Neuromuscular Disorders

All adults, including pregnant and postpartum women, should be screened for depression, according to new recommendations of the U.S. Preventive Services Task Force.

The recommendation also calls for screening to be coupled with “adequate systems” to ensure diagnosis, treatment, and follow-up (JAMA. 2016 Jan 26;315[4]:380-7).

The depression screening recommendation, authored by Dr. Albert L. Siu and the other members of the USPSTF, is a level B recommendation, meaning that it has either high certainty of moderate net benefit, or moderate certainty of moderate to substantial net benefit.

The new guidance in screening for depression helps address a disorder that is “the leading cause of disability among adults in high-income countries,” said Dr. Siu and his coauthors. Lost productivity attributable to depression cost $23 billion in the United States in 2011, and $22.8 billion was spent on treatments for depression in 2009, the last year for which figures are available.

Dr. Siu, chair of geriatrics and palliative medicine at Icahn School of Medicine at Mount Sinai, New York, and his coauthors cited “convincing evidence that screening improves the accurate identification of adult patients with depression in primary care settings, including pregnant and postpartum women.”
 
In addition, the task force found convincing evidence that for older adults as well as the general adult population, treatment of “depression identified through screening in primary care settings with antidepressants, psychotherapy, or both decreases clinical morbidity.”
For pregnant and postpartum women with depression, Dr. Siu and his coauthors found “adequate” evidence that cognitive behavioral therapy (CBT) improves outcomes.

The recommendation does not identify optimal timing and intervals for depression screening, citing a need for more research in this area. However, “a pragmatic approach might include screening all adults who have not been screened previously and using clinical judgment in consideration of risk factors, comorbid conditions, and life events to determine if additional screening of high-risk patients is warranted,” explained Dr. Siu and his coauthors.

The new depression screening recommendation from USPSTF updates the 2009 recommendation, which recommended universal screening if “staff-assisted depression care supports” were in place, and targeted screening based on clinical judgment and patient preference if such support were unavailable.
The rationale for the current recommendation of universal screening for those 18 years and older is the “recognition that such support is now much more widely available and accepted as part of mental health care,” the task force members said.

Any potential harms of screening, said Dr. Siu and his coauthors, were minimal to nonexistent.
 
Overall, the USPSTF assigned a small to moderate risk to the use of medication in depression. However, the use of “second-generation” antidepressants – mostly SSRIs – was associated with some harms, including increased risk of suicidal behavior in young adults and of gastrointestinal bleeding in older adults, as well as potential fetal harms in pregnant women taking antidepressants.

Using CBT to treat depression in pregnant and postpartum women was also associated with minimal to no harm.

The USPSTF screening recommendation is aligned with the American Academy of Family Physicians’ recommendation to screen the general adult population for depression, and with the American Academy of Pediatrics’ recommendation that pediatricians screen mothers for depression at their babies’ 1-, 2-, and 4-month office visits.

Released in draft form in July 2015, the depression screening recommendation was available for public comment for a period of 4 weeks. In response to public input, the final recommendation’s implementation section clarifies and characterizes an “adequate system” of screening, and gives more resources for evidence-based depression screening and treatment.

The Agency for Healthcare Research and Quality supports the operations of the USPSTF, but the task force’s recommendations are independent of the federal government. Dr. Siu and the other task force members reported no conflicts of interest.

[email protected]
On Twitter @karioakes

All adults, including pregnant and postpartum women, should be screened for depression, according to new recommendations of the U.S. Preventive Services Task Force.

The recommendation also calls for screening to be coupled with “adequate systems” to ensure diagnosis, treatment, and follow-up (JAMA. 2016 Jan 26;315[4]:380-7).

The depression screening recommendation, authored by Dr. Albert L. Siu and the other members of the USPSTF, is a level B recommendation, meaning that it has either high certainty of moderate net benefit, or moderate certainty of moderate to substantial net benefit.

The new guidance in screening for depression helps address a disorder that is “the leading cause of disability among adults in high-income countries,” said Dr. Siu and his coauthors. Lost productivity attributable to depression cost $23 billion in the United States in 2011, and $22.8 billion was spent on treatments for depression in 2009, the last year for which figures are available.

Dr. Siu, chair of geriatrics and palliative medicine at Icahn School of Medicine at Mount Sinai, New York, and his coauthors cited “convincing evidence that screening improves the accurate identification of adult patients with depression in primary care settings, including pregnant and postpartum women.”
 
In addition, the task force found convincing evidence that for older adults as well as the general adult population, treatment of “depression identified through screening in primary care settings with antidepressants, psychotherapy, or both decreases clinical morbidity.”
For pregnant and postpartum women with depression, Dr. Siu and his coauthors found “adequate” evidence that cognitive behavioral therapy (CBT) improves outcomes.

The recommendation does not identify optimal timing and intervals for depression screening, citing a need for more research in this area. However, “a pragmatic approach might include screening all adults who have not been screened previously and using clinical judgment in consideration of risk factors, comorbid conditions, and life events to determine if additional screening of high-risk patients is warranted,” explained Dr. Siu and his coauthors.

The new depression screening recommendation from USPSTF updates the 2009 recommendation, which recommended universal screening if “staff-assisted depression care supports” were in place, and targeted screening based on clinical judgment and patient preference if such support were unavailable.
The rationale for the current recommendation of universal screening for those 18 years and older is the “recognition that such support is now much more widely available and accepted as part of mental health care,” the task force members said.

Any potential harms of screening, said Dr. Siu and his coauthors, were minimal to nonexistent.
 
Overall, the USPSTF assigned a small to moderate risk to the use of medication in depression. However, the use of “second-generation” antidepressants – mostly SSRIs – was associated with some harms, including increased risk of suicidal behavior in young adults and of gastrointestinal bleeding in older adults, as well as potential fetal harms in pregnant women taking antidepressants.

Using CBT to treat depression in pregnant and postpartum women was also associated with minimal to no harm.

The USPSTF screening recommendation is aligned with the American Academy of Family Physicians’ recommendation to screen the general adult population for depression, and with the American Academy of Pediatrics’ recommendation that pediatricians screen mothers for depression at their babies’ 1-, 2-, and 4-month office visits.

Released in draft form in July 2015, the depression screening recommendation was available for public comment for a period of 4 weeks. In response to public input, the final recommendation’s implementation section clarifies and characterizes an “adequate system” of screening, and gives more resources for evidence-based depression screening and treatment.

The Agency for Healthcare Research and Quality supports the operations of the USPSTF, but the task force’s recommendations are independent of the federal government. Dr. Siu and the other task force members reported no conflicts of interest.

[email protected]
On Twitter @karioakes

All adults, including pregnant and postpartum women, should be screened for depression, according to new recommendations of the U.S. Preventive Services Task Force.

The recommendation also calls for screening to be coupled with “adequate systems” to ensure diagnosis, treatment, and follow-up (JAMA. 2016 Jan 26;315[4]:380-7).

The depression screening recommendation, authored by Dr. Albert L. Siu and the other members of the USPSTF, is a level B recommendation, meaning that it has either high certainty of moderate net benefit, or moderate certainty of moderate to substantial net benefit.

The new guidance in screening for depression helps address a disorder that is “the leading cause of disability among adults in high-income countries,” said Dr. Siu and his coauthors. Lost productivity attributable to depression cost $23 billion in the United States in 2011, and $22.8 billion was spent on treatments for depression in 2009, the last year for which figures are available.

Dr. Siu, chair of geriatrics and palliative medicine at Icahn School of Medicine at Mount Sinai, New York, and his coauthors cited “convincing evidence that screening improves the accurate identification of adult patients with depression in primary care settings, including pregnant and postpartum women.”
 
In addition, the task force found convincing evidence that for older adults as well as the general adult population, treatment of “depression identified through screening in primary care settings with antidepressants, psychotherapy, or both decreases clinical morbidity.”
For pregnant and postpartum women with depression, Dr. Siu and his coauthors found “adequate” evidence that cognitive behavioral therapy (CBT) improves outcomes.

The recommendation does not identify optimal timing and intervals for depression screening, citing a need for more research in this area. However, “a pragmatic approach might include screening all adults who have not been screened previously and using clinical judgment in consideration of risk factors, comorbid conditions, and life events to determine if additional screening of high-risk patients is warranted,” explained Dr. Siu and his coauthors.

The new depression screening recommendation from USPSTF updates the 2009 recommendation, which recommended universal screening if “staff-assisted depression care supports” were in place, and targeted screening based on clinical judgment and patient preference if such support were unavailable.
The rationale for the current recommendation of universal screening for those 18 years and older is the “recognition that such support is now much more widely available and accepted as part of mental health care,” the task force members said.

Any potential harms of screening, said Dr. Siu and his coauthors, were minimal to nonexistent.
 
Overall, the USPSTF assigned a small to moderate risk to the use of medication in depression. However, the use of “second-generation” antidepressants – mostly SSRIs – was associated with some harms, including increased risk of suicidal behavior in young adults and of gastrointestinal bleeding in older adults, as well as potential fetal harms in pregnant women taking antidepressants.

Using CBT to treat depression in pregnant and postpartum women was also associated with minimal to no harm.

The USPSTF screening recommendation is aligned with the American Academy of Family Physicians’ recommendation to screen the general adult population for depression, and with the American Academy of Pediatrics’ recommendation that pediatricians screen mothers for depression at their babies’ 1-, 2-, and 4-month office visits.

Released in draft form in July 2015, the depression screening recommendation was available for public comment for a period of 4 weeks. In response to public input, the final recommendation’s implementation section clarifies and characterizes an “adequate system” of screening, and gives more resources for evidence-based depression screening and treatment.

The Agency for Healthcare Research and Quality supports the operations of the USPSTF, but the task force’s recommendations are independent of the federal government. Dr. Siu and the other task force members reported no conflicts of interest.

[email protected]
On Twitter @karioakes

PHOENIX – In the clinical experience of Dr. Joshua R. Sonett, VATS thymectomy for myasthenia gravis is best performed in a bilateral thoracoscopic fashion.

In this approach, surgeons do about 95% of the operation on the left side to form a maximal thymectomy, “and finish taking out the specimen on the right side, making sure we can see both phrenic nerves in their entirety,” Dr. Sonett, chief of general thoracic surgery at Columbia University Medical Center, New York, said in a video interview at the annual meeting of the Society of Thoracic Surgeons.

Although there is no proof to date that thymectomy improves long-term outcomes for patients with myasthenia gravis, results from a large, international trial sponsored by the National Institutes of Health are expected to inform clinical practice about this topic, said Dr. Sonett, who is also director of the university’s high-risk lung assessment program.

Dr. Sonett reported having no relevant financial conflicts.

[email protected]

PHOENIX – In the clinical experience of Dr. Joshua R. Sonett, VATS thymectomy for myasthenia gravis is best performed in a bilateral thoracoscopic fashion.

In this approach, surgeons do about 95% of the operation on the left side to form a maximal thymectomy, “and finish taking out the specimen on the right side, making sure we can see both phrenic nerves in their entirety,” Dr. Sonett, chief of general thoracic surgery at Columbia University Medical Center, New York, said in a video interview at the annual meeting of the Society of Thoracic Surgeons.

Although there is no proof to date that thymectomy improves long-term outcomes for patients with myasthenia gravis, results from a large, international trial sponsored by the National Institutes of Health are expected to inform clinical practice about this topic, said Dr. Sonett, who is also director of the university’s high-risk lung assessment program.

Dr. Sonett reported having no relevant financial conflicts.

[email protected]

PHOENIX – In the clinical experience of Dr. Joshua R. Sonett, VATS thymectomy for myasthenia gravis is best performed in a bilateral thoracoscopic fashion.

In this approach, surgeons do about 95% of the operation on the left side to form a maximal thymectomy, “and finish taking out the specimen on the right side, making sure we can see both phrenic nerves in their entirety,” Dr. Sonett, chief of general thoracic surgery at Columbia University Medical Center, New York, said in a video interview at the annual meeting of the Society of Thoracic Surgeons.

Although there is no proof to date that thymectomy improves long-term outcomes for patients with myasthenia gravis, results from a large, international trial sponsored by the National Institutes of Health are expected to inform clinical practice about this topic, said Dr. Sonett, who is also director of the university’s high-risk lung assessment program.

Dr. Sonett reported having no relevant financial conflicts.

[email protected]

The Food and Drug Administration has decided against approving the exon 51-skipping antisense oligonucleotide drug drisapersen for forms of Duchenne muscular dystrophy amenable to exon skipping.

The agency’s complete response letter to BioMarin Pharmaceutical, the developer of drisapersen (Kyndrisa), said that the standard of substantial evidence of effectiveness had not been met, according to a written statement from the company on Jan. 14.

In a Nov. 24, 2015, meeting of the FDA’s Peripheral and Central Nervous System Drugs Advisory Committee, panel members generally felt that drisapersen’s efficacy data were not persuasive enough for an approval.

Courtesy Wikimedia Commons/FitzColinGerald/Creative Commons License

Drisapersen targets frame-disrupting mutations found in exon 51 of the dystrophin gene, which produces a nonfunctional protein in individuals with a certain form of Duchenne, by restoring expression of the mutated dystrophin gene. There are currently no FDA-approved drugs to treat Duchenne, which affects approximately 1 in every 3,500 to 1 in 5,000 male children, making it the most common fatal genetic disorder diagnosed in childhood.

BioMarin said that extension studies of drisapersen will continue as the company determines the next steps in its new drug application, as will the ongoing clinical trials for other exon-skipping oligonucleotides it is developing. The drug is still under review by the European Medicines Agency.

[email protected]

The Food and Drug Administration has decided against approving the exon 51-skipping antisense oligonucleotide drug drisapersen for forms of Duchenne muscular dystrophy amenable to exon skipping.

The agency’s complete response letter to BioMarin Pharmaceutical, the developer of drisapersen (Kyndrisa), said that the standard of substantial evidence of effectiveness had not been met, according to a written statement from the company on Jan. 14.

In a Nov. 24, 2015, meeting of the FDA’s Peripheral and Central Nervous System Drugs Advisory Committee, panel members generally felt that drisapersen’s efficacy data were not persuasive enough for an approval.

Courtesy Wikimedia Commons/FitzColinGerald/Creative Commons License

Drisapersen targets frame-disrupting mutations found in exon 51 of the dystrophin gene, which produces a nonfunctional protein in individuals with a certain form of Duchenne, by restoring expression of the mutated dystrophin gene. There are currently no FDA-approved drugs to treat Duchenne, which affects approximately 1 in every 3,500 to 1 in 5,000 male children, making it the most common fatal genetic disorder diagnosed in childhood.

BioMarin said that extension studies of drisapersen will continue as the company determines the next steps in its new drug application, as will the ongoing clinical trials for other exon-skipping oligonucleotides it is developing. The drug is still under review by the European Medicines Agency.

[email protected]

The Food and Drug Administration has decided against approving the exon 51-skipping antisense oligonucleotide drug drisapersen for forms of Duchenne muscular dystrophy amenable to exon skipping.

The agency’s complete response letter to BioMarin Pharmaceutical, the developer of drisapersen (Kyndrisa), said that the standard of substantial evidence of effectiveness had not been met, according to a written statement from the company on Jan. 14.

In a Nov. 24, 2015, meeting of the FDA’s Peripheral and Central Nervous System Drugs Advisory Committee, panel members generally felt that drisapersen’s efficacy data were not persuasive enough for an approval.

Courtesy Wikimedia Commons/FitzColinGerald/Creative Commons License

Drisapersen targets frame-disrupting mutations found in exon 51 of the dystrophin gene, which produces a nonfunctional protein in individuals with a certain form of Duchenne, by restoring expression of the mutated dystrophin gene. There are currently no FDA-approved drugs to treat Duchenne, which affects approximately 1 in every 3,500 to 1 in 5,000 male children, making it the most common fatal genetic disorder diagnosed in childhood.

BioMarin said that extension studies of drisapersen will continue as the company determines the next steps in its new drug application, as will the ongoing clinical trials for other exon-skipping oligonucleotides it is developing. The drug is still under review by the European Medicines Agency.

[email protected]

SAN DIEGO – Compared with age-matched controls, patients with cervical spondylotic myelopathy had a significantly increased incidence of falls, hip fractures, and other injuries, preliminary results from a study of Medicare data suggest.

“Cervical myelopathy is the most common cause of spinal cord dysfunction in patients over age 55,” Dr. Daniel J. Blizzard said at the annual meeting of the Cervical Spine Research Society. “In general, it’s cord compression secondary to their ossification of posterior latitudinal ligament, congenital stenosis, and/or degenerative changes to vertebral bodies, discs, and facet joints. These create an upper motor neuron lesion, which causes gait disturbances, imbalance, loss of manual dexterity and coordination, and sensory changes and weakness.”

Dr. Blizzard, an orthopedic surgery resident at Duke University, Durham, N.C., noted that myelopathy gait is the most common presenting symptom in cervical spondylotic myelopathy (CSM), affecting almost 30% of patients. “It’s present in three-quarters of CSM patients undergoing decompression,” he said. “Cord compression can lead to impaired proprioception, spasticity, and stiffness. We know that this gait dysfunction is multifactorial. Imbalance and unsteadiness lead to compensatory broad-based arrhythmic shuffling and clumsy-appearing gait to maintain balance.”

An estimated one-third of people over age 65 fall at least once per year and this may lead to significant morbidity, including institutionalization, loss of independence, and mortality, Dr. Blizzard continued. “We know that gait dysfunction is a significant risk factor for falls,” he said. “This can be CSM, lower extremity osteoarthritis, deconditioning, or poor vision. The primary cause of a gait disturbance may not be accurately identified, especially if a more obvious cause is already known.”

The researchers set out to determine the fall and injury risk of patients with CSM, “with the goal of guiding attention to what we thought might be a potentially underestimated disease with regard to morbidity, and to provide data to consider when determining the type and timing of CSM treatment,” Dr. Blizzard said. They used the PearlDiver database to search the Medicare sample during 2005-2012, and used ICD-9 codes to identify patients with CSM. They also identified a subpopulation of CSM patients that underwent decompression, “not for the purpose of comparing the effect of decompression, but to identify a population with more severe disease,” he explained. They included a control population with no CSM, vestibular disease, or Parkinson’s disease.

Dr. Blizzard reported preliminary results from a total of 601,390 patients with CSM, 77,346 patients with CSM plus decompression, and 49,550,651 controls. They looked at the incidence of falls, head injuries, skull fractures, subdural hematomas, and other orthopedic injuries including fractures of the hip, femur, leg, ankle, pelvis, and lower extremity sprains. The researchers found that when compared with controls, patients with CSM had a statistically significant increased incidence of all injuries, including hip fracture (risk ratio, 2.62), head injury (RR, 7.34), and fall (RR, 8.08). The incidence of hip fracture, head injury, and fall was also increased among the subset of CSM patients who had undergone decompression (RR of 2.25, 8.34, and 9.62, respectively).

Dr. Blizzard acknowledged certain limitations of the study, including its retrospective design. “Statistical and clinical significance are two very different things,” he emphasized. “When we get numbers this big, everything will become statistically significant, but whether things are clinically significant is up to interpretation. The presence of disease and complications is contingent upon proper coding and recognition by providers. We have no measures of severity, extent, or chronicity of disease.”

Despite such limitations, he concluded that the findings suggest that impact of CSM on morbidity “is probably underestimated by many. Symptoms of CSM can be insidious or masked. Patients can often attribute these to normal effects of aging, and often primary care physicians will not recognize these initial symptoms, especially if there is another confounding presenting complaint.”

Conservative interventions for CSM patients, he said, include gait training/physical therapy, assistive aids, hip pads, exercise programs with balance training, and an assessment of hazards in the home environment. From a surgical standpoint, the findings raise the possibility that surgeons may want to “be more aggressive” in their decision to operate on patients with CSM. “This dataset is in no way able to address this question, but I think it provides interesting information regarding the true morbidity of the disease,” Dr. Blizzard said. “There is clear risk and morbidity with cervical compression. Studies show improvement in patients regardless of age, severity, and chronicity.”

Dr. Blizzard reported having no financial disclosures.

[email protected]

SAN DIEGO – Compared with age-matched controls, patients with cervical spondylotic myelopathy had a significantly increased incidence of falls, hip fractures, and other injuries, preliminary results from a study of Medicare data suggest.

“Cervical myelopathy is the most common cause of spinal cord dysfunction in patients over age 55,” Dr. Daniel J. Blizzard said at the annual meeting of the Cervical Spine Research Society. “In general, it’s cord compression secondary to their ossification of posterior latitudinal ligament, congenital stenosis, and/or degenerative changes to vertebral bodies, discs, and facet joints. These create an upper motor neuron lesion, which causes gait disturbances, imbalance, loss of manual dexterity and coordination, and sensory changes and weakness.”

Dr. Blizzard, an orthopedic surgery resident at Duke University, Durham, N.C., noted that myelopathy gait is the most common presenting symptom in cervical spondylotic myelopathy (CSM), affecting almost 30% of patients. “It’s present in three-quarters of CSM patients undergoing decompression,” he said. “Cord compression can lead to impaired proprioception, spasticity, and stiffness. We know that this gait dysfunction is multifactorial. Imbalance and unsteadiness lead to compensatory broad-based arrhythmic shuffling and clumsy-appearing gait to maintain balance.”

An estimated one-third of people over age 65 fall at least once per year and this may lead to significant morbidity, including institutionalization, loss of independence, and mortality, Dr. Blizzard continued. “We know that gait dysfunction is a significant risk factor for falls,” he said. “This can be CSM, lower extremity osteoarthritis, deconditioning, or poor vision. The primary cause of a gait disturbance may not be accurately identified, especially if a more obvious cause is already known.”

The researchers set out to determine the fall and injury risk of patients with CSM, “with the goal of guiding attention to what we thought might be a potentially underestimated disease with regard to morbidity, and to provide data to consider when determining the type and timing of CSM treatment,” Dr. Blizzard said. They used the PearlDiver database to search the Medicare sample during 2005-2012, and used ICD-9 codes to identify patients with CSM. They also identified a subpopulation of CSM patients that underwent decompression, “not for the purpose of comparing the effect of decompression, but to identify a population with more severe disease,” he explained. They included a control population with no CSM, vestibular disease, or Parkinson’s disease.

Dr. Blizzard reported preliminary results from a total of 601,390 patients with CSM, 77,346 patients with CSM plus decompression, and 49,550,651 controls. They looked at the incidence of falls, head injuries, skull fractures, subdural hematomas, and other orthopedic injuries including fractures of the hip, femur, leg, ankle, pelvis, and lower extremity sprains. The researchers found that when compared with controls, patients with CSM had a statistically significant increased incidence of all injuries, including hip fracture (risk ratio, 2.62), head injury (RR, 7.34), and fall (RR, 8.08). The incidence of hip fracture, head injury, and fall was also increased among the subset of CSM patients who had undergone decompression (RR of 2.25, 8.34, and 9.62, respectively).

Dr. Blizzard acknowledged certain limitations of the study, including its retrospective design. “Statistical and clinical significance are two very different things,” he emphasized. “When we get numbers this big, everything will become statistically significant, but whether things are clinically significant is up to interpretation. The presence of disease and complications is contingent upon proper coding and recognition by providers. We have no measures of severity, extent, or chronicity of disease.”

Despite such limitations, he concluded that the findings suggest that impact of CSM on morbidity “is probably underestimated by many. Symptoms of CSM can be insidious or masked. Patients can often attribute these to normal effects of aging, and often primary care physicians will not recognize these initial symptoms, especially if there is another confounding presenting complaint.”

Conservative interventions for CSM patients, he said, include gait training/physical therapy, assistive aids, hip pads, exercise programs with balance training, and an assessment of hazards in the home environment. From a surgical standpoint, the findings raise the possibility that surgeons may want to “be more aggressive” in their decision to operate on patients with CSM. “This dataset is in no way able to address this question, but I think it provides interesting information regarding the true morbidity of the disease,” Dr. Blizzard said. “There is clear risk and morbidity with cervical compression. Studies show improvement in patients regardless of age, severity, and chronicity.”

Dr. Blizzard reported having no financial disclosures.

[email protected]

SAN DIEGO – Compared with age-matched controls, patients with cervical spondylotic myelopathy had a significantly increased incidence of falls, hip fractures, and other injuries, preliminary results from a study of Medicare data suggest.

“Cervical myelopathy is the most common cause of spinal cord dysfunction in patients over age 55,” Dr. Daniel J. Blizzard said at the annual meeting of the Cervical Spine Research Society. “In general, it’s cord compression secondary to their ossification of posterior latitudinal ligament, congenital stenosis, and/or degenerative changes to vertebral bodies, discs, and facet joints. These create an upper motor neuron lesion, which causes gait disturbances, imbalance, loss of manual dexterity and coordination, and sensory changes and weakness.”

Dr. Blizzard, an orthopedic surgery resident at Duke University, Durham, N.C., noted that myelopathy gait is the most common presenting symptom in cervical spondylotic myelopathy (CSM), affecting almost 30% of patients. “It’s present in three-quarters of CSM patients undergoing decompression,” he said. “Cord compression can lead to impaired proprioception, spasticity, and stiffness. We know that this gait dysfunction is multifactorial. Imbalance and unsteadiness lead to compensatory broad-based arrhythmic shuffling and clumsy-appearing gait to maintain balance.”

An estimated one-third of people over age 65 fall at least once per year and this may lead to significant morbidity, including institutionalization, loss of independence, and mortality, Dr. Blizzard continued. “We know that gait dysfunction is a significant risk factor for falls,” he said. “This can be CSM, lower extremity osteoarthritis, deconditioning, or poor vision. The primary cause of a gait disturbance may not be accurately identified, especially if a more obvious cause is already known.”

The researchers set out to determine the fall and injury risk of patients with CSM, “with the goal of guiding attention to what we thought might be a potentially underestimated disease with regard to morbidity, and to provide data to consider when determining the type and timing of CSM treatment,” Dr. Blizzard said. They used the PearlDiver database to search the Medicare sample during 2005-2012, and used ICD-9 codes to identify patients with CSM. They also identified a subpopulation of CSM patients that underwent decompression, “not for the purpose of comparing the effect of decompression, but to identify a population with more severe disease,” he explained. They included a control population with no CSM, vestibular disease, or Parkinson’s disease.

Dr. Blizzard reported preliminary results from a total of 601,390 patients with CSM, 77,346 patients with CSM plus decompression, and 49,550,651 controls. They looked at the incidence of falls, head injuries, skull fractures, subdural hematomas, and other orthopedic injuries including fractures of the hip, femur, leg, ankle, pelvis, and lower extremity sprains. The researchers found that when compared with controls, patients with CSM had a statistically significant increased incidence of all injuries, including hip fracture (risk ratio, 2.62), head injury (RR, 7.34), and fall (RR, 8.08). The incidence of hip fracture, head injury, and fall was also increased among the subset of CSM patients who had undergone decompression (RR of 2.25, 8.34, and 9.62, respectively).

Dr. Blizzard acknowledged certain limitations of the study, including its retrospective design. “Statistical and clinical significance are two very different things,” he emphasized. “When we get numbers this big, everything will become statistically significant, but whether things are clinically significant is up to interpretation. The presence of disease and complications is contingent upon proper coding and recognition by providers. We have no measures of severity, extent, or chronicity of disease.”

Despite such limitations, he concluded that the findings suggest that impact of CSM on morbidity “is probably underestimated by many. Symptoms of CSM can be insidious or masked. Patients can often attribute these to normal effects of aging, and often primary care physicians will not recognize these initial symptoms, especially if there is another confounding presenting complaint.”

Conservative interventions for CSM patients, he said, include gait training/physical therapy, assistive aids, hip pads, exercise programs with balance training, and an assessment of hazards in the home environment. From a surgical standpoint, the findings raise the possibility that surgeons may want to “be more aggressive” in their decision to operate on patients with CSM. “This dataset is in no way able to address this question, but I think it provides interesting information regarding the true morbidity of the disease,” Dr. Blizzard said. “There is clear risk and morbidity with cervical compression. Studies show improvement in patients regardless of age, severity, and chronicity.”

Dr. Blizzard reported having no financial disclosures.

[email protected]

U.S. Compounding Inc. is issuing a recall on all sterile products distributed between March 14, 2015, and Sept. 9, 2015, according to a safety alert from the Food and Drug Administration.

The product recall applies to all aseptically compounded and packaged USC sterile products distributed to hospitals, patients, providers, and clinics because of FDA concerns over lack of sterility assurance. Because of the risk to any patients using a compromised product, USC is proceeding voluntarily with the recall.

Patients or providers who received sterile compounded products from USC within the recall date and have not expired should stop using the products immediately, quarantine the product until proper disposal is possible, and contact USC as soon as possible to coordinate a plan to return the product.

Patients should also contact their physicians if they have experienced any issues relating to the recalled product, and physicians should contact patients to inform them of the recall and to advise them to stop using the product.

The USC recall does not apply to any nonsterile compounded medication produced or distributed by USC, according to the FDA alert.

Find the full safety alert on the FDA website.

[email protected]

U.S. Compounding Inc. is issuing a recall on all sterile products distributed between March 14, 2015, and Sept. 9, 2015, according to a safety alert from the Food and Drug Administration.

The product recall applies to all aseptically compounded and packaged USC sterile products distributed to hospitals, patients, providers, and clinics because of FDA concerns over lack of sterility assurance. Because of the risk to any patients using a compromised product, USC is proceeding voluntarily with the recall.

Patients or providers who received sterile compounded products from USC within the recall date and have not expired should stop using the products immediately, quarantine the product until proper disposal is possible, and contact USC as soon as possible to coordinate a plan to return the product.

Patients should also contact their physicians if they have experienced any issues relating to the recalled product, and physicians should contact patients to inform them of the recall and to advise them to stop using the product.

The USC recall does not apply to any nonsterile compounded medication produced or distributed by USC, according to the FDA alert.

Find the full safety alert on the FDA website.

[email protected]

U.S. Compounding Inc. is issuing a recall on all sterile products distributed between March 14, 2015, and Sept. 9, 2015, according to a safety alert from the Food and Drug Administration.

The product recall applies to all aseptically compounded and packaged USC sterile products distributed to hospitals, patients, providers, and clinics because of FDA concerns over lack of sterility assurance. Because of the risk to any patients using a compromised product, USC is proceeding voluntarily with the recall.

Patients or providers who received sterile compounded products from USC within the recall date and have not expired should stop using the products immediately, quarantine the product until proper disposal is possible, and contact USC as soon as possible to coordinate a plan to return the product.

Patients should also contact their physicians if they have experienced any issues relating to the recalled product, and physicians should contact patients to inform them of the recall and to advise them to stop using the product.

The USC recall does not apply to any nonsterile compounded medication produced or distributed by USC, according to the FDA alert.

Find the full safety alert on the FDA website.

[email protected]

A male immunodeficient patient excreted strains of a vaccine-derived poliovirus for 28 years, a study has found. This case suggests that there are new barriers to polio eradication, according to Glynis Dunn and coauthors of a research article published August 27 in PLoS Pathogens.

Poliovirus strains in the oral polio vaccine (OPV) can be transmitted from person to person in populations with low immunity and can cause outbreaks. The strains can also replicate for long periods of time in an immunodeficient individual. The patient in question received childhood OPV immunizations at 5, 7, and 12 months of age and a booster when he was about 7 years old. His case is the longest-known example of a vaccinated patient excreting the live poliovirus.

The researchers analyzed 185 stool samples that the patient provided between 1995 and 2015. All stools were positive for strain 2 polio virus; the virus titres shed in the stools were “comparable to virus titres shed by healthy vaccinees and paralytics cases infected with vaccine or wild poliovirus.”

The excreted virus began to diverge from the vaccine strain around the time of the individual’s last known OPV vaccination, acquiring various mutations that affected its antigenic structure.

The patient excreted “a highly virulent and antigenically modified type 2 poliovirus at high titres for a period estimated to be 28 years so far ... Provided antibody titres and immunizations coverage are maintained, it is likely that the population will be protected against paralytic disease, but it is also possible that this virus could circulate in populations only using [inactivated polio vaccine] as described in Israel for wild poliovirus, thus representing a possible source of polio reemergence,” according to the authors.

Read the full article in PLoS Pathogens (doi:10.1371/journal.ppat.1005114).

[email protected]

A male immunodeficient patient excreted strains of a vaccine-derived poliovirus for 28 years, a study has found. This case suggests that there are new barriers to polio eradication, according to Glynis Dunn and coauthors of a research article published August 27 in PLoS Pathogens.

Poliovirus strains in the oral polio vaccine (OPV) can be transmitted from person to person in populations with low immunity and can cause outbreaks. The strains can also replicate for long periods of time in an immunodeficient individual. The patient in question received childhood OPV immunizations at 5, 7, and 12 months of age and a booster when he was about 7 years old. His case is the longest-known example of a vaccinated patient excreting the live poliovirus.

The researchers analyzed 185 stool samples that the patient provided between 1995 and 2015. All stools were positive for strain 2 polio virus; the virus titres shed in the stools were “comparable to virus titres shed by healthy vaccinees and paralytics cases infected with vaccine or wild poliovirus.”

The excreted virus began to diverge from the vaccine strain around the time of the individual’s last known OPV vaccination, acquiring various mutations that affected its antigenic structure.

The patient excreted “a highly virulent and antigenically modified type 2 poliovirus at high titres for a period estimated to be 28 years so far ... Provided antibody titres and immunizations coverage are maintained, it is likely that the population will be protected against paralytic disease, but it is also possible that this virus could circulate in populations only using [inactivated polio vaccine] as described in Israel for wild poliovirus, thus representing a possible source of polio reemergence,” according to the authors.

Read the full article in PLoS Pathogens (doi:10.1371/journal.ppat.1005114).

[email protected]

A male immunodeficient patient excreted strains of a vaccine-derived poliovirus for 28 years, a study has found. This case suggests that there are new barriers to polio eradication, according to Glynis Dunn and coauthors of a research article published August 27 in PLoS Pathogens.

Poliovirus strains in the oral polio vaccine (OPV) can be transmitted from person to person in populations with low immunity and can cause outbreaks. The strains can also replicate for long periods of time in an immunodeficient individual. The patient in question received childhood OPV immunizations at 5, 7, and 12 months of age and a booster when he was about 7 years old. His case is the longest-known example of a vaccinated patient excreting the live poliovirus.

The researchers analyzed 185 stool samples that the patient provided between 1995 and 2015. All stools were positive for strain 2 polio virus; the virus titres shed in the stools were “comparable to virus titres shed by healthy vaccinees and paralytics cases infected with vaccine or wild poliovirus.”

The excreted virus began to diverge from the vaccine strain around the time of the individual’s last known OPV vaccination, acquiring various mutations that affected its antigenic structure.

The patient excreted “a highly virulent and antigenically modified type 2 poliovirus at high titres for a period estimated to be 28 years so far ... Provided antibody titres and immunizations coverage are maintained, it is likely that the population will be protected against paralytic disease, but it is also possible that this virus could circulate in populations only using [inactivated polio vaccine] as described in Israel for wild poliovirus, thus representing a possible source of polio reemergence,” according to the authors.

Read the full article in PLoS Pathogens (doi:10.1371/journal.ppat.1005114).

[email protected]

ROME – The Montreal Cognitive Assessment provides a quick and easy-to-use screening tool to identify patients with systemic lupus erythematosus with cognitive impairment, Dr. Zahi Touma reported in a poster at the European Congress of Rheumatology.

In a consecutive series of 78 patients screened with the Montreal Cognitive Assessment (MoCA), the free, single-page test, which can be administered in about 10 minutes, showed a sensitivity of 69% and specificity of 68%, compared with the current standard, the Hopkins Verbal Learning Test-Revised, said Dr. Touma, a rheumatologist at the University of Toronto.

Other easy-to-use and quick screening tools, such as the Mini-Mental State Examination, had substantially worse performance in the study. He and his associates found a sensitivity of 21% and specificity of 91% using the Mini-Mental State exam. For screening, higher sensitivity is desirable so that fewer patients with potential cognitive impairment are missed, he noted.

“Ease of use and time needed for assessment as well as appropriate psychometric properties make the MoCA the preferential screening test for cognitive impairment in patients with SLE,” Dr. Touma said in his poster.

Cognitive impairment is very common among patients with systemic lupus erythematosus (SLE). In this study, Dr Touma found a 47% prevalence using MoCA. Cognitive impairment, however, often goes unidentified in SLE patients, likely because of lack of awareness among rheumatologists as well as the absence of a quick and easily administered screening tool, he said in a video interview.

Dr. Touma said he hopes that the apparent efficacy of an easy-to-use screening tool like MoCA will help boost appreciation for the high prevalence of cognitive impairment in SLE patients. He suggested that clinicians screen for cognitive impairment as soon as SLE is diagnosed and that they perform follow-up screening during subsequent patient encounters with SLE patients who initially present without cognitive impairment.

Dr. Touma had no disclosures.

[email protected]

On Twitter @mitchelzoler

ROME – The Montreal Cognitive Assessment provides a quick and easy-to-use screening tool to identify patients with systemic lupus erythematosus with cognitive impairment, Dr. Zahi Touma reported in a poster at the European Congress of Rheumatology.

In a consecutive series of 78 patients screened with the Montreal Cognitive Assessment (MoCA), the free, single-page test, which can be administered in about 10 minutes, showed a sensitivity of 69% and specificity of 68%, compared with the current standard, the Hopkins Verbal Learning Test-Revised, said Dr. Touma, a rheumatologist at the University of Toronto.

Other easy-to-use and quick screening tools, such as the Mini-Mental State Examination, had substantially worse performance in the study. He and his associates found a sensitivity of 21% and specificity of 91% using the Mini-Mental State exam. For screening, higher sensitivity is desirable so that fewer patients with potential cognitive impairment are missed, he noted.

“Ease of use and time needed for assessment as well as appropriate psychometric properties make the MoCA the preferential screening test for cognitive impairment in patients with SLE,” Dr. Touma said in his poster.

Cognitive impairment is very common among patients with systemic lupus erythematosus (SLE). In this study, Dr Touma found a 47% prevalence using MoCA. Cognitive impairment, however, often goes unidentified in SLE patients, likely because of lack of awareness among rheumatologists as well as the absence of a quick and easily administered screening tool, he said in a video interview.

Dr. Touma said he hopes that the apparent efficacy of an easy-to-use screening tool like MoCA will help boost appreciation for the high prevalence of cognitive impairment in SLE patients. He suggested that clinicians screen for cognitive impairment as soon as SLE is diagnosed and that they perform follow-up screening during subsequent patient encounters with SLE patients who initially present without cognitive impairment.

Dr. Touma had no disclosures.

[email protected]

On Twitter @mitchelzoler

ROME – The Montreal Cognitive Assessment provides a quick and easy-to-use screening tool to identify patients with systemic lupus erythematosus with cognitive impairment, Dr. Zahi Touma reported in a poster at the European Congress of Rheumatology.

In a consecutive series of 78 patients screened with the Montreal Cognitive Assessment (MoCA), the free, single-page test, which can be administered in about 10 minutes, showed a sensitivity of 69% and specificity of 68%, compared with the current standard, the Hopkins Verbal Learning Test-Revised, said Dr. Touma, a rheumatologist at the University of Toronto.

Other easy-to-use and quick screening tools, such as the Mini-Mental State Examination, had substantially worse performance in the study. He and his associates found a sensitivity of 21% and specificity of 91% using the Mini-Mental State exam. For screening, higher sensitivity is desirable so that fewer patients with potential cognitive impairment are missed, he noted.

“Ease of use and time needed for assessment as well as appropriate psychometric properties make the MoCA the preferential screening test for cognitive impairment in patients with SLE,” Dr. Touma said in his poster.

Cognitive impairment is very common among patients with systemic lupus erythematosus (SLE). In this study, Dr Touma found a 47% prevalence using MoCA. Cognitive impairment, however, often goes unidentified in SLE patients, likely because of lack of awareness among rheumatologists as well as the absence of a quick and easily administered screening tool, he said in a video interview.

Dr. Touma said he hopes that the apparent efficacy of an easy-to-use screening tool like MoCA will help boost appreciation for the high prevalence of cognitive impairment in SLE patients. He suggested that clinicians screen for cognitive impairment as soon as SLE is diagnosed and that they perform follow-up screening during subsequent patient encounters with SLE patients who initially present without cognitive impairment.

Dr. Touma had no disclosures.

[email protected]

On Twitter @mitchelzoler

Individuals with biopsy-confirmed celiac disease have more than double the risk of receiving a diagnosis of neuropathy when compared with the general population, and the risk persists even when other potentially contributing conditions and lifestyle factors are considered.

The use of Swedish population registries enabled first author Dr. Sujata P. Thawani of Columbia University, New York, and her colleagues to find that the risk of neuropathy was increased both before and after a diagnosis of celiac disease (CD).

“We found an increased risk of neuropathy in patients with CD that persists after CD diagnosis. Although absolute risks for neuropathy are low, CD is a potentially treatable condition with a young age of onset. Our findings suggest that screening could be beneficial in patients with neuropathy,” they wrote (JAMA Neurol. 2015 May 11 [doi:10.1001/jamaneurol.2015.0475]).Neuropathy has a known association with CD, an immune-mediated disorder characterized by sensitivity to gluten with an incidence of about 1% in Western Europe. Previous studies had reported that up to one-third of celiac disease patients also experienced neuropathy, but the literature had not completely characterized the prevalence of neuropathy in the CD population.

©xrender/thinkstockphotos.com

Dr. Thawani and her associates used Swedish pathology registers to identify individuals whose small intestine biopsies showed villous atrophy between 1969 and 2008 (Marsh stage 3, n = 28,232). These individuals were categorized as having CD. Neuropathy diagnoses were drawn from national patient and pharmacy registers. Each CD patient was matched with up to five age- and sex-matched controls (n = 139,473) from the Swedish Total Population Registry, all of whom were diagnosed in the same year and were from the same county as the matched CD patient.

Although 41.7% of CD patients were diagnosed in childhood, the median age at diagnosis was 29 years. About 62% of patients in both groups were female. For CD patients, the absolute risk of neuropathy was 64 per 100,000 patient-years, compared with 15 per 100,000 patients-years in the control group (hazard ratio, 2.5; 95% confidence interval, 2.0-2.9; P < .001).

The risk of neuropathy for patients with CD was not affected by gender, absolute age, or age at diagnosis. The risk of neuropathy for those with CD remained about 2.5 times higher than the matched controls, even after accounting for diabetes status, the presence of other autoimmune disorders, vitamin deficiencies, and alcohol use. Although vitamin B₁₂ deficiency has been associated with CD and may contribute to neuropathy, the investigators noted that, “in our analysis, the influence of vitamin deficiencies did not significantly affect our risk estimate.”

Nonspecified neuropathy was the most commonly reported type of neuropathy. Other subtypes of neuropathy were tracked, but limitations of coding and reporting prevented tracking sensory ganglionopathy, the second most commonly reported neuropathy in CD.

The strengths of the study included the large sample size and the study’s statistical strengths. The retrospective nature of the study was an overall limitation, and the homogeneous study population (over 90% of patients in both arms were of Nordic heritage) limited the study’s generalizability.

Surveillance bias may account for some of the increased risk for neuropathy, noted Dr. Thawani and her colleagues. This was hinted at by the fact that a diagnosis of neuropathy tended to follow closely on the CD diagnosis; physicians may have been more attuned to detecting potential sequelae of the CD diagnosis during this time period. Notably, though, patients with a prior neuropathy diagnosis also were more likely to be diagnosed with CD, showing a bidirectional relationship.

“These data may also suggest that the two diseases may share risk factors or a common underlying etiology for the development of neuropathy, such as a potential role of immunologic mechanisms,” they wrote.

The authors reported no conflicts of interest. The investigators received support from the Swedish Society of Medicine, the Swedish Research Council, and the National Center for Advancing Translational Sciences.

Individuals with biopsy-confirmed celiac disease have more than double the risk of receiving a diagnosis of neuropathy when compared with the general population, and the risk persists even when other potentially contributing conditions and lifestyle factors are considered.

The use of Swedish population registries enabled first author Dr. Sujata P. Thawani of Columbia University, New York, and her colleagues to find that the risk of neuropathy was increased both before and after a diagnosis of celiac disease (CD).

“We found an increased risk of neuropathy in patients with CD that persists after CD diagnosis. Although absolute risks for neuropathy are low, CD is a potentially treatable condition with a young age of onset. Our findings suggest that screening could be beneficial in patients with neuropathy,” they wrote (JAMA Neurol. 2015 May 11 [doi:10.1001/jamaneurol.2015.0475]).Neuropathy has a known association with CD, an immune-mediated disorder characterized by sensitivity to gluten with an incidence of about 1% in Western Europe. Previous studies had reported that up to one-third of celiac disease patients also experienced neuropathy, but the literature had not completely characterized the prevalence of neuropathy in the CD population.

©xrender/thinkstockphotos.com

Dr. Thawani and her associates used Swedish pathology registers to identify individuals whose small intestine biopsies showed villous atrophy between 1969 and 2008 (Marsh stage 3, n = 28,232). These individuals were categorized as having CD. Neuropathy diagnoses were drawn from national patient and pharmacy registers. Each CD patient was matched with up to five age- and sex-matched controls (n = 139,473) from the Swedish Total Population Registry, all of whom were diagnosed in the same year and were from the same county as the matched CD patient.

Although 41.7% of CD patients were diagnosed in childhood, the median age at diagnosis was 29 years. About 62% of patients in both groups were female. For CD patients, the absolute risk of neuropathy was 64 per 100,000 patient-years, compared with 15 per 100,000 patients-years in the control group (hazard ratio, 2.5; 95% confidence interval, 2.0-2.9; P < .001).

The risk of neuropathy for patients with CD was not affected by gender, absolute age, or age at diagnosis. The risk of neuropathy for those with CD remained about 2.5 times higher than the matched controls, even after accounting for diabetes status, the presence of other autoimmune disorders, vitamin deficiencies, and alcohol use. Although vitamin B₁₂ deficiency has been associated with CD and may contribute to neuropathy, the investigators noted that, “in our analysis, the influence of vitamin deficiencies did not significantly affect our risk estimate.”

Nonspecified neuropathy was the most commonly reported type of neuropathy. Other subtypes of neuropathy were tracked, but limitations of coding and reporting prevented tracking sensory ganglionopathy, the second most commonly reported neuropathy in CD.

The strengths of the study included the large sample size and the study’s statistical strengths. The retrospective nature of the study was an overall limitation, and the homogeneous study population (over 90% of patients in both arms were of Nordic heritage) limited the study’s generalizability.

Surveillance bias may account for some of the increased risk for neuropathy, noted Dr. Thawani and her colleagues. This was hinted at by the fact that a diagnosis of neuropathy tended to follow closely on the CD diagnosis; physicians may have been more attuned to detecting potential sequelae of the CD diagnosis during this time period. Notably, though, patients with a prior neuropathy diagnosis also were more likely to be diagnosed with CD, showing a bidirectional relationship.

“These data may also suggest that the two diseases may share risk factors or a common underlying etiology for the development of neuropathy, such as a potential role of immunologic mechanisms,” they wrote.

The authors reported no conflicts of interest. The investigators received support from the Swedish Society of Medicine, the Swedish Research Council, and the National Center for Advancing Translational Sciences.

Individuals with biopsy-confirmed celiac disease have more than double the risk of receiving a diagnosis of neuropathy when compared with the general population, and the risk persists even when other potentially contributing conditions and lifestyle factors are considered.

The use of Swedish population registries enabled first author Dr. Sujata P. Thawani of Columbia University, New York, and her colleagues to find that the risk of neuropathy was increased both before and after a diagnosis of celiac disease (CD).

“We found an increased risk of neuropathy in patients with CD that persists after CD diagnosis. Although absolute risks for neuropathy are low, CD is a potentially treatable condition with a young age of onset. Our findings suggest that screening could be beneficial in patients with neuropathy,” they wrote (JAMA Neurol. 2015 May 11 [doi:10.1001/jamaneurol.2015.0475]).Neuropathy has a known association with CD, an immune-mediated disorder characterized by sensitivity to gluten with an incidence of about 1% in Western Europe. Previous studies had reported that up to one-third of celiac disease patients also experienced neuropathy, but the literature had not completely characterized the prevalence of neuropathy in the CD population.

©xrender/thinkstockphotos.com

Dr. Thawani and her associates used Swedish pathology registers to identify individuals whose small intestine biopsies showed villous atrophy between 1969 and 2008 (Marsh stage 3, n = 28,232). These individuals were categorized as having CD. Neuropathy diagnoses were drawn from national patient and pharmacy registers. Each CD patient was matched with up to five age- and sex-matched controls (n = 139,473) from the Swedish Total Population Registry, all of whom were diagnosed in the same year and were from the same county as the matched CD patient.

Although 41.7% of CD patients were diagnosed in childhood, the median age at diagnosis was 29 years. About 62% of patients in both groups were female. For CD patients, the absolute risk of neuropathy was 64 per 100,000 patient-years, compared with 15 per 100,000 patients-years in the control group (hazard ratio, 2.5; 95% confidence interval, 2.0-2.9; P < .001).

The risk of neuropathy for patients with CD was not affected by gender, absolute age, or age at diagnosis. The risk of neuropathy for those with CD remained about 2.5 times higher than the matched controls, even after accounting for diabetes status, the presence of other autoimmune disorders, vitamin deficiencies, and alcohol use. Although vitamin B₁₂ deficiency has been associated with CD and may contribute to neuropathy, the investigators noted that, “in our analysis, the influence of vitamin deficiencies did not significantly affect our risk estimate.”

Nonspecified neuropathy was the most commonly reported type of neuropathy. Other subtypes of neuropathy were tracked, but limitations of coding and reporting prevented tracking sensory ganglionopathy, the second most commonly reported neuropathy in CD.

The strengths of the study included the large sample size and the study’s statistical strengths. The retrospective nature of the study was an overall limitation, and the homogeneous study population (over 90% of patients in both arms were of Nordic heritage) limited the study’s generalizability.

Surveillance bias may account for some of the increased risk for neuropathy, noted Dr. Thawani and her colleagues. This was hinted at by the fact that a diagnosis of neuropathy tended to follow closely on the CD diagnosis; physicians may have been more attuned to detecting potential sequelae of the CD diagnosis during this time period. Notably, though, patients with a prior neuropathy diagnosis also were more likely to be diagnosed with CD, showing a bidirectional relationship.

“These data may also suggest that the two diseases may share risk factors or a common underlying etiology for the development of neuropathy, such as a potential role of immunologic mechanisms,” they wrote.

The authors reported no conflicts of interest. The investigators received support from the Swedish Society of Medicine, the Swedish Research Council, and the National Center for Advancing Translational Sciences.

A U.S. physician exposed to Ebola virus received an investigational vaccine afterward and didn’t contract the disease, but the vaccine’s effectiveness remains unknown, according to report published online March 5 in JAMA.

The vaccine, VSV[Delta]G-ZEBOV, is based on a vesicular stomatitis virus with the glycoprotein gene replaced by a Zaire Ebola glycoprotein gene.

The physician received the vaccine slightly less than 2 days after Ebola exposure. After 12 hours, symptoms appeared that are associated with vesicular stomatitis virus. Those dissipated after 3-4 days, noted Dr. Lilin Lai of Emory University, Atlanta, and her colleagues.

No Ebola symptoms were detected, but the patient tested positive for Ebola virus glycoprotein-specific antibodies and T cells, which was an intended effect of the vaccine.

A single case report cannot provide a definitive answer to the effectiveness of VSV[Delta]G-ZEBOV, noted Thomas W. Geisbert, Ph.D. of the Galveston National Laboratory, University of Texas Medical Branch, in a related editorial. However, “this incident serves as an example of how important it is to have safe and effective countermeasures available in sufficient quantities that can be rapidly deployed for emergency use for both medical workers and affected populations.”

Find the full study and editorial in JAMA: (doi: 10.1001/jama.2015.1995) and (doi: 10.1001/jama.2015.2057).

A U.S. physician exposed to Ebola virus received an investigational vaccine afterward and didn’t contract the disease, but the vaccine’s effectiveness remains unknown, according to report published online March 5 in JAMA.

The vaccine, VSV[Delta]G-ZEBOV, is based on a vesicular stomatitis virus with the glycoprotein gene replaced by a Zaire Ebola glycoprotein gene.

The physician received the vaccine slightly less than 2 days after Ebola exposure. After 12 hours, symptoms appeared that are associated with vesicular stomatitis virus. Those dissipated after 3-4 days, noted Dr. Lilin Lai of Emory University, Atlanta, and her colleagues.

No Ebola symptoms were detected, but the patient tested positive for Ebola virus glycoprotein-specific antibodies and T cells, which was an intended effect of the vaccine.

A single case report cannot provide a definitive answer to the effectiveness of VSV[Delta]G-ZEBOV, noted Thomas W. Geisbert, Ph.D. of the Galveston National Laboratory, University of Texas Medical Branch, in a related editorial. However, “this incident serves as an example of how important it is to have safe and effective countermeasures available in sufficient quantities that can be rapidly deployed for emergency use for both medical workers and affected populations.”

Find the full study and editorial in JAMA: (doi: 10.1001/jama.2015.1995) and (doi: 10.1001/jama.2015.2057).

A U.S. physician exposed to Ebola virus received an investigational vaccine afterward and didn’t contract the disease, but the vaccine’s effectiveness remains unknown, according to report published online March 5 in JAMA.

The vaccine, VSV[Delta]G-ZEBOV, is based on a vesicular stomatitis virus with the glycoprotein gene replaced by a Zaire Ebola glycoprotein gene.

The physician received the vaccine slightly less than 2 days after Ebola exposure. After 12 hours, symptoms appeared that are associated with vesicular stomatitis virus. Those dissipated after 3-4 days, noted Dr. Lilin Lai of Emory University, Atlanta, and her colleagues.

No Ebola symptoms were detected, but the patient tested positive for Ebola virus glycoprotein-specific antibodies and T cells, which was an intended effect of the vaccine.

A single case report cannot provide a definitive answer to the effectiveness of VSV[Delta]G-ZEBOV, noted Thomas W. Geisbert, Ph.D. of the Galveston National Laboratory, University of Texas Medical Branch, in a related editorial. However, “this incident serves as an example of how important it is to have safe and effective countermeasures available in sufficient quantities that can be rapidly deployed for emergency use for both medical workers and affected populations.”

Find the full study and editorial in JAMA: (doi: 10.1001/jama.2015.1995) and (doi: 10.1001/jama.2015.2057).

MAUI, HAWAII – Rheumatologists and other providers need to ask patients if they’ve had metal-on-metal hip implants.

That goes for hip resurfacing – which by definition is metal on metal – as well as actual metal-on-metal hips. Signs of trouble can be as subtle as mental status changes, and they go well beyond the traditional issues with worn-out artificial joints.

During a video interview at the 2015 Rheumatology Winter Clinical Symposium, Dr. Bill Bugbee, an orthopedic surgeon and professor at the University of California, San Diego, explained the problems and the warning signs for which physicians should watch.

[email protected]

MAUI, HAWAII – Rheumatologists and other providers need to ask patients if they’ve had metal-on-metal hip implants.

That goes for hip resurfacing – which by definition is metal on metal – as well as actual metal-on-metal hips. Signs of trouble can be as subtle as mental status changes, and they go well beyond the traditional issues with worn-out artificial joints.

During a video interview at the 2015 Rheumatology Winter Clinical Symposium, Dr. Bill Bugbee, an orthopedic surgeon and professor at the University of California, San Diego, explained the problems and the warning signs for which physicians should watch.

[email protected]

MAUI, HAWAII – Rheumatologists and other providers need to ask patients if they’ve had metal-on-metal hip implants.

That goes for hip resurfacing – which by definition is metal on metal – as well as actual metal-on-metal hips. Signs of trouble can be as subtle as mental status changes, and they go well beyond the traditional issues with worn-out artificial joints.

During a video interview at the 2015 Rheumatology Winter Clinical Symposium, Dr. Bill Bugbee, an orthopedic surgeon and professor at the University of California, San Diego, explained the problems and the warning signs for which physicians should watch.

[email protected]