M. Alexander Otto

VANCOUVER, B.C. – When adults with moderate to severe psoriasis fail one anti-TNF agent, most will still respond to another anti-TNF or ustekinumab, according to data from an investigation at two University of Toronto hospitals.

Researchers reviewed the outcomes of 155 patients who were switched to a second biologic after failing at least 12 weeks of treatment with their first, which was usually an anti–tumor necrosis factor (TNF) agent. Ustekinumab was often plan B. Of the 65 patients switched to it after failing initial anti-TNF therapy, 47 (72%) had a significant response, defined as at least a 75% improvement in the Psoriasis Area & Severity Index score (PASI 75) after 12 weeks of treatment. Ten more patients (15%) achieved PASI 50.

Meanwhile, of the 82 switched to a second anti-TNF, 48 (59%) reached PASI 75 and more achieved PASI 50 after 12 weeks.

“Clinicians switch biologics all the time, but there are no clear guidelines” on how to do it, “so it was worth looking into,” investigator Whan Kim, a medical student at McMaster University in Hamilton, Ont., said at the World Congress of Dermatology.

“This is one of the largest studies to date that determines the effectiveness of real-life switching of biologic therapies in patients with moderate to severe psoriasis. This study suggests switching to ustekinumab would induce the highest response rate – 72% was surprising,” he said. “Failing a biologic doesn’t preclude responding to another one. Don’t give up,” Mr. Kim added.

The team did find, however, that patients with two previously failed biologics were about half as likely to respond to a third biologic, compared with those who had failed just one (odds ratio, 0.474; 95% confidence interval, 0.23-0.96; P = 0.04).

The patients averaged 50 years of age and had psoriasis for approximately 17 years. Half had psoriatic arthritis, and the study population included slightly more women than men. Of the 155 patients, 93 failed initial treatment with etanercept. Seven of 12 (58%) who switched to infliximab, 24 of 43 (56%) who switched to adalimumab, and 27 of 38 (71%) who switched to ustekinumab achieved PASI 75.

Twenty-three failed initial infliximab. Three of four (75%) who switched to etanercept, four of seven (57%) who switched to adalimumab, and nine of 12 (75%) who switched to ustekinumab had a significant response.

Thirty-one patients failed initial adalimumab. Seven of 11 (64%) who switched to etanercept, 3 of 5 (60%) who switched to infliximab, and 11 of 15 (73%) who switched to ustekinumab had a significant response.

Of eight patients who failed initial ustekinumab, three (38%) switched to etanercept and had a significant response after 12 weeks.

There was no outside funding for the work, and Mr. Kim had no disclosures. The senior investigator is a speaker, consultant, and investigator for AbbVie, Amgen, and Janssen.

aotto@frontlinemedcom.com

VANCOUVER, B.C. – When adults with moderate to severe psoriasis fail one anti-TNF agent, most will still respond to another anti-TNF or ustekinumab, according to data from an investigation at two University of Toronto hospitals.

Researchers reviewed the outcomes of 155 patients who were switched to a second biologic after failing at least 12 weeks of treatment with their first, which was usually an anti–tumor necrosis factor (TNF) agent. Ustekinumab was often plan B. Of the 65 patients switched to it after failing initial anti-TNF therapy, 47 (72%) had a significant response, defined as at least a 75% improvement in the Psoriasis Area & Severity Index score (PASI 75) after 12 weeks of treatment. Ten more patients (15%) achieved PASI 50.

Meanwhile, of the 82 switched to a second anti-TNF, 48 (59%) reached PASI 75 and more achieved PASI 50 after 12 weeks.

“Clinicians switch biologics all the time, but there are no clear guidelines” on how to do it, “so it was worth looking into,” investigator Whan Kim, a medical student at McMaster University in Hamilton, Ont., said at the World Congress of Dermatology.

“This is one of the largest studies to date that determines the effectiveness of real-life switching of biologic therapies in patients with moderate to severe psoriasis. This study suggests switching to ustekinumab would induce the highest response rate – 72% was surprising,” he said. “Failing a biologic doesn’t preclude responding to another one. Don’t give up,” Mr. Kim added.

The team did find, however, that patients with two previously failed biologics were about half as likely to respond to a third biologic, compared with those who had failed just one (odds ratio, 0.474; 95% confidence interval, 0.23-0.96; P = 0.04).

The patients averaged 50 years of age and had psoriasis for approximately 17 years. Half had psoriatic arthritis, and the study population included slightly more women than men. Of the 155 patients, 93 failed initial treatment with etanercept. Seven of 12 (58%) who switched to infliximab, 24 of 43 (56%) who switched to adalimumab, and 27 of 38 (71%) who switched to ustekinumab achieved PASI 75.

Twenty-three failed initial infliximab. Three of four (75%) who switched to etanercept, four of seven (57%) who switched to adalimumab, and nine of 12 (75%) who switched to ustekinumab had a significant response.

Thirty-one patients failed initial adalimumab. Seven of 11 (64%) who switched to etanercept, 3 of 5 (60%) who switched to infliximab, and 11 of 15 (73%) who switched to ustekinumab had a significant response.

Of eight patients who failed initial ustekinumab, three (38%) switched to etanercept and had a significant response after 12 weeks.

There was no outside funding for the work, and Mr. Kim had no disclosures. The senior investigator is a speaker, consultant, and investigator for AbbVie, Amgen, and Janssen.

aotto@frontlinemedcom.com

VANCOUVER, B.C. – When adults with moderate to severe psoriasis fail one anti-TNF agent, most will still respond to another anti-TNF or ustekinumab, according to data from an investigation at two University of Toronto hospitals.

Researchers reviewed the outcomes of 155 patients who were switched to a second biologic after failing at least 12 weeks of treatment with their first, which was usually an anti–tumor necrosis factor (TNF) agent. Ustekinumab was often plan B. Of the 65 patients switched to it after failing initial anti-TNF therapy, 47 (72%) had a significant response, defined as at least a 75% improvement in the Psoriasis Area & Severity Index score (PASI 75) after 12 weeks of treatment. Ten more patients (15%) achieved PASI 50.

Meanwhile, of the 82 switched to a second anti-TNF, 48 (59%) reached PASI 75 and more achieved PASI 50 after 12 weeks.

“Clinicians switch biologics all the time, but there are no clear guidelines” on how to do it, “so it was worth looking into,” investigator Whan Kim, a medical student at McMaster University in Hamilton, Ont., said at the World Congress of Dermatology.

“This is one of the largest studies to date that determines the effectiveness of real-life switching of biologic therapies in patients with moderate to severe psoriasis. This study suggests switching to ustekinumab would induce the highest response rate – 72% was surprising,” he said. “Failing a biologic doesn’t preclude responding to another one. Don’t give up,” Mr. Kim added.

The team did find, however, that patients with two previously failed biologics were about half as likely to respond to a third biologic, compared with those who had failed just one (odds ratio, 0.474; 95% confidence interval, 0.23-0.96; P = 0.04).

The patients averaged 50 years of age and had psoriasis for approximately 17 years. Half had psoriatic arthritis, and the study population included slightly more women than men. Of the 155 patients, 93 failed initial treatment with etanercept. Seven of 12 (58%) who switched to infliximab, 24 of 43 (56%) who switched to adalimumab, and 27 of 38 (71%) who switched to ustekinumab achieved PASI 75.

Twenty-three failed initial infliximab. Three of four (75%) who switched to etanercept, four of seven (57%) who switched to adalimumab, and nine of 12 (75%) who switched to ustekinumab had a significant response.

Thirty-one patients failed initial adalimumab. Seven of 11 (64%) who switched to etanercept, 3 of 5 (60%) who switched to infliximab, and 11 of 15 (73%) who switched to ustekinumab had a significant response.

Of eight patients who failed initial ustekinumab, three (38%) switched to etanercept and had a significant response after 12 weeks.

There was no outside funding for the work, and Mr. Kim had no disclosures. The senior investigator is a speaker, consultant, and investigator for AbbVie, Amgen, and Janssen.

aotto@frontlinemedcom.com

NASHVILLE, TENN. – When ordering a fasting blood test for patients with diabetes, it’s prudent to have them cut back on their insulin and oral hypoglycemic agents to avoid hypoglycemia.

Unless they take such protective actions, an estimated half or more will be hypoglycemic by the time their blood is drawn, according to a survey from Michigan State University.

Alex Otto/Frontline Medical News

Of the 74 study participants – mostly people with type 2 diabetes – who have enrolled so far in the ongoing project, 37 (50%) reported overnight fasting for lipid profiles or other tests in the previous year. Just three cut back on their medications, either on their own or on the advice of their doctors. Just over half the subjects were women, about three-quarters had type 2 diabetes, and the average age in the study was 53 years.

Twenty-three of the 37 patients (62%) reported at least one hypoglycemic event while fasting, with plasma glucose falling below 70 mg/dL. Some had up to seven events. Most told their doctors what had happened, but steps weren’t often taken to prevent future events.

“These interim results vividly confirm the occurrence of” fasting hypoglycemia “in clinical practice, and indicate a significant prevalence” among patients with diabetes. “This study serves as a means of increasing awareness about” the problem, “which clinicians appear to overlook,” concluded the investigators, led by Dr. Saleh Aldasouqi, associate professor of medicine and chief of endocrinology at Michigan State, East Lansing.

Dr. Aldasouqi first noticed the problem several years ago when practicing in Cape Girardeau, Mo. He fielded several calls there from nervous lab technicians reporting hypoglycemia in patients with diabetes who had fasted overnight. “We looked at the world literature on this at the time and found zero,” he said, except for a case report of a woman who collapsed and died while waiting for a lipid draw after fasting the night before. Her blood glucose was zero.

That report prompted Dr. Aldasouqi and his colleagues in Cape Girardeau to study the issue. They found that hypoglycemia ranged from 69-30 mg/dL among 35 patients with diabetes who recalled fasting or possibly fasting for a blood test. None recalled adjusting their medications (Diabetes Care 2011;34:e52).

Dr. Aldasouqi dubbed the problem fasting-evoked en-route hypoglycemia in diabetes (FEEHD): “en-route” to invoke the possibility that patients with diabetes might crash if their blood sugar drops too low while driving in for a blood draw, he said at the annual meeting of the American Association of Clinical Endocrinologists.

The next step in Cape Girardeau was a prevention program to monitor blood glucose and adjust medications for patients with diabetes who were fasting for a test. It reduced the incidence of hypoglycemic events by 68%, with an even greater drop in the incidence of severe hypoglycemia below 50 mg/dL (Postgrad. Med. 2013;125:136-43).

“We’ve been trying to build a case” that FEEHD really is a problem, but there’s been some skepticism because “we are trying to change a deeply rooted tradition” and the notion that diabetics can fast just like anyone else. Even so, “people are coming around now that we have data,” Dr. Aldasouqi said. Currently at Michigan State, “my group is not ordering fasting” for lipid tests, although it remains routine in other clinics there. They opted for that approach, instead of reducing diabetes medications during fasts, because of the growing evidence that patients – whether they have diabetes or not – really don’t need to fast for lipid panels, he said (Circulation 2015;131:e471).

There was no external funding for the project. Dr. Aldasouqi is a speaker or adviser for Janssen, Sanofi, and Takeda.

aotto@frontlinemedcom.com

NASHVILLE, TENN. – When ordering a fasting blood test for patients with diabetes, it’s prudent to have them cut back on their insulin and oral hypoglycemic agents to avoid hypoglycemia.

Unless they take such protective actions, an estimated half or more will be hypoglycemic by the time their blood is drawn, according to a survey from Michigan State University.

Alex Otto/Frontline Medical News

Of the 74 study participants – mostly people with type 2 diabetes – who have enrolled so far in the ongoing project, 37 (50%) reported overnight fasting for lipid profiles or other tests in the previous year. Just three cut back on their medications, either on their own or on the advice of their doctors. Just over half the subjects were women, about three-quarters had type 2 diabetes, and the average age in the study was 53 years.

Twenty-three of the 37 patients (62%) reported at least one hypoglycemic event while fasting, with plasma glucose falling below 70 mg/dL. Some had up to seven events. Most told their doctors what had happened, but steps weren’t often taken to prevent future events.

“These interim results vividly confirm the occurrence of” fasting hypoglycemia “in clinical practice, and indicate a significant prevalence” among patients with diabetes. “This study serves as a means of increasing awareness about” the problem, “which clinicians appear to overlook,” concluded the investigators, led by Dr. Saleh Aldasouqi, associate professor of medicine and chief of endocrinology at Michigan State, East Lansing.

Dr. Aldasouqi first noticed the problem several years ago when practicing in Cape Girardeau, Mo. He fielded several calls there from nervous lab technicians reporting hypoglycemia in patients with diabetes who had fasted overnight. “We looked at the world literature on this at the time and found zero,” he said, except for a case report of a woman who collapsed and died while waiting for a lipid draw after fasting the night before. Her blood glucose was zero.

That report prompted Dr. Aldasouqi and his colleagues in Cape Girardeau to study the issue. They found that hypoglycemia ranged from 69-30 mg/dL among 35 patients with diabetes who recalled fasting or possibly fasting for a blood test. None recalled adjusting their medications (Diabetes Care 2011;34:e52).

Dr. Aldasouqi dubbed the problem fasting-evoked en-route hypoglycemia in diabetes (FEEHD): “en-route” to invoke the possibility that patients with diabetes might crash if their blood sugar drops too low while driving in for a blood draw, he said at the annual meeting of the American Association of Clinical Endocrinologists.

The next step in Cape Girardeau was a prevention program to monitor blood glucose and adjust medications for patients with diabetes who were fasting for a test. It reduced the incidence of hypoglycemic events by 68%, with an even greater drop in the incidence of severe hypoglycemia below 50 mg/dL (Postgrad. Med. 2013;125:136-43).

“We’ve been trying to build a case” that FEEHD really is a problem, but there’s been some skepticism because “we are trying to change a deeply rooted tradition” and the notion that diabetics can fast just like anyone else. Even so, “people are coming around now that we have data,” Dr. Aldasouqi said. Currently at Michigan State, “my group is not ordering fasting” for lipid tests, although it remains routine in other clinics there. They opted for that approach, instead of reducing diabetes medications during fasts, because of the growing evidence that patients – whether they have diabetes or not – really don’t need to fast for lipid panels, he said (Circulation 2015;131:e471).

There was no external funding for the project. Dr. Aldasouqi is a speaker or adviser for Janssen, Sanofi, and Takeda.

aotto@frontlinemedcom.com

NASHVILLE, TENN. – When ordering a fasting blood test for patients with diabetes, it’s prudent to have them cut back on their insulin and oral hypoglycemic agents to avoid hypoglycemia.

Unless they take such protective actions, an estimated half or more will be hypoglycemic by the time their blood is drawn, according to a survey from Michigan State University.

Alex Otto/Frontline Medical News

Of the 74 study participants – mostly people with type 2 diabetes – who have enrolled so far in the ongoing project, 37 (50%) reported overnight fasting for lipid profiles or other tests in the previous year. Just three cut back on their medications, either on their own or on the advice of their doctors. Just over half the subjects were women, about three-quarters had type 2 diabetes, and the average age in the study was 53 years.

Twenty-three of the 37 patients (62%) reported at least one hypoglycemic event while fasting, with plasma glucose falling below 70 mg/dL. Some had up to seven events. Most told their doctors what had happened, but steps weren’t often taken to prevent future events.

“These interim results vividly confirm the occurrence of” fasting hypoglycemia “in clinical practice, and indicate a significant prevalence” among patients with diabetes. “This study serves as a means of increasing awareness about” the problem, “which clinicians appear to overlook,” concluded the investigators, led by Dr. Saleh Aldasouqi, associate professor of medicine and chief of endocrinology at Michigan State, East Lansing.

Dr. Aldasouqi first noticed the problem several years ago when practicing in Cape Girardeau, Mo. He fielded several calls there from nervous lab technicians reporting hypoglycemia in patients with diabetes who had fasted overnight. “We looked at the world literature on this at the time and found zero,” he said, except for a case report of a woman who collapsed and died while waiting for a lipid draw after fasting the night before. Her blood glucose was zero.

That report prompted Dr. Aldasouqi and his colleagues in Cape Girardeau to study the issue. They found that hypoglycemia ranged from 69-30 mg/dL among 35 patients with diabetes who recalled fasting or possibly fasting for a blood test. None recalled adjusting their medications (Diabetes Care 2011;34:e52).

Dr. Aldasouqi dubbed the problem fasting-evoked en-route hypoglycemia in diabetes (FEEHD): “en-route” to invoke the possibility that patients with diabetes might crash if their blood sugar drops too low while driving in for a blood draw, he said at the annual meeting of the American Association of Clinical Endocrinologists.

The next step in Cape Girardeau was a prevention program to monitor blood glucose and adjust medications for patients with diabetes who were fasting for a test. It reduced the incidence of hypoglycemic events by 68%, with an even greater drop in the incidence of severe hypoglycemia below 50 mg/dL (Postgrad. Med. 2013;125:136-43).

“We’ve been trying to build a case” that FEEHD really is a problem, but there’s been some skepticism because “we are trying to change a deeply rooted tradition” and the notion that diabetics can fast just like anyone else. Even so, “people are coming around now that we have data,” Dr. Aldasouqi said. Currently at Michigan State, “my group is not ordering fasting” for lipid tests, although it remains routine in other clinics there. They opted for that approach, instead of reducing diabetes medications during fasts, because of the growing evidence that patients – whether they have diabetes or not – really don’t need to fast for lipid panels, he said (Circulation 2015;131:e471).

There was no external funding for the project. Dr. Aldasouqi is a speaker or adviser for Janssen, Sanofi, and Takeda.

aotto@frontlinemedcom.com

NASHVILLE, TENN. – Neck circumferences at or above 36 cm in women and 39 cm in men might signal impending metabolic problems, according to researchers from the Medical University of Sofia, Bulgaria.

When patients have necks larger than that, “it is an argument to start more active preventative strategies because they will likely develop metabolic syndrome, if it’s not already present,” said investigator Dr. Zdravko Kamenov, an endocrinologist at the university.

The conclusion is based on a study of waist and neck circumference in 168 obese, hospitalized patients to see which better correlated with metabolic lab values. All the patients had a body mass index above 30 kg/m²; the average BMI was 35. About 70% of the participants were women, and patients with known diabetes, cancer, or chronic kidney or liver disease were excluded from the study.

Waist circumference is well accepted as a marker for abdominal fat and metabolic risk, but it can be difficult to measure and unreliable in obese people, and there are different opinions about where to place the measuring tape. Over the past few years, neck circumference has emerged as an easier alternative and has been associated with metabolic syndrome, obstructive sleep apnea, and heart disease when large.

“At this point, it’s probably better to measure both to increase the predictive value of anthropomorphic measurements,” Dr. Kamenov said at the annual meeting of the American Association of Clinical Endocrinologists.

Measuring both seems best because, in the study, waist circumference correlated better with plasma glucose problems, while neck circumference correlated better with other metabolic issues. Neck circumference also seemed to work better in women than in men, probably because of differences in neck musculature.

For instance, a neck circumference above 35.75 cm was the better predictor of dyslipidemia in women (odds ratio, 4.7; 95% confidence interval, 1.9-12.1,;P = .001). Neck circumference above 34.5 cm in women (OR 5.4; 95% CI 1.80-16.0; P = .003) and 38.75 cm in men (OR 24.6, 95% CI 1.5-398.1, P = 0.024) better predicted metabolic syndrome.

On the other hand, waist circumference over 100.5 cm was more predictive of type 2 diabetes in women (OR 3.2; 95% CI 1.1-9.4; P = .029). Waist circumference above 96.5 cm in women (OR 3.2; 95% CI 1.1-9.5; P = .033) and 101 cm in men was the better predictor of insulin resistance, with a sensitivity of 93% and specificity of 75% in men.

Waist circumference was taken at the midpoint between the inferior costal margin and the superior border of the iliac crest on the mid-axillary line. Neck circumference was measured between the mid-cervical spine and mid-anterior neck just below the laryngeal prominence.

To some extent, neck and waist circumference measure different things. While waist circumference measures visceral fat and to a lesser extent subcutaneous fat, neck circumference is largely a measure of subcutaneous upper body fat, which is important for the generation of the free fatty acids associated with metabolic syndrome, Dr. Kamenov said.

Patients were, on average, 52 years old; 41% turned had type 2 diabetes; 42% had prediabetes; and 87% had metabolic syndrome.

Dr. Kamenov has no disclosures, and there was no outside funding for the work.

aotto@frontlinemedcom.com

NASHVILLE, TENN. – Neck circumferences at or above 36 cm in women and 39 cm in men might signal impending metabolic problems, according to researchers from the Medical University of Sofia, Bulgaria.

When patients have necks larger than that, “it is an argument to start more active preventative strategies because they will likely develop metabolic syndrome, if it’s not already present,” said investigator Dr. Zdravko Kamenov, an endocrinologist at the university.

The conclusion is based on a study of waist and neck circumference in 168 obese, hospitalized patients to see which better correlated with metabolic lab values. All the patients had a body mass index above 30 kg/m²; the average BMI was 35. About 70% of the participants were women, and patients with known diabetes, cancer, or chronic kidney or liver disease were excluded from the study.

Waist circumference is well accepted as a marker for abdominal fat and metabolic risk, but it can be difficult to measure and unreliable in obese people, and there are different opinions about where to place the measuring tape. Over the past few years, neck circumference has emerged as an easier alternative and has been associated with metabolic syndrome, obstructive sleep apnea, and heart disease when large.

“At this point, it’s probably better to measure both to increase the predictive value of anthropomorphic measurements,” Dr. Kamenov said at the annual meeting of the American Association of Clinical Endocrinologists.

Measuring both seems best because, in the study, waist circumference correlated better with plasma glucose problems, while neck circumference correlated better with other metabolic issues. Neck circumference also seemed to work better in women than in men, probably because of differences in neck musculature.

For instance, a neck circumference above 35.75 cm was the better predictor of dyslipidemia in women (odds ratio, 4.7; 95% confidence interval, 1.9-12.1,;P = .001). Neck circumference above 34.5 cm in women (OR 5.4; 95% CI 1.80-16.0; P = .003) and 38.75 cm in men (OR 24.6, 95% CI 1.5-398.1, P = 0.024) better predicted metabolic syndrome.

On the other hand, waist circumference over 100.5 cm was more predictive of type 2 diabetes in women (OR 3.2; 95% CI 1.1-9.4; P = .029). Waist circumference above 96.5 cm in women (OR 3.2; 95% CI 1.1-9.5; P = .033) and 101 cm in men was the better predictor of insulin resistance, with a sensitivity of 93% and specificity of 75% in men.

Waist circumference was taken at the midpoint between the inferior costal margin and the superior border of the iliac crest on the mid-axillary line. Neck circumference was measured between the mid-cervical spine and mid-anterior neck just below the laryngeal prominence.

To some extent, neck and waist circumference measure different things. While waist circumference measures visceral fat and to a lesser extent subcutaneous fat, neck circumference is largely a measure of subcutaneous upper body fat, which is important for the generation of the free fatty acids associated with metabolic syndrome, Dr. Kamenov said.

Patients were, on average, 52 years old; 41% turned had type 2 diabetes; 42% had prediabetes; and 87% had metabolic syndrome.

Dr. Kamenov has no disclosures, and there was no outside funding for the work.

aotto@frontlinemedcom.com

NASHVILLE, TENN. – Neck circumferences at or above 36 cm in women and 39 cm in men might signal impending metabolic problems, according to researchers from the Medical University of Sofia, Bulgaria.

When patients have necks larger than that, “it is an argument to start more active preventative strategies because they will likely develop metabolic syndrome, if it’s not already present,” said investigator Dr. Zdravko Kamenov, an endocrinologist at the university.

The conclusion is based on a study of waist and neck circumference in 168 obese, hospitalized patients to see which better correlated with metabolic lab values. All the patients had a body mass index above 30 kg/m²; the average BMI was 35. About 70% of the participants were women, and patients with known diabetes, cancer, or chronic kidney or liver disease were excluded from the study.

Waist circumference is well accepted as a marker for abdominal fat and metabolic risk, but it can be difficult to measure and unreliable in obese people, and there are different opinions about where to place the measuring tape. Over the past few years, neck circumference has emerged as an easier alternative and has been associated with metabolic syndrome, obstructive sleep apnea, and heart disease when large.

“At this point, it’s probably better to measure both to increase the predictive value of anthropomorphic measurements,” Dr. Kamenov said at the annual meeting of the American Association of Clinical Endocrinologists.

Measuring both seems best because, in the study, waist circumference correlated better with plasma glucose problems, while neck circumference correlated better with other metabolic issues. Neck circumference also seemed to work better in women than in men, probably because of differences in neck musculature.

For instance, a neck circumference above 35.75 cm was the better predictor of dyslipidemia in women (odds ratio, 4.7; 95% confidence interval, 1.9-12.1,;P = .001). Neck circumference above 34.5 cm in women (OR 5.4; 95% CI 1.80-16.0; P = .003) and 38.75 cm in men (OR 24.6, 95% CI 1.5-398.1, P = 0.024) better predicted metabolic syndrome.

On the other hand, waist circumference over 100.5 cm was more predictive of type 2 diabetes in women (OR 3.2; 95% CI 1.1-9.4; P = .029). Waist circumference above 96.5 cm in women (OR 3.2; 95% CI 1.1-9.5; P = .033) and 101 cm in men was the better predictor of insulin resistance, with a sensitivity of 93% and specificity of 75% in men.

Waist circumference was taken at the midpoint between the inferior costal margin and the superior border of the iliac crest on the mid-axillary line. Neck circumference was measured between the mid-cervical spine and mid-anterior neck just below the laryngeal prominence.

To some extent, neck and waist circumference measure different things. While waist circumference measures visceral fat and to a lesser extent subcutaneous fat, neck circumference is largely a measure of subcutaneous upper body fat, which is important for the generation of the free fatty acids associated with metabolic syndrome, Dr. Kamenov said.

Patients were, on average, 52 years old; 41% turned had type 2 diabetes; 42% had prediabetes; and 87% had metabolic syndrome.

Dr. Kamenov has no disclosures, and there was no outside funding for the work.

aotto@frontlinemedcom.com

NASHVILLE, TENN. – Postprandial hyperinsulinemic hypoglycemia after gastric bypass surgery can be managed or even corrected by medical management with calcium channel blockers or acarbose.

First described in 2005, it is a rare complication distinct from dumping syndrome, which is common after bypass. For unknown reasons, the pancreas starts to oversecrete insulin in response to even small meals a few months to a few decades after gastric bypass surgery. Until now, treatment has often meant partial or even total pancreatectomy (N. Engl. J. Med. 2005;353:249-54).

“The message from me is very simple: There’s a medical alternative to surgery. Before you take these people to surgery, try medical management,” said Dr. John Mordes, an endocrinologist and professor of medicine at the University of Massachusetts Medical School in Worcester.

The study involved five patients, who were seen there after suddenly developing severe, sometimes daily, postprandial hypoglycemic attacks from 1 to 26 years after Roux-en-Y bypass; several had passed out after meals. On 75-g fasting-glucose challenges, their insulin levels were at or above 17 microU/mL, despite glucose concentrations at or below 54 mg/dL. None of the patients had evidence of insulinomas, and none was on exogenous insulin or diabetes drugs. Their hemoglobin A_1c levels were below 6% (Endocr. Pract. 2015;21:237-46).

The first patient refused surgery, “so we researched the literature” and found that nifedipine helped infants with congenital nesidioblastosis in a study from India. The drug worked at a dose of 30 mg extended release once daily; 30 mg t.i.d. worked in the second patient. Calcium channel blockers blunt insulin secretion, which probably explains why nifedipine helped, Dr. Mordes said at the annual meeting of the American Association of Clinical Endocrinologists.

Both patients stopped taking the pills on their own after about 3 years; their symptoms hadn’t returned after a year or more of follow-up.

The third and fourth patients couldn’t tolerate nifedipine, so Dr. Mordes tried acarbose to slow absorption of glucose from the gut; it also worked. One patient has had only two mild attacks on 50 mg t.i.d for 15 months; the fourth was symptom free while on 25 mg t.i.d for 2 months. That patient stopped the drug at that point, and remained symptom free for 9 more months, but since then has had about one attack a month. The fifth patient has been symptom free for about 6 months on a combination of nifedipine 20 mg t.i.d. and acarbose 50 mg t.i.d, and has no intention of stopping either.

The subjects gained from a few to almost 50 pounds while on the drugs, which might also have contributed to their recovery. Overall, they “are fine now. None of them have needed surgery,” and they’re happy to have avoided it, Dr. Mordes said.

All that’s needed to diagnose the problem is a history of exclusively postprandial symptoms of hypoglycemia with no vasomotor or bowel symptoms suggestive of dumping, plus confirmatory blood work. Invasive tests aren’t necessary, he said.

A sixth patient didn’t respond to nifedipine, acarbose, or the insulinoma drug diazoxide, but she was atypical in that she had a decades-long history of nocturnal hypoglycemic events following a gastric bypass in Mexico at age 13 years for pyloric stenosis. “Something is very different about her,” Dr. Mordes said.

He said he had no relevant financial disclosures, and no outside funding for his work.

aotto@frontlinemedcom.com

NASHVILLE, TENN. – Postprandial hyperinsulinemic hypoglycemia after gastric bypass surgery can be managed or even corrected by medical management with calcium channel blockers or acarbose.

First described in 2005, it is a rare complication distinct from dumping syndrome, which is common after bypass. For unknown reasons, the pancreas starts to oversecrete insulin in response to even small meals a few months to a few decades after gastric bypass surgery. Until now, treatment has often meant partial or even total pancreatectomy (N. Engl. J. Med. 2005;353:249-54).

“The message from me is very simple: There’s a medical alternative to surgery. Before you take these people to surgery, try medical management,” said Dr. John Mordes, an endocrinologist and professor of medicine at the University of Massachusetts Medical School in Worcester.

The study involved five patients, who were seen there after suddenly developing severe, sometimes daily, postprandial hypoglycemic attacks from 1 to 26 years after Roux-en-Y bypass; several had passed out after meals. On 75-g fasting-glucose challenges, their insulin levels were at or above 17 microU/mL, despite glucose concentrations at or below 54 mg/dL. None of the patients had evidence of insulinomas, and none was on exogenous insulin or diabetes drugs. Their hemoglobin A_1c levels were below 6% (Endocr. Pract. 2015;21:237-46).

The first patient refused surgery, “so we researched the literature” and found that nifedipine helped infants with congenital nesidioblastosis in a study from India. The drug worked at a dose of 30 mg extended release once daily; 30 mg t.i.d. worked in the second patient. Calcium channel blockers blunt insulin secretion, which probably explains why nifedipine helped, Dr. Mordes said at the annual meeting of the American Association of Clinical Endocrinologists.

Both patients stopped taking the pills on their own after about 3 years; their symptoms hadn’t returned after a year or more of follow-up.

The third and fourth patients couldn’t tolerate nifedipine, so Dr. Mordes tried acarbose to slow absorption of glucose from the gut; it also worked. One patient has had only two mild attacks on 50 mg t.i.d for 15 months; the fourth was symptom free while on 25 mg t.i.d for 2 months. That patient stopped the drug at that point, and remained symptom free for 9 more months, but since then has had about one attack a month. The fifth patient has been symptom free for about 6 months on a combination of nifedipine 20 mg t.i.d. and acarbose 50 mg t.i.d, and has no intention of stopping either.

The subjects gained from a few to almost 50 pounds while on the drugs, which might also have contributed to their recovery. Overall, they “are fine now. None of them have needed surgery,” and they’re happy to have avoided it, Dr. Mordes said.

All that’s needed to diagnose the problem is a history of exclusively postprandial symptoms of hypoglycemia with no vasomotor or bowel symptoms suggestive of dumping, plus confirmatory blood work. Invasive tests aren’t necessary, he said.

A sixth patient didn’t respond to nifedipine, acarbose, or the insulinoma drug diazoxide, but she was atypical in that she had a decades-long history of nocturnal hypoglycemic events following a gastric bypass in Mexico at age 13 years for pyloric stenosis. “Something is very different about her,” Dr. Mordes said.

He said he had no relevant financial disclosures, and no outside funding for his work.

aotto@frontlinemedcom.com

NASHVILLE, TENN. – Postprandial hyperinsulinemic hypoglycemia after gastric bypass surgery can be managed or even corrected by medical management with calcium channel blockers or acarbose.

First described in 2005, it is a rare complication distinct from dumping syndrome, which is common after bypass. For unknown reasons, the pancreas starts to oversecrete insulin in response to even small meals a few months to a few decades after gastric bypass surgery. Until now, treatment has often meant partial or even total pancreatectomy (N. Engl. J. Med. 2005;353:249-54).

“The message from me is very simple: There’s a medical alternative to surgery. Before you take these people to surgery, try medical management,” said Dr. John Mordes, an endocrinologist and professor of medicine at the University of Massachusetts Medical School in Worcester.

The study involved five patients, who were seen there after suddenly developing severe, sometimes daily, postprandial hypoglycemic attacks from 1 to 26 years after Roux-en-Y bypass; several had passed out after meals. On 75-g fasting-glucose challenges, their insulin levels were at or above 17 microU/mL, despite glucose concentrations at or below 54 mg/dL. None of the patients had evidence of insulinomas, and none was on exogenous insulin or diabetes drugs. Their hemoglobin A_1c levels were below 6% (Endocr. Pract. 2015;21:237-46).

The first patient refused surgery, “so we researched the literature” and found that nifedipine helped infants with congenital nesidioblastosis in a study from India. The drug worked at a dose of 30 mg extended release once daily; 30 mg t.i.d. worked in the second patient. Calcium channel blockers blunt insulin secretion, which probably explains why nifedipine helped, Dr. Mordes said at the annual meeting of the American Association of Clinical Endocrinologists.

Both patients stopped taking the pills on their own after about 3 years; their symptoms hadn’t returned after a year or more of follow-up.

The third and fourth patients couldn’t tolerate nifedipine, so Dr. Mordes tried acarbose to slow absorption of glucose from the gut; it also worked. One patient has had only two mild attacks on 50 mg t.i.d for 15 months; the fourth was symptom free while on 25 mg t.i.d for 2 months. That patient stopped the drug at that point, and remained symptom free for 9 more months, but since then has had about one attack a month. The fifth patient has been symptom free for about 6 months on a combination of nifedipine 20 mg t.i.d. and acarbose 50 mg t.i.d, and has no intention of stopping either.

The subjects gained from a few to almost 50 pounds while on the drugs, which might also have contributed to their recovery. Overall, they “are fine now. None of them have needed surgery,” and they’re happy to have avoided it, Dr. Mordes said.

All that’s needed to diagnose the problem is a history of exclusively postprandial symptoms of hypoglycemia with no vasomotor or bowel symptoms suggestive of dumping, plus confirmatory blood work. Invasive tests aren’t necessary, he said.

A sixth patient didn’t respond to nifedipine, acarbose, or the insulinoma drug diazoxide, but she was atypical in that she had a decades-long history of nocturnal hypoglycemic events following a gastric bypass in Mexico at age 13 years for pyloric stenosis. “Something is very different about her,” Dr. Mordes said.

He said he had no relevant financial disclosures, and no outside funding for his work.

aotto@frontlinemedcom.com

SEATTLE – Aortic valve–sparing procedures have better outcomes than Bentall procedures with biologic or mechanical valves, according to a review of 1,187 aortic root cases at the University of Toronto.

“If the aortic valve can be spared, AVS [aortic valve–sparing] procedures should be considered for patients undergoing aortic root replacement,” concluded the investigators, led by Dr. Maral Ouzounian, a cardiovascular surgeon at the university.

Alex Otto/Frontline Medical News

The team reviewed surgical outcomes there from 1990 to 2010; 282 patients had AVS procedures, 562 had Bentall procedures with biologic valve replacements (b-Bentall); and 343 had Bentalls with mechanical valve replacements (m-Bentall). About 7.5% of AVS patients had bicuspid aortic valves, versus 67.6% in the b-Bentall group and 51.7% in the m-Bentall group.

To control for confounders, patients were matched into 185 triads based on age, year of surgery, and stage of heart failure. The surgeries were all elective; patients with endocarditis or aortic dissections were excluded from the analysis.

Early postoperative outcomes and overall long-term survival were similar between the groups, with about 80% of patients in all three alive at 15-year follow-up.

However, AVS procedures had better long-term freedom from cardiac death (95% at 15 years versus 93% in the b-Bentall and 90% in the m-Bentall groups). Also, AVS patients had lower rates of anticoagulant-related hemorrhages, compared with m-Bentall patients (3.2% versus 17.8%), and lower rates of structural valve deterioration (0% versus 6.5%) and reoperations (6.5% versus 13.5%) than b-Bentall patients. The differences were statistically significant.

About 5% of AVS patients had previous cardiac surgery, versus 12.4% in the b-Bentall and 36.2% in the m-Bentall groups. AVS patients were more likely to have Marfan syndrome, and about 8% of AVS patients had preoperative ejection fractions below 40%, versus 9.3% in the b-Bentall and 13% in the m-Bentall groups. There were no between-group differences in the rates of concomitant coronary bypass or mitral valve surgery. Patients were about 50 years old on average, and about 80% were men.

“In Toronto, we are quite aggressive with valve-sparing operations. We believe in this operation, so whenever we can spare the valve, we do.” Although valve-sparing procedures have become more common in large, high-volume surgery centers over the past 20 years, “community surgeons in small-volume centers are still much more likely to do a Bentall because of the complexity of AVS operations and the art it takes to get it right,” Dr. Ouzounian said at the annual meeting of the American Association for Thoracic Surgery.

Previous investigations have found benefits for AVS procedures, as well. One concluded that “there is no significant difference in terms of re-operation between patients, who presented with [bicuspid or tricuspid aortic valves]. Re-operation rates are higher for patients who presented with severe [aortic regurgitation], but these rates do not reach statistical significance. Hence, root replacement with aortic valve sparing should be offered even in the presence of a” bicuspid aortic valve or severe aortic regurgitation (Eur. J. Cardiothorac. Surg. 2010;38:515-22).

Dr. Ouzounian said she has no disclosures.

aotto@frontlinemedcom.com

SEATTLE – Aortic valve–sparing procedures have better outcomes than Bentall procedures with biologic or mechanical valves, according to a review of 1,187 aortic root cases at the University of Toronto.

“If the aortic valve can be spared, AVS [aortic valve–sparing] procedures should be considered for patients undergoing aortic root replacement,” concluded the investigators, led by Dr. Maral Ouzounian, a cardiovascular surgeon at the university.

Alex Otto/Frontline Medical News

The team reviewed surgical outcomes there from 1990 to 2010; 282 patients had AVS procedures, 562 had Bentall procedures with biologic valve replacements (b-Bentall); and 343 had Bentalls with mechanical valve replacements (m-Bentall). About 7.5% of AVS patients had bicuspid aortic valves, versus 67.6% in the b-Bentall group and 51.7% in the m-Bentall group.

To control for confounders, patients were matched into 185 triads based on age, year of surgery, and stage of heart failure. The surgeries were all elective; patients with endocarditis or aortic dissections were excluded from the analysis.

Early postoperative outcomes and overall long-term survival were similar between the groups, with about 80% of patients in all three alive at 15-year follow-up.

However, AVS procedures had better long-term freedom from cardiac death (95% at 15 years versus 93% in the b-Bentall and 90% in the m-Bentall groups). Also, AVS patients had lower rates of anticoagulant-related hemorrhages, compared with m-Bentall patients (3.2% versus 17.8%), and lower rates of structural valve deterioration (0% versus 6.5%) and reoperations (6.5% versus 13.5%) than b-Bentall patients. The differences were statistically significant.

About 5% of AVS patients had previous cardiac surgery, versus 12.4% in the b-Bentall and 36.2% in the m-Bentall groups. AVS patients were more likely to have Marfan syndrome, and about 8% of AVS patients had preoperative ejection fractions below 40%, versus 9.3% in the b-Bentall and 13% in the m-Bentall groups. There were no between-group differences in the rates of concomitant coronary bypass or mitral valve surgery. Patients were about 50 years old on average, and about 80% were men.

“In Toronto, we are quite aggressive with valve-sparing operations. We believe in this operation, so whenever we can spare the valve, we do.” Although valve-sparing procedures have become more common in large, high-volume surgery centers over the past 20 years, “community surgeons in small-volume centers are still much more likely to do a Bentall because of the complexity of AVS operations and the art it takes to get it right,” Dr. Ouzounian said at the annual meeting of the American Association for Thoracic Surgery.

Previous investigations have found benefits for AVS procedures, as well. One concluded that “there is no significant difference in terms of re-operation between patients, who presented with [bicuspid or tricuspid aortic valves]. Re-operation rates are higher for patients who presented with severe [aortic regurgitation], but these rates do not reach statistical significance. Hence, root replacement with aortic valve sparing should be offered even in the presence of a” bicuspid aortic valve or severe aortic regurgitation (Eur. J. Cardiothorac. Surg. 2010;38:515-22).

Dr. Ouzounian said she has no disclosures.

aotto@frontlinemedcom.com

SEATTLE – Aortic valve–sparing procedures have better outcomes than Bentall procedures with biologic or mechanical valves, according to a review of 1,187 aortic root cases at the University of Toronto.

“If the aortic valve can be spared, AVS [aortic valve–sparing] procedures should be considered for patients undergoing aortic root replacement,” concluded the investigators, led by Dr. Maral Ouzounian, a cardiovascular surgeon at the university.

Alex Otto/Frontline Medical News

The team reviewed surgical outcomes there from 1990 to 2010; 282 patients had AVS procedures, 562 had Bentall procedures with biologic valve replacements (b-Bentall); and 343 had Bentalls with mechanical valve replacements (m-Bentall). About 7.5% of AVS patients had bicuspid aortic valves, versus 67.6% in the b-Bentall group and 51.7% in the m-Bentall group.

To control for confounders, patients were matched into 185 triads based on age, year of surgery, and stage of heart failure. The surgeries were all elective; patients with endocarditis or aortic dissections were excluded from the analysis.

Early postoperative outcomes and overall long-term survival were similar between the groups, with about 80% of patients in all three alive at 15-year follow-up.

However, AVS procedures had better long-term freedom from cardiac death (95% at 15 years versus 93% in the b-Bentall and 90% in the m-Bentall groups). Also, AVS patients had lower rates of anticoagulant-related hemorrhages, compared with m-Bentall patients (3.2% versus 17.8%), and lower rates of structural valve deterioration (0% versus 6.5%) and reoperations (6.5% versus 13.5%) than b-Bentall patients. The differences were statistically significant.

About 5% of AVS patients had previous cardiac surgery, versus 12.4% in the b-Bentall and 36.2% in the m-Bentall groups. AVS patients were more likely to have Marfan syndrome, and about 8% of AVS patients had preoperative ejection fractions below 40%, versus 9.3% in the b-Bentall and 13% in the m-Bentall groups. There were no between-group differences in the rates of concomitant coronary bypass or mitral valve surgery. Patients were about 50 years old on average, and about 80% were men.

“In Toronto, we are quite aggressive with valve-sparing operations. We believe in this operation, so whenever we can spare the valve, we do.” Although valve-sparing procedures have become more common in large, high-volume surgery centers over the past 20 years, “community surgeons in small-volume centers are still much more likely to do a Bentall because of the complexity of AVS operations and the art it takes to get it right,” Dr. Ouzounian said at the annual meeting of the American Association for Thoracic Surgery.

Previous investigations have found benefits for AVS procedures, as well. One concluded that “there is no significant difference in terms of re-operation between patients, who presented with [bicuspid or tricuspid aortic valves]. Re-operation rates are higher for patients who presented with severe [aortic regurgitation], but these rates do not reach statistical significance. Hence, root replacement with aortic valve sparing should be offered even in the presence of a” bicuspid aortic valve or severe aortic regurgitation (Eur. J. Cardiothorac. Surg. 2010;38:515-22).

Dr. Ouzounian said she has no disclosures.

aotto@frontlinemedcom.com

SEATTLE – Adding radiotherapy to neoadjuvant chemotherapy does not improve long-term survival after pneumonectomy for non–small cell lung cancer, according to a Turkish investigation of 140 patients.

In the study, 100 (71.4%) patients had two to six cycles of platinum-based chemotherapy at least 3 weeks before surgery; 40 (28.6%) others underwent the same regimen with the addition of radiotherapy dosed at 45-66 Gy 6-8 weeks before surgery.

Five-year survival was 48% in the chemotherapy group and 50% in the chemoradiation group, an insignificant difference (P = .7).

“Chemotherapy before surgery is definitely beneficial, but I think we will get rid of the radiotherapy” in patients with operable tumors, said lead investigator Dr. Cengiz Gebitekin, professor and head of thoracic surgery at Uludag University in Bursa, Turkey.

“It does not provide any survival benefit,” and it might cause harm, he noted, adding that “the benefit of neoadjuvant treatment comes from the chemotherapy.”

The chemoradiation group showed a tendency toward tumor down-staging and higher complete response rates, but also a trend toward more radiation-induced tissue damage. The rate of bronchopleural fistula was 3% in the chemotherapy group and 5% in the chemoradiation group, although the difference was not significant. Even so, “some of these patients had pneumonectomies because of lung damage from the radiotherapy,” Dr. Gebitekin said at the annual meeting of the American Association for Thoracic Surgery.

It’s uncertain why radiation didn’t improve survival. The investigators excluded patients with known metastases or other malignancies, but it’s possible that some patients had occult metastases that had spread beyond the field of their localized neoadjuvant radiation, he said.

The patients were treated between 2000 and 2013 at Uludag University, Istanbul University, and Zurich University Hospital. They were 55 years old on average, and 84% were men.

About 40% of patients in both the chemotherapy and chemoradiation groups had right pneumonectomies; the rest had left pneumonectomies. Bronchopleural fistulas and other comorbidities were more common after right pneumonectomies, but not significantly so.

Seven patients (5%) in the chemotherapy group but none in the chemoradiation group died within 90 days of surgery.

About 32% of chemotherapy patients and 28% of chemoradiation patients (P = .6) developed major morbidities following surgery, including arrhythmias, pneumonia, empyema, and other problems.

Staples were used to close the bronchus in almost all patients, with the stump covered with live tissue in about 70%.

The majority of patients had stage IIb or IIIa disease on postop staging; postop staging was the only factor predictive of long-term survival, with higher-stage patients doing worse.

Dr. Gebitekin said that he had no relevant disclosures.

aotto@frontlinemedcom.com

SEATTLE – Adding radiotherapy to neoadjuvant chemotherapy does not improve long-term survival after pneumonectomy for non–small cell lung cancer, according to a Turkish investigation of 140 patients.

In the study, 100 (71.4%) patients had two to six cycles of platinum-based chemotherapy at least 3 weeks before surgery; 40 (28.6%) others underwent the same regimen with the addition of radiotherapy dosed at 45-66 Gy 6-8 weeks before surgery.

Five-year survival was 48% in the chemotherapy group and 50% in the chemoradiation group, an insignificant difference (P = .7).

“Chemotherapy before surgery is definitely beneficial, but I think we will get rid of the radiotherapy” in patients with operable tumors, said lead investigator Dr. Cengiz Gebitekin, professor and head of thoracic surgery at Uludag University in Bursa, Turkey.

“It does not provide any survival benefit,” and it might cause harm, he noted, adding that “the benefit of neoadjuvant treatment comes from the chemotherapy.”

The chemoradiation group showed a tendency toward tumor down-staging and higher complete response rates, but also a trend toward more radiation-induced tissue damage. The rate of bronchopleural fistula was 3% in the chemotherapy group and 5% in the chemoradiation group, although the difference was not significant. Even so, “some of these patients had pneumonectomies because of lung damage from the radiotherapy,” Dr. Gebitekin said at the annual meeting of the American Association for Thoracic Surgery.

It’s uncertain why radiation didn’t improve survival. The investigators excluded patients with known metastases or other malignancies, but it’s possible that some patients had occult metastases that had spread beyond the field of their localized neoadjuvant radiation, he said.

The patients were treated between 2000 and 2013 at Uludag University, Istanbul University, and Zurich University Hospital. They were 55 years old on average, and 84% were men.

About 40% of patients in both the chemotherapy and chemoradiation groups had right pneumonectomies; the rest had left pneumonectomies. Bronchopleural fistulas and other comorbidities were more common after right pneumonectomies, but not significantly so.

Seven patients (5%) in the chemotherapy group but none in the chemoradiation group died within 90 days of surgery.

About 32% of chemotherapy patients and 28% of chemoradiation patients (P = .6) developed major morbidities following surgery, including arrhythmias, pneumonia, empyema, and other problems.

Staples were used to close the bronchus in almost all patients, with the stump covered with live tissue in about 70%.

The majority of patients had stage IIb or IIIa disease on postop staging; postop staging was the only factor predictive of long-term survival, with higher-stage patients doing worse.

Dr. Gebitekin said that he had no relevant disclosures.

aotto@frontlinemedcom.com

SEATTLE – Adding radiotherapy to neoadjuvant chemotherapy does not improve long-term survival after pneumonectomy for non–small cell lung cancer, according to a Turkish investigation of 140 patients.

In the study, 100 (71.4%) patients had two to six cycles of platinum-based chemotherapy at least 3 weeks before surgery; 40 (28.6%) others underwent the same regimen with the addition of radiotherapy dosed at 45-66 Gy 6-8 weeks before surgery.

Five-year survival was 48% in the chemotherapy group and 50% in the chemoradiation group, an insignificant difference (P = .7).

“Chemotherapy before surgery is definitely beneficial, but I think we will get rid of the radiotherapy” in patients with operable tumors, said lead investigator Dr. Cengiz Gebitekin, professor and head of thoracic surgery at Uludag University in Bursa, Turkey.

“It does not provide any survival benefit,” and it might cause harm, he noted, adding that “the benefit of neoadjuvant treatment comes from the chemotherapy.”

The chemoradiation group showed a tendency toward tumor down-staging and higher complete response rates, but also a trend toward more radiation-induced tissue damage. The rate of bronchopleural fistula was 3% in the chemotherapy group and 5% in the chemoradiation group, although the difference was not significant. Even so, “some of these patients had pneumonectomies because of lung damage from the radiotherapy,” Dr. Gebitekin said at the annual meeting of the American Association for Thoracic Surgery.

It’s uncertain why radiation didn’t improve survival. The investigators excluded patients with known metastases or other malignancies, but it’s possible that some patients had occult metastases that had spread beyond the field of their localized neoadjuvant radiation, he said.

The patients were treated between 2000 and 2013 at Uludag University, Istanbul University, and Zurich University Hospital. They were 55 years old on average, and 84% were men.

About 40% of patients in both the chemotherapy and chemoradiation groups had right pneumonectomies; the rest had left pneumonectomies. Bronchopleural fistulas and other comorbidities were more common after right pneumonectomies, but not significantly so.

Seven patients (5%) in the chemotherapy group but none in the chemoradiation group died within 90 days of surgery.

About 32% of chemotherapy patients and 28% of chemoradiation patients (P = .6) developed major morbidities following surgery, including arrhythmias, pneumonia, empyema, and other problems.

Staples were used to close the bronchus in almost all patients, with the stump covered with live tissue in about 70%.

The majority of patients had stage IIb or IIIa disease on postop staging; postop staging was the only factor predictive of long-term survival, with higher-stage patients doing worse.

Dr. Gebitekin said that he had no relevant disclosures.

aotto@frontlinemedcom.com

SEATTLE – Thoracic duct ligation did not seem to prevent chylothorax in a review of 827 esophagectomy cases at Brigham and Women’s Hospital in Boston.

In fact, chylothorax was most likely in patients who had mass ligation of the duct and its surrounding soft tissue, instead of ligation of simply the duct itself.

The results are surprising because ligation is actually meant to prevent chylothorax, but “it didn’t serve that purpose,” said lead investigator Dr. Yifan Zheng, a clinical research fellow at the hospital.

Results have been mixed in previous studies of ligation, with some finding benefit for preventing chylothorax but others not. With contradictory evidence, some surgeons – including some in the Brigham and Women’s review, which covered 11 years of data – opt for routine ligation, while others don’t, Dr. Zheng said at the annual meeting of the American Association for Thoracic Surgery.

At this point, “if you see the thoracic duct and you have concerns about ductal injury, your best bet is to ligate the duct directly. We observed in our series that there is a significantly higher incidence of chylothorax” with mass ligation, she said.

Of the 827 esophagectomies, 635 were performed without thoracic duct ligation; 33 (5.2%) cases developed postop chylothorax. Among the 56 cases with explicit identification and ligation of the thoracic duct alone, chylothorax developed in four (7.1%). There were 136 esophagectomies with mass ligation; 27 (19.9%) developed chylothorax (P = .0314).

The majority of the ligations were performed during open procedures. Mass ligations were mostly done with surgical sutures, while clips were used for direct ductal ligations. It’s likely that surgeons opted for direct ligation when they could see the duct and mass ligation when they could not.

Esophagectomy patients in the study were largely the same, so it’s unclear why some were ligated but others were not. About 75% in both groups had adenocarcinomas, most of which were in the distal esophagus or gastroesophageal junction. About half of the ligated group had preop chemoradiation, versus about 60% in the nonligated group.

Patients who developed postop chyle leaks were also similar, whether or not they were ligated. Most had adenocarcinomas in the distal esophagus or gastroesophageal junction, and the majority had received neoadjuvant therapy. “It’s unlikely that operative approach influenced the development of chylothorax,” Dr. Zheng said.

Both ligated and nonligated patients responded well to chylothorax management. Of the 64 total cases, 28 were successfully treated by thoracic duct embolization and 20 were successfully treated by operative thoracic duct ligation. In 10 cases, thoracic duct embolization was attempted but unsuccessful and all were successfully treated with operative ligation. Six cases were managed with chest tube drainage and total parenteral nutrition. It is possible that patients were ligated because they appeared during surgery to be at risk for postop chylothorax, which would help explain the findings.

It also is possible, however, that ligation itself – especially mass ligation – increases the risk. “The thoracic duct is a high-pressure system, so [blocking it] could create a pressure buildup and a potential leak,” Dr. Zheng said. That might be especially true with mass ligation, when both the thoracic duct and its tributaries are tied off.

Dr. Zheng said that she had no relevant disclosures.

aotto@frontlinemedcom.com

SEATTLE – Thoracic duct ligation did not seem to prevent chylothorax in a review of 827 esophagectomy cases at Brigham and Women’s Hospital in Boston.

In fact, chylothorax was most likely in patients who had mass ligation of the duct and its surrounding soft tissue, instead of ligation of simply the duct itself.

The results are surprising because ligation is actually meant to prevent chylothorax, but “it didn’t serve that purpose,” said lead investigator Dr. Yifan Zheng, a clinical research fellow at the hospital.

Results have been mixed in previous studies of ligation, with some finding benefit for preventing chylothorax but others not. With contradictory evidence, some surgeons – including some in the Brigham and Women’s review, which covered 11 years of data – opt for routine ligation, while others don’t, Dr. Zheng said at the annual meeting of the American Association for Thoracic Surgery.

At this point, “if you see the thoracic duct and you have concerns about ductal injury, your best bet is to ligate the duct directly. We observed in our series that there is a significantly higher incidence of chylothorax” with mass ligation, she said.

Of the 827 esophagectomies, 635 were performed without thoracic duct ligation; 33 (5.2%) cases developed postop chylothorax. Among the 56 cases with explicit identification and ligation of the thoracic duct alone, chylothorax developed in four (7.1%). There were 136 esophagectomies with mass ligation; 27 (19.9%) developed chylothorax (P = .0314).

The majority of the ligations were performed during open procedures. Mass ligations were mostly done with surgical sutures, while clips were used for direct ductal ligations. It’s likely that surgeons opted for direct ligation when they could see the duct and mass ligation when they could not.

Esophagectomy patients in the study were largely the same, so it’s unclear why some were ligated but others were not. About 75% in both groups had adenocarcinomas, most of which were in the distal esophagus or gastroesophageal junction. About half of the ligated group had preop chemoradiation, versus about 60% in the nonligated group.

Patients who developed postop chyle leaks were also similar, whether or not they were ligated. Most had adenocarcinomas in the distal esophagus or gastroesophageal junction, and the majority had received neoadjuvant therapy. “It’s unlikely that operative approach influenced the development of chylothorax,” Dr. Zheng said.

Both ligated and nonligated patients responded well to chylothorax management. Of the 64 total cases, 28 were successfully treated by thoracic duct embolization and 20 were successfully treated by operative thoracic duct ligation. In 10 cases, thoracic duct embolization was attempted but unsuccessful and all were successfully treated with operative ligation. Six cases were managed with chest tube drainage and total parenteral nutrition. It is possible that patients were ligated because they appeared during surgery to be at risk for postop chylothorax, which would help explain the findings.

It also is possible, however, that ligation itself – especially mass ligation – increases the risk. “The thoracic duct is a high-pressure system, so [blocking it] could create a pressure buildup and a potential leak,” Dr. Zheng said. That might be especially true with mass ligation, when both the thoracic duct and its tributaries are tied off.

Dr. Zheng said that she had no relevant disclosures.

aotto@frontlinemedcom.com

SEATTLE – Thoracic duct ligation did not seem to prevent chylothorax in a review of 827 esophagectomy cases at Brigham and Women’s Hospital in Boston.

In fact, chylothorax was most likely in patients who had mass ligation of the duct and its surrounding soft tissue, instead of ligation of simply the duct itself.

The results are surprising because ligation is actually meant to prevent chylothorax, but “it didn’t serve that purpose,” said lead investigator Dr. Yifan Zheng, a clinical research fellow at the hospital.

Results have been mixed in previous studies of ligation, with some finding benefit for preventing chylothorax but others not. With contradictory evidence, some surgeons – including some in the Brigham and Women’s review, which covered 11 years of data – opt for routine ligation, while others don’t, Dr. Zheng said at the annual meeting of the American Association for Thoracic Surgery.

At this point, “if you see the thoracic duct and you have concerns about ductal injury, your best bet is to ligate the duct directly. We observed in our series that there is a significantly higher incidence of chylothorax” with mass ligation, she said.

Of the 827 esophagectomies, 635 were performed without thoracic duct ligation; 33 (5.2%) cases developed postop chylothorax. Among the 56 cases with explicit identification and ligation of the thoracic duct alone, chylothorax developed in four (7.1%). There were 136 esophagectomies with mass ligation; 27 (19.9%) developed chylothorax (P = .0314).

The majority of the ligations were performed during open procedures. Mass ligations were mostly done with surgical sutures, while clips were used for direct ductal ligations. It’s likely that surgeons opted for direct ligation when they could see the duct and mass ligation when they could not.

Esophagectomy patients in the study were largely the same, so it’s unclear why some were ligated but others were not. About 75% in both groups had adenocarcinomas, most of which were in the distal esophagus or gastroesophageal junction. About half of the ligated group had preop chemoradiation, versus about 60% in the nonligated group.

Patients who developed postop chyle leaks were also similar, whether or not they were ligated. Most had adenocarcinomas in the distal esophagus or gastroesophageal junction, and the majority had received neoadjuvant therapy. “It’s unlikely that operative approach influenced the development of chylothorax,” Dr. Zheng said.

Both ligated and nonligated patients responded well to chylothorax management. Of the 64 total cases, 28 were successfully treated by thoracic duct embolization and 20 were successfully treated by operative thoracic duct ligation. In 10 cases, thoracic duct embolization was attempted but unsuccessful and all were successfully treated with operative ligation. Six cases were managed with chest tube drainage and total parenteral nutrition. It is possible that patients were ligated because they appeared during surgery to be at risk for postop chylothorax, which would help explain the findings.

It also is possible, however, that ligation itself – especially mass ligation – increases the risk. “The thoracic duct is a high-pressure system, so [blocking it] could create a pressure buildup and a potential leak,” Dr. Zheng said. That might be especially true with mass ligation, when both the thoracic duct and its tributaries are tied off.

Dr. Zheng said that she had no relevant disclosures.

aotto@frontlinemedcom.com

Buprenorphine is the treatment of choice for opioid addiction during pregnancy, according to Dr. Marjorie Meyer, of the department of maternal fetal medicine at the University of Vermont in Burlington.

As an in-office prescription, buprenorphine is easier to access than methadone, and a large, randomized trial that pitted methadone against buprenorphine found that women treated with buprenorphine have fewer delivery complications (N. Engl. J. Med. 2010;363:2320-31). Their babies are also born heavier and at greater gestational age than those born to mothers on methadone, and require less morphine for neonatal abstinence syndrome and recover from it sooner, Dr. Meyer said during a webinar sponsored by Premier Inc., a health care performance improvement alliance of about 3,400 U.S. hospitals and 110,000 other providers.

The evidence from the trial – the most rigorous to date comparing the two options – all favors buprenorphine, she said.

“The concerning thing about this study was that a third of women dropped out during buprenorphine induction; the way they induced I think might precipitate a little bit of withdrawal,” she said. If that’s avoided, “you can get the dropout rate down.”

In general, treatment for addicted mothers “improves pregnancy outcomes, and should be offered,” but traditional detox is not optimal therapy, Dr. Meyer said. It can help prevent neonatal abstinence, but the dropout rate is high, perhaps about 50%. Even if women stick with the program, “what you have is a very sick mother who is unable to parent,” she said.

There are still many questions about what physicians can do for pain when women on methadone or buprenorphine go into labor. Full-agonist opioid or regional analgesia are good options, but not nalbuphine and butorphanol, Dr. Meyer said. As partial opioid agonists, they can throw women into withdrawal.

“One thing that is very reassuring is that spinals and epidurals actually work just as well,” she said.

There’s no need to increase pain control after vaginal delivery in women on buprenorphine or methadone maintenance. Routine postpartum orders with p.r.n. opioids for 24 hours should be effective, Dr. Meyer said.

After cesarean delivery, however, these women need more opioids for the first few days, generally about 50%-70% more.

“We tend to go ahead and give them higher doses of p.o. dilaudid and it seems to work very well” dosed at 4-6 mg every 4-6 hours. Treatment doesn’t need to last longer than in other women, only about a week. Transversus abdominis plane (TAP) blocks have also very effective, Dr. Meyer said.

If women receive nalbuphine and butorphanol by mistake at some point during labor and delivery, Dr. Meyer said she’s seen IV morphine work well for rescue.

Patients on maintenance therapy often ask if there’s something they can do to help prevent their baby from going into withdrawal. “The obvious answer is ‘yes, stop smoking,’” she said.

The vast majority of opioid abusers smoke cigarettes, and smoking has been shown to be “a very important contributor to neonatal abstinence syndrome,” she said. “I use this [fact] as a tool to really encourage smoking cessation, or even smoking reduction.”

Dr. Meyer reported having no relevant financial disclosures.

aotto@frontlinemedcom.com

Buprenorphine is the treatment of choice for opioid addiction during pregnancy, according to Dr. Marjorie Meyer, of the department of maternal fetal medicine at the University of Vermont in Burlington.

As an in-office prescription, buprenorphine is easier to access than methadone, and a large, randomized trial that pitted methadone against buprenorphine found that women treated with buprenorphine have fewer delivery complications (N. Engl. J. Med. 2010;363:2320-31). Their babies are also born heavier and at greater gestational age than those born to mothers on methadone, and require less morphine for neonatal abstinence syndrome and recover from it sooner, Dr. Meyer said during a webinar sponsored by Premier Inc., a health care performance improvement alliance of about 3,400 U.S. hospitals and 110,000 other providers.

The evidence from the trial – the most rigorous to date comparing the two options – all favors buprenorphine, she said.

“The concerning thing about this study was that a third of women dropped out during buprenorphine induction; the way they induced I think might precipitate a little bit of withdrawal,” she said. If that’s avoided, “you can get the dropout rate down.”

In general, treatment for addicted mothers “improves pregnancy outcomes, and should be offered,” but traditional detox is not optimal therapy, Dr. Meyer said. It can help prevent neonatal abstinence, but the dropout rate is high, perhaps about 50%. Even if women stick with the program, “what you have is a very sick mother who is unable to parent,” she said.

There are still many questions about what physicians can do for pain when women on methadone or buprenorphine go into labor. Full-agonist opioid or regional analgesia are good options, but not nalbuphine and butorphanol, Dr. Meyer said. As partial opioid agonists, they can throw women into withdrawal.

“One thing that is very reassuring is that spinals and epidurals actually work just as well,” she said.

There’s no need to increase pain control after vaginal delivery in women on buprenorphine or methadone maintenance. Routine postpartum orders with p.r.n. opioids for 24 hours should be effective, Dr. Meyer said.

After cesarean delivery, however, these women need more opioids for the first few days, generally about 50%-70% more.

“We tend to go ahead and give them higher doses of p.o. dilaudid and it seems to work very well” dosed at 4-6 mg every 4-6 hours. Treatment doesn’t need to last longer than in other women, only about a week. Transversus abdominis plane (TAP) blocks have also very effective, Dr. Meyer said.

If women receive nalbuphine and butorphanol by mistake at some point during labor and delivery, Dr. Meyer said she’s seen IV morphine work well for rescue.

Patients on maintenance therapy often ask if there’s something they can do to help prevent their baby from going into withdrawal. “The obvious answer is ‘yes, stop smoking,’” she said.

The vast majority of opioid abusers smoke cigarettes, and smoking has been shown to be “a very important contributor to neonatal abstinence syndrome,” she said. “I use this [fact] as a tool to really encourage smoking cessation, or even smoking reduction.”

Dr. Meyer reported having no relevant financial disclosures.

aotto@frontlinemedcom.com

Buprenorphine is the treatment of choice for opioid addiction during pregnancy, according to Dr. Marjorie Meyer, of the department of maternal fetal medicine at the University of Vermont in Burlington.

As an in-office prescription, buprenorphine is easier to access than methadone, and a large, randomized trial that pitted methadone against buprenorphine found that women treated with buprenorphine have fewer delivery complications (N. Engl. J. Med. 2010;363:2320-31). Their babies are also born heavier and at greater gestational age than those born to mothers on methadone, and require less morphine for neonatal abstinence syndrome and recover from it sooner, Dr. Meyer said during a webinar sponsored by Premier Inc., a health care performance improvement alliance of about 3,400 U.S. hospitals and 110,000 other providers.

The evidence from the trial – the most rigorous to date comparing the two options – all favors buprenorphine, she said.

“The concerning thing about this study was that a third of women dropped out during buprenorphine induction; the way they induced I think might precipitate a little bit of withdrawal,” she said. If that’s avoided, “you can get the dropout rate down.”

In general, treatment for addicted mothers “improves pregnancy outcomes, and should be offered,” but traditional detox is not optimal therapy, Dr. Meyer said. It can help prevent neonatal abstinence, but the dropout rate is high, perhaps about 50%. Even if women stick with the program, “what you have is a very sick mother who is unable to parent,” she said.

There are still many questions about what physicians can do for pain when women on methadone or buprenorphine go into labor. Full-agonist opioid or regional analgesia are good options, but not nalbuphine and butorphanol, Dr. Meyer said. As partial opioid agonists, they can throw women into withdrawal.

“One thing that is very reassuring is that spinals and epidurals actually work just as well,” she said.

There’s no need to increase pain control after vaginal delivery in women on buprenorphine or methadone maintenance. Routine postpartum orders with p.r.n. opioids for 24 hours should be effective, Dr. Meyer said.

After cesarean delivery, however, these women need more opioids for the first few days, generally about 50%-70% more.

“We tend to go ahead and give them higher doses of p.o. dilaudid and it seems to work very well” dosed at 4-6 mg every 4-6 hours. Treatment doesn’t need to last longer than in other women, only about a week. Transversus abdominis plane (TAP) blocks have also very effective, Dr. Meyer said.

If women receive nalbuphine and butorphanol by mistake at some point during labor and delivery, Dr. Meyer said she’s seen IV morphine work well for rescue.

Patients on maintenance therapy often ask if there’s something they can do to help prevent their baby from going into withdrawal. “The obvious answer is ‘yes, stop smoking,’” she said.

The vast majority of opioid abusers smoke cigarettes, and smoking has been shown to be “a very important contributor to neonatal abstinence syndrome,” she said. “I use this [fact] as a tool to really encourage smoking cessation, or even smoking reduction.”

Dr. Meyer reported having no relevant financial disclosures.

aotto@frontlinemedcom.com