Mixed Topics

Jonathan Meyer, MD, notes that TD has been the bane of the psychiatrist’s existence for the better part of a half century. In this Masterclass edition from the 2018 AACP Encore meeting in Las Vegas, Dr. Meyer talks about this movement disorder and analyzes how psychiatrists should approach treatment today.

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Apple Podcasts
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Jonathan Meyer, MD, notes that TD has been the bane of the psychiatrist’s existence for the better part of a half century. In this Masterclass edition from the 2018 AACP Encore meeting in Las Vegas, Dr. Meyer talks about this movement disorder and analyzes how psychiatrists should approach treatment today.

Amazon
Apple Podcasts
Google Podcasts
Spotify


 

Jonathan Meyer, MD, notes that TD has been the bane of the psychiatrist’s existence for the better part of a half century. In this Masterclass edition from the 2018 AACP Encore meeting in Las Vegas, Dr. Meyer talks about this movement disorder and analyzes how psychiatrists should approach treatment today.

Amazon
Apple Podcasts
Google Podcasts
Spotify


 

Dermatologists are prescribing fewer antibiotics for acne and rosacea, but prescribing after dermatologic surgery has increased in the past decade.

In a study published online Jan. 16 in JAMA Dermatology, researchers report the results of a cross-sectional analysis of antibiotic prescribing by 11,986 dermatologists between 2008 and 2016, using commercial claims data.

The analysis showed that, over this period of time, the overall rate of antibiotic prescribing by dermatologists decreased by 36.6%, from 3.36 courses per 100 dermatologist visits to 2.13 courses. In particular, antibiotic prescribing for acne decreased by 28.1%, from 11.76 courses per 100 visits to 8.45 courses, and for rosacea it decreased by 18.1%, from 10.89 courses per 100 visits to 8.92 courses.

John S. Barbieri, MD, of the department of dermatology, University of Pennsylvania, and his coauthors described the overall decline in antibiotic prescribing as “encouraging,” considering that in 2013 dermatologists were identified as the “most frequent prescribers of oral antibiotics per clinician.” The decline resulted in an estimated 480,000 fewer antibiotic courses a year, they noted.

“Much of the decrease in extended courses of antibiotic therapy is associated with visits for acne and rosacea,” they wrote. “Although recent guidelines suggest limiting the duration of therapy in this patient population, course duration has remained stable over time, suggesting that this decrease may be due to fewer patients being treated with antibiotics rather than patients being treated for a shorter duration.”

However, the rate of oral antibiotic prescriptions associated with surgical visits increased by 69.6%, from 3.92 courses per 100 visits to 6.65. This increase was concerning, given the risk of surgical-site infections was low, the authors pointed out. “In addition, a 2008 advisory statement on antibiotic prophylaxis recommends single-dose perioperative antibiotics for patients at increased risk of surgical-site infection,” they added.

The study also noted a 35.3% increase in antibiotic prescribing for cysts and a 3.2% increase for hidradenitis suppurativa.

Over the entire study period, nearly 1 million courses of oral antibiotics were prescribed. Doxycycline hyclate accounted for around one quarter of prescriptions, as did minocycline, while 19.9% of prescriptions were for cephalexin.

“Given the low rate of infectious complications, even for Mohs surgery, and the lack of evidence to support the use of prolonged rather than single-dose perioperative regimens, the postoperative courses of antibiotics identified in this study may increase risks to patients without substantial benefits,” they added.

The study was partly supported by the National Institute of Arthritis and Musculoskeletal Skin Diseases. No conflicts of interest were declared.

SOURCE: Barbieri J et al. JAMA Dermatology. 2019 Jan 16. doi: 10.1001/jamadermatol.2018.4944.

Dermatologists are prescribing fewer antibiotics for acne and rosacea, but prescribing after dermatologic surgery has increased in the past decade.

In a study published online Jan. 16 in JAMA Dermatology, researchers report the results of a cross-sectional analysis of antibiotic prescribing by 11,986 dermatologists between 2008 and 2016, using commercial claims data.

The analysis showed that, over this period of time, the overall rate of antibiotic prescribing by dermatologists decreased by 36.6%, from 3.36 courses per 100 dermatologist visits to 2.13 courses. In particular, antibiotic prescribing for acne decreased by 28.1%, from 11.76 courses per 100 visits to 8.45 courses, and for rosacea it decreased by 18.1%, from 10.89 courses per 100 visits to 8.92 courses.

John S. Barbieri, MD, of the department of dermatology, University of Pennsylvania, and his coauthors described the overall decline in antibiotic prescribing as “encouraging,” considering that in 2013 dermatologists were identified as the “most frequent prescribers of oral antibiotics per clinician.” The decline resulted in an estimated 480,000 fewer antibiotic courses a year, they noted.

“Much of the decrease in extended courses of antibiotic therapy is associated with visits for acne and rosacea,” they wrote. “Although recent guidelines suggest limiting the duration of therapy in this patient population, course duration has remained stable over time, suggesting that this decrease may be due to fewer patients being treated with antibiotics rather than patients being treated for a shorter duration.”

However, the rate of oral antibiotic prescriptions associated with surgical visits increased by 69.6%, from 3.92 courses per 100 visits to 6.65. This increase was concerning, given the risk of surgical-site infections was low, the authors pointed out. “In addition, a 2008 advisory statement on antibiotic prophylaxis recommends single-dose perioperative antibiotics for patients at increased risk of surgical-site infection,” they added.

The study also noted a 35.3% increase in antibiotic prescribing for cysts and a 3.2% increase for hidradenitis suppurativa.

Over the entire study period, nearly 1 million courses of oral antibiotics were prescribed. Doxycycline hyclate accounted for around one quarter of prescriptions, as did minocycline, while 19.9% of prescriptions were for cephalexin.

“Given the low rate of infectious complications, even for Mohs surgery, and the lack of evidence to support the use of prolonged rather than single-dose perioperative regimens, the postoperative courses of antibiotics identified in this study may increase risks to patients without substantial benefits,” they added.

The study was partly supported by the National Institute of Arthritis and Musculoskeletal Skin Diseases. No conflicts of interest were declared.

SOURCE: Barbieri J et al. JAMA Dermatology. 2019 Jan 16. doi: 10.1001/jamadermatol.2018.4944.

Dermatologists are prescribing fewer antibiotics for acne and rosacea, but prescribing after dermatologic surgery has increased in the past decade.

In a study published online Jan. 16 in JAMA Dermatology, researchers report the results of a cross-sectional analysis of antibiotic prescribing by 11,986 dermatologists between 2008 and 2016, using commercial claims data.

The analysis showed that, over this period of time, the overall rate of antibiotic prescribing by dermatologists decreased by 36.6%, from 3.36 courses per 100 dermatologist visits to 2.13 courses. In particular, antibiotic prescribing for acne decreased by 28.1%, from 11.76 courses per 100 visits to 8.45 courses, and for rosacea it decreased by 18.1%, from 10.89 courses per 100 visits to 8.92 courses.

John S. Barbieri, MD, of the department of dermatology, University of Pennsylvania, and his coauthors described the overall decline in antibiotic prescribing as “encouraging,” considering that in 2013 dermatologists were identified as the “most frequent prescribers of oral antibiotics per clinician.” The decline resulted in an estimated 480,000 fewer antibiotic courses a year, they noted.

“Much of the decrease in extended courses of antibiotic therapy is associated with visits for acne and rosacea,” they wrote. “Although recent guidelines suggest limiting the duration of therapy in this patient population, course duration has remained stable over time, suggesting that this decrease may be due to fewer patients being treated with antibiotics rather than patients being treated for a shorter duration.”

However, the rate of oral antibiotic prescriptions associated with surgical visits increased by 69.6%, from 3.92 courses per 100 visits to 6.65. This increase was concerning, given the risk of surgical-site infections was low, the authors pointed out. “In addition, a 2008 advisory statement on antibiotic prophylaxis recommends single-dose perioperative antibiotics for patients at increased risk of surgical-site infection,” they added.

The study also noted a 35.3% increase in antibiotic prescribing for cysts and a 3.2% increase for hidradenitis suppurativa.

Over the entire study period, nearly 1 million courses of oral antibiotics were prescribed. Doxycycline hyclate accounted for around one quarter of prescriptions, as did minocycline, while 19.9% of prescriptions were for cephalexin.

“Given the low rate of infectious complications, even for Mohs surgery, and the lack of evidence to support the use of prolonged rather than single-dose perioperative regimens, the postoperative courses of antibiotics identified in this study may increase risks to patients without substantial benefits,” they added.

The study was partly supported by the National Institute of Arthritis and Musculoskeletal Skin Diseases. No conflicts of interest were declared.

SOURCE: Barbieri J et al. JAMA Dermatology. 2019 Jan 16. doi: 10.1001/jamadermatol.2018.4944.

Promoting school attendance can have positive effects on children’s health, according to a new policy statement from the American Academy of Pediatrics’ Council on School Health.

School absence can affect not only children’s academic achievement but also their health, and the AAP advises health care providers to promote regular school attendance as preventive medicine, wrote Mandy Allison, MD, of the University of Colorado and Children’s Hospital Colorado, both in Aurora, and Elliott Attisha, DO, FAAP, of the Detroit Public Schools Community District.

In the statement, published in Pediatrics, the authors detailed factors associated with chronic absenteeism and provided guidelines for how clinicians can help reduce and prevent the problem. “Regardless of whether absences are unexcused or excused, chronic absenteeism typically results in poor academic outcomes and is linked to poor health outcomes,” they noted.

Factors linked with chronic absenteeism, defined by the U.S. Department of Education as missing 15 or more days of school in a year, include socioeconomic factors such as poverty, domestic violence, and foster care, as well as poorly controlled health conditions, such as asthma and diabetes. Approximately 13% of all students meet criteria for chronic absenteeism, the researchers noted.

Chronic absenteeism has been linked to an increased risk of unhealthy behaviors, including mental health problems in teens and poor health in adulthood, and students who miss school often struggle academically and may be more likely to drop out, they noted.

The AAP statement emphasizes school strategies to improve attendance, including education on hand washing and other infection prevention measures, use of school-based flu vaccination programs, availability of school nurses and counselors, and other school-based health and nutrition services.

The policy statement encourages pediatricians and other health care providers to promote school attendance in the office setting and the community.

The AAP encourages pediatricians and their colleagues caring for children to promote school attendance. In the office setting, the AAP recommends the clinicians stress the importance of school attendance, ask whether children have been absent from school and how often, encourage families to share any health concerns with the school nurse, and provide firm and specific guidance on when children should go to school or stay home. The AAP also recommends encouraging well children to return to school after routine appointments rather than miss a whole day and documenting medical needs for an Individualized Education Program or 504 Plan to maximize learning and promote attendance.

For students who are chronically absent from school (missing 2-3 days/month), the AAP encourages clinicians to identify physical health issues and psychosocial factors that may be contributing to absenteeism and to communicate with school health providers. In rare cases, out-of-school educational services may be justified, but with an established time line for returning to school, according to the statement.

In addition, the AAP encourages clinicians to advocate in the community in support of school attendance by sharing relevant data on chronic absences, working with community leaders to send a consistent message about the value of school attendance, and serving as a school physician or on a school board or wellness committee to promote attendance.

The full statement is available online and includes links to parent handouts, a waiting room video, and a mobile-friendly website for preteens, teens, and parents.

The researchers had no financial conflicts to disclose.

SOURCE: Allison MA et al. Pediatrics. 2019. doi: 10.1542/peds.2018-3648.

Promoting school attendance can have positive effects on children’s health, according to a new policy statement from the American Academy of Pediatrics’ Council on School Health.

School absence can affect not only children’s academic achievement but also their health, and the AAP advises health care providers to promote regular school attendance as preventive medicine, wrote Mandy Allison, MD, of the University of Colorado and Children’s Hospital Colorado, both in Aurora, and Elliott Attisha, DO, FAAP, of the Detroit Public Schools Community District.

In the statement, published in Pediatrics, the authors detailed factors associated with chronic absenteeism and provided guidelines for how clinicians can help reduce and prevent the problem. “Regardless of whether absences are unexcused or excused, chronic absenteeism typically results in poor academic outcomes and is linked to poor health outcomes,” they noted.

Factors linked with chronic absenteeism, defined by the U.S. Department of Education as missing 15 or more days of school in a year, include socioeconomic factors such as poverty, domestic violence, and foster care, as well as poorly controlled health conditions, such as asthma and diabetes. Approximately 13% of all students meet criteria for chronic absenteeism, the researchers noted.

Chronic absenteeism has been linked to an increased risk of unhealthy behaviors, including mental health problems in teens and poor health in adulthood, and students who miss school often struggle academically and may be more likely to drop out, they noted.

The AAP statement emphasizes school strategies to improve attendance, including education on hand washing and other infection prevention measures, use of school-based flu vaccination programs, availability of school nurses and counselors, and other school-based health and nutrition services.

The policy statement encourages pediatricians and other health care providers to promote school attendance in the office setting and the community.

The AAP encourages pediatricians and their colleagues caring for children to promote school attendance. In the office setting, the AAP recommends the clinicians stress the importance of school attendance, ask whether children have been absent from school and how often, encourage families to share any health concerns with the school nurse, and provide firm and specific guidance on when children should go to school or stay home. The AAP also recommends encouraging well children to return to school after routine appointments rather than miss a whole day and documenting medical needs for an Individualized Education Program or 504 Plan to maximize learning and promote attendance.

For students who are chronically absent from school (missing 2-3 days/month), the AAP encourages clinicians to identify physical health issues and psychosocial factors that may be contributing to absenteeism and to communicate with school health providers. In rare cases, out-of-school educational services may be justified, but with an established time line for returning to school, according to the statement.

In addition, the AAP encourages clinicians to advocate in the community in support of school attendance by sharing relevant data on chronic absences, working with community leaders to send a consistent message about the value of school attendance, and serving as a school physician or on a school board or wellness committee to promote attendance.

The full statement is available online and includes links to parent handouts, a waiting room video, and a mobile-friendly website for preteens, teens, and parents.

The researchers had no financial conflicts to disclose.

SOURCE: Allison MA et al. Pediatrics. 2019. doi: 10.1542/peds.2018-3648.

Promoting school attendance can have positive effects on children’s health, according to a new policy statement from the American Academy of Pediatrics’ Council on School Health.

School absence can affect not only children’s academic achievement but also their health, and the AAP advises health care providers to promote regular school attendance as preventive medicine, wrote Mandy Allison, MD, of the University of Colorado and Children’s Hospital Colorado, both in Aurora, and Elliott Attisha, DO, FAAP, of the Detroit Public Schools Community District.

In the statement, published in Pediatrics, the authors detailed factors associated with chronic absenteeism and provided guidelines for how clinicians can help reduce and prevent the problem. “Regardless of whether absences are unexcused or excused, chronic absenteeism typically results in poor academic outcomes and is linked to poor health outcomes,” they noted.

Factors linked with chronic absenteeism, defined by the U.S. Department of Education as missing 15 or more days of school in a year, include socioeconomic factors such as poverty, domestic violence, and foster care, as well as poorly controlled health conditions, such as asthma and diabetes. Approximately 13% of all students meet criteria for chronic absenteeism, the researchers noted.

Chronic absenteeism has been linked to an increased risk of unhealthy behaviors, including mental health problems in teens and poor health in adulthood, and students who miss school often struggle academically and may be more likely to drop out, they noted.

The AAP statement emphasizes school strategies to improve attendance, including education on hand washing and other infection prevention measures, use of school-based flu vaccination programs, availability of school nurses and counselors, and other school-based health and nutrition services.

The policy statement encourages pediatricians and other health care providers to promote school attendance in the office setting and the community.

The AAP encourages pediatricians and their colleagues caring for children to promote school attendance. In the office setting, the AAP recommends the clinicians stress the importance of school attendance, ask whether children have been absent from school and how often, encourage families to share any health concerns with the school nurse, and provide firm and specific guidance on when children should go to school or stay home. The AAP also recommends encouraging well children to return to school after routine appointments rather than miss a whole day and documenting medical needs for an Individualized Education Program or 504 Plan to maximize learning and promote attendance.

For students who are chronically absent from school (missing 2-3 days/month), the AAP encourages clinicians to identify physical health issues and psychosocial factors that may be contributing to absenteeism and to communicate with school health providers. In rare cases, out-of-school educational services may be justified, but with an established time line for returning to school, according to the statement.

In addition, the AAP encourages clinicians to advocate in the community in support of school attendance by sharing relevant data on chronic absences, working with community leaders to send a consistent message about the value of school attendance, and serving as a school physician or on a school board or wellness committee to promote attendance.

The full statement is available online and includes links to parent handouts, a waiting room video, and a mobile-friendly website for preteens, teens, and parents.

The researchers had no financial conflicts to disclose.

SOURCE: Allison MA et al. Pediatrics. 2019. doi: 10.1542/peds.2018-3648.

CHICAGO – Inhibition of PCSK9 puts only a modest dent in markedly elevated lipoprotein (a) levels and doesn’t attenuate the associated arterial wall inflammation, according to the results of the ANITSCHKOW study, Erik S. Stroes, MD, PhD, reported at the American Heart Association scientific sessions.

Bruce Jancin/MDedge News

“The reality is that for now we don’t have any drugs to significantly lower elevated Lp(a),” he said. “We can identify patients with elevated Lp(a), but we don’t have a clue how to treat them.”

Elevated Lp(a) is a highly prevalent lipid abnormality. It induces arterial wall inflammation, a known predictor of future cardiovascular events. The monoclonal antibodies that inhibit PCSK9 (proprotein convertase subtilisin/kexin type 9) dramatically reduce LDL cholesterol and also reduce arterial wall inflammation. In the published studies, PCSK9 inhibitors also reduced Lp(a) by an average of 27%; however, most participants in those studies had isolated high LDL with a normal or slightly elevated Lp(a).

ANITSCHKOW was the first double-blind, randomized, placebo-controlled study to look at the effects of a PCSK9 inhibitor – in this case, evolocumab (Repatha) – in patients with severe elevations in both LDL and Lp(a). The results proved disappointing yet informative, according to Dr. Stroes, professor of internal medicine and a vascular medicine specialist at the University of Amsterdam.

The 16-week, 14-site trial included 128 Dutch, American, and Canadian patients with a mean baseline LDL of 146 mg/dL and a median Lp(a) of 202 nmol/L who were randomized to monthly subcutanous injections of evolocumab at 420 mg or placebo. All participants had evidence of significant arterial wall inflammation at baseline as measured by PET-CT. Of the subjects, 54% were on statin therapy.

Evolucumab achieved a placebo-subtracted 61% reduction in LDL to 60 mg/dL but a mere 14% reduction in Lp(a) to 188 nmol/L, still far in excess of the 50 nmol/L cutoff defining elevated Lp(a).

The primary endpoint was change in arterial wall inflammation from baseline to week 16 as measured using PET-CT. Based upon the results of other studies showing a 3.3% drop in arterial wall inflammation for every 10% reduction in LDL, Dr. Stroes and his coinvestigators expected to see a 20% decrease in arterial wall inflammation in the evolocumab group. Instead, they found a mere 8.4% reduction, which wasn’t significantly different than in placebo-treated controls. And there was no difference in arterial wall inflammation between the group on concomitant statin therapy and those who weren’t.

The implication is that the residual Lp(a) elevation despite PCSK9 inhibitor therapy might explain the discrepancy, compared with previous studies in which LDL lowering did reduce arterial wall inflammation, according to Dr. Stroes.

“Persistent arterial wall inflammation on PET-CT after evolocumab, potentially related to persistent Lp(a) elevation, implies the need for additional therapies to decrease the proinflammatory state in Lp(a) elevation,” he observed.

Lp(a) in the spotlight

An elevated Lp(a) of 50 nmol/L or more is present in 20% of the general population, according to a Danish study. More than 70% of a person’s Lp(a) level is genetically driven. And a genetically driven elevated Lp(a) has been shown to be associated with a twofold to fourfold increased risk of cardiovascular events.

Moreover, other investigators have shown that a severely elevated Lp(a) (greater than 180 nmol/L) poses a cardiovascular risk comparable with that of heterozygous familial hypercholesterolemia and is present in 1 in 100 individuals.

“We spend a lot of time on familial hypercholesterolemia, and we should. But mind you, this severe Lp(a) elevation is more frequent than heterozygous FH,” Dr. Stroes said.

Session cochair Robert H. Eckel, MD, asked the audience for a show of hands by those who regularly measure Lp(a) in their patients. Very few hands were raised.

“I measure Lp(a) frequently, and I think it’s a very important risk factor,” declared Dr. Eckel, professor of medicine and director of the lipid clinic at University of Colorado Hospital, Aurora.

The ANITSCHKOW study was sponsored by Amgen. Dr. Stroes reported receiving institutional research grants from and serving as a paid speaker for Amgen, Merck, Novartis, and Regeneron.

[email protected]

CHICAGO – Inhibition of PCSK9 puts only a modest dent in markedly elevated lipoprotein (a) levels and doesn’t attenuate the associated arterial wall inflammation, according to the results of the ANITSCHKOW study, Erik S. Stroes, MD, PhD, reported at the American Heart Association scientific sessions.

Bruce Jancin/MDedge News

“The reality is that for now we don’t have any drugs to significantly lower elevated Lp(a),” he said. “We can identify patients with elevated Lp(a), but we don’t have a clue how to treat them.”

Elevated Lp(a) is a highly prevalent lipid abnormality. It induces arterial wall inflammation, a known predictor of future cardiovascular events. The monoclonal antibodies that inhibit PCSK9 (proprotein convertase subtilisin/kexin type 9) dramatically reduce LDL cholesterol and also reduce arterial wall inflammation. In the published studies, PCSK9 inhibitors also reduced Lp(a) by an average of 27%; however, most participants in those studies had isolated high LDL with a normal or slightly elevated Lp(a).

ANITSCHKOW was the first double-blind, randomized, placebo-controlled study to look at the effects of a PCSK9 inhibitor – in this case, evolocumab (Repatha) – in patients with severe elevations in both LDL and Lp(a). The results proved disappointing yet informative, according to Dr. Stroes, professor of internal medicine and a vascular medicine specialist at the University of Amsterdam.

The 16-week, 14-site trial included 128 Dutch, American, and Canadian patients with a mean baseline LDL of 146 mg/dL and a median Lp(a) of 202 nmol/L who were randomized to monthly subcutanous injections of evolocumab at 420 mg or placebo. All participants had evidence of significant arterial wall inflammation at baseline as measured by PET-CT. Of the subjects, 54% were on statin therapy.

Evolucumab achieved a placebo-subtracted 61% reduction in LDL to 60 mg/dL but a mere 14% reduction in Lp(a) to 188 nmol/L, still far in excess of the 50 nmol/L cutoff defining elevated Lp(a).

The primary endpoint was change in arterial wall inflammation from baseline to week 16 as measured using PET-CT. Based upon the results of other studies showing a 3.3% drop in arterial wall inflammation for every 10% reduction in LDL, Dr. Stroes and his coinvestigators expected to see a 20% decrease in arterial wall inflammation in the evolocumab group. Instead, they found a mere 8.4% reduction, which wasn’t significantly different than in placebo-treated controls. And there was no difference in arterial wall inflammation between the group on concomitant statin therapy and those who weren’t.

The implication is that the residual Lp(a) elevation despite PCSK9 inhibitor therapy might explain the discrepancy, compared with previous studies in which LDL lowering did reduce arterial wall inflammation, according to Dr. Stroes.

“Persistent arterial wall inflammation on PET-CT after evolocumab, potentially related to persistent Lp(a) elevation, implies the need for additional therapies to decrease the proinflammatory state in Lp(a) elevation,” he observed.

Lp(a) in the spotlight

An elevated Lp(a) of 50 nmol/L or more is present in 20% of the general population, according to a Danish study. More than 70% of a person’s Lp(a) level is genetically driven. And a genetically driven elevated Lp(a) has been shown to be associated with a twofold to fourfold increased risk of cardiovascular events.

Moreover, other investigators have shown that a severely elevated Lp(a) (greater than 180 nmol/L) poses a cardiovascular risk comparable with that of heterozygous familial hypercholesterolemia and is present in 1 in 100 individuals.

“We spend a lot of time on familial hypercholesterolemia, and we should. But mind you, this severe Lp(a) elevation is more frequent than heterozygous FH,” Dr. Stroes said.

Session cochair Robert H. Eckel, MD, asked the audience for a show of hands by those who regularly measure Lp(a) in their patients. Very few hands were raised.

“I measure Lp(a) frequently, and I think it’s a very important risk factor,” declared Dr. Eckel, professor of medicine and director of the lipid clinic at University of Colorado Hospital, Aurora.

The ANITSCHKOW study was sponsored by Amgen. Dr. Stroes reported receiving institutional research grants from and serving as a paid speaker for Amgen, Merck, Novartis, and Regeneron.

[email protected]

CHICAGO – Inhibition of PCSK9 puts only a modest dent in markedly elevated lipoprotein (a) levels and doesn’t attenuate the associated arterial wall inflammation, according to the results of the ANITSCHKOW study, Erik S. Stroes, MD, PhD, reported at the American Heart Association scientific sessions.

Bruce Jancin/MDedge News

“The reality is that for now we don’t have any drugs to significantly lower elevated Lp(a),” he said. “We can identify patients with elevated Lp(a), but we don’t have a clue how to treat them.”

Elevated Lp(a) is a highly prevalent lipid abnormality. It induces arterial wall inflammation, a known predictor of future cardiovascular events. The monoclonal antibodies that inhibit PCSK9 (proprotein convertase subtilisin/kexin type 9) dramatically reduce LDL cholesterol and also reduce arterial wall inflammation. In the published studies, PCSK9 inhibitors also reduced Lp(a) by an average of 27%; however, most participants in those studies had isolated high LDL with a normal or slightly elevated Lp(a).

ANITSCHKOW was the first double-blind, randomized, placebo-controlled study to look at the effects of a PCSK9 inhibitor – in this case, evolocumab (Repatha) – in patients with severe elevations in both LDL and Lp(a). The results proved disappointing yet informative, according to Dr. Stroes, professor of internal medicine and a vascular medicine specialist at the University of Amsterdam.

The 16-week, 14-site trial included 128 Dutch, American, and Canadian patients with a mean baseline LDL of 146 mg/dL and a median Lp(a) of 202 nmol/L who were randomized to monthly subcutanous injections of evolocumab at 420 mg or placebo. All participants had evidence of significant arterial wall inflammation at baseline as measured by PET-CT. Of the subjects, 54% were on statin therapy.

Evolucumab achieved a placebo-subtracted 61% reduction in LDL to 60 mg/dL but a mere 14% reduction in Lp(a) to 188 nmol/L, still far in excess of the 50 nmol/L cutoff defining elevated Lp(a).

The primary endpoint was change in arterial wall inflammation from baseline to week 16 as measured using PET-CT. Based upon the results of other studies showing a 3.3% drop in arterial wall inflammation for every 10% reduction in LDL, Dr. Stroes and his coinvestigators expected to see a 20% decrease in arterial wall inflammation in the evolocumab group. Instead, they found a mere 8.4% reduction, which wasn’t significantly different than in placebo-treated controls. And there was no difference in arterial wall inflammation between the group on concomitant statin therapy and those who weren’t.

The implication is that the residual Lp(a) elevation despite PCSK9 inhibitor therapy might explain the discrepancy, compared with previous studies in which LDL lowering did reduce arterial wall inflammation, according to Dr. Stroes.

“Persistent arterial wall inflammation on PET-CT after evolocumab, potentially related to persistent Lp(a) elevation, implies the need for additional therapies to decrease the proinflammatory state in Lp(a) elevation,” he observed.

Lp(a) in the spotlight

An elevated Lp(a) of 50 nmol/L or more is present in 20% of the general population, according to a Danish study. More than 70% of a person’s Lp(a) level is genetically driven. And a genetically driven elevated Lp(a) has been shown to be associated with a twofold to fourfold increased risk of cardiovascular events.

Moreover, other investigators have shown that a severely elevated Lp(a) (greater than 180 nmol/L) poses a cardiovascular risk comparable with that of heterozygous familial hypercholesterolemia and is present in 1 in 100 individuals.

“We spend a lot of time on familial hypercholesterolemia, and we should. But mind you, this severe Lp(a) elevation is more frequent than heterozygous FH,” Dr. Stroes said.

Session cochair Robert H. Eckel, MD, asked the audience for a show of hands by those who regularly measure Lp(a) in their patients. Very few hands were raised.

“I measure Lp(a) frequently, and I think it’s a very important risk factor,” declared Dr. Eckel, professor of medicine and director of the lipid clinic at University of Colorado Hospital, Aurora.

The ANITSCHKOW study was sponsored by Amgen. Dr. Stroes reported receiving institutional research grants from and serving as a paid speaker for Amgen, Merck, Novartis, and Regeneron.

[email protected]

Patients with self-reported mild bleeding symptoms may have impaired clot lysis, according to investigators. This finding is remarkable because it contrasts with known bleeding disorders, such as hemophilia, which are associated with enhanced clot lysis, reported lead author Minka J.A. Vries, MD, of the Cardiovascular Research Institute Maastricht (CARIM) at Maastricht (the Netherlands) University and her colleagues.

Svisio/Thinkstock

The observational study, which included 335 patients undergoing elective surgery at Maastricht University Medical Center, was conducted to better understand lysis capacity, which is challenging to assess in a clinical setting. Although the Euglobulin Lysis Time (ELT) is often used in the clinic, it cannot determine the influence of hemostatic proteins or formation of a fibrin clot under physiological conditions.

“In the more recently developed lysis assays,” the investigators wrote in Thrombosis Research, “the turbidity lysis assay and the tissue plasminogen activator–rotational thromboelastometry (tPA-ROTEM) [assay], all plasma proteins are present and fibrin is formed under more physiological conditions for the measurement of fibrinolysis.” These two tests were used in the present study.

Of the 335 adult patients, 240 had self-reported mild bleeding symptoms, and 95 did not. Patients with bleeding disorders, thrombocytopenia, or anemia were excluded, as were pregnant women and those taking blood thinners or NSAIDs. Along with assessing time parameters of fibrinolysis, clot-associated proteins were measured for possible imbalances.

“We hypothesized that clot lysis capacity is enhanced in patients with mild bleeding symptoms,” the investigators wrote, based on other bleeding disorders. Surprisingly, the results told a different story.

After adjusting for sex, BMI, and age, patients with bleeding symptoms had lower tPA-ROTEM lysis speed (beta −0.35; P = .007) and longer tPA-ROTEM lysis time (beta 0.29; P = .022) than did patients without bleeding symptoms. The investigators found that tPA-ROTEM measurements depended on factor II, factor XII, alpha2-antiplasmin, plasminogen, thrombin activatable fibrinolysis inhibitor (TAFI), and plasminogen activator inhibitor–1 (PAI-1) level. In contrast, turbidity lysis assay measurements were not significantly different between groups. This latter assay was influenced by alpha2-antiplasmin, TAFI, and PAI-1.

“We did not find evidence for systemic hyperfibrinolytic capacity in patients reporting mild bleeding symptoms in comparison to patients not reporting bleeding symptoms,” the investigators concluded. “tPA-ROTEM even suggested a slower clot lysis in these patients. Though this may appear counterintuitive, our results are in line with two papers assessing systemic clot lysis in mild bleeders.”

While this phenomenon gains supporting evidence, it remains poorly understood.

“We have no good explanation for these findings,” the investigators noted.

This study was funded by the Sint Annadal Foundation Maastricht, Maastricht University Medical Centre, CTMM INCOAG Maastricht, Cardiovascular Research Institute Maastricht, and the British Heart Foundation. No conflicts of interest were reported.

SOURCE: Vries MJA et al. Thromb Res. 2018 Dec 4. doi: 10.1016/j.thromres.2018.12.004.

Patients with self-reported mild bleeding symptoms may have impaired clot lysis, according to investigators. This finding is remarkable because it contrasts with known bleeding disorders, such as hemophilia, which are associated with enhanced clot lysis, reported lead author Minka J.A. Vries, MD, of the Cardiovascular Research Institute Maastricht (CARIM) at Maastricht (the Netherlands) University and her colleagues.

Svisio/Thinkstock

The observational study, which included 335 patients undergoing elective surgery at Maastricht University Medical Center, was conducted to better understand lysis capacity, which is challenging to assess in a clinical setting. Although the Euglobulin Lysis Time (ELT) is often used in the clinic, it cannot determine the influence of hemostatic proteins or formation of a fibrin clot under physiological conditions.

“In the more recently developed lysis assays,” the investigators wrote in Thrombosis Research, “the turbidity lysis assay and the tissue plasminogen activator–rotational thromboelastometry (tPA-ROTEM) [assay], all plasma proteins are present and fibrin is formed under more physiological conditions for the measurement of fibrinolysis.” These two tests were used in the present study.

Of the 335 adult patients, 240 had self-reported mild bleeding symptoms, and 95 did not. Patients with bleeding disorders, thrombocytopenia, or anemia were excluded, as were pregnant women and those taking blood thinners or NSAIDs. Along with assessing time parameters of fibrinolysis, clot-associated proteins were measured for possible imbalances.

“We hypothesized that clot lysis capacity is enhanced in patients with mild bleeding symptoms,” the investigators wrote, based on other bleeding disorders. Surprisingly, the results told a different story.

After adjusting for sex, BMI, and age, patients with bleeding symptoms had lower tPA-ROTEM lysis speed (beta −0.35; P = .007) and longer tPA-ROTEM lysis time (beta 0.29; P = .022) than did patients without bleeding symptoms. The investigators found that tPA-ROTEM measurements depended on factor II, factor XII, alpha2-antiplasmin, plasminogen, thrombin activatable fibrinolysis inhibitor (TAFI), and plasminogen activator inhibitor–1 (PAI-1) level. In contrast, turbidity lysis assay measurements were not significantly different between groups. This latter assay was influenced by alpha2-antiplasmin, TAFI, and PAI-1.

“We did not find evidence for systemic hyperfibrinolytic capacity in patients reporting mild bleeding symptoms in comparison to patients not reporting bleeding symptoms,” the investigators concluded. “tPA-ROTEM even suggested a slower clot lysis in these patients. Though this may appear counterintuitive, our results are in line with two papers assessing systemic clot lysis in mild bleeders.”

While this phenomenon gains supporting evidence, it remains poorly understood.

“We have no good explanation for these findings,” the investigators noted.

This study was funded by the Sint Annadal Foundation Maastricht, Maastricht University Medical Centre, CTMM INCOAG Maastricht, Cardiovascular Research Institute Maastricht, and the British Heart Foundation. No conflicts of interest were reported.

SOURCE: Vries MJA et al. Thromb Res. 2018 Dec 4. doi: 10.1016/j.thromres.2018.12.004.

Patients with self-reported mild bleeding symptoms may have impaired clot lysis, according to investigators. This finding is remarkable because it contrasts with known bleeding disorders, such as hemophilia, which are associated with enhanced clot lysis, reported lead author Minka J.A. Vries, MD, of the Cardiovascular Research Institute Maastricht (CARIM) at Maastricht (the Netherlands) University and her colleagues.

Svisio/Thinkstock

The observational study, which included 335 patients undergoing elective surgery at Maastricht University Medical Center, was conducted to better understand lysis capacity, which is challenging to assess in a clinical setting. Although the Euglobulin Lysis Time (ELT) is often used in the clinic, it cannot determine the influence of hemostatic proteins or formation of a fibrin clot under physiological conditions.

“In the more recently developed lysis assays,” the investigators wrote in Thrombosis Research, “the turbidity lysis assay and the tissue plasminogen activator–rotational thromboelastometry (tPA-ROTEM) [assay], all plasma proteins are present and fibrin is formed under more physiological conditions for the measurement of fibrinolysis.” These two tests were used in the present study.

Of the 335 adult patients, 240 had self-reported mild bleeding symptoms, and 95 did not. Patients with bleeding disorders, thrombocytopenia, or anemia were excluded, as were pregnant women and those taking blood thinners or NSAIDs. Along with assessing time parameters of fibrinolysis, clot-associated proteins were measured for possible imbalances.

“We hypothesized that clot lysis capacity is enhanced in patients with mild bleeding symptoms,” the investigators wrote, based on other bleeding disorders. Surprisingly, the results told a different story.

After adjusting for sex, BMI, and age, patients with bleeding symptoms had lower tPA-ROTEM lysis speed (beta −0.35; P = .007) and longer tPA-ROTEM lysis time (beta 0.29; P = .022) than did patients without bleeding symptoms. The investigators found that tPA-ROTEM measurements depended on factor II, factor XII, alpha2-antiplasmin, plasminogen, thrombin activatable fibrinolysis inhibitor (TAFI), and plasminogen activator inhibitor–1 (PAI-1) level. In contrast, turbidity lysis assay measurements were not significantly different between groups. This latter assay was influenced by alpha2-antiplasmin, TAFI, and PAI-1.

“We did not find evidence for systemic hyperfibrinolytic capacity in patients reporting mild bleeding symptoms in comparison to patients not reporting bleeding symptoms,” the investigators concluded. “tPA-ROTEM even suggested a slower clot lysis in these patients. Though this may appear counterintuitive, our results are in line with two papers assessing systemic clot lysis in mild bleeders.”

While this phenomenon gains supporting evidence, it remains poorly understood.

“We have no good explanation for these findings,” the investigators noted.

This study was funded by the Sint Annadal Foundation Maastricht, Maastricht University Medical Centre, CTMM INCOAG Maastricht, Cardiovascular Research Institute Maastricht, and the British Heart Foundation. No conflicts of interest were reported.

SOURCE: Vries MJA et al. Thromb Res. 2018 Dec 4. doi: 10.1016/j.thromres.2018.12.004.

Young women who delay starting contraception when they start sexual activity are at increased risk of unwanted pregnancy. Also today, disease-modifying therapies and stem cell transplants both reduce disease progression in MS, the American Academy of Pediatrics guidelines on hemangioma should empower primary care clinicians, and a treat-to-target approach for CVD risk factors decreased atherosclerosis in patients with rheumatoid arthritis.

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Young women who delay starting contraception when they start sexual activity are at increased risk of unwanted pregnancy. Also today, disease-modifying therapies and stem cell transplants both reduce disease progression in MS, the American Academy of Pediatrics guidelines on hemangioma should empower primary care clinicians, and a treat-to-target approach for CVD risk factors decreased atherosclerosis in patients with rheumatoid arthritis.

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Young women who delay starting contraception when they start sexual activity are at increased risk of unwanted pregnancy. Also today, disease-modifying therapies and stem cell transplants both reduce disease progression in MS, the American Academy of Pediatrics guidelines on hemangioma should empower primary care clinicians, and a treat-to-target approach for CVD risk factors decreased atherosclerosis in patients with rheumatoid arthritis.

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To the Editor:
Kwashiorkor, or protein-calorie malnutrition, is a common issue in developing countries subject to starvation. In economically advanced nations, however, kwashiorkor is extremely rare and may appear in children placed on restrictive diets instituted by well-meaning guardians. Kwashiorkor also may occur because of gastrointestinal malabsorption. We present a unique case of kwashiorkor that revealed an underlying diagnosis of pancreatic insufficiency.

A 12-year-old girl presented to the hospital with 4 days of watery nonbloody diarrhea occurring with every feeding as well as new onset of presumed diaper dermatitis that had not responded to nystatin cream. Facial swelling also was noted the day prior to admission. Her medical history was notable for cerebral palsy secondary to nonaccidental trauma, leaving the patient nonverbal and quadriplegic. She had numerous prior admissions for sepsis with marked hypotension and more recently was diagnosed with insulin-dependent type 2 diabetes mellitus. She had never lived outside the United States and resided at home with her adoptive parents.

Physical examination revealed a nonverbal underweight girl (weight, 25 kg). Large areas of denudation with surrounding desquamated skin resembling flaking enamel paint covered the buttocks and posterior legs bilaterally (Figure). She had linear hyperpigmented patches on the dorsal hands with one superficial erosion on the left wrist. Marked periorbital edema as well as nonpitting edema of the face, arms, and legs were present.

Children in the United States developing kwashiorkor secondary to severely restrictive diets has been reported.³ However, kwashiorkor also may occur due to underlying chronic malabsorptive disease. There have been rare reports of children with cystic fibrosis presenting with kwashiorkor,⁴ as well as a case of kwashiorkor secondary to underlying infantile Crohn disease.⁵

Cerebral palsy is associated with multiple different risk factors for malnutrition. Musculoskeletal deformities, oral-motor difficulties, medication side effects, limited communication skills, compromised pulmonary status, and poor muscle tone can all contribute to energy and nutrient deprivation.⁶ A 2018 study including 728 children registered into the Bangladesh Cerebral Palsy Register between January 2015 and December 2016 demonstrated that more than two-thirds were underweight (70.0%) and stunted (73.1%) and that children with tri/quadriplegic cerebral palsy presented with the highest proportion of severe malnutrition.⁷ In another report (N=142), up to 85% of children with spastic quadriplegia had severe feeding problems,⁸ making this population particularly high risk for poor nutritional status.

Pancreatic exocrine insufficiency is characterized by reduced secretion of amylase, lipase, and protease, and it may result in diarrhea, weight loss, malabsorption of essential nutrients, and malnutrition. Pancreatic exocrine insufficiency may occur in the setting of chronic pancreatitis, pancreatic surgery, and cystic fibrosis. Our patient had numerous hospitalizations for sepsis marked by hypotension, and in the absence of more typical causes, we postulate that both endocrine and exocrine pancreatic damage resulted from prolonged hypotension. A sweat chloride test was not performed, as the patient had not experienced frequent pulmonary infections or other signs of cystic fibrosis.

According to a report from the Food and Agriculture Organization of the United Nations/World Health Organization/United Nations University (FAO/WHO/UNU), protein should provide at least 10% of the total caloric intake in a child.⁹ Although the adoptive parent approximated that our patient received 12% of her daily calories in the form of protein, the amount that she absorbed in the context of pancreatic insufficiency was undoubtedly much lower.

In this case, the diagnosis of kwashiorkor led to the discovery of underlying pancreatic exocrine insufficiency. Low stool elastase confirmed the diagnosis. Because kwashiorkor is rare in developed countries, the classic signs and symptoms may go unrecognized, which can lead to delayed diagnosis and notable morbidity and mortality. New-onset edema and desquamative rash in a child, especially a child with cerebral palsy, should alert physicians to the possibility of acute kwashiorkor and prompt investigation into underlying medical issues that may have contributed to its development.

To the Editor:
Kwashiorkor, or protein-calorie malnutrition, is a common issue in developing countries subject to starvation. In economically advanced nations, however, kwashiorkor is extremely rare and may appear in children placed on restrictive diets instituted by well-meaning guardians. Kwashiorkor also may occur because of gastrointestinal malabsorption. We present a unique case of kwashiorkor that revealed an underlying diagnosis of pancreatic insufficiency.

A 12-year-old girl presented to the hospital with 4 days of watery nonbloody diarrhea occurring with every feeding as well as new onset of presumed diaper dermatitis that had not responded to nystatin cream. Facial swelling also was noted the day prior to admission. Her medical history was notable for cerebral palsy secondary to nonaccidental trauma, leaving the patient nonverbal and quadriplegic. She had numerous prior admissions for sepsis with marked hypotension and more recently was diagnosed with insulin-dependent type 2 diabetes mellitus. She had never lived outside the United States and resided at home with her adoptive parents.

Physical examination revealed a nonverbal underweight girl (weight, 25 kg). Large areas of denudation with surrounding desquamated skin resembling flaking enamel paint covered the buttocks and posterior legs bilaterally (Figure). She had linear hyperpigmented patches on the dorsal hands with one superficial erosion on the left wrist. Marked periorbital edema as well as nonpitting edema of the face, arms, and legs were present.

Children in the United States developing kwashiorkor secondary to severely restrictive diets has been reported.³ However, kwashiorkor also may occur due to underlying chronic malabsorptive disease. There have been rare reports of children with cystic fibrosis presenting with kwashiorkor,⁴ as well as a case of kwashiorkor secondary to underlying infantile Crohn disease.⁵

Cerebral palsy is associated with multiple different risk factors for malnutrition. Musculoskeletal deformities, oral-motor difficulties, medication side effects, limited communication skills, compromised pulmonary status, and poor muscle tone can all contribute to energy and nutrient deprivation.⁶ A 2018 study including 728 children registered into the Bangladesh Cerebral Palsy Register between January 2015 and December 2016 demonstrated that more than two-thirds were underweight (70.0%) and stunted (73.1%) and that children with tri/quadriplegic cerebral palsy presented with the highest proportion of severe malnutrition.⁷ In another report (N=142), up to 85% of children with spastic quadriplegia had severe feeding problems,⁸ making this population particularly high risk for poor nutritional status.

Pancreatic exocrine insufficiency is characterized by reduced secretion of amylase, lipase, and protease, and it may result in diarrhea, weight loss, malabsorption of essential nutrients, and malnutrition. Pancreatic exocrine insufficiency may occur in the setting of chronic pancreatitis, pancreatic surgery, and cystic fibrosis. Our patient had numerous hospitalizations for sepsis marked by hypotension, and in the absence of more typical causes, we postulate that both endocrine and exocrine pancreatic damage resulted from prolonged hypotension. A sweat chloride test was not performed, as the patient had not experienced frequent pulmonary infections or other signs of cystic fibrosis.

According to a report from the Food and Agriculture Organization of the United Nations/World Health Organization/United Nations University (FAO/WHO/UNU), protein should provide at least 10% of the total caloric intake in a child.⁹ Although the adoptive parent approximated that our patient received 12% of her daily calories in the form of protein, the amount that she absorbed in the context of pancreatic insufficiency was undoubtedly much lower.

In this case, the diagnosis of kwashiorkor led to the discovery of underlying pancreatic exocrine insufficiency. Low stool elastase confirmed the diagnosis. Because kwashiorkor is rare in developed countries, the classic signs and symptoms may go unrecognized, which can lead to delayed diagnosis and notable morbidity and mortality. New-onset edema and desquamative rash in a child, especially a child with cerebral palsy, should alert physicians to the possibility of acute kwashiorkor and prompt investigation into underlying medical issues that may have contributed to its development.

To the Editor:
Kwashiorkor, or protein-calorie malnutrition, is a common issue in developing countries subject to starvation. In economically advanced nations, however, kwashiorkor is extremely rare and may appear in children placed on restrictive diets instituted by well-meaning guardians. Kwashiorkor also may occur because of gastrointestinal malabsorption. We present a unique case of kwashiorkor that revealed an underlying diagnosis of pancreatic insufficiency.

A 12-year-old girl presented to the hospital with 4 days of watery nonbloody diarrhea occurring with every feeding as well as new onset of presumed diaper dermatitis that had not responded to nystatin cream. Facial swelling also was noted the day prior to admission. Her medical history was notable for cerebral palsy secondary to nonaccidental trauma, leaving the patient nonverbal and quadriplegic. She had numerous prior admissions for sepsis with marked hypotension and more recently was diagnosed with insulin-dependent type 2 diabetes mellitus. She had never lived outside the United States and resided at home with her adoptive parents.

Physical examination revealed a nonverbal underweight girl (weight, 25 kg). Large areas of denudation with surrounding desquamated skin resembling flaking enamel paint covered the buttocks and posterior legs bilaterally (Figure). She had linear hyperpigmented patches on the dorsal hands with one superficial erosion on the left wrist. Marked periorbital edema as well as nonpitting edema of the face, arms, and legs were present.

Children in the United States developing kwashiorkor secondary to severely restrictive diets has been reported.³ However, kwashiorkor also may occur due to underlying chronic malabsorptive disease. There have been rare reports of children with cystic fibrosis presenting with kwashiorkor,⁴ as well as a case of kwashiorkor secondary to underlying infantile Crohn disease.⁵

Cerebral palsy is associated with multiple different risk factors for malnutrition. Musculoskeletal deformities, oral-motor difficulties, medication side effects, limited communication skills, compromised pulmonary status, and poor muscle tone can all contribute to energy and nutrient deprivation.⁶ A 2018 study including 728 children registered into the Bangladesh Cerebral Palsy Register between January 2015 and December 2016 demonstrated that more than two-thirds were underweight (70.0%) and stunted (73.1%) and that children with tri/quadriplegic cerebral palsy presented with the highest proportion of severe malnutrition.⁷ In another report (N=142), up to 85% of children with spastic quadriplegia had severe feeding problems,⁸ making this population particularly high risk for poor nutritional status.

Pancreatic exocrine insufficiency is characterized by reduced secretion of amylase, lipase, and protease, and it may result in diarrhea, weight loss, malabsorption of essential nutrients, and malnutrition. Pancreatic exocrine insufficiency may occur in the setting of chronic pancreatitis, pancreatic surgery, and cystic fibrosis. Our patient had numerous hospitalizations for sepsis marked by hypotension, and in the absence of more typical causes, we postulate that both endocrine and exocrine pancreatic damage resulted from prolonged hypotension. A sweat chloride test was not performed, as the patient had not experienced frequent pulmonary infections or other signs of cystic fibrosis.

According to a report from the Food and Agriculture Organization of the United Nations/World Health Organization/United Nations University (FAO/WHO/UNU), protein should provide at least 10% of the total caloric intake in a child.⁹ Although the adoptive parent approximated that our patient received 12% of her daily calories in the form of protein, the amount that she absorbed in the context of pancreatic insufficiency was undoubtedly much lower.

In this case, the diagnosis of kwashiorkor led to the discovery of underlying pancreatic exocrine insufficiency. Low stool elastase confirmed the diagnosis. Because kwashiorkor is rare in developed countries, the classic signs and symptoms may go unrecognized, which can lead to delayed diagnosis and notable morbidity and mortality. New-onset edema and desquamative rash in a child, especially a child with cerebral palsy, should alert physicians to the possibility of acute kwashiorkor and prompt investigation into underlying medical issues that may have contributed to its development.

Federal judges have blocked the Trump administration from weakening the Affordable Care Act’s contraceptive mandate. Too much sleep and too little sleep are linked to atherosclerosis, there is no drop in gout prevalence, but there isn’t an increase either, and back pain persists in one in five patients.

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Federal judges have blocked the Trump administration from weakening the Affordable Care Act’s contraceptive mandate. Too much sleep and too little sleep are linked to atherosclerosis, there is no drop in gout prevalence, but there isn’t an increase either, and back pain persists in one in five patients.

Amazon Alexa

Apple Podcasts

Google Podcasts

Spotify
 

Federal judges have blocked the Trump administration from weakening the Affordable Care Act’s contraceptive mandate. Too much sleep and too little sleep are linked to atherosclerosis, there is no drop in gout prevalence, but there isn’t an increase either, and back pain persists in one in five patients.

Amazon Alexa

Apple Podcasts

Google Podcasts

Spotify
 

Soy intake did not increase all-cause mortality among breast cancer survivors. Also today there is more benefit to chemoradiation earlier in small cell lung cancer, traditional jet nebulizers beat breath-enhanced nebulizers in pediatric asthma, and both new and existing drugs are fueling price inflation.

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Spotify
 

Soy intake did not increase all-cause mortality among breast cancer survivors. Also today there is more benefit to chemoradiation earlier in small cell lung cancer, traditional jet nebulizers beat breath-enhanced nebulizers in pediatric asthma, and both new and existing drugs are fueling price inflation.

Amazon Alexa

Apple Podcasts

Google Podcasts

Spotify
 

Soy intake did not increase all-cause mortality among breast cancer survivors. Also today there is more benefit to chemoradiation earlier in small cell lung cancer, traditional jet nebulizers beat breath-enhanced nebulizers in pediatric asthma, and both new and existing drugs are fueling price inflation.

Amazon Alexa

Apple Podcasts

Google Podcasts

Spotify
 

Too little and too much sleep, along with fragmented sleep, were independently linked with increased subclinical, noncardiac atherosclerotic plaque in healthy middle-aged men and women in a Spanish investigation of bank employees.

Wavebreak Media/Thinkstockphotos

“Overall, our findings support the potential role of healthy sleeping in protecting against atherosclerosis. Thus, recommending a good sleep hygiene” – 7-8 hours a night – “should be part of the lifestyle modifications provided in our daily clinical practice,” said investigators led by Fernando Domínguez, MD, PhD, of Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid. The report is in the Journal of the American College of Cardiology.

Studies have linked sleep problems to increased cardiovascular risk before, but the investigations tended to focus on patients with obstructive sleep apnea (OSA) and other problems, and often relied on patient self-report. The investors wanted to see if the relationship held in healthy adults, using an objective measure.

The participants – all with no known cardiovascular disease – wore Acti Trainers accelerometers (Actigraph, Pensacola, Fla.) around their waists for 7 days to record sleep duration and quality. Subjects also had their plaque burdens assessed by 3-dimensional vascular ultrasound (VUS) at their carotid and femoral arteries bilaterally. Cardiac CT was used to assess coronary artery calcification as a surrogate for coronary artery atherosclerosis.

The 3,974 participants had a mean age of 46 years, and a third were women; they had a low prevalence of both hypertension and diabetes. OSA patients were excluded from the study. Overall, 27% had very short sleep duration (VSSD), less than 6 hours a night; 38% had short sleep duration (SSD), 31% slept from 7 to 8 hours per night, and served as the reference group for healthy sleep habits; and 4% had long sleep duration (LSD), greater than 8 hours.

After adjustment for a wide range of cardiovascular risk factors, including body mass index, hypertension, and smoking, VSSD was independently associated with a higher atherosclerotic burden, compared to the reference group (odds ratio, 1.27; 95% confidence interval, 1.06-1.52; P = 0.008). Participants in the highest quintile of sleep fragmentation were more likely to have plaques at multiple sites (OR, 1.34; 95% CI, 1.09-1.64; P = 0.006). The Framingham risk score at both 10 and 30 years was significantly higher in participants with VSSD or SSD, and in the highest quintiles of sleep fragmentation.

LSD was also associated with a higher plaque burden, which reached statistical significance in women. “Too-long sleep duration may not be healthy either ... Recommendations should be restricted to 7 to 8 hours,” the investigators said.

Sleep duration and quality were not associated with inflammation markers or coronary artery calcification. The investigators noted that CT for coronary artery calcification might not be as sensitive as VUS for picking up subclinical atherosclerosis.

Short sleepers tended to have higher intakes of alcohol and caffeine than did those in the 7- to 8-hour group.

The work was funded by CNIC and Banco Santander, among others. Dr. Domínguez had no disclosures. Investigator Hector Bueno, MD, PhD, reported research funding and fees from a number of companies, including AstraZeneca and Novartis. The second author, Valentín Fuster, MD, PhD, is the editor of the Journal of the American College of Cardiology, which published the report.

[email protected]

SOURCE: Domínguez F et al. J Am Coll Cardiol 2019;73:134-44.

Too little and too much sleep, along with fragmented sleep, were independently linked with increased subclinical, noncardiac atherosclerotic plaque in healthy middle-aged men and women in a Spanish investigation of bank employees.

Wavebreak Media/Thinkstockphotos

“Overall, our findings support the potential role of healthy sleeping in protecting against atherosclerosis. Thus, recommending a good sleep hygiene” – 7-8 hours a night – “should be part of the lifestyle modifications provided in our daily clinical practice,” said investigators led by Fernando Domínguez, MD, PhD, of Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid. The report is in the Journal of the American College of Cardiology.

Studies have linked sleep problems to increased cardiovascular risk before, but the investigations tended to focus on patients with obstructive sleep apnea (OSA) and other problems, and often relied on patient self-report. The investors wanted to see if the relationship held in healthy adults, using an objective measure.

The participants – all with no known cardiovascular disease – wore Acti Trainers accelerometers (Actigraph, Pensacola, Fla.) around their waists for 7 days to record sleep duration and quality. Subjects also had their plaque burdens assessed by 3-dimensional vascular ultrasound (VUS) at their carotid and femoral arteries bilaterally. Cardiac CT was used to assess coronary artery calcification as a surrogate for coronary artery atherosclerosis.

The 3,974 participants had a mean age of 46 years, and a third were women; they had a low prevalence of both hypertension and diabetes. OSA patients were excluded from the study. Overall, 27% had very short sleep duration (VSSD), less than 6 hours a night; 38% had short sleep duration (SSD), 31% slept from 7 to 8 hours per night, and served as the reference group for healthy sleep habits; and 4% had long sleep duration (LSD), greater than 8 hours.

After adjustment for a wide range of cardiovascular risk factors, including body mass index, hypertension, and smoking, VSSD was independently associated with a higher atherosclerotic burden, compared to the reference group (odds ratio, 1.27; 95% confidence interval, 1.06-1.52; P = 0.008). Participants in the highest quintile of sleep fragmentation were more likely to have plaques at multiple sites (OR, 1.34; 95% CI, 1.09-1.64; P = 0.006). The Framingham risk score at both 10 and 30 years was significantly higher in participants with VSSD or SSD, and in the highest quintiles of sleep fragmentation.

LSD was also associated with a higher plaque burden, which reached statistical significance in women. “Too-long sleep duration may not be healthy either ... Recommendations should be restricted to 7 to 8 hours,” the investigators said.

Sleep duration and quality were not associated with inflammation markers or coronary artery calcification. The investigators noted that CT for coronary artery calcification might not be as sensitive as VUS for picking up subclinical atherosclerosis.

Short sleepers tended to have higher intakes of alcohol and caffeine than did those in the 7- to 8-hour group.

The work was funded by CNIC and Banco Santander, among others. Dr. Domínguez had no disclosures. Investigator Hector Bueno, MD, PhD, reported research funding and fees from a number of companies, including AstraZeneca and Novartis. The second author, Valentín Fuster, MD, PhD, is the editor of the Journal of the American College of Cardiology, which published the report.

[email protected]

SOURCE: Domínguez F et al. J Am Coll Cardiol 2019;73:134-44.

Too little and too much sleep, along with fragmented sleep, were independently linked with increased subclinical, noncardiac atherosclerotic plaque in healthy middle-aged men and women in a Spanish investigation of bank employees.

Wavebreak Media/Thinkstockphotos

“Overall, our findings support the potential role of healthy sleeping in protecting against atherosclerosis. Thus, recommending a good sleep hygiene” – 7-8 hours a night – “should be part of the lifestyle modifications provided in our daily clinical practice,” said investigators led by Fernando Domínguez, MD, PhD, of Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid. The report is in the Journal of the American College of Cardiology.

Studies have linked sleep problems to increased cardiovascular risk before, but the investigations tended to focus on patients with obstructive sleep apnea (OSA) and other problems, and often relied on patient self-report. The investors wanted to see if the relationship held in healthy adults, using an objective measure.

The participants – all with no known cardiovascular disease – wore Acti Trainers accelerometers (Actigraph, Pensacola, Fla.) around their waists for 7 days to record sleep duration and quality. Subjects also had their plaque burdens assessed by 3-dimensional vascular ultrasound (VUS) at their carotid and femoral arteries bilaterally. Cardiac CT was used to assess coronary artery calcification as a surrogate for coronary artery atherosclerosis.

The 3,974 participants had a mean age of 46 years, and a third were women; they had a low prevalence of both hypertension and diabetes. OSA patients were excluded from the study. Overall, 27% had very short sleep duration (VSSD), less than 6 hours a night; 38% had short sleep duration (SSD), 31% slept from 7 to 8 hours per night, and served as the reference group for healthy sleep habits; and 4% had long sleep duration (LSD), greater than 8 hours.

After adjustment for a wide range of cardiovascular risk factors, including body mass index, hypertension, and smoking, VSSD was independently associated with a higher atherosclerotic burden, compared to the reference group (odds ratio, 1.27; 95% confidence interval, 1.06-1.52; P = 0.008). Participants in the highest quintile of sleep fragmentation were more likely to have plaques at multiple sites (OR, 1.34; 95% CI, 1.09-1.64; P = 0.006). The Framingham risk score at both 10 and 30 years was significantly higher in participants with VSSD or SSD, and in the highest quintiles of sleep fragmentation.

LSD was also associated with a higher plaque burden, which reached statistical significance in women. “Too-long sleep duration may not be healthy either ... Recommendations should be restricted to 7 to 8 hours,” the investigators said.

Sleep duration and quality were not associated with inflammation markers or coronary artery calcification. The investigators noted that CT for coronary artery calcification might not be as sensitive as VUS for picking up subclinical atherosclerosis.

Short sleepers tended to have higher intakes of alcohol and caffeine than did those in the 7- to 8-hour group.

The work was funded by CNIC and Banco Santander, among others. Dr. Domínguez had no disclosures. Investigator Hector Bueno, MD, PhD, reported research funding and fees from a number of companies, including AstraZeneca and Novartis. The second author, Valentín Fuster, MD, PhD, is the editor of the Journal of the American College of Cardiology, which published the report.

[email protected]

SOURCE: Domínguez F et al. J Am Coll Cardiol 2019;73:134-44.