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M. Alexander Otto began his reporting career early in 1999 covering the pharmaceutical industry for a national pharmacists' magazine and freelancing for the Washington Post and other newspapers. He then joined BNA, now part of Bloomberg News, covering health law and the protection of people and animals in medical research. Alex next worked for the McClatchy Company. Based on his work, Alex won a year-long Knight Science Journalism Fellowship to MIT in 2008-2009. He joined the company shortly thereafter. Alex has a newspaper journalism degree from Syracuse (N.Y.) University and a master's degree in medical science -- a physician assistant degree -- from George Washington University. Alex is based in Seattle.
VIDEO: Negative online reviews don’t have to hurt your practice
SAN FRANCISCO – By some estimates, about two-thirds of people check online reviews before they select a doctor.
That’s not necessarily a bad thing, according to Dr. Jeffrey Benabio, a dermatologist and director of health care transformation at Kaiser Permanente in San Diego.
Reviews can help you identify where you need to tighten up your practice and also can help open a dialogue with your patients. You don’t have to pull your hair out over a bad review either; bad reviews can be handled productively. Dr Benabio explained how in an interview at the annual meeting of the American Academy of Dermatology.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
SAN FRANCISCO – By some estimates, about two-thirds of people check online reviews before they select a doctor.
That’s not necessarily a bad thing, according to Dr. Jeffrey Benabio, a dermatologist and director of health care transformation at Kaiser Permanente in San Diego.
Reviews can help you identify where you need to tighten up your practice and also can help open a dialogue with your patients. You don’t have to pull your hair out over a bad review either; bad reviews can be handled productively. Dr Benabio explained how in an interview at the annual meeting of the American Academy of Dermatology.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
SAN FRANCISCO – By some estimates, about two-thirds of people check online reviews before they select a doctor.
That’s not necessarily a bad thing, according to Dr. Jeffrey Benabio, a dermatologist and director of health care transformation at Kaiser Permanente in San Diego.
Reviews can help you identify where you need to tighten up your practice and also can help open a dialogue with your patients. You don’t have to pull your hair out over a bad review either; bad reviews can be handled productively. Dr Benabio explained how in an interview at the annual meeting of the American Academy of Dermatology.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
AT THE AAD ANNUAL MEETING
VIDEO: Meet Frankie and Sophie, the thyroid cancer–sniffing dogs
SAN DIEGO – Researchers at the University of Arkansas for Medical Sciences in Little Rock are teaching dogs to detect thyroid cancer from urine samples.
The dogs become alert on samples if they detect cancer, but remain passive if they don’t. The first graduate of the program, a German shepherd mix named Frankie, got it right in 30 of 34 cases, matching final surgical pathology results with a sensitivity of 86.6% and a specificity of 89.5%.
With results like those, it might not be too long before Frankie and his colleagues are providing inexpensive adjunct diagnostic services when test results are uncertain, and helping underserved areas with limited diagnostic capacity, the researchers noted.
At the Endocrine Society meeting, investigator Dr. Andrew Hinson shared clips of Frankie and another recent graduate, a border collie mix named Sophie, and explained the project’s next steps.
Frankie was rescued by principal investigator Dr. Arny Ferrando. Sophie and other dogs in the program were also rescued from local animal shelters.
More information is available at www.thefrankiefoundation.org.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
SAN DIEGO – Researchers at the University of Arkansas for Medical Sciences in Little Rock are teaching dogs to detect thyroid cancer from urine samples.
The dogs become alert on samples if they detect cancer, but remain passive if they don’t. The first graduate of the program, a German shepherd mix named Frankie, got it right in 30 of 34 cases, matching final surgical pathology results with a sensitivity of 86.6% and a specificity of 89.5%.
With results like those, it might not be too long before Frankie and his colleagues are providing inexpensive adjunct diagnostic services when test results are uncertain, and helping underserved areas with limited diagnostic capacity, the researchers noted.
At the Endocrine Society meeting, investigator Dr. Andrew Hinson shared clips of Frankie and another recent graduate, a border collie mix named Sophie, and explained the project’s next steps.
Frankie was rescued by principal investigator Dr. Arny Ferrando. Sophie and other dogs in the program were also rescued from local animal shelters.
More information is available at www.thefrankiefoundation.org.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
SAN DIEGO – Researchers at the University of Arkansas for Medical Sciences in Little Rock are teaching dogs to detect thyroid cancer from urine samples.
The dogs become alert on samples if they detect cancer, but remain passive if they don’t. The first graduate of the program, a German shepherd mix named Frankie, got it right in 30 of 34 cases, matching final surgical pathology results with a sensitivity of 86.6% and a specificity of 89.5%.
With results like those, it might not be too long before Frankie and his colleagues are providing inexpensive adjunct diagnostic services when test results are uncertain, and helping underserved areas with limited diagnostic capacity, the researchers noted.
At the Endocrine Society meeting, investigator Dr. Andrew Hinson shared clips of Frankie and another recent graduate, a border collie mix named Sophie, and explained the project’s next steps.
Frankie was rescued by principal investigator Dr. Arny Ferrando. Sophie and other dogs in the program were also rescued from local animal shelters.
More information is available at www.thefrankiefoundation.org.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
AT ENDO 2015
Microbiome research is decades away from benefiting human health
MAUI, HAWAII – Don’t look for findings about the human microbiome to have any imminent impact on health, said rheumatologist Peter Lipsky.
The human microbiome “is the most exciting area in science at the moment, but also the most hyped. There’s a tendency in this field driven both by scientists and the NIH [National Institutes of Health], as well as by commercial interests, to explain every [condition as it relates to] the microbiome,” he said at the 2015 Rheumatology Winter Clinical Symposium.
Most of our understanding about the microbiome comes from “very reductionist experiments” in genetically altered mice, often raised in germ-free environments “where you can control everything.” The findings have no clear use in human medicine, and have not led to any breakthroughs. To date, there have been only a few microbiome studies in people, and they’ve been solely descriptive, said Dr. Lipsky, former chief of the autoimmunity branch at the National Institute of Arthritis and Musculoskeletal and Skin Diseases.
Microbiome research examines how normal human bacteria might have something to do with illness. The field has much in common with human genome mapping in the mid-1990s; it is in the data-gathering phase with little evidence of benefit.
It will take decades to fully figure out how vast and ever-changing communities of bacteria interact with each other and the human body, and how to selectively manipulate them to improve human health. Humans carry about 3 pounds of bacteria on and in their bodies, with bacterial cells outnumbering human cells by about 10:1. Those 3 pounds are composed of thousands of bacterial species, and new species are being discovered almost daily, thanks to advances in molecular technology.
“It’s impossible with the technology that we have now to integrate the actions of all these organisms,” said Dr. Lipsky of Charlottesville, Va.
Even so, the Internet is awash in ads for prebiotics, probiotics, and other products to balance the human microbiome. There are companies that take stool samples to diagnose and correct microbiome imbalances.
“Does this make any sense today? No,” Dr. Lipsky said. “You are never going to be able to stop patients from taking risks, but there is a certain amount of caution that needs to be exerted here. What you can tell patients is that this is an exciting area, but it’s in its early stage. There is really no scientific basis for any of these products. Most of them probably don’t do any harm, but I don’t know that for certain. The same organism that might protect against colon cancer could facilitate rheumatoid arthritis or periodontal disease,” he said.
Dr. Lipsky supported his thesis with a review of the latest human findings. One study found an aberration in oral microbiota in new-onset rheumatoid arthritis (RA). A stool sample study correlated an overabundance of gut Prevotella copri with RA. Another found changes in gut bacteria in psoriasis and psoriatic arthritis that seem similar to those seen in inflammatory bowel disease. It’s unknown if the disease caused the imbalance or visa versa.
Another small study found a drop in gut Firmicutes families in lupus (mBio 2014;5:e01548-14). “How and why this microbial community influences [lupus] remains to be elucidated,” the authors noted.
Dr. Lipsky is an adviser for Janssen and a consultant for Pfizer.
MAUI, HAWAII – Don’t look for findings about the human microbiome to have any imminent impact on health, said rheumatologist Peter Lipsky.
The human microbiome “is the most exciting area in science at the moment, but also the most hyped. There’s a tendency in this field driven both by scientists and the NIH [National Institutes of Health], as well as by commercial interests, to explain every [condition as it relates to] the microbiome,” he said at the 2015 Rheumatology Winter Clinical Symposium.
Most of our understanding about the microbiome comes from “very reductionist experiments” in genetically altered mice, often raised in germ-free environments “where you can control everything.” The findings have no clear use in human medicine, and have not led to any breakthroughs. To date, there have been only a few microbiome studies in people, and they’ve been solely descriptive, said Dr. Lipsky, former chief of the autoimmunity branch at the National Institute of Arthritis and Musculoskeletal and Skin Diseases.
Microbiome research examines how normal human bacteria might have something to do with illness. The field has much in common with human genome mapping in the mid-1990s; it is in the data-gathering phase with little evidence of benefit.
It will take decades to fully figure out how vast and ever-changing communities of bacteria interact with each other and the human body, and how to selectively manipulate them to improve human health. Humans carry about 3 pounds of bacteria on and in their bodies, with bacterial cells outnumbering human cells by about 10:1. Those 3 pounds are composed of thousands of bacterial species, and new species are being discovered almost daily, thanks to advances in molecular technology.
“It’s impossible with the technology that we have now to integrate the actions of all these organisms,” said Dr. Lipsky of Charlottesville, Va.
Even so, the Internet is awash in ads for prebiotics, probiotics, and other products to balance the human microbiome. There are companies that take stool samples to diagnose and correct microbiome imbalances.
“Does this make any sense today? No,” Dr. Lipsky said. “You are never going to be able to stop patients from taking risks, but there is a certain amount of caution that needs to be exerted here. What you can tell patients is that this is an exciting area, but it’s in its early stage. There is really no scientific basis for any of these products. Most of them probably don’t do any harm, but I don’t know that for certain. The same organism that might protect against colon cancer could facilitate rheumatoid arthritis or periodontal disease,” he said.
Dr. Lipsky supported his thesis with a review of the latest human findings. One study found an aberration in oral microbiota in new-onset rheumatoid arthritis (RA). A stool sample study correlated an overabundance of gut Prevotella copri with RA. Another found changes in gut bacteria in psoriasis and psoriatic arthritis that seem similar to those seen in inflammatory bowel disease. It’s unknown if the disease caused the imbalance or visa versa.
Another small study found a drop in gut Firmicutes families in lupus (mBio 2014;5:e01548-14). “How and why this microbial community influences [lupus] remains to be elucidated,” the authors noted.
Dr. Lipsky is an adviser for Janssen and a consultant for Pfizer.
MAUI, HAWAII – Don’t look for findings about the human microbiome to have any imminent impact on health, said rheumatologist Peter Lipsky.
The human microbiome “is the most exciting area in science at the moment, but also the most hyped. There’s a tendency in this field driven both by scientists and the NIH [National Institutes of Health], as well as by commercial interests, to explain every [condition as it relates to] the microbiome,” he said at the 2015 Rheumatology Winter Clinical Symposium.
Most of our understanding about the microbiome comes from “very reductionist experiments” in genetically altered mice, often raised in germ-free environments “where you can control everything.” The findings have no clear use in human medicine, and have not led to any breakthroughs. To date, there have been only a few microbiome studies in people, and they’ve been solely descriptive, said Dr. Lipsky, former chief of the autoimmunity branch at the National Institute of Arthritis and Musculoskeletal and Skin Diseases.
Microbiome research examines how normal human bacteria might have something to do with illness. The field has much in common with human genome mapping in the mid-1990s; it is in the data-gathering phase with little evidence of benefit.
It will take decades to fully figure out how vast and ever-changing communities of bacteria interact with each other and the human body, and how to selectively manipulate them to improve human health. Humans carry about 3 pounds of bacteria on and in their bodies, with bacterial cells outnumbering human cells by about 10:1. Those 3 pounds are composed of thousands of bacterial species, and new species are being discovered almost daily, thanks to advances in molecular technology.
“It’s impossible with the technology that we have now to integrate the actions of all these organisms,” said Dr. Lipsky of Charlottesville, Va.
Even so, the Internet is awash in ads for prebiotics, probiotics, and other products to balance the human microbiome. There are companies that take stool samples to diagnose and correct microbiome imbalances.
“Does this make any sense today? No,” Dr. Lipsky said. “You are never going to be able to stop patients from taking risks, but there is a certain amount of caution that needs to be exerted here. What you can tell patients is that this is an exciting area, but it’s in its early stage. There is really no scientific basis for any of these products. Most of them probably don’t do any harm, but I don’t know that for certain. The same organism that might protect against colon cancer could facilitate rheumatoid arthritis or periodontal disease,” he said.
Dr. Lipsky supported his thesis with a review of the latest human findings. One study found an aberration in oral microbiota in new-onset rheumatoid arthritis (RA). A stool sample study correlated an overabundance of gut Prevotella copri with RA. Another found changes in gut bacteria in psoriasis and psoriatic arthritis that seem similar to those seen in inflammatory bowel disease. It’s unknown if the disease caused the imbalance or visa versa.
Another small study found a drop in gut Firmicutes families in lupus (mBio 2014;5:e01548-14). “How and why this microbial community influences [lupus] remains to be elucidated,” the authors noted.
Dr. Lipsky is an adviser for Janssen and a consultant for Pfizer.
EXPERT ANALYSIS FROM RWCS 2015
Ranolazine plus beta-blockers might prevent postop AF
PHOENIX – Twice-daily ranolazine following adult cardiac surgery seemed to protect against atrial fibrillation, based on a retrospective cohort study at the University of Florida Jacksonville Medical Center.
Ranolazine (Ranexa) was dosed orally at 1,000 mg the morning of surgery, and then resumed after extubation, generally the night of surgery. The goal was 1,000 mg orally twice a day, for a maximum of 7 hospital days; patients usually went home before then, so they received an average of nine doses. The drug was discontinued at discharge.
Six (10.5%) of 57 patients in the ranolazine group developed postoperative atrial fibrillation (POAF) versus 26 (45.6%) of 57 matched controls (P < .0001). The first case came at postop day 3 in the ranolazine group, but within 24 hours in the control group. One person in the ranolazine group and one in the control group had a history of AF.
There was no statistical difference in ICU length of stay, 30-day readmission for cardiac causes, or 30-day cardiovascular mortality; the one cardiovascular death was in the control group.
Two-thirds of the patients had coronary artery bypass grafts, and the rest had either valve surgery or a combination of both surgeries. Patients were 60 years old on average, and two-thirds were men, Drayton Hammond, Pharm.D., said at the Critical Care Congress, sponsored by the Society for Critical Care Medicine.
Ranolazine is indicated for chronic angina, not POAF prevention, but some previous investigations have suggested a possible benefit. A randomized, controlled clinical trial is currently looking into the matter.
At least retrospectively, the drug was “beneficial, definitely. There is about a 35% absolute-risk reduction,” said Dr. Hammond, who conducted the study while at the Jacksonville hospital.
Doctors there continue to use ranolazine for postop AF prophylaxis, as they see fit, said Dr. Hammond, now an assistant professor of pharmacy practice at the University of Arkansas for Medical Sciences, in Little Rock.
Gilead, the maker of the Ranexa, is also working on a ranolazine-dronedarone combination for paroxysmal AF.
More than half of the ranolazine patients in the study developed symptomatic hypotension within 72 hours of surgery, versus about a third in the control group (P = .0004). The drug was discontinued in one ranolazine patient because of hypotension. The problem resolved after 72 hours.
“We don’t have a good explanation” for the side effect. Perhaps there were differences in myocardial stunning or vasopressor use between the groups, but “we had the same three surgeons” for all the cases, Dr. Hammond said.
Ranolazine labeling notes the risk of hypotension and orthostatic hypotension. Labeling also warns of QT interval prolongation and renal failure in susceptible patients. The investigators found no between-group differences in bradycardia, new renal failure, or neurological events.
Overall, 53 (93%) patients in the ranolazine group were on postoperative beta-blockers, and 54 (94.7%) on postop statins; 48 (84.2%) in the control group were on beta-blockers postop and 47 (82.5%) on statins. Beta-blockers are first-line treatment to prevent postop AF; patients on any other antiarrhythmic were excluded from the trial, as were those who died during surgery.
PHOENIX – Twice-daily ranolazine following adult cardiac surgery seemed to protect against atrial fibrillation, based on a retrospective cohort study at the University of Florida Jacksonville Medical Center.
Ranolazine (Ranexa) was dosed orally at 1,000 mg the morning of surgery, and then resumed after extubation, generally the night of surgery. The goal was 1,000 mg orally twice a day, for a maximum of 7 hospital days; patients usually went home before then, so they received an average of nine doses. The drug was discontinued at discharge.
Six (10.5%) of 57 patients in the ranolazine group developed postoperative atrial fibrillation (POAF) versus 26 (45.6%) of 57 matched controls (P < .0001). The first case came at postop day 3 in the ranolazine group, but within 24 hours in the control group. One person in the ranolazine group and one in the control group had a history of AF.
There was no statistical difference in ICU length of stay, 30-day readmission for cardiac causes, or 30-day cardiovascular mortality; the one cardiovascular death was in the control group.
Two-thirds of the patients had coronary artery bypass grafts, and the rest had either valve surgery or a combination of both surgeries. Patients were 60 years old on average, and two-thirds were men, Drayton Hammond, Pharm.D., said at the Critical Care Congress, sponsored by the Society for Critical Care Medicine.
Ranolazine is indicated for chronic angina, not POAF prevention, but some previous investigations have suggested a possible benefit. A randomized, controlled clinical trial is currently looking into the matter.
At least retrospectively, the drug was “beneficial, definitely. There is about a 35% absolute-risk reduction,” said Dr. Hammond, who conducted the study while at the Jacksonville hospital.
Doctors there continue to use ranolazine for postop AF prophylaxis, as they see fit, said Dr. Hammond, now an assistant professor of pharmacy practice at the University of Arkansas for Medical Sciences, in Little Rock.
Gilead, the maker of the Ranexa, is also working on a ranolazine-dronedarone combination for paroxysmal AF.
More than half of the ranolazine patients in the study developed symptomatic hypotension within 72 hours of surgery, versus about a third in the control group (P = .0004). The drug was discontinued in one ranolazine patient because of hypotension. The problem resolved after 72 hours.
“We don’t have a good explanation” for the side effect. Perhaps there were differences in myocardial stunning or vasopressor use between the groups, but “we had the same three surgeons” for all the cases, Dr. Hammond said.
Ranolazine labeling notes the risk of hypotension and orthostatic hypotension. Labeling also warns of QT interval prolongation and renal failure in susceptible patients. The investigators found no between-group differences in bradycardia, new renal failure, or neurological events.
Overall, 53 (93%) patients in the ranolazine group were on postoperative beta-blockers, and 54 (94.7%) on postop statins; 48 (84.2%) in the control group were on beta-blockers postop and 47 (82.5%) on statins. Beta-blockers are first-line treatment to prevent postop AF; patients on any other antiarrhythmic were excluded from the trial, as were those who died during surgery.
PHOENIX – Twice-daily ranolazine following adult cardiac surgery seemed to protect against atrial fibrillation, based on a retrospective cohort study at the University of Florida Jacksonville Medical Center.
Ranolazine (Ranexa) was dosed orally at 1,000 mg the morning of surgery, and then resumed after extubation, generally the night of surgery. The goal was 1,000 mg orally twice a day, for a maximum of 7 hospital days; patients usually went home before then, so they received an average of nine doses. The drug was discontinued at discharge.
Six (10.5%) of 57 patients in the ranolazine group developed postoperative atrial fibrillation (POAF) versus 26 (45.6%) of 57 matched controls (P < .0001). The first case came at postop day 3 in the ranolazine group, but within 24 hours in the control group. One person in the ranolazine group and one in the control group had a history of AF.
There was no statistical difference in ICU length of stay, 30-day readmission for cardiac causes, or 30-day cardiovascular mortality; the one cardiovascular death was in the control group.
Two-thirds of the patients had coronary artery bypass grafts, and the rest had either valve surgery or a combination of both surgeries. Patients were 60 years old on average, and two-thirds were men, Drayton Hammond, Pharm.D., said at the Critical Care Congress, sponsored by the Society for Critical Care Medicine.
Ranolazine is indicated for chronic angina, not POAF prevention, but some previous investigations have suggested a possible benefit. A randomized, controlled clinical trial is currently looking into the matter.
At least retrospectively, the drug was “beneficial, definitely. There is about a 35% absolute-risk reduction,” said Dr. Hammond, who conducted the study while at the Jacksonville hospital.
Doctors there continue to use ranolazine for postop AF prophylaxis, as they see fit, said Dr. Hammond, now an assistant professor of pharmacy practice at the University of Arkansas for Medical Sciences, in Little Rock.
Gilead, the maker of the Ranexa, is also working on a ranolazine-dronedarone combination for paroxysmal AF.
More than half of the ranolazine patients in the study developed symptomatic hypotension within 72 hours of surgery, versus about a third in the control group (P = .0004). The drug was discontinued in one ranolazine patient because of hypotension. The problem resolved after 72 hours.
“We don’t have a good explanation” for the side effect. Perhaps there were differences in myocardial stunning or vasopressor use between the groups, but “we had the same three surgeons” for all the cases, Dr. Hammond said.
Ranolazine labeling notes the risk of hypotension and orthostatic hypotension. Labeling also warns of QT interval prolongation and renal failure in susceptible patients. The investigators found no between-group differences in bradycardia, new renal failure, or neurological events.
Overall, 53 (93%) patients in the ranolazine group were on postoperative beta-blockers, and 54 (94.7%) on postop statins; 48 (84.2%) in the control group were on beta-blockers postop and 47 (82.5%) on statins. Beta-blockers are first-line treatment to prevent postop AF; patients on any other antiarrhythmic were excluded from the trial, as were those who died during surgery.
AT THE CRITICAL CARE CONGRESS
Key clinical point: Ranolazine’s protective effect seems to come at the cost of symptomatic hypotension in the first 3 days after surgery.
Major finding: Postop atrial fibrillation occurred in 6 (10.5%) of 57 patients in the ranolazine group and 26 (45.6%) of 57 matched controls (P < .0001).
Data source: Retrospective cohort study of postop follow-up in 114 adults who had cardiac surgery.
Disclosures: There was no outside funding for the work. The investigators said they have no financial relationship with Gilead, maker of ranolazine (Ranexa).
CHADS2 predicts postop atrial fibrillation
PHOENIX – For every unit increase in baseline CHADS2 score, the risk of postop atrial fibrillation increases by 17%, according to a retrospective chart review of 1,550 adults who had major vascular or thoracic surgery at the Mayo Clinic in Rochester, Minn.
On multivariate analysis, postop day 1 Sequential Organ Failure Assessment score (HR 1.08, 95% CI 1.03-1.12, per unit increase) and cumulative fluid balance (HR 1.03, 95% CI 1.01-1.06, per 1,000 mL) also correlated with the risk for new-onset atrial fibrillation (AF).
Baseline calcium channel blockers protected against new-onset AF (HR 0.52, 95% CI 0.37-0.73), but, paradoxically, the risk increased with baseline (HR 1.78, 95% CI 1.24-2.56) and postop (HR 1.44, 95% CI 1.05-1.99) beta-blocker use.
The relationship of CHADS2 to new-onset AF (HR 1.17, 95% CI 1.04-1.31) could prove handy in the surgical ICU because “everyone is familiar with it, and it’s easy to calculate.” CHADS2 (heart failure, hypertension, age, diabetes, prior stroke) has also recently been shown to predict AF after cardiac surgery, said lead investigator Kirstin Kooda, Pharm.D., a critical care pharmacist at Mayo.
The beta-blocker finding was a surprise, since beta-blockers are a standard AF treatment, Dr. Kooda said at the Critical Care Congress, sponsored by the Society for Critical Care Medicine. About 80% (175) of new-onset AF patients were on baseline beta-blockers, versus about 68% (892) who did not develop AF. Patients using beta-blockers received them the morning of surgery, and resumed them a median of 7 hours afterward. There were no significant differences in heart rates during surgery.
The team excluded patients with any history of AF and censored patients if they developed it, so the drugs’ use probably wasn’t related to a concern about the condition. Just under 70% of patients in both groups had baseline hypertension, another indication for the drugs.
Even so, the finding is probably real given the number of patients in the study. Most likely, the drugs were markers for additional risk factors not captured in the study, Dr. Kooda said.
Overall, 112 (20.7%) of the 540 thoracic patients and 107 (11%) of the 1,010 vascular patients developed new-onset AF a median of 55 hours after surgery. The incidence difference and timing are in line with previous reports.
The mean age in the AF group was 70 years, and in the non-AF group it was 66 years. In both, 65% were men, 5% had heart failure, 30% had diabetes, and 10% had prior strokes. Patients with pacemakers and recent myocardial infarctions – also possible settings for beta-blockers – were excluded from the trial.
The majority of the vascular cases were open aortic aneurysms, aortic bypasses, and thrombectomies or endarterectomies of central arteries. Most of the thoracic surgeries were lobectomies, pneumonectomies, and wedge or chest wall resections.
PHOENIX – For every unit increase in baseline CHADS2 score, the risk of postop atrial fibrillation increases by 17%, according to a retrospective chart review of 1,550 adults who had major vascular or thoracic surgery at the Mayo Clinic in Rochester, Minn.
On multivariate analysis, postop day 1 Sequential Organ Failure Assessment score (HR 1.08, 95% CI 1.03-1.12, per unit increase) and cumulative fluid balance (HR 1.03, 95% CI 1.01-1.06, per 1,000 mL) also correlated with the risk for new-onset atrial fibrillation (AF).
Baseline calcium channel blockers protected against new-onset AF (HR 0.52, 95% CI 0.37-0.73), but, paradoxically, the risk increased with baseline (HR 1.78, 95% CI 1.24-2.56) and postop (HR 1.44, 95% CI 1.05-1.99) beta-blocker use.
The relationship of CHADS2 to new-onset AF (HR 1.17, 95% CI 1.04-1.31) could prove handy in the surgical ICU because “everyone is familiar with it, and it’s easy to calculate.” CHADS2 (heart failure, hypertension, age, diabetes, prior stroke) has also recently been shown to predict AF after cardiac surgery, said lead investigator Kirstin Kooda, Pharm.D., a critical care pharmacist at Mayo.
The beta-blocker finding was a surprise, since beta-blockers are a standard AF treatment, Dr. Kooda said at the Critical Care Congress, sponsored by the Society for Critical Care Medicine. About 80% (175) of new-onset AF patients were on baseline beta-blockers, versus about 68% (892) who did not develop AF. Patients using beta-blockers received them the morning of surgery, and resumed them a median of 7 hours afterward. There were no significant differences in heart rates during surgery.
The team excluded patients with any history of AF and censored patients if they developed it, so the drugs’ use probably wasn’t related to a concern about the condition. Just under 70% of patients in both groups had baseline hypertension, another indication for the drugs.
Even so, the finding is probably real given the number of patients in the study. Most likely, the drugs were markers for additional risk factors not captured in the study, Dr. Kooda said.
Overall, 112 (20.7%) of the 540 thoracic patients and 107 (11%) of the 1,010 vascular patients developed new-onset AF a median of 55 hours after surgery. The incidence difference and timing are in line with previous reports.
The mean age in the AF group was 70 years, and in the non-AF group it was 66 years. In both, 65% were men, 5% had heart failure, 30% had diabetes, and 10% had prior strokes. Patients with pacemakers and recent myocardial infarctions – also possible settings for beta-blockers – were excluded from the trial.
The majority of the vascular cases were open aortic aneurysms, aortic bypasses, and thrombectomies or endarterectomies of central arteries. Most of the thoracic surgeries were lobectomies, pneumonectomies, and wedge or chest wall resections.
PHOENIX – For every unit increase in baseline CHADS2 score, the risk of postop atrial fibrillation increases by 17%, according to a retrospective chart review of 1,550 adults who had major vascular or thoracic surgery at the Mayo Clinic in Rochester, Minn.
On multivariate analysis, postop day 1 Sequential Organ Failure Assessment score (HR 1.08, 95% CI 1.03-1.12, per unit increase) and cumulative fluid balance (HR 1.03, 95% CI 1.01-1.06, per 1,000 mL) also correlated with the risk for new-onset atrial fibrillation (AF).
Baseline calcium channel blockers protected against new-onset AF (HR 0.52, 95% CI 0.37-0.73), but, paradoxically, the risk increased with baseline (HR 1.78, 95% CI 1.24-2.56) and postop (HR 1.44, 95% CI 1.05-1.99) beta-blocker use.
The relationship of CHADS2 to new-onset AF (HR 1.17, 95% CI 1.04-1.31) could prove handy in the surgical ICU because “everyone is familiar with it, and it’s easy to calculate.” CHADS2 (heart failure, hypertension, age, diabetes, prior stroke) has also recently been shown to predict AF after cardiac surgery, said lead investigator Kirstin Kooda, Pharm.D., a critical care pharmacist at Mayo.
The beta-blocker finding was a surprise, since beta-blockers are a standard AF treatment, Dr. Kooda said at the Critical Care Congress, sponsored by the Society for Critical Care Medicine. About 80% (175) of new-onset AF patients were on baseline beta-blockers, versus about 68% (892) who did not develop AF. Patients using beta-blockers received them the morning of surgery, and resumed them a median of 7 hours afterward. There were no significant differences in heart rates during surgery.
The team excluded patients with any history of AF and censored patients if they developed it, so the drugs’ use probably wasn’t related to a concern about the condition. Just under 70% of patients in both groups had baseline hypertension, another indication for the drugs.
Even so, the finding is probably real given the number of patients in the study. Most likely, the drugs were markers for additional risk factors not captured in the study, Dr. Kooda said.
Overall, 112 (20.7%) of the 540 thoracic patients and 107 (11%) of the 1,010 vascular patients developed new-onset AF a median of 55 hours after surgery. The incidence difference and timing are in line with previous reports.
The mean age in the AF group was 70 years, and in the non-AF group it was 66 years. In both, 65% were men, 5% had heart failure, 30% had diabetes, and 10% had prior strokes. Patients with pacemakers and recent myocardial infarctions – also possible settings for beta-blockers – were excluded from the trial.
The majority of the vascular cases were open aortic aneurysms, aortic bypasses, and thrombectomies or endarterectomies of central arteries. Most of the thoracic surgeries were lobectomies, pneumonectomies, and wedge or chest wall resections.
AT THE CRITICAL CARE CONGRESS
Key clinical point: Postop atrial fibrillation is more likely if patients go into surgery with an elevated CHADS 2 score.
Major finding: For every unit increase in baseline CHADS2 score, there is a 17% increase in the risk of new-onset AF following major vascular or thoracic surgery (HR 1.17, 95% CI 1.04-1.31).
Data source: Retrospective chart review of 1,550 adult patients.
Disclosures: The investigators said they had no disclosures. No outside funding was reported for the work.
Increase enoxaparin doses to prevent VTEs in trauma patients
PHOENIX – Trauma patients probably need an elevated dose of enoxaparin – perhaps 40 mg twice daily – to prevent venous thromboembolisms, according to a prospective study of 85 trauma patients at the Palmetto Health Richland hospital in Columbia, S.C.
Also, antifactor 10a – a blood test often used in research to gauge how well enoxaparin (Lovenox) is thinning the blood – doesn’t work very well as an empiric measure of anticoagulation; thromboelastography (TEG) may be better, lead investigator Janise Phillips, Pharm.D., said at the Critical Care Congress, sponsored by the Society of Critical Care Medicine.
Her team tracked trauma patients who had at least three consecutive doses of enoxaparin prophylaxis for venous thromboembolism (VTE) and at least one peak antifactor 10a level drawn; enoxaparin doses were adjusted as needed to hit a weekly antifactor 10a level of 0.20-0.40 IU/mL, which is thought to be the therapeutic range for enoxaparin. Patients were in the ICU for a median of about 10 days, and in the hospital for about 2-3 weeks.
The types of trauma were not reported in the study, but the investigation confirms prior findings that critically ill trauma patients – and perhaps burn patients – need higher anticoagulant doses.
Overall, 65% (13) of patients on an initial enoxaparin regimen of 30 mg subcutaneously twice daily were below anti-factor 10a levels of 0.20-0.40 IU/mL after their first dose; 22% (8) were subtherapeutic after an initial dose of 40 mg once daily; and 21% (6) were subtherapeutic after an initial dose of 40 mg twice daily.
Antifactor 10a levels didn’t match well with clinical benefit. VTEs were diagnosed in 15% (4) of patients with an initial subtherapeutic antifactor 10a level, but 15% (4) bled on their subtherapeutic dose; 8.5% (4) of patients with an initial therapeutic level had a VTE, vs. none who were supratherapeutic after their initial dose. However, 9% (1) of supratherapeutic patients had an enoxaparin bleed.
“These were trauma patients in and out of surgery. A lot of the time, we had to stop the dose and hold it, which may” explain why subtherapeutic patients had the highest VTE risk, said Dr. Phillips, now a critical care pharmacist at the Cleveland Clinic hospital in Abu Dhabi, United Arab Emirates.
More than half of the patients were men, and being male was the only factor that seemed to increase the risk of subtherapeutic enoxaparin levels (P = .04). There was a trend for subtherapeutic levels in heavier patients – which might help explain the higher risk in men – and those with diminished kidney function. Even so, the fact that both VTEs and bleeding were most likely in underdosed patients could mean that antifactor 10a “is really not the best marker for VTE risk. At $80 a pop, it isn’t cost-effective, and [even] patients with therapeutic levels ended up with clots. TEG gives you a real time view of the coagulation status of the patient,” and may be the way to go, Dr. Phillips said.
PHOENIX – Trauma patients probably need an elevated dose of enoxaparin – perhaps 40 mg twice daily – to prevent venous thromboembolisms, according to a prospective study of 85 trauma patients at the Palmetto Health Richland hospital in Columbia, S.C.
Also, antifactor 10a – a blood test often used in research to gauge how well enoxaparin (Lovenox) is thinning the blood – doesn’t work very well as an empiric measure of anticoagulation; thromboelastography (TEG) may be better, lead investigator Janise Phillips, Pharm.D., said at the Critical Care Congress, sponsored by the Society of Critical Care Medicine.
Her team tracked trauma patients who had at least three consecutive doses of enoxaparin prophylaxis for venous thromboembolism (VTE) and at least one peak antifactor 10a level drawn; enoxaparin doses were adjusted as needed to hit a weekly antifactor 10a level of 0.20-0.40 IU/mL, which is thought to be the therapeutic range for enoxaparin. Patients were in the ICU for a median of about 10 days, and in the hospital for about 2-3 weeks.
The types of trauma were not reported in the study, but the investigation confirms prior findings that critically ill trauma patients – and perhaps burn patients – need higher anticoagulant doses.
Overall, 65% (13) of patients on an initial enoxaparin regimen of 30 mg subcutaneously twice daily were below anti-factor 10a levels of 0.20-0.40 IU/mL after their first dose; 22% (8) were subtherapeutic after an initial dose of 40 mg once daily; and 21% (6) were subtherapeutic after an initial dose of 40 mg twice daily.
Antifactor 10a levels didn’t match well with clinical benefit. VTEs were diagnosed in 15% (4) of patients with an initial subtherapeutic antifactor 10a level, but 15% (4) bled on their subtherapeutic dose; 8.5% (4) of patients with an initial therapeutic level had a VTE, vs. none who were supratherapeutic after their initial dose. However, 9% (1) of supratherapeutic patients had an enoxaparin bleed.
“These were trauma patients in and out of surgery. A lot of the time, we had to stop the dose and hold it, which may” explain why subtherapeutic patients had the highest VTE risk, said Dr. Phillips, now a critical care pharmacist at the Cleveland Clinic hospital in Abu Dhabi, United Arab Emirates.
More than half of the patients were men, and being male was the only factor that seemed to increase the risk of subtherapeutic enoxaparin levels (P = .04). There was a trend for subtherapeutic levels in heavier patients – which might help explain the higher risk in men – and those with diminished kidney function. Even so, the fact that both VTEs and bleeding were most likely in underdosed patients could mean that antifactor 10a “is really not the best marker for VTE risk. At $80 a pop, it isn’t cost-effective, and [even] patients with therapeutic levels ended up with clots. TEG gives you a real time view of the coagulation status of the patient,” and may be the way to go, Dr. Phillips said.
PHOENIX – Trauma patients probably need an elevated dose of enoxaparin – perhaps 40 mg twice daily – to prevent venous thromboembolisms, according to a prospective study of 85 trauma patients at the Palmetto Health Richland hospital in Columbia, S.C.
Also, antifactor 10a – a blood test often used in research to gauge how well enoxaparin (Lovenox) is thinning the blood – doesn’t work very well as an empiric measure of anticoagulation; thromboelastography (TEG) may be better, lead investigator Janise Phillips, Pharm.D., said at the Critical Care Congress, sponsored by the Society of Critical Care Medicine.
Her team tracked trauma patients who had at least three consecutive doses of enoxaparin prophylaxis for venous thromboembolism (VTE) and at least one peak antifactor 10a level drawn; enoxaparin doses were adjusted as needed to hit a weekly antifactor 10a level of 0.20-0.40 IU/mL, which is thought to be the therapeutic range for enoxaparin. Patients were in the ICU for a median of about 10 days, and in the hospital for about 2-3 weeks.
The types of trauma were not reported in the study, but the investigation confirms prior findings that critically ill trauma patients – and perhaps burn patients – need higher anticoagulant doses.
Overall, 65% (13) of patients on an initial enoxaparin regimen of 30 mg subcutaneously twice daily were below anti-factor 10a levels of 0.20-0.40 IU/mL after their first dose; 22% (8) were subtherapeutic after an initial dose of 40 mg once daily; and 21% (6) were subtherapeutic after an initial dose of 40 mg twice daily.
Antifactor 10a levels didn’t match well with clinical benefit. VTEs were diagnosed in 15% (4) of patients with an initial subtherapeutic antifactor 10a level, but 15% (4) bled on their subtherapeutic dose; 8.5% (4) of patients with an initial therapeutic level had a VTE, vs. none who were supratherapeutic after their initial dose. However, 9% (1) of supratherapeutic patients had an enoxaparin bleed.
“These were trauma patients in and out of surgery. A lot of the time, we had to stop the dose and hold it, which may” explain why subtherapeutic patients had the highest VTE risk, said Dr. Phillips, now a critical care pharmacist at the Cleveland Clinic hospital in Abu Dhabi, United Arab Emirates.
More than half of the patients were men, and being male was the only factor that seemed to increase the risk of subtherapeutic enoxaparin levels (P = .04). There was a trend for subtherapeutic levels in heavier patients – which might help explain the higher risk in men – and those with diminished kidney function. Even so, the fact that both VTEs and bleeding were most likely in underdosed patients could mean that antifactor 10a “is really not the best marker for VTE risk. At $80 a pop, it isn’t cost-effective, and [even] patients with therapeutic levels ended up with clots. TEG gives you a real time view of the coagulation status of the patient,” and may be the way to go, Dr. Phillips said.
AT THE SCCM CRITICAL CARE CONGRESS
Key clinical point: Enoxaparin at 30 mg twice daily isn’t adequate for preventing VTEs in trauma patients.
Major finding: Overall, 65% of patients on an initial enoxaparin regimen of 30 mg subcutaneously twice daily were below anti-factor 10a levels of 0.20-0.40 IU/mL after their first dose; 22% were subtherapeutic after an initial dose of 40 mg once daily; and 21% were subtherapeutic after an initial dose of 40 mg twice daily.
Data source: Prospective study of 85 trauma patients atthe Palmetto Health Richland hospital in Columbia, S.C.
Disclosures: The lead investigator said she has no disclosures, and no outside funding was reported for the work.
Vasculitis patients need up-front protection from steroid side effects
MAUI, HAWAII – When vasculitis patients are started on corticosteroids, they should also be started on treatments to protect them from the adverse effects of steroids, said Dr. Alvin Wells, director of the Rheumatology and Immunotherapy Center in Franklin, Wis.
“You give a decent dose of corticosteroids” for giant cell arteritis (GCA), and generally smaller but still significant doses for polymyalgia rheumatica (PMR). In either case, “many of these patients will be on [steroids] for a long time. Indeed, many people will be on them lifelong, so you really have to think about protection up front,” Dr. Wells said at the 2015 Rheumatology Winter Clinical Symposium.
That means bisphosphonates or some other agent to protect against steroid-induced bone loss, and proton-pump inhibitors to protect against gastric ulcers that can occur with high-dose prednisone. If not contraindicated, baby aspirin to protect against a potentially heightened risk of ischemic cardiovascular events should be considered in GCA patients.
Unfortunately, “it’s hard to take [vasculitis patients] off their steroids,” and there’s no single go-to therapy to prevent vasculitis flares when steroids are tapered, Dr. Wells said. “We’ve all tried everything that comes up on the short list,” such as methotrexate, azathioprine, dapsone, tocilizumab, and others. Methotrexate has only been shown to be of marginal benefit, and there’s only anecdotal support for other options. Many flare treatments “really aren’t steroid sparing” and probably offer little or no benefit.
In PMR, the possibility of cancer has to be kept in mind, as well. Although uncommon, PMR can be the first sign of malignancy, so “these patients need to be screened aggressively regardless of their age and what [treatment] guidelines say,” he said.
Recently, interleukin-10 (IL-10), an anti-inflammatory cytokine, has been shown to be down regulated in antineutrophil cytoplasmic antibody (ANCA)–associated vasculitis, and especially in patients with active disease. People with the condition have lower numbers of IL-10–producing B cells than healthy controls have.
“IL-10 seems to be playing a role. The caveat is that this is not ready for primetime.” There are issues with how best to define levels and measure IL-10, and at what time of day. Even so, “I think the future will be in measuring [cytokines to] predict who’s going to have a flare and who needs more aggressive therapy. I think this [new finding] is a piece of data that might help us out,” Dr. Wells said.
Here’s another issue “that comes up all the time” with systemic vasculitis: “Do we still need cyclophosphamide,” with all its side effects? The risk-benefit discussion can be tough, especially when you have to tell young people, “I’m going to give you cyclophosphamide and, by the way, you’re not going to be able to have kids,” Dr. Wells said.
Over the past few years, induction and maintenance with other agents – such as rituximab – have been shown “to be pretty decent.” Dr. Wells said he seldom needs to have those conversations these days; “I can reserve cyclophosphamide for the really, really sick patients.”
Dr. Wells is on the speakers bureaus of AbbVie, Amgen, Bristol-Myers Squibb, and Pfizer.
MAUI, HAWAII – When vasculitis patients are started on corticosteroids, they should also be started on treatments to protect them from the adverse effects of steroids, said Dr. Alvin Wells, director of the Rheumatology and Immunotherapy Center in Franklin, Wis.
“You give a decent dose of corticosteroids” for giant cell arteritis (GCA), and generally smaller but still significant doses for polymyalgia rheumatica (PMR). In either case, “many of these patients will be on [steroids] for a long time. Indeed, many people will be on them lifelong, so you really have to think about protection up front,” Dr. Wells said at the 2015 Rheumatology Winter Clinical Symposium.
That means bisphosphonates or some other agent to protect against steroid-induced bone loss, and proton-pump inhibitors to protect against gastric ulcers that can occur with high-dose prednisone. If not contraindicated, baby aspirin to protect against a potentially heightened risk of ischemic cardiovascular events should be considered in GCA patients.
Unfortunately, “it’s hard to take [vasculitis patients] off their steroids,” and there’s no single go-to therapy to prevent vasculitis flares when steroids are tapered, Dr. Wells said. “We’ve all tried everything that comes up on the short list,” such as methotrexate, azathioprine, dapsone, tocilizumab, and others. Methotrexate has only been shown to be of marginal benefit, and there’s only anecdotal support for other options. Many flare treatments “really aren’t steroid sparing” and probably offer little or no benefit.
In PMR, the possibility of cancer has to be kept in mind, as well. Although uncommon, PMR can be the first sign of malignancy, so “these patients need to be screened aggressively regardless of their age and what [treatment] guidelines say,” he said.
Recently, interleukin-10 (IL-10), an anti-inflammatory cytokine, has been shown to be down regulated in antineutrophil cytoplasmic antibody (ANCA)–associated vasculitis, and especially in patients with active disease. People with the condition have lower numbers of IL-10–producing B cells than healthy controls have.
“IL-10 seems to be playing a role. The caveat is that this is not ready for primetime.” There are issues with how best to define levels and measure IL-10, and at what time of day. Even so, “I think the future will be in measuring [cytokines to] predict who’s going to have a flare and who needs more aggressive therapy. I think this [new finding] is a piece of data that might help us out,” Dr. Wells said.
Here’s another issue “that comes up all the time” with systemic vasculitis: “Do we still need cyclophosphamide,” with all its side effects? The risk-benefit discussion can be tough, especially when you have to tell young people, “I’m going to give you cyclophosphamide and, by the way, you’re not going to be able to have kids,” Dr. Wells said.
Over the past few years, induction and maintenance with other agents – such as rituximab – have been shown “to be pretty decent.” Dr. Wells said he seldom needs to have those conversations these days; “I can reserve cyclophosphamide for the really, really sick patients.”
Dr. Wells is on the speakers bureaus of AbbVie, Amgen, Bristol-Myers Squibb, and Pfizer.
MAUI, HAWAII – When vasculitis patients are started on corticosteroids, they should also be started on treatments to protect them from the adverse effects of steroids, said Dr. Alvin Wells, director of the Rheumatology and Immunotherapy Center in Franklin, Wis.
“You give a decent dose of corticosteroids” for giant cell arteritis (GCA), and generally smaller but still significant doses for polymyalgia rheumatica (PMR). In either case, “many of these patients will be on [steroids] for a long time. Indeed, many people will be on them lifelong, so you really have to think about protection up front,” Dr. Wells said at the 2015 Rheumatology Winter Clinical Symposium.
That means bisphosphonates or some other agent to protect against steroid-induced bone loss, and proton-pump inhibitors to protect against gastric ulcers that can occur with high-dose prednisone. If not contraindicated, baby aspirin to protect against a potentially heightened risk of ischemic cardiovascular events should be considered in GCA patients.
Unfortunately, “it’s hard to take [vasculitis patients] off their steroids,” and there’s no single go-to therapy to prevent vasculitis flares when steroids are tapered, Dr. Wells said. “We’ve all tried everything that comes up on the short list,” such as methotrexate, azathioprine, dapsone, tocilizumab, and others. Methotrexate has only been shown to be of marginal benefit, and there’s only anecdotal support for other options. Many flare treatments “really aren’t steroid sparing” and probably offer little or no benefit.
In PMR, the possibility of cancer has to be kept in mind, as well. Although uncommon, PMR can be the first sign of malignancy, so “these patients need to be screened aggressively regardless of their age and what [treatment] guidelines say,” he said.
Recently, interleukin-10 (IL-10), an anti-inflammatory cytokine, has been shown to be down regulated in antineutrophil cytoplasmic antibody (ANCA)–associated vasculitis, and especially in patients with active disease. People with the condition have lower numbers of IL-10–producing B cells than healthy controls have.
“IL-10 seems to be playing a role. The caveat is that this is not ready for primetime.” There are issues with how best to define levels and measure IL-10, and at what time of day. Even so, “I think the future will be in measuring [cytokines to] predict who’s going to have a flare and who needs more aggressive therapy. I think this [new finding] is a piece of data that might help us out,” Dr. Wells said.
Here’s another issue “that comes up all the time” with systemic vasculitis: “Do we still need cyclophosphamide,” with all its side effects? The risk-benefit discussion can be tough, especially when you have to tell young people, “I’m going to give you cyclophosphamide and, by the way, you’re not going to be able to have kids,” Dr. Wells said.
Over the past few years, induction and maintenance with other agents – such as rituximab – have been shown “to be pretty decent.” Dr. Wells said he seldom needs to have those conversations these days; “I can reserve cyclophosphamide for the really, really sick patients.”
Dr. Wells is on the speakers bureaus of AbbVie, Amgen, Bristol-Myers Squibb, and Pfizer.
EXPERT ANALYSIS AT RWCS 2015
VIDEO: Couples more likely to conceive if men get healthy
SAN DIEGO – Conception is more likely if obese women lose weight and make other healthy lifestyle changes. What hasn’t been known until now is that the same holds true for their male partners, according to a prospective trial from the University of Sherbrooke, Quebec.
Forty-nine overweight women who were having a hard time conceiving worked with nutritionists, kinesiologists, and counselors there to improve their chances. When the investigators invited partners to join them, 25 men accepted the offer.
The men tended to be overweight and sedentary, too, compared with Canadian averages, and the program didn’t do much to change that. Even so, after about 1.5 years follow-up, couples were 33% more likely to conceive for each 1% of weight the men lost (odds ratio, 1.33; 95% confidence interval, 1.05-1.83, P = .013), with similar benefits for cutting back on soda, eating more fruits and vegetables, and other healthy diet changes.
Senior investigator Dr. Jean-Patrice Baillargeon, a professor of medicine at Sherbrooke, explained
the implications of those findings in an interview at the Endocrine Society's annual meeting.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
SAN DIEGO – Conception is more likely if obese women lose weight and make other healthy lifestyle changes. What hasn’t been known until now is that the same holds true for their male partners, according to a prospective trial from the University of Sherbrooke, Quebec.
Forty-nine overweight women who were having a hard time conceiving worked with nutritionists, kinesiologists, and counselors there to improve their chances. When the investigators invited partners to join them, 25 men accepted the offer.
The men tended to be overweight and sedentary, too, compared with Canadian averages, and the program didn’t do much to change that. Even so, after about 1.5 years follow-up, couples were 33% more likely to conceive for each 1% of weight the men lost (odds ratio, 1.33; 95% confidence interval, 1.05-1.83, P = .013), with similar benefits for cutting back on soda, eating more fruits and vegetables, and other healthy diet changes.
Senior investigator Dr. Jean-Patrice Baillargeon, a professor of medicine at Sherbrooke, explained
the implications of those findings in an interview at the Endocrine Society's annual meeting.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
SAN DIEGO – Conception is more likely if obese women lose weight and make other healthy lifestyle changes. What hasn’t been known until now is that the same holds true for their male partners, according to a prospective trial from the University of Sherbrooke, Quebec.
Forty-nine overweight women who were having a hard time conceiving worked with nutritionists, kinesiologists, and counselors there to improve their chances. When the investigators invited partners to join them, 25 men accepted the offer.
The men tended to be overweight and sedentary, too, compared with Canadian averages, and the program didn’t do much to change that. Even so, after about 1.5 years follow-up, couples were 33% more likely to conceive for each 1% of weight the men lost (odds ratio, 1.33; 95% confidence interval, 1.05-1.83, P = .013), with similar benefits for cutting back on soda, eating more fruits and vegetables, and other healthy diet changes.
Senior investigator Dr. Jean-Patrice Baillargeon, a professor of medicine at Sherbrooke, explained
the implications of those findings in an interview at the Endocrine Society's annual meeting.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
AT ENDO 2015
Hypothyroidism less common with preemptive levothyroxine after Graves’ treatment
San Diego – Preemptive levothyroxine seems to help prevent hypothyroidism after radioactive iodine treatment for Graves’ disease, according to an interim analysis of an ongoing randomized, placebo-controlled trial at the Mayo Clinic in Rochester, Minn.
Following iodine treatment, the team is randomizing adult patients to levothyroxine 25 mcg/day or placebo at 4 weeks, then increasing the levothyroxine dose to 50 mcg/day at 6 weeks. The enrollment goal is 60 patients; the team presented results for the first 17 at the Endocrine Society annual meeting.
At 8 weeks, six of 11 (54.5%) levothyroxine patients – but four of the six (66.7%) placebo patients – had overt hypothyroidism.
Hyperthyroidism is the main concern with preemptive levothyroxine, but that hasn’t been a problem so far; in fact, the levothyroxine group has had lower rates of hyperthyroidism (18.2%) than the placebo group (33.3%). Quality of life indicators haven’t separated much; at 8 weeks, thyroid Specific Questionnaire scores were about 12 in both groups, and levothyroxine patients did slightly worse on the hypothyroid–Health Related Quality of Life survey (46 vs. 36).
Given the low numbers, you can’t put too much stock in the findings yet, but the prevention trends are moving in the right direction, said lead investigator Dr. Spyridoula Maraka, a Mayo endocrinology fellow.
“As expected, none of the analyses reached statistical significance given that the sample size is 25% of the planned population,” but “it is reassuring that initiating low-dose levothyroxine 4 weeks after [Graves’ treatment] appears safe, without an increased prevalence of hyperthyroidism. There is an encouraging trend for prevention of overt hypothyroidism .... Accordingly, we plan to continue the trial to completion,” she said.
The work is important because, in many places, the first follow-up visit after Graves’ treatment is at 2 or even 3 months. By then, the majority of patients are hypothyroid, and may even have new or worsened Graves’ orbitopathy. The hope is that pre-emptive levothyroxine will counter the problem.
The fact that more than half of the levothyroxine subjects developed hypothryroidism suggests that “maybe we need a higher dose,” Dr. Maraka said.
If nothing else, the findings argue for earlier follow-up after radioactive iodine treatment, when there’s still a chance of catching nascent hypothyroidism before symptoms set in. “Try to see your patients earlier than week 8.” Six weeks might be a good goal, Dr. Maraka said.
There were no significant baseline differences between the placebo and levothyroxine arms of the study. In both, patients were in their mid-50s, on average, with thyroids of about 30 grams; about two-thirds of patients in both arms were women.
There’s been one adverse event so far; a levothyroxine patient with a history of atrial fibrillation had heart palpitations after quitting her beta-blocker, and dropped out of the study.
Pre-emptive levothyroxine has been studied before, but only retrospectively.
Dr. Maraka has no disclosures, and there was no outside funding for the work.
San Diego – Preemptive levothyroxine seems to help prevent hypothyroidism after radioactive iodine treatment for Graves’ disease, according to an interim analysis of an ongoing randomized, placebo-controlled trial at the Mayo Clinic in Rochester, Minn.
Following iodine treatment, the team is randomizing adult patients to levothyroxine 25 mcg/day or placebo at 4 weeks, then increasing the levothyroxine dose to 50 mcg/day at 6 weeks. The enrollment goal is 60 patients; the team presented results for the first 17 at the Endocrine Society annual meeting.
At 8 weeks, six of 11 (54.5%) levothyroxine patients – but four of the six (66.7%) placebo patients – had overt hypothyroidism.
Hyperthyroidism is the main concern with preemptive levothyroxine, but that hasn’t been a problem so far; in fact, the levothyroxine group has had lower rates of hyperthyroidism (18.2%) than the placebo group (33.3%). Quality of life indicators haven’t separated much; at 8 weeks, thyroid Specific Questionnaire scores were about 12 in both groups, and levothyroxine patients did slightly worse on the hypothyroid–Health Related Quality of Life survey (46 vs. 36).
Given the low numbers, you can’t put too much stock in the findings yet, but the prevention trends are moving in the right direction, said lead investigator Dr. Spyridoula Maraka, a Mayo endocrinology fellow.
“As expected, none of the analyses reached statistical significance given that the sample size is 25% of the planned population,” but “it is reassuring that initiating low-dose levothyroxine 4 weeks after [Graves’ treatment] appears safe, without an increased prevalence of hyperthyroidism. There is an encouraging trend for prevention of overt hypothyroidism .... Accordingly, we plan to continue the trial to completion,” she said.
The work is important because, in many places, the first follow-up visit after Graves’ treatment is at 2 or even 3 months. By then, the majority of patients are hypothyroid, and may even have new or worsened Graves’ orbitopathy. The hope is that pre-emptive levothyroxine will counter the problem.
The fact that more than half of the levothyroxine subjects developed hypothryroidism suggests that “maybe we need a higher dose,” Dr. Maraka said.
If nothing else, the findings argue for earlier follow-up after radioactive iodine treatment, when there’s still a chance of catching nascent hypothyroidism before symptoms set in. “Try to see your patients earlier than week 8.” Six weeks might be a good goal, Dr. Maraka said.
There were no significant baseline differences between the placebo and levothyroxine arms of the study. In both, patients were in their mid-50s, on average, with thyroids of about 30 grams; about two-thirds of patients in both arms were women.
There’s been one adverse event so far; a levothyroxine patient with a history of atrial fibrillation had heart palpitations after quitting her beta-blocker, and dropped out of the study.
Pre-emptive levothyroxine has been studied before, but only retrospectively.
Dr. Maraka has no disclosures, and there was no outside funding for the work.
San Diego – Preemptive levothyroxine seems to help prevent hypothyroidism after radioactive iodine treatment for Graves’ disease, according to an interim analysis of an ongoing randomized, placebo-controlled trial at the Mayo Clinic in Rochester, Minn.
Following iodine treatment, the team is randomizing adult patients to levothyroxine 25 mcg/day or placebo at 4 weeks, then increasing the levothyroxine dose to 50 mcg/day at 6 weeks. The enrollment goal is 60 patients; the team presented results for the first 17 at the Endocrine Society annual meeting.
At 8 weeks, six of 11 (54.5%) levothyroxine patients – but four of the six (66.7%) placebo patients – had overt hypothyroidism.
Hyperthyroidism is the main concern with preemptive levothyroxine, but that hasn’t been a problem so far; in fact, the levothyroxine group has had lower rates of hyperthyroidism (18.2%) than the placebo group (33.3%). Quality of life indicators haven’t separated much; at 8 weeks, thyroid Specific Questionnaire scores were about 12 in both groups, and levothyroxine patients did slightly worse on the hypothyroid–Health Related Quality of Life survey (46 vs. 36).
Given the low numbers, you can’t put too much stock in the findings yet, but the prevention trends are moving in the right direction, said lead investigator Dr. Spyridoula Maraka, a Mayo endocrinology fellow.
“As expected, none of the analyses reached statistical significance given that the sample size is 25% of the planned population,” but “it is reassuring that initiating low-dose levothyroxine 4 weeks after [Graves’ treatment] appears safe, without an increased prevalence of hyperthyroidism. There is an encouraging trend for prevention of overt hypothyroidism .... Accordingly, we plan to continue the trial to completion,” she said.
The work is important because, in many places, the first follow-up visit after Graves’ treatment is at 2 or even 3 months. By then, the majority of patients are hypothyroid, and may even have new or worsened Graves’ orbitopathy. The hope is that pre-emptive levothyroxine will counter the problem.
The fact that more than half of the levothyroxine subjects developed hypothryroidism suggests that “maybe we need a higher dose,” Dr. Maraka said.
If nothing else, the findings argue for earlier follow-up after radioactive iodine treatment, when there’s still a chance of catching nascent hypothyroidism before symptoms set in. “Try to see your patients earlier than week 8.” Six weeks might be a good goal, Dr. Maraka said.
There were no significant baseline differences between the placebo and levothyroxine arms of the study. In both, patients were in their mid-50s, on average, with thyroids of about 30 grams; about two-thirds of patients in both arms were women.
There’s been one adverse event so far; a levothyroxine patient with a history of atrial fibrillation had heart palpitations after quitting her beta-blocker, and dropped out of the study.
Pre-emptive levothyroxine has been studied before, but only retrospectively.
Dr. Maraka has no disclosures, and there was no outside funding for the work.
AT ENDO 2015
Key clinical point: Don’t wait 8 weeks to see Graves’ patients after radioactive iodine treatment.
Major finding: Eight weeks following radioactive iodine treatment for Graves’ disease, 54.5% of patients started preemptively on levothyroxine at 4 weeks had overt hypothyroidism, versus 66.7% of placebo patients.
Data source: First 17 patients of a randomized, controlled clinical trial at the Mayo Clinic in Rochester, Minn.
Disclosures: There was no outside funding for the work, and the lead investigator has no disclosures.
VIDEO: Metabolic syndrome less likely in kids who eat nuts
SAN DIEGO – Encourage teens with metabolic syndrome to snack on nuts; it just might improve their health.
Investigators from the University of Texas Southwestern Medical Center, in Dallas, found that children who ate 12.9 g of nuts per day – the equivalent of a small handful of peanuts, almonds, walnuts, and the like 3 times a week – had less than half the risk of metabolic syndrome, compared with those who did not, when age, sex, race, household income, and daily intake of sugar, fruits, and vegetables were controlled for (odds ratio, 0.43; 95% confidence interval, 0.20-0.92). The benefit persisted up to about 50 g/day, then tapered off, perhaps because the extra calories offset the metabolic benefit.
Adolescents who ate nuts a few times a week also had lower body mass index z scores, smaller waists, lower systolic blood pressure, and higher HDL cholesterol levels. Similar benefits have been found in adults.
The data come from the 2003-2010 National Health and Nutrition Examination Survey (NHANES) of 2,233 12- to 19-year-olds; nut consumption was self-reported.
Pediatrician and lead investigator Dr. Roy Kim stressed that the correlations don’t prove cause and effect. Still, he said he now encourages his patients to eat nuts. He explained why in an interview at a meeting of the Endocrine Society.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
SAN DIEGO – Encourage teens with metabolic syndrome to snack on nuts; it just might improve their health.
Investigators from the University of Texas Southwestern Medical Center, in Dallas, found that children who ate 12.9 g of nuts per day – the equivalent of a small handful of peanuts, almonds, walnuts, and the like 3 times a week – had less than half the risk of metabolic syndrome, compared with those who did not, when age, sex, race, household income, and daily intake of sugar, fruits, and vegetables were controlled for (odds ratio, 0.43; 95% confidence interval, 0.20-0.92). The benefit persisted up to about 50 g/day, then tapered off, perhaps because the extra calories offset the metabolic benefit.
Adolescents who ate nuts a few times a week also had lower body mass index z scores, smaller waists, lower systolic blood pressure, and higher HDL cholesterol levels. Similar benefits have been found in adults.
The data come from the 2003-2010 National Health and Nutrition Examination Survey (NHANES) of 2,233 12- to 19-year-olds; nut consumption was self-reported.
Pediatrician and lead investigator Dr. Roy Kim stressed that the correlations don’t prove cause and effect. Still, he said he now encourages his patients to eat nuts. He explained why in an interview at a meeting of the Endocrine Society.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
SAN DIEGO – Encourage teens with metabolic syndrome to snack on nuts; it just might improve their health.
Investigators from the University of Texas Southwestern Medical Center, in Dallas, found that children who ate 12.9 g of nuts per day – the equivalent of a small handful of peanuts, almonds, walnuts, and the like 3 times a week – had less than half the risk of metabolic syndrome, compared with those who did not, when age, sex, race, household income, and daily intake of sugar, fruits, and vegetables were controlled for (odds ratio, 0.43; 95% confidence interval, 0.20-0.92). The benefit persisted up to about 50 g/day, then tapered off, perhaps because the extra calories offset the metabolic benefit.
Adolescents who ate nuts a few times a week also had lower body mass index z scores, smaller waists, lower systolic blood pressure, and higher HDL cholesterol levels. Similar benefits have been found in adults.
The data come from the 2003-2010 National Health and Nutrition Examination Survey (NHANES) of 2,233 12- to 19-year-olds; nut consumption was self-reported.
Pediatrician and lead investigator Dr. Roy Kim stressed that the correlations don’t prove cause and effect. Still, he said he now encourages his patients to eat nuts. He explained why in an interview at a meeting of the Endocrine Society.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
AT ENDO 2015