Bruce Jancin

GOTHENBURG, SWEDEN — Patients with cutaneous lupus erythematosus appear to have an elevated overall risk of cancer, especially nonmelanoma skin cancer, lung cancer, and non-Hodgkin's lymphoma.

That's the preliminary conclusion from a Swedish national cohort study involving 3,788 Swedes with cutaneous LE (CLE), each matched to three controls and followed for an average of 4.1 years, said Dr. Carina M. Grönhagen.

The take-home message from this first-ever look at the cancer risk associated with CLE is that patients with this skin disease need to be followed regularly for the emergence of malignancy. And they need a strong antismoking message.

“Many of these cancers are connected to smoking, and patients with CLE are known to be smokers to a higher degree than in a normal population,” observed Dr. Grönhagen, a dermatology resident at Danderyd Hospital and doctoral candidate in medical epidemiology at the Karolinska Institute, Stockholm.

She looked at cancer rates in patients with CLE because CLE is an autoimmune disease, and epidemiologic studies indicate other autoimmune diseases are associated with increased cancer risk.

The overall number of cases of cancer documented in the CLE group during the study period was 188, compared with an expected 112. This 67% increased incidence rate ratio remained significant after adjustment for comorbid SLE, which dropped the ratio only to 60%.

The greatest increase in cancer risk seen in the CLE cohort was for nonmelanoma skin cancer, with a 4.3-fold relative risk, compared with controls. The other strongest risk increases were the 2.9-fold increase in lung cancer, the 2.7-fold increase in non-Hodgkin's lymphoma, and the 2.7-fold rise in buccal cancer.

Asked if she thinks the observed increase in cancer in association with CLE is caused by the skin disease itself, or instead perhaps the immunosuppressive therapies employed in its treatment, Dr. Grönhagen replied that the well-established high rate of smoking among CLE patients is probably a significant contributor. But the immunologic derangement inherent in CLE is also likely to play a role, especially with regard to the increase in nonmelanoma skin cancer.

She declared having no relevant financial relationships.

GOTHENBURG, SWEDEN — Patients with cutaneous lupus erythematosus appear to have an elevated overall risk of cancer, especially nonmelanoma skin cancer, lung cancer, and non-Hodgkin's lymphoma.

That's the preliminary conclusion from a Swedish national cohort study involving 3,788 Swedes with cutaneous LE (CLE), each matched to three controls and followed for an average of 4.1 years, said Dr. Carina M. Grönhagen.

The take-home message from this first-ever look at the cancer risk associated with CLE is that patients with this skin disease need to be followed regularly for the emergence of malignancy. And they need a strong antismoking message.

“Many of these cancers are connected to smoking, and patients with CLE are known to be smokers to a higher degree than in a normal population,” observed Dr. Grönhagen, a dermatology resident at Danderyd Hospital and doctoral candidate in medical epidemiology at the Karolinska Institute, Stockholm.

She looked at cancer rates in patients with CLE because CLE is an autoimmune disease, and epidemiologic studies indicate other autoimmune diseases are associated with increased cancer risk.

The overall number of cases of cancer documented in the CLE group during the study period was 188, compared with an expected 112. This 67% increased incidence rate ratio remained significant after adjustment for comorbid SLE, which dropped the ratio only to 60%.

The greatest increase in cancer risk seen in the CLE cohort was for nonmelanoma skin cancer, with a 4.3-fold relative risk, compared with controls. The other strongest risk increases were the 2.9-fold increase in lung cancer, the 2.7-fold increase in non-Hodgkin's lymphoma, and the 2.7-fold rise in buccal cancer.

Asked if she thinks the observed increase in cancer in association with CLE is caused by the skin disease itself, or instead perhaps the immunosuppressive therapies employed in its treatment, Dr. Grönhagen replied that the well-established high rate of smoking among CLE patients is probably a significant contributor. But the immunologic derangement inherent in CLE is also likely to play a role, especially with regard to the increase in nonmelanoma skin cancer.

She declared having no relevant financial relationships.

GOTHENBURG, SWEDEN — Patients with cutaneous lupus erythematosus appear to have an elevated overall risk of cancer, especially nonmelanoma skin cancer, lung cancer, and non-Hodgkin's lymphoma.

That's the preliminary conclusion from a Swedish national cohort study involving 3,788 Swedes with cutaneous LE (CLE), each matched to three controls and followed for an average of 4.1 years, said Dr. Carina M. Grönhagen.

The take-home message from this first-ever look at the cancer risk associated with CLE is that patients with this skin disease need to be followed regularly for the emergence of malignancy. And they need a strong antismoking message.

“Many of these cancers are connected to smoking, and patients with CLE are known to be smokers to a higher degree than in a normal population,” observed Dr. Grönhagen, a dermatology resident at Danderyd Hospital and doctoral candidate in medical epidemiology at the Karolinska Institute, Stockholm.

She looked at cancer rates in patients with CLE because CLE is an autoimmune disease, and epidemiologic studies indicate other autoimmune diseases are associated with increased cancer risk.

The overall number of cases of cancer documented in the CLE group during the study period was 188, compared with an expected 112. This 67% increased incidence rate ratio remained significant after adjustment for comorbid SLE, which dropped the ratio only to 60%.

The greatest increase in cancer risk seen in the CLE cohort was for nonmelanoma skin cancer, with a 4.3-fold relative risk, compared with controls. The other strongest risk increases were the 2.9-fold increase in lung cancer, the 2.7-fold increase in non-Hodgkin's lymphoma, and the 2.7-fold rise in buccal cancer.

Asked if she thinks the observed increase in cancer in association with CLE is caused by the skin disease itself, or instead perhaps the immunosuppressive therapies employed in its treatment, Dr. Grönhagen replied that the well-established high rate of smoking among CLE patients is probably a significant contributor. But the immunologic derangement inherent in CLE is also likely to play a role, especially with regard to the increase in nonmelanoma skin cancer.

She declared having no relevant financial relationships.

EDINBURGH — Depression is common, underdiagnosed, and undertreated in patients with psoriatic arthritis.

Psychiatric evaluation of 50 consecutive patients at the University of Glasgow psoriatic arthritis clinic indicated that 15 patients (30%) were depressed. Three were rated as severely depressed based on their scores on the Hospital Anxiety and Depression Scale (HADS); 12 others had moderate depression, Dr. Rajeev Krishnadas reported.

This high prevalence of depression in psoriatic arthritis patients is consistent with reports in the dermatologic literature (Br. J. Dermatol. 2008;159:704–10).

Of note, none of the depressed Scottish patients was on a therapeutic dose of an antidepressant, added Dr. Krishnadas of the Sackler Institute of Psychobiological Research, Southern General Hospital, Glasgow.

This study is part of a larger ongoing investigation into the relationship between systemic inflammation and depression in patients with rheumatoid arthritis or psoriatic arthritis. In this portion of the study, a positive association was noted between HADS scores and C-reactive protein levels in the psoriatic arthritis cohort, although it must be noted that CRP scores accounted for only 7% of the overall variance in HADS scores. Higher HADS scores were associated with worse quality of life as assessed by the Dermatology Quality of Life Questionnaire as well as with higher scores on a self-rated pain scale.

A negative correlation was found between HADS scores and emotional intelligence as measured by the Trait Emotional Intelligence Questionnaire – Short Form. High trait emotional intelligence reflects greater awareness of one's own feelings as well as the feelings of others. Individuals with high emotional intelligence are better able to regulate their emotions than are those with lower trait emotional intelligence.

Patients who scored high in trait emotional intelligence had higher quality of life scores, lower CRP levels, and lower scores on the pain scale.

These findings are consistent with the hypothesis that a poor ability to be aware of and regulate one's emotions predisposes to depression in the presence of a chronic medical condition or other major stressor, said to Dr. Krishnadas, who declared having no conflicts of interest.

EDINBURGH — Depression is common, underdiagnosed, and undertreated in patients with psoriatic arthritis.

Psychiatric evaluation of 50 consecutive patients at the University of Glasgow psoriatic arthritis clinic indicated that 15 patients (30%) were depressed. Three were rated as severely depressed based on their scores on the Hospital Anxiety and Depression Scale (HADS); 12 others had moderate depression, Dr. Rajeev Krishnadas reported.

This high prevalence of depression in psoriatic arthritis patients is consistent with reports in the dermatologic literature (Br. J. Dermatol. 2008;159:704–10).

Of note, none of the depressed Scottish patients was on a therapeutic dose of an antidepressant, added Dr. Krishnadas of the Sackler Institute of Psychobiological Research, Southern General Hospital, Glasgow.

This study is part of a larger ongoing investigation into the relationship between systemic inflammation and depression in patients with rheumatoid arthritis or psoriatic arthritis. In this portion of the study, a positive association was noted between HADS scores and C-reactive protein levels in the psoriatic arthritis cohort, although it must be noted that CRP scores accounted for only 7% of the overall variance in HADS scores. Higher HADS scores were associated with worse quality of life as assessed by the Dermatology Quality of Life Questionnaire as well as with higher scores on a self-rated pain scale.

A negative correlation was found between HADS scores and emotional intelligence as measured by the Trait Emotional Intelligence Questionnaire – Short Form. High trait emotional intelligence reflects greater awareness of one's own feelings as well as the feelings of others. Individuals with high emotional intelligence are better able to regulate their emotions than are those with lower trait emotional intelligence.

Patients who scored high in trait emotional intelligence had higher quality of life scores, lower CRP levels, and lower scores on the pain scale.

These findings are consistent with the hypothesis that a poor ability to be aware of and regulate one's emotions predisposes to depression in the presence of a chronic medical condition or other major stressor, said to Dr. Krishnadas, who declared having no conflicts of interest.

EDINBURGH — Depression is common, underdiagnosed, and undertreated in patients with psoriatic arthritis.

Psychiatric evaluation of 50 consecutive patients at the University of Glasgow psoriatic arthritis clinic indicated that 15 patients (30%) were depressed. Three were rated as severely depressed based on their scores on the Hospital Anxiety and Depression Scale (HADS); 12 others had moderate depression, Dr. Rajeev Krishnadas reported.

This high prevalence of depression in psoriatic arthritis patients is consistent with reports in the dermatologic literature (Br. J. Dermatol. 2008;159:704–10).

Of note, none of the depressed Scottish patients was on a therapeutic dose of an antidepressant, added Dr. Krishnadas of the Sackler Institute of Psychobiological Research, Southern General Hospital, Glasgow.

This study is part of a larger ongoing investigation into the relationship between systemic inflammation and depression in patients with rheumatoid arthritis or psoriatic arthritis. In this portion of the study, a positive association was noted between HADS scores and C-reactive protein levels in the psoriatic arthritis cohort, although it must be noted that CRP scores accounted for only 7% of the overall variance in HADS scores. Higher HADS scores were associated with worse quality of life as assessed by the Dermatology Quality of Life Questionnaire as well as with higher scores on a self-rated pain scale.

A negative correlation was found between HADS scores and emotional intelligence as measured by the Trait Emotional Intelligence Questionnaire – Short Form. High trait emotional intelligence reflects greater awareness of one's own feelings as well as the feelings of others. Individuals with high emotional intelligence are better able to regulate their emotions than are those with lower trait emotional intelligence.

Patients who scored high in trait emotional intelligence had higher quality of life scores, lower CRP levels, and lower scores on the pain scale.

These findings are consistent with the hypothesis that a poor ability to be aware of and regulate one's emotions predisposes to depression in the presence of a chronic medical condition or other major stressor, said to Dr. Krishnadas, who declared having no conflicts of interest.

VAIL, COLO. — A 5-year-old boy finds a used condom in the park. He decides it's a really cool balloon, so he puts it in his mouth and tries to blow it up.

Would you offer HIV postexposure prophylaxis or not?

How about prophylaxis for a 3-year-old girl with an accidental fingerstick from a needle she found while playing in a park? Or for an 18-month-old girl in a homeless shelter who reached under a sofa cushion and discovered treasure in the form of an old tampon with dried blood on it, which she promptly put in her mouth? Or a 3-year-old boy who cut himself on the cheek while pretending to shave with a used razor belonging to his HIV-positive uncle?

The pediatric infectious diseases staff at the Children's Hospital, Denver, has encountered all of these situations. Those clinicians recommended HIV postexposure prophylaxis in only one of the four cases: the boy who sustained a large laceration while playing with his HIV-positive uncle's razor, Heather R. Heizer said at the conference which was sponsored by the hospital.

That is consistent with a generally conservative approach to postexposure prophylaxis that prevails among the hospital's infectious diseases staff. That stance is based upon the intervention's substantial financial cost, significant toxicities, and a complete absence of pediatric clinical trials data that might help guide clinical decision making, explained Ms. Heizer, a physician assistant and instructor in pediatrics at the hospital and the University of Colorado, Denver.

When the Denver pediatric infectious diseases staff does offer HIV postexposure prophylaxis following nonsexual, nonoccupational exposures, the favored approach – based largely upon animal studies – is a triple-drug antiviral regimen that is prescribed for 28 days, but only if it can be started within 72 hours of the exposure.

In children younger than age 13 years who may have difficulty swallowing pills, the staff generally uses 28 days of zidovudine (Retrovir), lamivudine (Epivir), and Kaletra (a combination of lopinavir plus ritonavir), because all are available in liquid formulations. Older children receive Combivir (zidovudine plus lamivudine) and Truvada (tenofovir plus emtricitabine), or Combivir plus Kaletra.

HIV transmission requires exposure to an infectious body fluid (defined as blood, breast milk, semen, or vaginal secretions) through broken skin or mucous membranes. Saliva, tears, and urine are considered noninfectious unless blood is visibly present. The half-life of HIV in serum is about 1.2 days; the virus can survive only for about 6 hours extracellularly.

Returning to her specific case examples of potential HIV exposure, Ms. Heizer said that the pediatric infectious diseases staff declined to offer prophylaxis to the young girl in the homeless shelter with the bloody tampon. The tampon was old and the blood was dried, making for an extremely low HIV transmission risk.

Similarly, the boy with the “balloon” was deemed at very low risk because the condom was old and dried out, with no visible blood or semen.

The girl who stuck herself with a needle that she found in a park was not offered postexposure prophylaxis, Ms. Heizer explained, because there was no visible blood in the needle, the park wasn't thought to be a hangout for injection drug use, and exposure to discarded needles is generally thought to carry a low risk of transmission. That last point was demonstrated in a classic study of 308 children who were exposed to discarded needles and were subsequently tested for HIV: Not one case of transmission occurred (Pediatrics 1999;104:318-24).

More recently, pediatricians in Montreal reported on 274 patients with community-acquired needlestick injuries. In all, 82 received postexposure prophylaxis, of whom 69 completed the 4-week treatment course. No seroconversions occurred in the 274 patients, confirming that the transmission risk is quite low, Ms. Heizer noted.

She found that study particularly useful because it paints a picture of situations in which accidental pediatric needlesticks are most likely to occur, and to whom. About 29% of the needlesticks happened in a street or alley, and another 24% occurred in a park. The patients' mean age was 7.9 years. Nearly two-thirds of the injuries occurred in boys. In 65% of the injuries, the child purposely picked up the needle.

A particularly gratifying study finding was that three-quarters of the children with community-acquired needlestick injuries were brought to medical attention on the day of the injury (Pediatrics 2008;122:e487-92).

Ms. Heizer said she had no financial conflicts regarding her presentation.

VAIL, COLO. — A 5-year-old boy finds a used condom in the park. He decides it's a really cool balloon, so he puts it in his mouth and tries to blow it up.

Would you offer HIV postexposure prophylaxis or not?

How about prophylaxis for a 3-year-old girl with an accidental fingerstick from a needle she found while playing in a park? Or for an 18-month-old girl in a homeless shelter who reached under a sofa cushion and discovered treasure in the form of an old tampon with dried blood on it, which she promptly put in her mouth? Or a 3-year-old boy who cut himself on the cheek while pretending to shave with a used razor belonging to his HIV-positive uncle?

The pediatric infectious diseases staff at the Children's Hospital, Denver, has encountered all of these situations. Those clinicians recommended HIV postexposure prophylaxis in only one of the four cases: the boy who sustained a large laceration while playing with his HIV-positive uncle's razor, Heather R. Heizer said at the conference which was sponsored by the hospital.

That is consistent with a generally conservative approach to postexposure prophylaxis that prevails among the hospital's infectious diseases staff. That stance is based upon the intervention's substantial financial cost, significant toxicities, and a complete absence of pediatric clinical trials data that might help guide clinical decision making, explained Ms. Heizer, a physician assistant and instructor in pediatrics at the hospital and the University of Colorado, Denver.

When the Denver pediatric infectious diseases staff does offer HIV postexposure prophylaxis following nonsexual, nonoccupational exposures, the favored approach – based largely upon animal studies – is a triple-drug antiviral regimen that is prescribed for 28 days, but only if it can be started within 72 hours of the exposure.

In children younger than age 13 years who may have difficulty swallowing pills, the staff generally uses 28 days of zidovudine (Retrovir), lamivudine (Epivir), and Kaletra (a combination of lopinavir plus ritonavir), because all are available in liquid formulations. Older children receive Combivir (zidovudine plus lamivudine) and Truvada (tenofovir plus emtricitabine), or Combivir plus Kaletra.

HIV transmission requires exposure to an infectious body fluid (defined as blood, breast milk, semen, or vaginal secretions) through broken skin or mucous membranes. Saliva, tears, and urine are considered noninfectious unless blood is visibly present. The half-life of HIV in serum is about 1.2 days; the virus can survive only for about 6 hours extracellularly.

Returning to her specific case examples of potential HIV exposure, Ms. Heizer said that the pediatric infectious diseases staff declined to offer prophylaxis to the young girl in the homeless shelter with the bloody tampon. The tampon was old and the blood was dried, making for an extremely low HIV transmission risk.

Similarly, the boy with the “balloon” was deemed at very low risk because the condom was old and dried out, with no visible blood or semen.

The girl who stuck herself with a needle that she found in a park was not offered postexposure prophylaxis, Ms. Heizer explained, because there was no visible blood in the needle, the park wasn't thought to be a hangout for injection drug use, and exposure to discarded needles is generally thought to carry a low risk of transmission. That last point was demonstrated in a classic study of 308 children who were exposed to discarded needles and were subsequently tested for HIV: Not one case of transmission occurred (Pediatrics 1999;104:318-24).

More recently, pediatricians in Montreal reported on 274 patients with community-acquired needlestick injuries. In all, 82 received postexposure prophylaxis, of whom 69 completed the 4-week treatment course. No seroconversions occurred in the 274 patients, confirming that the transmission risk is quite low, Ms. Heizer noted.

She found that study particularly useful because it paints a picture of situations in which accidental pediatric needlesticks are most likely to occur, and to whom. About 29% of the needlesticks happened in a street or alley, and another 24% occurred in a park. The patients' mean age was 7.9 years. Nearly two-thirds of the injuries occurred in boys. In 65% of the injuries, the child purposely picked up the needle.

A particularly gratifying study finding was that three-quarters of the children with community-acquired needlestick injuries were brought to medical attention on the day of the injury (Pediatrics 2008;122:e487-92).

Ms. Heizer said she had no financial conflicts regarding her presentation.

VAIL, COLO. — A 5-year-old boy finds a used condom in the park. He decides it's a really cool balloon, so he puts it in his mouth and tries to blow it up.

Would you offer HIV postexposure prophylaxis or not?

How about prophylaxis for a 3-year-old girl with an accidental fingerstick from a needle she found while playing in a park? Or for an 18-month-old girl in a homeless shelter who reached under a sofa cushion and discovered treasure in the form of an old tampon with dried blood on it, which she promptly put in her mouth? Or a 3-year-old boy who cut himself on the cheek while pretending to shave with a used razor belonging to his HIV-positive uncle?

The pediatric infectious diseases staff at the Children's Hospital, Denver, has encountered all of these situations. Those clinicians recommended HIV postexposure prophylaxis in only one of the four cases: the boy who sustained a large laceration while playing with his HIV-positive uncle's razor, Heather R. Heizer said at the conference which was sponsored by the hospital.

That is consistent with a generally conservative approach to postexposure prophylaxis that prevails among the hospital's infectious diseases staff. That stance is based upon the intervention's substantial financial cost, significant toxicities, and a complete absence of pediatric clinical trials data that might help guide clinical decision making, explained Ms. Heizer, a physician assistant and instructor in pediatrics at the hospital and the University of Colorado, Denver.

When the Denver pediatric infectious diseases staff does offer HIV postexposure prophylaxis following nonsexual, nonoccupational exposures, the favored approach – based largely upon animal studies – is a triple-drug antiviral regimen that is prescribed for 28 days, but only if it can be started within 72 hours of the exposure.

In children younger than age 13 years who may have difficulty swallowing pills, the staff generally uses 28 days of zidovudine (Retrovir), lamivudine (Epivir), and Kaletra (a combination of lopinavir plus ritonavir), because all are available in liquid formulations. Older children receive Combivir (zidovudine plus lamivudine) and Truvada (tenofovir plus emtricitabine), or Combivir plus Kaletra.

HIV transmission requires exposure to an infectious body fluid (defined as blood, breast milk, semen, or vaginal secretions) through broken skin or mucous membranes. Saliva, tears, and urine are considered noninfectious unless blood is visibly present. The half-life of HIV in serum is about 1.2 days; the virus can survive only for about 6 hours extracellularly.

Returning to her specific case examples of potential HIV exposure, Ms. Heizer said that the pediatric infectious diseases staff declined to offer prophylaxis to the young girl in the homeless shelter with the bloody tampon. The tampon was old and the blood was dried, making for an extremely low HIV transmission risk.

Similarly, the boy with the “balloon” was deemed at very low risk because the condom was old and dried out, with no visible blood or semen.

The girl who stuck herself with a needle that she found in a park was not offered postexposure prophylaxis, Ms. Heizer explained, because there was no visible blood in the needle, the park wasn't thought to be a hangout for injection drug use, and exposure to discarded needles is generally thought to carry a low risk of transmission. That last point was demonstrated in a classic study of 308 children who were exposed to discarded needles and were subsequently tested for HIV: Not one case of transmission occurred (Pediatrics 1999;104:318-24).

More recently, pediatricians in Montreal reported on 274 patients with community-acquired needlestick injuries. In all, 82 received postexposure prophylaxis, of whom 69 completed the 4-week treatment course. No seroconversions occurred in the 274 patients, confirming that the transmission risk is quite low, Ms. Heizer noted.

She found that study particularly useful because it paints a picture of situations in which accidental pediatric needlesticks are most likely to occur, and to whom. About 29% of the needlesticks happened in a street or alley, and another 24% occurred in a park. The patients' mean age was 7.9 years. Nearly two-thirds of the injuries occurred in boys. In 65% of the injuries, the child purposely picked up the needle.

A particularly gratifying study finding was that three-quarters of the children with community-acquired needlestick injuries were brought to medical attention on the day of the injury (Pediatrics 2008;122:e487-92).

Ms. Heizer said she had no financial conflicts regarding her presentation.

DENVER — Doubling the currently low alcohol tax would result in roughly a 35% reduction in direct alcohol-related mortality as well as substantial benefits across a range of other important public health outcomes, a meta-analysis has shown.

“We have a lot of literature. This is probably the most studied preventive health policy issue. The magnitude of the observed effects is larger and more consistent than for most other preventive efforts that've been studied,” Alexander C. Wagenaar, Ph.D., said at the meeting.

He presented a meta-analysis based on what he described as “an exhaustive search” of the past 50 years of published studies on the effects of alcohol tax pricing policies on a whole range of public health outcomes.

In summary, a 10% increase in the alcohol tax and a commensurate price increase would result in an across-the-board 5% reduction in drinking across all groups: underage teens as well as adults, moderate as well as heavy drinkers.

The meta-analysis of 50 studies showed that doubling the alcohol tax would be associated on average with a 35% reduction in deaths due to cirrhosis, some cancers, and other directly alcohol-related causes; an 11% drop in traffic crash morbidity and mortality; a 6% decrease in sexually transmitted infections; a 2% reduction in violence; and a 1% decrease in crime and delinquent misbehavior. All of these effects were statistically significant, according to Dr. Wagenaar, professor of epidemiology and health policy at the University of Florida, Gainesville.

“This is a policy that applies at the population level. It's not just for the high-risk group, it's not only for the people that get into treatment. When a tax change is implemented, it changes the environment slightly across the entire population such that there's a reduction in drinking, and that effect ripples across these whole sets of alcohol-related outcomes,” explained the researcher, whose prior health policy studies have been credited as playing a key role in establishing the uniform nationwide drinking age of 21.

Suicide was the only outcome the investigators studied that didn't show a significant decrease in response to an increased tax on alcohol. Most of the 11 relevant studies have been conducted by only two research groups.

“There's not enough evidence yet to determine conclusively whether change in alcohol taxes influences suicide rates,” Dr. Wagenaar said.

He pointed out several practical advantages to raising the alcohol tax, beyond the striking public health benefits.

An alcohol tax increase would generate additional revenues that could be used to fund other public health objectives or to bolster the general fund. No costly new bureaucratic infrastructure is required to implement an alcohol tax increase; the tax structures are already present. And alcohol tax rates are now at historic lows because they're volume-based and aren't adjusted for inflation.

“That's how we've gotten into this situation where the tax rates now are only a fraction of what they were in the 1950s, '60s, and '70s. If we were to simply return the tax rates in most jurisdictions to the rates that were in place in the '60s and '70s, we would see the kinds of effects that we're seeing in the meta-analysis, because in many areas that would involve a doubling of the tax rates,” Dr. Wagenaar said.

In response to an audience question, he said the available evidence indicates there is no threshold effect for the relationship between alcohol tax increases and public health benefits. In other words, if the alcohol tax is increased by, say, one-quarter, public health benefits will accrue, albeit not with the same large effect sizes as with a doubling of the tax.

Dr. Wagenaar's study was funded by the Robert Wood Johnson Foundation. He said he has no relevant financial conflicts of interest.

A 10% tax increase and a price increase would result in a 5% reduction in drinking across all groups.

Source DR. WAGENAAR

A change in the alcohol tax has a ripple effect “at the population level.”

Source ©Dethchimo/Fotolia.com

DENVER — Doubling the currently low alcohol tax would result in roughly a 35% reduction in direct alcohol-related mortality as well as substantial benefits across a range of other important public health outcomes, a meta-analysis has shown.

“We have a lot of literature. This is probably the most studied preventive health policy issue. The magnitude of the observed effects is larger and more consistent than for most other preventive efforts that've been studied,” Alexander C. Wagenaar, Ph.D., said at the meeting.

He presented a meta-analysis based on what he described as “an exhaustive search” of the past 50 years of published studies on the effects of alcohol tax pricing policies on a whole range of public health outcomes.

In summary, a 10% increase in the alcohol tax and a commensurate price increase would result in an across-the-board 5% reduction in drinking across all groups: underage teens as well as adults, moderate as well as heavy drinkers.

The meta-analysis of 50 studies showed that doubling the alcohol tax would be associated on average with a 35% reduction in deaths due to cirrhosis, some cancers, and other directly alcohol-related causes; an 11% drop in traffic crash morbidity and mortality; a 6% decrease in sexually transmitted infections; a 2% reduction in violence; and a 1% decrease in crime and delinquent misbehavior. All of these effects were statistically significant, according to Dr. Wagenaar, professor of epidemiology and health policy at the University of Florida, Gainesville.

“This is a policy that applies at the population level. It's not just for the high-risk group, it's not only for the people that get into treatment. When a tax change is implemented, it changes the environment slightly across the entire population such that there's a reduction in drinking, and that effect ripples across these whole sets of alcohol-related outcomes,” explained the researcher, whose prior health policy studies have been credited as playing a key role in establishing the uniform nationwide drinking age of 21.

Suicide was the only outcome the investigators studied that didn't show a significant decrease in response to an increased tax on alcohol. Most of the 11 relevant studies have been conducted by only two research groups.

“There's not enough evidence yet to determine conclusively whether change in alcohol taxes influences suicide rates,” Dr. Wagenaar said.

He pointed out several practical advantages to raising the alcohol tax, beyond the striking public health benefits.

An alcohol tax increase would generate additional revenues that could be used to fund other public health objectives or to bolster the general fund. No costly new bureaucratic infrastructure is required to implement an alcohol tax increase; the tax structures are already present. And alcohol tax rates are now at historic lows because they're volume-based and aren't adjusted for inflation.

“That's how we've gotten into this situation where the tax rates now are only a fraction of what they were in the 1950s, '60s, and '70s. If we were to simply return the tax rates in most jurisdictions to the rates that were in place in the '60s and '70s, we would see the kinds of effects that we're seeing in the meta-analysis, because in many areas that would involve a doubling of the tax rates,” Dr. Wagenaar said.

In response to an audience question, he said the available evidence indicates there is no threshold effect for the relationship between alcohol tax increases and public health benefits. In other words, if the alcohol tax is increased by, say, one-quarter, public health benefits will accrue, albeit not with the same large effect sizes as with a doubling of the tax.

Dr. Wagenaar's study was funded by the Robert Wood Johnson Foundation. He said he has no relevant financial conflicts of interest.

A 10% tax increase and a price increase would result in a 5% reduction in drinking across all groups.

Source DR. WAGENAAR

A change in the alcohol tax has a ripple effect “at the population level.”

Source ©Dethchimo/Fotolia.com

DENVER — Doubling the currently low alcohol tax would result in roughly a 35% reduction in direct alcohol-related mortality as well as substantial benefits across a range of other important public health outcomes, a meta-analysis has shown.

“We have a lot of literature. This is probably the most studied preventive health policy issue. The magnitude of the observed effects is larger and more consistent than for most other preventive efforts that've been studied,” Alexander C. Wagenaar, Ph.D., said at the meeting.

He presented a meta-analysis based on what he described as “an exhaustive search” of the past 50 years of published studies on the effects of alcohol tax pricing policies on a whole range of public health outcomes.

In summary, a 10% increase in the alcohol tax and a commensurate price increase would result in an across-the-board 5% reduction in drinking across all groups: underage teens as well as adults, moderate as well as heavy drinkers.

The meta-analysis of 50 studies showed that doubling the alcohol tax would be associated on average with a 35% reduction in deaths due to cirrhosis, some cancers, and other directly alcohol-related causes; an 11% drop in traffic crash morbidity and mortality; a 6% decrease in sexually transmitted infections; a 2% reduction in violence; and a 1% decrease in crime and delinquent misbehavior. All of these effects were statistically significant, according to Dr. Wagenaar, professor of epidemiology and health policy at the University of Florida, Gainesville.

“This is a policy that applies at the population level. It's not just for the high-risk group, it's not only for the people that get into treatment. When a tax change is implemented, it changes the environment slightly across the entire population such that there's a reduction in drinking, and that effect ripples across these whole sets of alcohol-related outcomes,” explained the researcher, whose prior health policy studies have been credited as playing a key role in establishing the uniform nationwide drinking age of 21.

Suicide was the only outcome the investigators studied that didn't show a significant decrease in response to an increased tax on alcohol. Most of the 11 relevant studies have been conducted by only two research groups.

“There's not enough evidence yet to determine conclusively whether change in alcohol taxes influences suicide rates,” Dr. Wagenaar said.

He pointed out several practical advantages to raising the alcohol tax, beyond the striking public health benefits.

An alcohol tax increase would generate additional revenues that could be used to fund other public health objectives or to bolster the general fund. No costly new bureaucratic infrastructure is required to implement an alcohol tax increase; the tax structures are already present. And alcohol tax rates are now at historic lows because they're volume-based and aren't adjusted for inflation.

“That's how we've gotten into this situation where the tax rates now are only a fraction of what they were in the 1950s, '60s, and '70s. If we were to simply return the tax rates in most jurisdictions to the rates that were in place in the '60s and '70s, we would see the kinds of effects that we're seeing in the meta-analysis, because in many areas that would involve a doubling of the tax rates,” Dr. Wagenaar said.

In response to an audience question, he said the available evidence indicates there is no threshold effect for the relationship between alcohol tax increases and public health benefits. In other words, if the alcohol tax is increased by, say, one-quarter, public health benefits will accrue, albeit not with the same large effect sizes as with a doubling of the tax.

Dr. Wagenaar's study was funded by the Robert Wood Johnson Foundation. He said he has no relevant financial conflicts of interest.

A 10% tax increase and a price increase would result in a 5% reduction in drinking across all groups.

Source DR. WAGENAAR

A change in the alcohol tax has a ripple effect “at the population level.”

Source ©Dethchimo/Fotolia.com

Major Finding: Complete clearance of actinic keratoses was achieved in 41% of patients treated wtih diclofenac 3% gel, compared to 0% in the control group.

Data Source: The 32 organ transplant patients were randomized 3-to-1 to diclofenac or a vehicle control.

Disclosures: Dr. Stockfleth disclosed serving as a consultant to Graceway, Almirall, Spirig, Itendis, Meda, Abbott, and Leo.

GOTHENBURG, SWEDEN – Topical diclofenac 3% gel proved effective for the treatment of actinic keratoses in organ transplant recipients, according to the results of a new study.

Sixteen weeks of twice-daily therapy with 3% diclofenac in 2.5% hyaluronic acid (Solaraze) not only proved effective and well tolerated for actinic keratoses (AK) clearance in a randomized, placebo-controlled trial, it also prevented invasive squamous cell carcinomas (SCCs) in organ transplant recipients, Dr. Eggert Stockfleth reported at the congress.

Based upon an earlier favorable but uncontrolled six-patient series (Br. J. Dermatol. 2007;156 Suppl. 3:40-2), Dr. Stockfleth and his coworkers conducted a follow-up randomized trial of topical diclofenace 3% gel in 32 organ transplant recipients.

Organ transplant recipients' immunocompromised status makes them highly vulnerable to multiple invasive SCCs, he said. As graft survival has improved over time, the high incidence of aggressive cutaneous malignancies in transplant recipients has grown into a major concern.

In Australia and New Zealand, cancer is now the No. 1 cause of death in organ transplant recipients, not heart disease, graft rejection, or infection. The risk of aggressive skin cancers in these patients is far higher than that of other malignancies, said Dr. Stockfleth, director of the skin cancer center at Charité University Hospital, Berlin.

The 32 study participants were randomized 3-to-1 to diclofenac or a vehicle control. Study eligibility required a stable graft during the previous 12 months plus three or more AKs in a 50-cm

Twenty-eight patients (88%) completed the 16-week, twice-daily treatment phase and presented for final evaluation 4 weeks later. Complete clearance of AKs was achieved in 9 of 22 (41%) of the diclofenac group, compared to 0 of 6 controls.

Side effects were limited to mild erythema and mild to moderate swelling of treated areas.

With further follow-up, 55% of the patients who had previously cleared developed new AKs in the treated areas an average of 9.3 months after treatment ended. None of these patients developed invasive SCC in the study area within 24 months of follow-up, suggesting that topical diclofenac gel may also prevent invasive SCCs in this high-risk population.

Therapy with 3% diclofenac acid also prevented invasive squamous cell carcinomas.

Source DR. STOCKFLETH

Major Finding: Complete clearance of actinic keratoses was achieved in 41% of patients treated wtih diclofenac 3% gel, compared to 0% in the control group.

Data Source: The 32 organ transplant patients were randomized 3-to-1 to diclofenac or a vehicle control.

Disclosures: Dr. Stockfleth disclosed serving as a consultant to Graceway, Almirall, Spirig, Itendis, Meda, Abbott, and Leo.

GOTHENBURG, SWEDEN – Topical diclofenac 3% gel proved effective for the treatment of actinic keratoses in organ transplant recipients, according to the results of a new study.

Sixteen weeks of twice-daily therapy with 3% diclofenac in 2.5% hyaluronic acid (Solaraze) not only proved effective and well tolerated for actinic keratoses (AK) clearance in a randomized, placebo-controlled trial, it also prevented invasive squamous cell carcinomas (SCCs) in organ transplant recipients, Dr. Eggert Stockfleth reported at the congress.

Based upon an earlier favorable but uncontrolled six-patient series (Br. J. Dermatol. 2007;156 Suppl. 3:40-2), Dr. Stockfleth and his coworkers conducted a follow-up randomized trial of topical diclofenace 3% gel in 32 organ transplant recipients.

Organ transplant recipients' immunocompromised status makes them highly vulnerable to multiple invasive SCCs, he said. As graft survival has improved over time, the high incidence of aggressive cutaneous malignancies in transplant recipients has grown into a major concern.

In Australia and New Zealand, cancer is now the No. 1 cause of death in organ transplant recipients, not heart disease, graft rejection, or infection. The risk of aggressive skin cancers in these patients is far higher than that of other malignancies, said Dr. Stockfleth, director of the skin cancer center at Charité University Hospital, Berlin.

The 32 study participants were randomized 3-to-1 to diclofenac or a vehicle control. Study eligibility required a stable graft during the previous 12 months plus three or more AKs in a 50-cm

Twenty-eight patients (88%) completed the 16-week, twice-daily treatment phase and presented for final evaluation 4 weeks later. Complete clearance of AKs was achieved in 9 of 22 (41%) of the diclofenac group, compared to 0 of 6 controls.

Side effects were limited to mild erythema and mild to moderate swelling of treated areas.

With further follow-up, 55% of the patients who had previously cleared developed new AKs in the treated areas an average of 9.3 months after treatment ended. None of these patients developed invasive SCC in the study area within 24 months of follow-up, suggesting that topical diclofenac gel may also prevent invasive SCCs in this high-risk population.

Therapy with 3% diclofenac acid also prevented invasive squamous cell carcinomas.

Source DR. STOCKFLETH

Major Finding: Complete clearance of actinic keratoses was achieved in 41% of patients treated wtih diclofenac 3% gel, compared to 0% in the control group.

Data Source: The 32 organ transplant patients were randomized 3-to-1 to diclofenac or a vehicle control.

Disclosures: Dr. Stockfleth disclosed serving as a consultant to Graceway, Almirall, Spirig, Itendis, Meda, Abbott, and Leo.

GOTHENBURG, SWEDEN – Topical diclofenac 3% gel proved effective for the treatment of actinic keratoses in organ transplant recipients, according to the results of a new study.

Sixteen weeks of twice-daily therapy with 3% diclofenac in 2.5% hyaluronic acid (Solaraze) not only proved effective and well tolerated for actinic keratoses (AK) clearance in a randomized, placebo-controlled trial, it also prevented invasive squamous cell carcinomas (SCCs) in organ transplant recipients, Dr. Eggert Stockfleth reported at the congress.

Based upon an earlier favorable but uncontrolled six-patient series (Br. J. Dermatol. 2007;156 Suppl. 3:40-2), Dr. Stockfleth and his coworkers conducted a follow-up randomized trial of topical diclofenace 3% gel in 32 organ transplant recipients.

Organ transplant recipients' immunocompromised status makes them highly vulnerable to multiple invasive SCCs, he said. As graft survival has improved over time, the high incidence of aggressive cutaneous malignancies in transplant recipients has grown into a major concern.

In Australia and New Zealand, cancer is now the No. 1 cause of death in organ transplant recipients, not heart disease, graft rejection, or infection. The risk of aggressive skin cancers in these patients is far higher than that of other malignancies, said Dr. Stockfleth, director of the skin cancer center at Charité University Hospital, Berlin.

The 32 study participants were randomized 3-to-1 to diclofenac or a vehicle control. Study eligibility required a stable graft during the previous 12 months plus three or more AKs in a 50-cm

Twenty-eight patients (88%) completed the 16-week, twice-daily treatment phase and presented for final evaluation 4 weeks later. Complete clearance of AKs was achieved in 9 of 22 (41%) of the diclofenac group, compared to 0 of 6 controls.

Side effects were limited to mild erythema and mild to moderate swelling of treated areas.

With further follow-up, 55% of the patients who had previously cleared developed new AKs in the treated areas an average of 9.3 months after treatment ended. None of these patients developed invasive SCC in the study area within 24 months of follow-up, suggesting that topical diclofenac gel may also prevent invasive SCCs in this high-risk population.

Therapy with 3% diclofenac acid also prevented invasive squamous cell carcinomas.

Source DR. STOCKFLETH

GOTHENBURG, SWEDEN — Consider rapidly growing nontuberculous mycobacteria infection as a distinct possibility in patients who present with a rash or other skin lesions within a new tattoo.

That's the advice of Mayo Clinic dermatologist Dr. Lisa A. Drage, who encountered six affected patients in relatively short order, all with tattoos done by the same artist at a single Rochester, Minn., tattoo parlor.

The likely source of this outbreak of Mycobacterium chelonae infection was the tap water the tattoo artist used to dilute black ink to create shades of gray for the popular gray wash technique, which creates a subtle photographic effect, she explained at the annual congress of the European Academy of Dermatology and Venereology.

The tipoff that the likely contaminant was tap water was that the skin lesions, although varied in appearance, were concentrated in the gray areas of the tattoos, with the deep black areas and clear-skin uninked portions largely spared, she said.

More broadly, she suggested keeping M. chelonae and the other rapidly growing mycobacteria (RGM) in mind when diagnosing any patient with a postprocedure skin infection that's not responding to appropriate antibiotic therapy.

“RGMs are underrecognized, underreported, and we think they're increasing in prevalence,” the dermatologist said.

“I think 'staph' first because it's so much more common. But if an infection isn't responding within a couple of weeks and tests show it's not methicillin-resistant staph – and especially if there's been a procedure – think RGM,” Dr. Drage said.

The reason RGM infections are underdiagnosed is that the culture techniques required to confirm the diagnosis are completely different from those utilized in conventional bacterial cultures. The techniques for nontuberculous mycobacteria (NTM) are quite involved, with multiple cultures needing to be started at a variety of temperatures, since some RGM will grow only at 28°–30°C while others require 35°–37°C. Unlike the case in M. tuberculosis infections, where polymerase chain reaction or other rapid diagnostic systems can be applied directly to the clinical specimen, the NTM organisms must first be grown out on solid culture media before DNA sequencing can be utilized to identify the species.

“Most physicians who send the specimen to the laboratory fail to order the appropriate test. If you just send it for bacteriologic testing, they won't do the specific techniques for mycobacteria, and you'll get a negative result. It's important to obtain cultures specifically for mycobacteria, along with susceptibility studies. I find it most helpful to speak with the lab so they know what I'm thinking and what to do,” she said.

The RGM, which include M. chelonae and M. fortuitum, are the most common NTM involved in community-acquired skin and soft-tissue infections. Indeed, M. fortuitum alone is believed to account for more than 60% of such infections.

These are environmental microorganisms; there is no person-to-person spread. Tap water is the most common source of contamination. The NTM reside in the biofilm. They are resistant to sterilizers, disinfectants, and antiseptics. Numerous infections have come from hospital water systems.

Cutaneous infections with RGM have been documented in association with a variety of procedures, including Mohs surgery, acupuncture, punch biopsy, liposuction, laser resurfacing and other cosmetic procedures, and tattooing. In one California study, 29 of 30 pedicure foot baths in 18 salons in five counties contained NTM.

The skin lesions typically appear within a couple of weeks after the procedure, but lengthy delay in diagnosis is common. Patients may initially shrug off the skin lesions as bug bites or something else not warranting medical attention. And once they visit a physician, further diagnostic delay often ensues. In the six Minnesota patients with M. chelonae infections in tattoos, for example, the skin lesions appeared 1-2 weeks after the tattoo was placed, and all patients sought medical care promptly, but they were treated for a diagnosis other than NTM infection. Indeed, the median time between tattoo placement and the correct diagnosis was 18 weeks.

Timely diagnosis of RGM infections is made more challenging by the highly variable clinical appearance of the skin lesions.

Painful red nodules that ulcerate and drain are one of the classic pictures. Pink or purple papules, granulomatous papules, pustules, plaques, folliculitis, cellulitis, and nonhealing ulcers can also be encountered.

“I've recently seen three patients referred for nonresponsive pyoderma gangrenosum that was actually due to NTM,” Dr. Drage recalled.

The histopathologic findings can vary widely as well. A tuberculoid granulomatous infiltrate is most helpful, but some patients may instead have a lymphohistiocytic infiltrate, palisading or sarcoidal granulomas, a mixed inflammatory infiltrate, or other nonspecific findings.

Acid-fast bacilli staining typically produces negative results.

Treatment of NTM skin infections is based entirely on susceptibility test results. There are no clearcut treatment guidelines. Many infections will be resistant to the more common antimicrobials, and it's quite common for resistance to emerge during the required lengthy course of treatment. How lengthy? The typical treatment duration required for a localized infection is about 4 months, climbing to 6 months for more severe or disseminated infection.

Oral clarithromycin at 500 mg twice daily is a good option to start with while awaiting the susceptibility test results, as it covers some of the more common NTM. Combination therapy is often employed to prevent or treat resistance. Surgical removal of isolated foci of infection is often helpful, according to Dr. Drage.

She reported having no relevant financial conflicts.

An outbreak of M. chelonae originated from tap water used to dilute black ink.

Source ©Davide Cardello/Fotolia.com

GOTHENBURG, SWEDEN — Consider rapidly growing nontuberculous mycobacteria infection as a distinct possibility in patients who present with a rash or other skin lesions within a new tattoo.

That's the advice of Mayo Clinic dermatologist Dr. Lisa A. Drage, who encountered six affected patients in relatively short order, all with tattoos done by the same artist at a single Rochester, Minn., tattoo parlor.

The likely source of this outbreak of Mycobacterium chelonae infection was the tap water the tattoo artist used to dilute black ink to create shades of gray for the popular gray wash technique, which creates a subtle photographic effect, she explained at the annual congress of the European Academy of Dermatology and Venereology.

The tipoff that the likely contaminant was tap water was that the skin lesions, although varied in appearance, were concentrated in the gray areas of the tattoos, with the deep black areas and clear-skin uninked portions largely spared, she said.

More broadly, she suggested keeping M. chelonae and the other rapidly growing mycobacteria (RGM) in mind when diagnosing any patient with a postprocedure skin infection that's not responding to appropriate antibiotic therapy.

“RGMs are underrecognized, underreported, and we think they're increasing in prevalence,” the dermatologist said.

“I think 'staph' first because it's so much more common. But if an infection isn't responding within a couple of weeks and tests show it's not methicillin-resistant staph – and especially if there's been a procedure – think RGM,” Dr. Drage said.

The reason RGM infections are underdiagnosed is that the culture techniques required to confirm the diagnosis are completely different from those utilized in conventional bacterial cultures. The techniques for nontuberculous mycobacteria (NTM) are quite involved, with multiple cultures needing to be started at a variety of temperatures, since some RGM will grow only at 28°–30°C while others require 35°–37°C. Unlike the case in M. tuberculosis infections, where polymerase chain reaction or other rapid diagnostic systems can be applied directly to the clinical specimen, the NTM organisms must first be grown out on solid culture media before DNA sequencing can be utilized to identify the species.

“Most physicians who send the specimen to the laboratory fail to order the appropriate test. If you just send it for bacteriologic testing, they won't do the specific techniques for mycobacteria, and you'll get a negative result. It's important to obtain cultures specifically for mycobacteria, along with susceptibility studies. I find it most helpful to speak with the lab so they know what I'm thinking and what to do,” she said.

The RGM, which include M. chelonae and M. fortuitum, are the most common NTM involved in community-acquired skin and soft-tissue infections. Indeed, M. fortuitum alone is believed to account for more than 60% of such infections.

These are environmental microorganisms; there is no person-to-person spread. Tap water is the most common source of contamination. The NTM reside in the biofilm. They are resistant to sterilizers, disinfectants, and antiseptics. Numerous infections have come from hospital water systems.

Cutaneous infections with RGM have been documented in association with a variety of procedures, including Mohs surgery, acupuncture, punch biopsy, liposuction, laser resurfacing and other cosmetic procedures, and tattooing. In one California study, 29 of 30 pedicure foot baths in 18 salons in five counties contained NTM.

The skin lesions typically appear within a couple of weeks after the procedure, but lengthy delay in diagnosis is common. Patients may initially shrug off the skin lesions as bug bites or something else not warranting medical attention. And once they visit a physician, further diagnostic delay often ensues. In the six Minnesota patients with M. chelonae infections in tattoos, for example, the skin lesions appeared 1-2 weeks after the tattoo was placed, and all patients sought medical care promptly, but they were treated for a diagnosis other than NTM infection. Indeed, the median time between tattoo placement and the correct diagnosis was 18 weeks.

Timely diagnosis of RGM infections is made more challenging by the highly variable clinical appearance of the skin lesions.

Painful red nodules that ulcerate and drain are one of the classic pictures. Pink or purple papules, granulomatous papules, pustules, plaques, folliculitis, cellulitis, and nonhealing ulcers can also be encountered.

“I've recently seen three patients referred for nonresponsive pyoderma gangrenosum that was actually due to NTM,” Dr. Drage recalled.

The histopathologic findings can vary widely as well. A tuberculoid granulomatous infiltrate is most helpful, but some patients may instead have a lymphohistiocytic infiltrate, palisading or sarcoidal granulomas, a mixed inflammatory infiltrate, or other nonspecific findings.

Acid-fast bacilli staining typically produces negative results.

Treatment of NTM skin infections is based entirely on susceptibility test results. There are no clearcut treatment guidelines. Many infections will be resistant to the more common antimicrobials, and it's quite common for resistance to emerge during the required lengthy course of treatment. How lengthy? The typical treatment duration required for a localized infection is about 4 months, climbing to 6 months for more severe or disseminated infection.

Oral clarithromycin at 500 mg twice daily is a good option to start with while awaiting the susceptibility test results, as it covers some of the more common NTM. Combination therapy is often employed to prevent or treat resistance. Surgical removal of isolated foci of infection is often helpful, according to Dr. Drage.

She reported having no relevant financial conflicts.

An outbreak of M. chelonae originated from tap water used to dilute black ink.

Source ©Davide Cardello/Fotolia.com

GOTHENBURG, SWEDEN — Consider rapidly growing nontuberculous mycobacteria infection as a distinct possibility in patients who present with a rash or other skin lesions within a new tattoo.

That's the advice of Mayo Clinic dermatologist Dr. Lisa A. Drage, who encountered six affected patients in relatively short order, all with tattoos done by the same artist at a single Rochester, Minn., tattoo parlor.

The likely source of this outbreak of Mycobacterium chelonae infection was the tap water the tattoo artist used to dilute black ink to create shades of gray for the popular gray wash technique, which creates a subtle photographic effect, she explained at the annual congress of the European Academy of Dermatology and Venereology.

The tipoff that the likely contaminant was tap water was that the skin lesions, although varied in appearance, were concentrated in the gray areas of the tattoos, with the deep black areas and clear-skin uninked portions largely spared, she said.

More broadly, she suggested keeping M. chelonae and the other rapidly growing mycobacteria (RGM) in mind when diagnosing any patient with a postprocedure skin infection that's not responding to appropriate antibiotic therapy.

“RGMs are underrecognized, underreported, and we think they're increasing in prevalence,” the dermatologist said.

“I think 'staph' first because it's so much more common. But if an infection isn't responding within a couple of weeks and tests show it's not methicillin-resistant staph – and especially if there's been a procedure – think RGM,” Dr. Drage said.

The reason RGM infections are underdiagnosed is that the culture techniques required to confirm the diagnosis are completely different from those utilized in conventional bacterial cultures. The techniques for nontuberculous mycobacteria (NTM) are quite involved, with multiple cultures needing to be started at a variety of temperatures, since some RGM will grow only at 28°–30°C while others require 35°–37°C. Unlike the case in M. tuberculosis infections, where polymerase chain reaction or other rapid diagnostic systems can be applied directly to the clinical specimen, the NTM organisms must first be grown out on solid culture media before DNA sequencing can be utilized to identify the species.

“Most physicians who send the specimen to the laboratory fail to order the appropriate test. If you just send it for bacteriologic testing, they won't do the specific techniques for mycobacteria, and you'll get a negative result. It's important to obtain cultures specifically for mycobacteria, along with susceptibility studies. I find it most helpful to speak with the lab so they know what I'm thinking and what to do,” she said.

The RGM, which include M. chelonae and M. fortuitum, are the most common NTM involved in community-acquired skin and soft-tissue infections. Indeed, M. fortuitum alone is believed to account for more than 60% of such infections.

These are environmental microorganisms; there is no person-to-person spread. Tap water is the most common source of contamination. The NTM reside in the biofilm. They are resistant to sterilizers, disinfectants, and antiseptics. Numerous infections have come from hospital water systems.

Cutaneous infections with RGM have been documented in association with a variety of procedures, including Mohs surgery, acupuncture, punch biopsy, liposuction, laser resurfacing and other cosmetic procedures, and tattooing. In one California study, 29 of 30 pedicure foot baths in 18 salons in five counties contained NTM.

The skin lesions typically appear within a couple of weeks after the procedure, but lengthy delay in diagnosis is common. Patients may initially shrug off the skin lesions as bug bites or something else not warranting medical attention. And once they visit a physician, further diagnostic delay often ensues. In the six Minnesota patients with M. chelonae infections in tattoos, for example, the skin lesions appeared 1-2 weeks after the tattoo was placed, and all patients sought medical care promptly, but they were treated for a diagnosis other than NTM infection. Indeed, the median time between tattoo placement and the correct diagnosis was 18 weeks.

Timely diagnosis of RGM infections is made more challenging by the highly variable clinical appearance of the skin lesions.

Painful red nodules that ulcerate and drain are one of the classic pictures. Pink or purple papules, granulomatous papules, pustules, plaques, folliculitis, cellulitis, and nonhealing ulcers can also be encountered.

“I've recently seen three patients referred for nonresponsive pyoderma gangrenosum that was actually due to NTM,” Dr. Drage recalled.

The histopathologic findings can vary widely as well. A tuberculoid granulomatous infiltrate is most helpful, but some patients may instead have a lymphohistiocytic infiltrate, palisading or sarcoidal granulomas, a mixed inflammatory infiltrate, or other nonspecific findings.

Acid-fast bacilli staining typically produces negative results.

Treatment of NTM skin infections is based entirely on susceptibility test results. There are no clearcut treatment guidelines. Many infections will be resistant to the more common antimicrobials, and it's quite common for resistance to emerge during the required lengthy course of treatment. How lengthy? The typical treatment duration required for a localized infection is about 4 months, climbing to 6 months for more severe or disseminated infection.

Oral clarithromycin at 500 mg twice daily is a good option to start with while awaiting the susceptibility test results, as it covers some of the more common NTM. Combination therapy is often employed to prevent or treat resistance. Surgical removal of isolated foci of infection is often helpful, according to Dr. Drage.

She reported having no relevant financial conflicts.

An outbreak of M. chelonae originated from tap water used to dilute black ink.

Source ©Davide Cardello/Fotolia.com

CHICAGO — Two major new clinical trials have failed to show improved outcomes for home telemonitoring of patients with heart failure, prompting a critical reappraisal of this once-promising disease management strategy.

“I think this is an important moment in our understanding of the contribution of this novel intervention in the overall management of heart failure – and I think the weight of evidence demonstrates that it is noncontributory,” Dr. Clyde W. Yancy said following presentation of the two randomized trials at the meeting.

“Evidence-based, guideline-driven therapy is the standard of care and should always be our first priority in the treatment of heart failure. The benefit of telemonitoring that has been demonstrated to be present has always been less in the few randomized controlled trials than the cohort studies, and we've allowed hyperbole and excitement to guide our judgment, rather than evidence,” added Dr. Yancy, medical director of the Baylor Heart and Vascular Institute and chief of cardiothoracic transplantation at Baylor University Medical Center in Dallas.

One of the studies presented at the AHA meeting was the Telemonitoring to Improve Heart Failure Outcomes (Tele-HF) trial, a National Heart, Lung, and Blood Institute–funded study involving 1,653 U.S. patients enrolled less than a month after discharge for acute decompensated heart failure.

After 6 months of daily remote telemonitoring using the commercially popular Tel-Assurance system marketed by Pharos Innovations, death and rehospitalization rates in patients using the automated telephone monitoring system were similar to those in controls receiving usual care, Dr. Sarwat I. Chaudhry of Yale University, New Haven, Conn., reported.

Similarly, the 2-year Telemedical Interventional Monitoring in Heart Failure (TIM-HF) trial, which enrolled 710 German patients with mild-to-moderate heart failure, failed to show that 24/7 access to remote telemonitoring improves all-cause mortality or heart failure hospitalization rates compared with usual care, according to Dr. Stefan D. Anker, professor of cardiology at Charite University Hospital, Berlin.

“There's no need to parse the data any further,” commented Dr. Yancy, a former AHA president. “There was no benefit seen in either of these well-designed clinical trials on outcomes that are important to patients with heart failure.”

The findings in these two definitive randomized trials underscore the limitations of meta-analyses based upon small studies with heterogeneous results, including a Cochrane Collaboration review published just a few months ago, he added. The Cochrane report, based upon 11 studies involving 2,710 patients, concluded that telemonitoring programs for patients with chronic heart failure reduced the risk of all-cause mortality by one-third and all-cause hospitalization by 21% (Cochrane Database Syst. Rev. Aug. 4, 2010;CD007228. Review).

Health systems are under mounting pressure to reduce hospital readmissions, pressure that will intensify under the Patient Protection and Affordable Care Act. In this regard, Dr. Yancy noted that his recent Google search of the terms 'telemonitoring and heart failure' brought up 87,000 entries. The entire first page consisted of commercial advertisements for available systems.

“Every commercial application I opened had an implicit promise, almost a guarantee, of reduced costs and better outcomes for your patients with heart failure. We need to retard this kind of unbridled rush to a technology,” he concluded.

Another discussant of the trials, Dr. Lynne Warner Stevenson, stressed that telemonitoring for heart failure isn't dead, but for it to be effective the right physiologic variables related to fluid balance need to be monitored. What's being monitored now – changes in body weight and symptoms – are inadequate as harbingers of decompensation. Ambulatory hemodynamic monitoring via implanted devices, now under study, holds more promise.

With more responsive physiologic measures and improved electronic technology, it should be possible for heart failure patients to monitor their disease status and adjust their own diuretic therapy without the labor-intense daily remote involvement of physicians and nurses, predicted Dr. Stevenson, professor of medicine at Harvard Medical School and director of the cardiomyopathy and heart failure program at Brigham and Women's Hospital, both in Boston.

Dr. Chaudhry, Dr. Yancy, and Dr. Stevenson declared having no relevant financial interests. The TIM-HF trial was funded by the German Federal Ministry of Economics and Technology in partnership with several technology companies. Dr. Anker disclosed that he serves as a consultant to one of those companies, Robert Bosch Healthcare.

'There was no benefit seen in either of these well-designed clinical trials.'

Source DR. YANCY

CHICAGO — Two major new clinical trials have failed to show improved outcomes for home telemonitoring of patients with heart failure, prompting a critical reappraisal of this once-promising disease management strategy.

“I think this is an important moment in our understanding of the contribution of this novel intervention in the overall management of heart failure – and I think the weight of evidence demonstrates that it is noncontributory,” Dr. Clyde W. Yancy said following presentation of the two randomized trials at the meeting.

“Evidence-based, guideline-driven therapy is the standard of care and should always be our first priority in the treatment of heart failure. The benefit of telemonitoring that has been demonstrated to be present has always been less in the few randomized controlled trials than the cohort studies, and we've allowed hyperbole and excitement to guide our judgment, rather than evidence,” added Dr. Yancy, medical director of the Baylor Heart and Vascular Institute and chief of cardiothoracic transplantation at Baylor University Medical Center in Dallas.

One of the studies presented at the AHA meeting was the Telemonitoring to Improve Heart Failure Outcomes (Tele-HF) trial, a National Heart, Lung, and Blood Institute–funded study involving 1,653 U.S. patients enrolled less than a month after discharge for acute decompensated heart failure.

After 6 months of daily remote telemonitoring using the commercially popular Tel-Assurance system marketed by Pharos Innovations, death and rehospitalization rates in patients using the automated telephone monitoring system were similar to those in controls receiving usual care, Dr. Sarwat I. Chaudhry of Yale University, New Haven, Conn., reported.

Similarly, the 2-year Telemedical Interventional Monitoring in Heart Failure (TIM-HF) trial, which enrolled 710 German patients with mild-to-moderate heart failure, failed to show that 24/7 access to remote telemonitoring improves all-cause mortality or heart failure hospitalization rates compared with usual care, according to Dr. Stefan D. Anker, professor of cardiology at Charite University Hospital, Berlin.

“There's no need to parse the data any further,” commented Dr. Yancy, a former AHA president. “There was no benefit seen in either of these well-designed clinical trials on outcomes that are important to patients with heart failure.”

The findings in these two definitive randomized trials underscore the limitations of meta-analyses based upon small studies with heterogeneous results, including a Cochrane Collaboration review published just a few months ago, he added. The Cochrane report, based upon 11 studies involving 2,710 patients, concluded that telemonitoring programs for patients with chronic heart failure reduced the risk of all-cause mortality by one-third and all-cause hospitalization by 21% (Cochrane Database Syst. Rev. Aug. 4, 2010;CD007228. Review).

Health systems are under mounting pressure to reduce hospital readmissions, pressure that will intensify under the Patient Protection and Affordable Care Act. In this regard, Dr. Yancy noted that his recent Google search of the terms 'telemonitoring and heart failure' brought up 87,000 entries. The entire first page consisted of commercial advertisements for available systems.

“Every commercial application I opened had an implicit promise, almost a guarantee, of reduced costs and better outcomes for your patients with heart failure. We need to retard this kind of unbridled rush to a technology,” he concluded.

Another discussant of the trials, Dr. Lynne Warner Stevenson, stressed that telemonitoring for heart failure isn't dead, but for it to be effective the right physiologic variables related to fluid balance need to be monitored. What's being monitored now – changes in body weight and symptoms – are inadequate as harbingers of decompensation. Ambulatory hemodynamic monitoring via implanted devices, now under study, holds more promise.

With more responsive physiologic measures and improved electronic technology, it should be possible for heart failure patients to monitor their disease status and adjust their own diuretic therapy without the labor-intense daily remote involvement of physicians and nurses, predicted Dr. Stevenson, professor of medicine at Harvard Medical School and director of the cardiomyopathy and heart failure program at Brigham and Women's Hospital, both in Boston.

Dr. Chaudhry, Dr. Yancy, and Dr. Stevenson declared having no relevant financial interests. The TIM-HF trial was funded by the German Federal Ministry of Economics and Technology in partnership with several technology companies. Dr. Anker disclosed that he serves as a consultant to one of those companies, Robert Bosch Healthcare.

'There was no benefit seen in either of these well-designed clinical trials.'

Source DR. YANCY

CHICAGO — Two major new clinical trials have failed to show improved outcomes for home telemonitoring of patients with heart failure, prompting a critical reappraisal of this once-promising disease management strategy.

“I think this is an important moment in our understanding of the contribution of this novel intervention in the overall management of heart failure – and I think the weight of evidence demonstrates that it is noncontributory,” Dr. Clyde W. Yancy said following presentation of the two randomized trials at the meeting.

“Evidence-based, guideline-driven therapy is the standard of care and should always be our first priority in the treatment of heart failure. The benefit of telemonitoring that has been demonstrated to be present has always been less in the few randomized controlled trials than the cohort studies, and we've allowed hyperbole and excitement to guide our judgment, rather than evidence,” added Dr. Yancy, medical director of the Baylor Heart and Vascular Institute and chief of cardiothoracic transplantation at Baylor University Medical Center in Dallas.

One of the studies presented at the AHA meeting was the Telemonitoring to Improve Heart Failure Outcomes (Tele-HF) trial, a National Heart, Lung, and Blood Institute–funded study involving 1,653 U.S. patients enrolled less than a month after discharge for acute decompensated heart failure.

After 6 months of daily remote telemonitoring using the commercially popular Tel-Assurance system marketed by Pharos Innovations, death and rehospitalization rates in patients using the automated telephone monitoring system were similar to those in controls receiving usual care, Dr. Sarwat I. Chaudhry of Yale University, New Haven, Conn., reported.

Similarly, the 2-year Telemedical Interventional Monitoring in Heart Failure (TIM-HF) trial, which enrolled 710 German patients with mild-to-moderate heart failure, failed to show that 24/7 access to remote telemonitoring improves all-cause mortality or heart failure hospitalization rates compared with usual care, according to Dr. Stefan D. Anker, professor of cardiology at Charite University Hospital, Berlin.

“There's no need to parse the data any further,” commented Dr. Yancy, a former AHA president. “There was no benefit seen in either of these well-designed clinical trials on outcomes that are important to patients with heart failure.”

The findings in these two definitive randomized trials underscore the limitations of meta-analyses based upon small studies with heterogeneous results, including a Cochrane Collaboration review published just a few months ago, he added. The Cochrane report, based upon 11 studies involving 2,710 patients, concluded that telemonitoring programs for patients with chronic heart failure reduced the risk of all-cause mortality by one-third and all-cause hospitalization by 21% (Cochrane Database Syst. Rev. Aug. 4, 2010;CD007228. Review).

Health systems are under mounting pressure to reduce hospital readmissions, pressure that will intensify under the Patient Protection and Affordable Care Act. In this regard, Dr. Yancy noted that his recent Google search of the terms 'telemonitoring and heart failure' brought up 87,000 entries. The entire first page consisted of commercial advertisements for available systems.

“Every commercial application I opened had an implicit promise, almost a guarantee, of reduced costs and better outcomes for your patients with heart failure. We need to retard this kind of unbridled rush to a technology,” he concluded.

Another discussant of the trials, Dr. Lynne Warner Stevenson, stressed that telemonitoring for heart failure isn't dead, but for it to be effective the right physiologic variables related to fluid balance need to be monitored. What's being monitored now – changes in body weight and symptoms – are inadequate as harbingers of decompensation. Ambulatory hemodynamic monitoring via implanted devices, now under study, holds more promise.

With more responsive physiologic measures and improved electronic technology, it should be possible for heart failure patients to monitor their disease status and adjust their own diuretic therapy without the labor-intense daily remote involvement of physicians and nurses, predicted Dr. Stevenson, professor of medicine at Harvard Medical School and director of the cardiomyopathy and heart failure program at Brigham and Women's Hospital, both in Boston.

Dr. Chaudhry, Dr. Yancy, and Dr. Stevenson declared having no relevant financial interests. The TIM-HF trial was funded by the German Federal Ministry of Economics and Technology in partnership with several technology companies. Dr. Anker disclosed that he serves as a consultant to one of those companies, Robert Bosch Healthcare.

'There was no benefit seen in either of these well-designed clinical trials.'

Source DR. YANCY

STOCKHOLM — Iron deficiency in patients with heart failure is common, occurs independently of anemia, and is strongly associated with exercise intolerance and increased risk of death or need for heart transplantation.

Moreover, iron deficiency in heart failure is not merely an independent predictor of poor outcomes, it's also emerging as an attractive target for treatment, Dr. Piotr Ponikowski said at the congress.

“Iron deficiency is pretty new stuff for cardiologists,” he observed in at a press conference. “Cardiologists should start to become more aware of the importance of iron deficiency in chronic heart failure patients and be able to evaluate iron status using a combination of simple, clinically applicable biomarkers of iron metabolism.”

Dr. Ponikowski, president of the Heart Failure Association of the European Society of Cardiology, was senior author of a prospective observational study in which 546 patients with stable systolic heart failure were tested for iron deficiency.

Thirty-seven percent of subjects were found to be iron deficient based on either a serum ferritin level below 100 mcg/L, or 100-300 mcg/L with a transferrin saturation below 20%. One-third of the iron-deficient patients were nonanemic. Iron deficiency was significantly more common in women, in subjects with C-reactive protein or plasma N-terminal pro type B natriuretic peptide levels above the median values, and in those with New York Heart Association (NYHA) class III-IV heart failure, although it was also found in 31% of patients who were class I-II (Eur. Heart J. Aug. 2010; 31:1872-80).

The mean 2-year survival rate free of heart transplantation was 53% in iron-deficient patients, significantly worse than the 67% in non–iron-deficient patients. In a multivariate analysis, the adjusted risk of death or heart transplantation in nonanemic heart failure patients with iron deficiency was 60% greater than in subjects without iron deficiency, noted Dr. Ponikowski, professor of cardiology at Wroclaw (Poland) Medical University.

He was also a coauthor of the first major treatment study, the Ferinject Assessment in Patients With Iron Deficiency and Chronic Heart Failure (FAIR-HF). In that double-blind, placebo-controlled, randomized trial, intravenous iron repletion of patients with heart failure resulted in significant improvement of all primary and secondary study end points, including exercise tolerance, self-reported patient global assessment scores, quality of life, and NYHA functional class (N. Engl. J. Med. 2009;361:2436-48). The improvement was apparent early, after two of the biweekly injections.

Asked whether it is now appropriate to prescribe iron therapy in iron-deficient patients with symptomatic heart failure, Dr. Ponikowski replied that he routinely screens symptomatic heart failure patients for iron deficiency and treats those who are deficient. “It's fairly safe and fairly straightforward. But we in the ESC [European Society of Cardiology] are very guideline-oriented people, and it's not in the guidelines yet,” he added.

He recommended intravenous iron over oral formulations. The bioavailability of iron from oral intake is poor, only 3-4 mg per dose. He and his colleagues have estimated that the total amount of iron that needs to be replaced in iron-deficient heart failure patients is on average 800-1,200 mg. That would require close to a year of daily oral therapy, which would be poorly tolerated gastrointestinally.

Dr. Ponikowski has received lecture and consulting fees from Vifor Pharma, which sponsored the FAIR-HF trial, as well as from Amgen.

It's safe to treat iron deficiency in patients with symptomatic heart failure, but it's not in the guidelines yet.'

Source DR. PONIKOWSKI

STOCKHOLM — Iron deficiency in patients with heart failure is common, occurs independently of anemia, and is strongly associated with exercise intolerance and increased risk of death or need for heart transplantation.

Moreover, iron deficiency in heart failure is not merely an independent predictor of poor outcomes, it's also emerging as an attractive target for treatment, Dr. Piotr Ponikowski said at the congress.

“Iron deficiency is pretty new stuff for cardiologists,” he observed in at a press conference. “Cardiologists should start to become more aware of the importance of iron deficiency in chronic heart failure patients and be able to evaluate iron status using a combination of simple, clinically applicable biomarkers of iron metabolism.”

Dr. Ponikowski, president of the Heart Failure Association of the European Society of Cardiology, was senior author of a prospective observational study in which 546 patients with stable systolic heart failure were tested for iron deficiency.

Thirty-seven percent of subjects were found to be iron deficient based on either a serum ferritin level below 100 mcg/L, or 100-300 mcg/L with a transferrin saturation below 20%. One-third of the iron-deficient patients were nonanemic. Iron deficiency was significantly more common in women, in subjects with C-reactive protein or plasma N-terminal pro type B natriuretic peptide levels above the median values, and in those with New York Heart Association (NYHA) class III-IV heart failure, although it was also found in 31% of patients who were class I-II (Eur. Heart J. Aug. 2010; 31:1872-80).

The mean 2-year survival rate free of heart transplantation was 53% in iron-deficient patients, significantly worse than the 67% in non–iron-deficient patients. In a multivariate analysis, the adjusted risk of death or heart transplantation in nonanemic heart failure patients with iron deficiency was 60% greater than in subjects without iron deficiency, noted Dr. Ponikowski, professor of cardiology at Wroclaw (Poland) Medical University.

He was also a coauthor of the first major treatment study, the Ferinject Assessment in Patients With Iron Deficiency and Chronic Heart Failure (FAIR-HF). In that double-blind, placebo-controlled, randomized trial, intravenous iron repletion of patients with heart failure resulted in significant improvement of all primary and secondary study end points, including exercise tolerance, self-reported patient global assessment scores, quality of life, and NYHA functional class (N. Engl. J. Med. 2009;361:2436-48). The improvement was apparent early, after two of the biweekly injections.

Asked whether it is now appropriate to prescribe iron therapy in iron-deficient patients with symptomatic heart failure, Dr. Ponikowski replied that he routinely screens symptomatic heart failure patients for iron deficiency and treats those who are deficient. “It's fairly safe and fairly straightforward. But we in the ESC [European Society of Cardiology] are very guideline-oriented people, and it's not in the guidelines yet,” he added.

He recommended intravenous iron over oral formulations. The bioavailability of iron from oral intake is poor, only 3-4 mg per dose. He and his colleagues have estimated that the total amount of iron that needs to be replaced in iron-deficient heart failure patients is on average 800-1,200 mg. That would require close to a year of daily oral therapy, which would be poorly tolerated gastrointestinally.

Dr. Ponikowski has received lecture and consulting fees from Vifor Pharma, which sponsored the FAIR-HF trial, as well as from Amgen.

It's safe to treat iron deficiency in patients with symptomatic heart failure, but it's not in the guidelines yet.'

Source DR. PONIKOWSKI

STOCKHOLM — Iron deficiency in patients with heart failure is common, occurs independently of anemia, and is strongly associated with exercise intolerance and increased risk of death or need for heart transplantation.

Moreover, iron deficiency in heart failure is not merely an independent predictor of poor outcomes, it's also emerging as an attractive target for treatment, Dr. Piotr Ponikowski said at the congress.

“Iron deficiency is pretty new stuff for cardiologists,” he observed in at a press conference. “Cardiologists should start to become more aware of the importance of iron deficiency in chronic heart failure patients and be able to evaluate iron status using a combination of simple, clinically applicable biomarkers of iron metabolism.”

Dr. Ponikowski, president of the Heart Failure Association of the European Society of Cardiology, was senior author of a prospective observational study in which 546 patients with stable systolic heart failure were tested for iron deficiency.

Thirty-seven percent of subjects were found to be iron deficient based on either a serum ferritin level below 100 mcg/L, or 100-300 mcg/L with a transferrin saturation below 20%. One-third of the iron-deficient patients were nonanemic. Iron deficiency was significantly more common in women, in subjects with C-reactive protein or plasma N-terminal pro type B natriuretic peptide levels above the median values, and in those with New York Heart Association (NYHA) class III-IV heart failure, although it was also found in 31% of patients who were class I-II (Eur. Heart J. Aug. 2010; 31:1872-80).

The mean 2-year survival rate free of heart transplantation was 53% in iron-deficient patients, significantly worse than the 67% in non–iron-deficient patients. In a multivariate analysis, the adjusted risk of death or heart transplantation in nonanemic heart failure patients with iron deficiency was 60% greater than in subjects without iron deficiency, noted Dr. Ponikowski, professor of cardiology at Wroclaw (Poland) Medical University.

He was also a coauthor of the first major treatment study, the Ferinject Assessment in Patients With Iron Deficiency and Chronic Heart Failure (FAIR-HF). In that double-blind, placebo-controlled, randomized trial, intravenous iron repletion of patients with heart failure resulted in significant improvement of all primary and secondary study end points, including exercise tolerance, self-reported patient global assessment scores, quality of life, and NYHA functional class (N. Engl. J. Med. 2009;361:2436-48). The improvement was apparent early, after two of the biweekly injections.

Asked whether it is now appropriate to prescribe iron therapy in iron-deficient patients with symptomatic heart failure, Dr. Ponikowski replied that he routinely screens symptomatic heart failure patients for iron deficiency and treats those who are deficient. “It's fairly safe and fairly straightforward. But we in the ESC [European Society of Cardiology] are very guideline-oriented people, and it's not in the guidelines yet,” he added.

He recommended intravenous iron over oral formulations. The bioavailability of iron from oral intake is poor, only 3-4 mg per dose. He and his colleagues have estimated that the total amount of iron that needs to be replaced in iron-deficient heart failure patients is on average 800-1,200 mg. That would require close to a year of daily oral therapy, which would be poorly tolerated gastrointestinally.

Dr. Ponikowski has received lecture and consulting fees from Vifor Pharma, which sponsored the FAIR-HF trial, as well as from Amgen.

It's safe to treat iron deficiency in patients with symptomatic heart failure, but it's not in the guidelines yet.'

Source DR. PONIKOWSKI

DENVER – Doubling the currently low alcohol tax would result in roughly a 35% reduction in direct alcohol-related mortality as well as substantial benefits across a range of other important public health outcomes, a meta-analysis has shown.

“We have a lot of literature. This is probably the most studied preventive health policy issue. The magnitude of the observed effects is larger and more consistent than for most other preventive efforts that have been studied,” Alexander C. Wagenaar, Ph.D., said at the meeting.

He presented a meta-analysis based on what he described as “an exhaustive search” of the past 50 years of published studies on the effects of alcohol tax pricing policies on a whole range of public health outcomes.

In summary, a 10% increase in the alcohol tax and a commensurate price increase would result in an across-the-board 5% reduction in drinking across all groups: underage teens as well as adults, moderate as well as heavy drinkers. The meta-analysis of 50 studies showed that doubling the alcohol tax would be associated on average with a 35% reduction in deaths due to cirrhosis, some cancers, and other directly alcohol-related causes; an 11% drop in traffic crash morbidity and mortality; a 6% decrease in sexually transmitted infections; a 2% reduction in violence; and a 1% decrease in crime and delinquent misbehavior. All of these effects were statistically significant, according to Dr. Wagenaar, professor of epidemiology and health policy at the University of Florida, Gainesville.

“This is a policy that applies at the population level. It's not just for the high-risk group, it's not only for the people that get into treatment. When a tax change is implemented, it changes the environment slightly across the entire population such that there's a reduction in drinking, and that effect ripples across these whole sets of alcohol-related outcomes,” explained the researcher, whose prior health policy studies have been credited as playing a key role in establishing the uniform nationwide drinking age of 21.

Suicide was the only outcome the investigators studied that didn't show a significant decrease in response to an increased tax on alcohol. Most of the 11 relevant studies have been conducted by only two research groups.

“There's not enough evidence yet to determine conclusively whether change in alcohol taxes influences suicide rates,” Dr. Wagenaar said.

He pointed out several practical advantages to raising the alcohol tax, beyond the striking public health benefits. An alcohol tax increase would generate additional revenues that could be used to fund other public health objectives or to bolster the general fund. No costly new bureaucratic infrastructure is required to implement an alcohol tax increase; the tax structures are already present. And alcohol tax rates are now at historic lows because they're volume-based and aren't adjusted for inflation.

“That's how we've gotten into this situation where the tax rates now are only a fraction of what they were in the 1950s, '60s, and '70s. If we were to simply return the tax rates in most jurisdictions to the rates that were in place in the '60s and '70s, we would see the kinds of effects that we're seeing in the meta-analysis, because in many areas that would involve a doubling of the tax rates,” Dr. Wagenaar said.

In response to an audience question, he said the available evidence indicates there is no threshold effect for the relationship between alcohol tax increases and public health benefits. In other words, if the alcohol tax is increased by, say, one-quarter, public health benefits will accrue, albeit not with the same large effect sizes as with a doubling of the tax.

Dr. Wagenaar's study was funded by the Robert Wood Johnson Foundation. He said he has no relevant financial conflicts of interest.

A 10% tax increase and a price increase would result in a 5% reduction in drinking across all groups.

Source DR. WAGENAAR

A change in the alcohol tax has a ripple effect “at the population level.”

Source ©DETHCHIMO/Fotolia.Com

DENVER – Doubling the currently low alcohol tax would result in roughly a 35% reduction in direct alcohol-related mortality as well as substantial benefits across a range of other important public health outcomes, a meta-analysis has shown.

“We have a lot of literature. This is probably the most studied preventive health policy issue. The magnitude of the observed effects is larger and more consistent than for most other preventive efforts that have been studied,” Alexander C. Wagenaar, Ph.D., said at the meeting.

He presented a meta-analysis based on what he described as “an exhaustive search” of the past 50 years of published studies on the effects of alcohol tax pricing policies on a whole range of public health outcomes.

In summary, a 10% increase in the alcohol tax and a commensurate price increase would result in an across-the-board 5% reduction in drinking across all groups: underage teens as well as adults, moderate as well as heavy drinkers. The meta-analysis of 50 studies showed that doubling the alcohol tax would be associated on average with a 35% reduction in deaths due to cirrhosis, some cancers, and other directly alcohol-related causes; an 11% drop in traffic crash morbidity and mortality; a 6% decrease in sexually transmitted infections; a 2% reduction in violence; and a 1% decrease in crime and delinquent misbehavior. All of these effects were statistically significant, according to Dr. Wagenaar, professor of epidemiology and health policy at the University of Florida, Gainesville.

“This is a policy that applies at the population level. It's not just for the high-risk group, it's not only for the people that get into treatment. When a tax change is implemented, it changes the environment slightly across the entire population such that there's a reduction in drinking, and that effect ripples across these whole sets of alcohol-related outcomes,” explained the researcher, whose prior health policy studies have been credited as playing a key role in establishing the uniform nationwide drinking age of 21.

Suicide was the only outcome the investigators studied that didn't show a significant decrease in response to an increased tax on alcohol. Most of the 11 relevant studies have been conducted by only two research groups.

“There's not enough evidence yet to determine conclusively whether change in alcohol taxes influences suicide rates,” Dr. Wagenaar said.

He pointed out several practical advantages to raising the alcohol tax, beyond the striking public health benefits. An alcohol tax increase would generate additional revenues that could be used to fund other public health objectives or to bolster the general fund. No costly new bureaucratic infrastructure is required to implement an alcohol tax increase; the tax structures are already present. And alcohol tax rates are now at historic lows because they're volume-based and aren't adjusted for inflation.

“That's how we've gotten into this situation where the tax rates now are only a fraction of what they were in the 1950s, '60s, and '70s. If we were to simply return the tax rates in most jurisdictions to the rates that were in place in the '60s and '70s, we would see the kinds of effects that we're seeing in the meta-analysis, because in many areas that would involve a doubling of the tax rates,” Dr. Wagenaar said.

In response to an audience question, he said the available evidence indicates there is no threshold effect for the relationship between alcohol tax increases and public health benefits. In other words, if the alcohol tax is increased by, say, one-quarter, public health benefits will accrue, albeit not with the same large effect sizes as with a doubling of the tax.

Dr. Wagenaar's study was funded by the Robert Wood Johnson Foundation. He said he has no relevant financial conflicts of interest.

A 10% tax increase and a price increase would result in a 5% reduction in drinking across all groups.

Source DR. WAGENAAR

A change in the alcohol tax has a ripple effect “at the population level.”

Source ©DETHCHIMO/Fotolia.Com

DENVER – Doubling the currently low alcohol tax would result in roughly a 35% reduction in direct alcohol-related mortality as well as substantial benefits across a range of other important public health outcomes, a meta-analysis has shown.

“We have a lot of literature. This is probably the most studied preventive health policy issue. The magnitude of the observed effects is larger and more consistent than for most other preventive efforts that have been studied,” Alexander C. Wagenaar, Ph.D., said at the meeting.

He presented a meta-analysis based on what he described as “an exhaustive search” of the past 50 years of published studies on the effects of alcohol tax pricing policies on a whole range of public health outcomes.

In summary, a 10% increase in the alcohol tax and a commensurate price increase would result in an across-the-board 5% reduction in drinking across all groups: underage teens as well as adults, moderate as well as heavy drinkers. The meta-analysis of 50 studies showed that doubling the alcohol tax would be associated on average with a 35% reduction in deaths due to cirrhosis, some cancers, and other directly alcohol-related causes; an 11% drop in traffic crash morbidity and mortality; a 6% decrease in sexually transmitted infections; a 2% reduction in violence; and a 1% decrease in crime and delinquent misbehavior. All of these effects were statistically significant, according to Dr. Wagenaar, professor of epidemiology and health policy at the University of Florida, Gainesville.

“This is a policy that applies at the population level. It's not just for the high-risk group, it's not only for the people that get into treatment. When a tax change is implemented, it changes the environment slightly across the entire population such that there's a reduction in drinking, and that effect ripples across these whole sets of alcohol-related outcomes,” explained the researcher, whose prior health policy studies have been credited as playing a key role in establishing the uniform nationwide drinking age of 21.

Suicide was the only outcome the investigators studied that didn't show a significant decrease in response to an increased tax on alcohol. Most of the 11 relevant studies have been conducted by only two research groups.

“There's not enough evidence yet to determine conclusively whether change in alcohol taxes influences suicide rates,” Dr. Wagenaar said.

He pointed out several practical advantages to raising the alcohol tax, beyond the striking public health benefits. An alcohol tax increase would generate additional revenues that could be used to fund other public health objectives or to bolster the general fund. No costly new bureaucratic infrastructure is required to implement an alcohol tax increase; the tax structures are already present. And alcohol tax rates are now at historic lows because they're volume-based and aren't adjusted for inflation.

“That's how we've gotten into this situation where the tax rates now are only a fraction of what they were in the 1950s, '60s, and '70s. If we were to simply return the tax rates in most jurisdictions to the rates that were in place in the '60s and '70s, we would see the kinds of effects that we're seeing in the meta-analysis, because in many areas that would involve a doubling of the tax rates,” Dr. Wagenaar said.

In response to an audience question, he said the available evidence indicates there is no threshold effect for the relationship between alcohol tax increases and public health benefits. In other words, if the alcohol tax is increased by, say, one-quarter, public health benefits will accrue, albeit not with the same large effect sizes as with a doubling of the tax.

Dr. Wagenaar's study was funded by the Robert Wood Johnson Foundation. He said he has no relevant financial conflicts of interest.

A 10% tax increase and a price increase would result in a 5% reduction in drinking across all groups.

Source DR. WAGENAAR

A change in the alcohol tax has a ripple effect “at the population level.”

Source ©DETHCHIMO/Fotolia.Com

SAN ANTONIO – Poor medication adherence is significantly more common in heart failure patients who have excessive daytime sleepiness, a study shows.

The implication of this finding is that interventions aimed at improving excessive daytime sleepiness may pay dividends in terms of better medication adherence. This would be particularly advantageous in a condition such as heart failure, in which patients take numerous drugs that are important in controlling the neuroendocrine response to the disease, Barbara Riegel, D.N.Sc., observed.

She presented a study of a convenience sample of 278 adult outpatients with chronic stage C heart failure who participated in structured in-home interviews by trained research assistants who assessed medication adherence during the previous month.

Participants were also evaluated for excessive daytime sleepiness according to the Epworth Sleepiness Scale. Excessive daytime sleepiness (defined as an Epworth score of 6 or greater) was present in 56.5% of patients. Among the subset of heart failure patients with excessive daytime sleepiness who had undergone testing in a sleep laboratory, the majority was found to have sleep-disordered breathing, with an apnea-hypopnea index of at least 15 events per hour, reported Dr. Riegel of the University of Pennsylvania School of Nursing, Philadelphia.

The most problematic medication adherence issue for the study participants was forgetting to take their medications on schedule. In all, 56% of heart failure patients with excessive daytime sleepiness reported often taking their medications more than 2 hours late, compared with 38% of nonsleepy subjects. In addition, 10% of subjects with excessive daytime sleepiness reported skipping consecutive medication doses, compared with 3% of nonsleepy patients.

This study was funded by the National Heart, Lung, and Blood Institute. Dr. Riegel reported having no financial conflicts.

SAN ANTONIO – Poor medication adherence is significantly more common in heart failure patients who have excessive daytime sleepiness, a study shows.

The implication of this finding is that interventions aimed at improving excessive daytime sleepiness may pay dividends in terms of better medication adherence. This would be particularly advantageous in a condition such as heart failure, in which patients take numerous drugs that are important in controlling the neuroendocrine response to the disease, Barbara Riegel, D.N.Sc., observed.

She presented a study of a convenience sample of 278 adult outpatients with chronic stage C heart failure who participated in structured in-home interviews by trained research assistants who assessed medication adherence during the previous month.

Participants were also evaluated for excessive daytime sleepiness according to the Epworth Sleepiness Scale. Excessive daytime sleepiness (defined as an Epworth score of 6 or greater) was present in 56.5% of patients. Among the subset of heart failure patients with excessive daytime sleepiness who had undergone testing in a sleep laboratory, the majority was found to have sleep-disordered breathing, with an apnea-hypopnea index of at least 15 events per hour, reported Dr. Riegel of the University of Pennsylvania School of Nursing, Philadelphia.

The most problematic medication adherence issue for the study participants was forgetting to take their medications on schedule. In all, 56% of heart failure patients with excessive daytime sleepiness reported often taking their medications more than 2 hours late, compared with 38% of nonsleepy subjects. In addition, 10% of subjects with excessive daytime sleepiness reported skipping consecutive medication doses, compared with 3% of nonsleepy patients.

This study was funded by the National Heart, Lung, and Blood Institute. Dr. Riegel reported having no financial conflicts.

SAN ANTONIO – Poor medication adherence is significantly more common in heart failure patients who have excessive daytime sleepiness, a study shows.

The implication of this finding is that interventions aimed at improving excessive daytime sleepiness may pay dividends in terms of better medication adherence. This would be particularly advantageous in a condition such as heart failure, in which patients take numerous drugs that are important in controlling the neuroendocrine response to the disease, Barbara Riegel, D.N.Sc., observed.

She presented a study of a convenience sample of 278 adult outpatients with chronic stage C heart failure who participated in structured in-home interviews by trained research assistants who assessed medication adherence during the previous month.

Participants were also evaluated for excessive daytime sleepiness according to the Epworth Sleepiness Scale. Excessive daytime sleepiness (defined as an Epworth score of 6 or greater) was present in 56.5% of patients. Among the subset of heart failure patients with excessive daytime sleepiness who had undergone testing in a sleep laboratory, the majority was found to have sleep-disordered breathing, with an apnea-hypopnea index of at least 15 events per hour, reported Dr. Riegel of the University of Pennsylvania School of Nursing, Philadelphia.

The most problematic medication adherence issue for the study participants was forgetting to take their medications on schedule. In all, 56% of heart failure patients with excessive daytime sleepiness reported often taking their medications more than 2 hours late, compared with 38% of nonsleepy subjects. In addition, 10% of subjects with excessive daytime sleepiness reported skipping consecutive medication doses, compared with 3% of nonsleepy patients.

This study was funded by the National Heart, Lung, and Blood Institute. Dr. Riegel reported having no financial conflicts.