dis. 2014 [doi: 10.1093/jpids/piu103]). Cases also have been reported in two individuals who were regular users of neti pots for sinus irrigation because the irrigating solution was prepared with contaminated tap water (Clin. Infect. Dis. 2012;55:e79-85). Clinical presentation is similar to bacterial meningitis. Helpful diagnostic clues may come from obtaining a history of swimming in freshwater within the 2 weeks prior to presentation, especially during the summer, or the use of nasal or sinus irrigation with untreated tap water. Consultation with an infectious disease specialist is recommended.

Acanthamoeba keratitis is a potentially blinding infection of the cornea that primarily occurs in individuals who wear contact lenses. Risk factors for the infection include swimming, showering, and use of hot tubs while wearing contact lenses. Improper storage and cleansing contacts with tap water are other risk factors. Anyone with corneal trauma and similar water exposures also would be at risk. Clinically, the history combined with a foreign-body sensation, pain, and decreased visual acuity should make one include this infection in the differential diagnosis. Referral to an ophthalmologist is required.

Finally, swimming with an open wound is a portal of entry for Vibrio vulnificus. It usually is associated with consumption of contaminated seafood, especially oysters. In immunocompromised individuals, especially those with chronic liver disease, this bacteria can cause a life-threatening illness leading to bacteremia, septic shock, and development of blistering skin lesions. Infections are fatal in approximately 50% of cases.

The goal of this brief review was not to discourage swimming, but to make your patients and their families healthy swimmers. Here are a few things the CDC is recommending to help them achieve that goal:

• Shower prior to going swimming.

• Do not swallow or drink pool water.

• Take bathroom breaks every hour and rinse off before going back into the water.

• Do not swim if you have diarrhea.

• Wait at least 2 weeks to go swimming if you have had diarrhea.

• Change swim diapers frequently and away from the water.

• Suggest patients download the free CDC app Healthy Swimming for more detailed information and suggest they visit cdc.gov/healthywater/swimming.

Dr. Word is a pediatric infectious disease specialist and director of the Houston Travel Medicine Clinic. She had no relevant financial disclosures. Write to Dr. Word at [email protected].

Most of our patients have been or will be exposed to water in a recreational setting this summer. As health care providers, we might not routinely consider illnesses associated with recreational water exposure or discuss preventive strategies; however, the Centers for Disease Control and Prevention has been actively promoting awareness about recreational water illnesses for years. May 18-24, 2015, was the 11th annual observance of Healthy and Safe Swimming Week, formerly known as Recreational Illness and Injury Prevention Week. The focus for 2015 was promoting the role of swimmers, residential pool owners, public health officials, and beach staff in the prevention of drownings, chemical injuries, and outbreaks of illness. One goal was for the swimmer to take a more active role in protecting themselves and preventing the spread of infections to others. For our colleagues, that means educating both parents and children.

To begin our discussion, let’s define recreational water illnesses (RWI). RWIs are caused by a variety of infectious pathogens transmitted by ingestion, inhalation of aerosols or mists, or having contact with contaminated water from both treated (swimming pools, hot tubs, water parks, and fountains) and untreated (lakes, rivers, and oceans) sources of water in recreational venues. RWIs also can be caused by chemicals that have evaporated from water leading to poor indoor air quality. However, I am focusing on the infectious etiologies.

A broad spectrum of infections are associated with RWIs, including infections of the gastrointestinal tract, ear, skin, eye, central nervous system, and wounds. Diarrhea is the most common infection. Implicated pathogens include Giardia, Shigella, norovirus, and Escherichia coli O157:H7, but it is Cryptosporidium that has emerged as the pathogen implicated most often in swimming pool–related outbreaks. Recently published data from the CDC revealed that in 2011-2012, there were 90 recreational-associated outbreaks reported from 32 states and Puerto Rico resulting in 1,788 infections, with 69 outbreaks occurring in treated water venues. Of these, 36 (51%) were caused by Cryptosporidium. Among 21 outbreaks occurring in untreated recreational water, E. coli was responsible for 7 (33%) (MMWR Morb. Mortal. Wkly Rep. 2015;64:668-72)

It’s no surprise diarrhea is the most common illness. Infection can easily occur after swallowing contaminated water. Many erroneously think chlorine kills all pathogens. Cryptosporidium is chlorine tolerant and can persist in treated water with the current recommended levels of chlorine for more than 10 days (J. Water Health 2008;6:513-20). For chlorine-sensitive pathogens, maintenance of the disinfection process must remain intact. What role do swimmers play? Most people have about 0.4 g of feces on their bottoms that can contaminate water when rinsed off. How many people enter a pool with a diarrheal illness? How many may go swimming after having recently recovered from a diarrheal illness and may have asymptomatic shedding? We all have cringed when we see a diapered child in the water. All of these are potential ways for the swimmer to contaminate an adequately treated pool. Additionally, while Cryptosporidium infections are usually self-limited, some individuals, including the immunocompromised host and especially those with advanced HIV and those who are solid organ transplant recipients, may have a protracted course of profuse diarrhea if infected.

While diarrhea maybe the most common RWI, it is not the only one. Acute otitis externa (AOE), more commonly known as “swimmer’s ear,” is one of the most frequent reasons for summer health care encounters. It has been estimated that in the United States in 2007, 2.4 million health care visits resulted in the diagnosis of AOE (MMWR Morb. Mortal. Wkly. Rep. 2011;60:605-9). Visits were highest among children aged 5-9 years; however, adults accounted for 53% of the encounters. Inflammation and infection of the external auditory canal is usually caused by bacteria. Pseudomonas aeruginosa or Staphylococcus aureus are the two most common etiologies. Water is easily introduced into the external auditory canal with recreational water activities, leading to maceration and subsequent infection of the canal. Simply reminding parents to thoroughly dry their child’s ears after water exposure can help prevent AOE.

© kali9/iStockphoto.com

P. aeruginosa also is the agent causing the self-limiting conditions hot tub folliculitis and hot-foot syndrome. Hot tub folliculitis is characterized by the development of tender, pruritic papules and papulopustules on the hips, buttocks, and axillae, usually developing 8-48 hours after exposure to water that has been contaminated because of inadequate chlorination. Hot-foot syndrome is characterized by painful planter nodules (N. Engl. J. Med. 2001;345:335).

Serious diseases are encountered infrequently, but there are some that require more urgent interventions. Primary amebic meningoencephalitis (PAM) is an extremely rare, progressive, and almost always fatal infection of the brain caused by Naegleria fowleri. The pathogen is found in warm freshwater including lakes, rivers, streams, and hot springs. It enters the body through the nose and travels via the olfactory nerve to the brain. Infection usually occurs when individuals swim or dive in warm freshwater. Most cases have been reported in children from Southern states. In 2010, the first case in a northern state was reported from Minnesota, and three additional cases have since been reported in Kansas and Indiana (J. Ped. Infect. Dis. 2014 [doi: 10.1093/jpids/piu103]). Cases also have been reported in two individuals who were regular users of neti pots for sinus irrigation because the irrigating solution was prepared with contaminated tap water (Clin. Infect. Dis. 2012;55:e79-85). Clinical presentation is similar to bacterial meningitis. Helpful diagnostic clues may come from obtaining a history of swimming in freshwater within the 2 weeks prior to presentation, especially during the summer, or the use of nasal or sinus irrigation with untreated tap water. Consultation with an infectious disease specialist is recommended.

Acanthamoeba keratitis is a potentially blinding infection of the cornea that primarily occurs in individuals who wear contact lenses. Risk factors for the infection include swimming, showering, and use of hot tubs while wearing contact lenses. Improper storage and cleansing contacts with tap water are other risk factors. Anyone with corneal trauma and similar water exposures also would be at risk. Clinically, the history combined with a foreign-body sensation, pain, and decreased visual acuity should make one include this infection in the differential diagnosis. Referral to an ophthalmologist is required.

Finally, swimming with an open wound is a portal of entry for Vibrio vulnificus. It usually is associated with consumption of contaminated seafood, especially oysters. In immunocompromised individuals, especially those with chronic liver disease, this bacteria can cause a life-threatening illness leading to bacteremia, septic shock, and development of blistering skin lesions. Infections are fatal in approximately 50% of cases.

The goal of this brief review was not to discourage swimming, but to make your patients and their families healthy swimmers. Here are a few things the CDC is recommending to help them achieve that goal:

• Shower prior to going swimming.

• Do not swallow or drink pool water.

• Take bathroom breaks every hour and rinse off before going back into the water.

• Do not swim if you have diarrhea.

• Wait at least 2 weeks to go swimming if you have had diarrhea.

• Change swim diapers frequently and away from the water.

• Suggest patients download the free CDC app Healthy Swimming for more detailed information and suggest they visit cdc.gov/healthywater/swimming.

Dr. Word is a pediatric infectious disease specialist and director of the Houston Travel Medicine Clinic. She had no relevant financial disclosures. Write to Dr. Word at [email protected].

TORONTO – The prevalence of occult cancer is low in patients with a first unprovoked venous thromboembolism, according to results from a multicenter, randomized study presented at the International Society on Thrombosis and Haemostasis congress.

In addition, routine screening with the addition of a comprehensive CT scan of the abdomen and pelvis was no better than routine screening alone in detecting occult cancer in this population.

Courtesy International Society on Thrombosis and Haemostasis

Those are key findings that Dr. Marc Carrier of the University of Ottawa presented from the Screening for Occult Malignancy in Patients with Idiopathic Venous Thromboembolism (SOME) trial, a multicenter, open-label, randomized controlled trial that compared the efficacy of conventional screening with or without comprehensive CT of the abdomen/pelvis for detecting occult cancers in patients with unprovoked venous thromboembolism (VTE). The results of this study were published the same day as his presentation in the New England Journal of Medicine.

“It has been described that up to 10% of patients with unprovoked VTE are diagnosed with cancer in the year following their VTE diagnosis,” Dr. Carrier said. “Therefore, it’s appealing for clinicians to screen these patients for occult cancer but it has led to a lot of great diversity in practices. Some clinicians prefer to use a limited screening strategy that would include a history, physical examination, routine blood tests, and a chest X-ray. Other clinicians prefer to use the limited screening strategy in combination with additional tests. That could be CT of the abdomen and pelvis, ultrasound, or tumor marker, or [computed axial tomography] scan. It’s hard for a physician to know what to use.”

For the SOME trial, a total of 854 patients with unprovoked VTE were randomized to two groups: 431 to limited occult cancer screening (basic blood work, chest X-ray, and breast/cervical/prostate cancer screening) and 423 to limited screening in combination with a comprehensive CT of the abdomen/pelvis. The comprehensive CT included a virtual colonoscopy and gastroscopy, a biphasic enhanced CT, a parenchymal pancreatogram, and a uniphasic enhanced CT of distended bladder. The primary outcome was confirmed cancer that was missed by the screening strategy and detected by the end of the 1-year follow-up period.

Dr. Carrier reported that 33 patients (3.9%) had a new diagnosis of cancer in the interval between randomization and 1-year follow-up: 14 in the limited-screening group and 19 in the limited-screening-plus-CT group, a difference that was not statistically significant (P = .28). In addition, the number of occult cancers missed by the end of the 1-year follow-up period was similar between the two groups: four in the limited-screening group and five in the limited-screening-plus-CT group.

He and his associates also found no significant differences between the limited-screening group and the limited-screening-plus-CT group in the rate of detection of early cancers (0.23% vs. 0.71%, respectively; P = .37), in overall mortality (1.4% vs. 1.2%; P > 0.99), or in cancer-related mortality (1.4% vs. 0.95%; P = .75).

“Occult cancers are not nearly as common as we thought they were, which is reassuring for clinicians and patients because then we don’t have to do a lot of investigations to try and find them, and often scare patients and expose them to radiation and additional procedures,” Dr. Carrier said in an interview. “Limited screening alone, which is what is recommended in Canada and in the United States for age- and gender-specific screening, is more than reasonable for these patients.”

The SOME trial was funded by the Heart and Stroke Foundation of Canada. Dr. Carrier had no relevant financial conflicts to disclose.

Therese Borden contributed to this article.

[email protected]

TORONTO – The prevalence of occult cancer is low in patients with a first unprovoked venous thromboembolism, according to results from a multicenter, randomized study presented at the International Society on Thrombosis and Haemostasis congress.

In addition, routine screening with the addition of a comprehensive CT scan of the abdomen and pelvis was no better than routine screening alone in detecting occult cancer in this population.

Courtesy International Society on Thrombosis and Haemostasis

Those are key findings that Dr. Marc Carrier of the University of Ottawa presented from the Screening for Occult Malignancy in Patients with Idiopathic Venous Thromboembolism (SOME) trial, a multicenter, open-label, randomized controlled trial that compared the efficacy of conventional screening with or without comprehensive CT of the abdomen/pelvis for detecting occult cancers in patients with unprovoked venous thromboembolism (VTE). The results of this study were published the same day as his presentation in the New England Journal of Medicine.

“It has been described that up to 10% of patients with unprovoked VTE are diagnosed with cancer in the year following their VTE diagnosis,” Dr. Carrier said. “Therefore, it’s appealing for clinicians to screen these patients for occult cancer but it has led to a lot of great diversity in practices. Some clinicians prefer to use a limited screening strategy that would include a history, physical examination, routine blood tests, and a chest X-ray. Other clinicians prefer to use the limited screening strategy in combination with additional tests. That could be CT of the abdomen and pelvis, ultrasound, or tumor marker, or [computed axial tomography] scan. It’s hard for a physician to know what to use.”

For the SOME trial, a total of 854 patients with unprovoked VTE were randomized to two groups: 431 to limited occult cancer screening (basic blood work, chest X-ray, and breast/cervical/prostate cancer screening) and 423 to limited screening in combination with a comprehensive CT of the abdomen/pelvis. The comprehensive CT included a virtual colonoscopy and gastroscopy, a biphasic enhanced CT, a parenchymal pancreatogram, and a uniphasic enhanced CT of distended bladder. The primary outcome was confirmed cancer that was missed by the screening strategy and detected by the end of the 1-year follow-up period.

Dr. Carrier reported that 33 patients (3.9%) had a new diagnosis of cancer in the interval between randomization and 1-year follow-up: 14 in the limited-screening group and 19 in the limited-screening-plus-CT group, a difference that was not statistically significant (P = .28). In addition, the number of occult cancers missed by the end of the 1-year follow-up period was similar between the two groups: four in the limited-screening group and five in the limited-screening-plus-CT group.

He and his associates also found no significant differences between the limited-screening group and the limited-screening-plus-CT group in the rate of detection of early cancers (0.23% vs. 0.71%, respectively; P = .37), in overall mortality (1.4% vs. 1.2%; P > 0.99), or in cancer-related mortality (1.4% vs. 0.95%; P = .75).

“Occult cancers are not nearly as common as we thought they were, which is reassuring for clinicians and patients because then we don’t have to do a lot of investigations to try and find them, and often scare patients and expose them to radiation and additional procedures,” Dr. Carrier said in an interview. “Limited screening alone, which is what is recommended in Canada and in the United States for age- and gender-specific screening, is more than reasonable for these patients.”

The SOME trial was funded by the Heart and Stroke Foundation of Canada. Dr. Carrier had no relevant financial conflicts to disclose.

Therese Borden contributed to this article.

[email protected]

TORONTO – The prevalence of occult cancer is low in patients with a first unprovoked venous thromboembolism, according to results from a multicenter, randomized study presented at the International Society on Thrombosis and Haemostasis congress.

In addition, routine screening with the addition of a comprehensive CT scan of the abdomen and pelvis was no better than routine screening alone in detecting occult cancer in this population.

Courtesy International Society on Thrombosis and Haemostasis

Those are key findings that Dr. Marc Carrier of the University of Ottawa presented from the Screening for Occult Malignancy in Patients with Idiopathic Venous Thromboembolism (SOME) trial, a multicenter, open-label, randomized controlled trial that compared the efficacy of conventional screening with or without comprehensive CT of the abdomen/pelvis for detecting occult cancers in patients with unprovoked venous thromboembolism (VTE). The results of this study were published the same day as his presentation in the New England Journal of Medicine.

“It has been described that up to 10% of patients with unprovoked VTE are diagnosed with cancer in the year following their VTE diagnosis,” Dr. Carrier said. “Therefore, it’s appealing for clinicians to screen these patients for occult cancer but it has led to a lot of great diversity in practices. Some clinicians prefer to use a limited screening strategy that would include a history, physical examination, routine blood tests, and a chest X-ray. Other clinicians prefer to use the limited screening strategy in combination with additional tests. That could be CT of the abdomen and pelvis, ultrasound, or tumor marker, or [computed axial tomography] scan. It’s hard for a physician to know what to use.”

For the SOME trial, a total of 854 patients with unprovoked VTE were randomized to two groups: 431 to limited occult cancer screening (basic blood work, chest X-ray, and breast/cervical/prostate cancer screening) and 423 to limited screening in combination with a comprehensive CT of the abdomen/pelvis. The comprehensive CT included a virtual colonoscopy and gastroscopy, a biphasic enhanced CT, a parenchymal pancreatogram, and a uniphasic enhanced CT of distended bladder. The primary outcome was confirmed cancer that was missed by the screening strategy and detected by the end of the 1-year follow-up period.

Dr. Carrier reported that 33 patients (3.9%) had a new diagnosis of cancer in the interval between randomization and 1-year follow-up: 14 in the limited-screening group and 19 in the limited-screening-plus-CT group, a difference that was not statistically significant (P = .28). In addition, the number of occult cancers missed by the end of the 1-year follow-up period was similar between the two groups: four in the limited-screening group and five in the limited-screening-plus-CT group.

He and his associates also found no significant differences between the limited-screening group and the limited-screening-plus-CT group in the rate of detection of early cancers (0.23% vs. 0.71%, respectively; P = .37), in overall mortality (1.4% vs. 1.2%; P > 0.99), or in cancer-related mortality (1.4% vs. 0.95%; P = .75).

“Occult cancers are not nearly as common as we thought they were, which is reassuring for clinicians and patients because then we don’t have to do a lot of investigations to try and find them, and often scare patients and expose them to radiation and additional procedures,” Dr. Carrier said in an interview. “Limited screening alone, which is what is recommended in Canada and in the United States for age- and gender-specific screening, is more than reasonable for these patients.”

The SOME trial was funded by the Heart and Stroke Foundation of Canada. Dr. Carrier had no relevant financial conflicts to disclose.

Therese Borden contributed to this article.

[email protected]