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Thứ Sáu, 28 tháng 8, 2015

Man Sheds Vaccine-Derived Poliovirus for 28 Years

Chronic virus excreters may complicate polio eradication efforts


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Action Points

  • Note that this case report describes a genetically immunocompromised individual who has been shedding vaccine-derived poliovirus for more than 25 years.
  • Be aware that these vaccine-derived viruses are unlikely to cause infection in vaccinated individuals.
Researchers report the unusual case of an immunodeficient man who has been excreting highly virulent, vaccine-derived poliovirus for 28 years in PLOS Pathogens.
Other so-called "chronic excreters" may be out there, and they may complicate the World Health Organization's (WHO) plans to eradicate polio, said senior investigator Javier Martin, PhD, of the U.K.'s National Institute for Biological Standards and Control in Potters Bar, and colleagues.
Chronic excreters are extremely rare. Only 73 have been identified since 1962. The man described in the study is the only one known to be excreting virus at present, and the only one to have produced vaccine-derived virus for such a long period of time, Martin and colleagues said.
However, vaccine-derived virus strains likely originating from immunodeficient individuals have been discovered in sewage samples in Slovakia, Finland, Estonia, and Israel, "indicating that an unknown number of these chronic excreters exist elsewhere," Martin and colleagues said.
The patient is a white male from the U.K. who received a full course of childhood immunizations, including the oral polio vaccine at 5, 7, and 12 months with a booster at age 7. He was later diagnosed with common variable immunodeficiency and started on immunoglobulin therapy.
The virus isolated from the man's stool samples is a highly antigenically drifted type 2 strain derived from the original Sabin 2 strain used in the oral vaccine. More than 90% of vaccine-derived polioviruses arise from the type 2 strain, which has not been found in the wild since 1999 and is believed to be eradicated, the scientists said.
Virus samples from the patient caused paralysis in unimmunized transgenic mice with the human poliovirus receptor. The conventional inactivated polio vaccine, based on wild poliovirus strains, protected these mice. Another vaccine, based on the Sabin oral vaccine strain, was less effective, having a variable response, the researchers reported.
Human sera from vaccinated individuals readily neutralized the most antigenically divergent strain of the vaccine-derived virus. "These results are reassuring in that they indicate that vaccinated humans are well protected against infection from these highly drifted ... strains," the scientists said.
The investigators concluded that "while maintaining high immunization coverage will likely confer protection against paralytic disease caused by these viruses, significant changes in immunization strategies might be required to effectively stop their occurrence and potential widespread transmission."
"Eventually, new stable live-attenuated polio vaccines with no risk of reversion might be required to respond to any poliovirus isolation in the post-eradication era," they said.
Other infectious disease experts said that monitoring for vaccine-derived viruses from immunocompromised individuals is important, but these viruses pose a minimal public health threat because they are typically unable to infect other people and circulate through a population.
Amesh Adalja, MD, of the University of Pittsburgh and spokesperson for the Infectious Disease Society of America, noted that the viruses obtained from the patient in the study were not able to recombine with other enteroviruses, which is how such viruses gain the ability to spread to and infect other people.
In addition, the mice in the study were challenged with the equivalent of 25 times the PD50 of live poliovirus, Adalja pointed out.
"That is a very high dose that doesn't mimic a natural infection," Adalja said. "It demonstrates the proof-of-concept that the virus could be virulent, but would a human that came into contact with the virus get what the mouse got? Probably not."
As long as the live oral polio vaccine is used, there will be some chance of outbreaks of circulating vaccine-derived polioviruses. However, the WHO reports that after more than 10 billion doses of the live vaccine were administered around the world, only 20 instances of vaccine-derived outbreaks were identified, resulting in 758 actual cases, Adalja said.
The more important task for public health officials is to eliminate wild poliovirus from the planet, he said. "Then we can tackle circulating vaccine-derived viruses."
The wild virus has mostly been eliminated, with some small pockets still existing in Pakistan and Afghanistan, said Cara Burns, PhD, of the CDC in Atlanta.
Public health officials are hopeful the wild virus will be completely eradicated in the next few years, though political turmoil in those countries has complicated the effort.
Vaccine-derived viruses from immunodeficient individuals "obviously could be a challenge post-eradication, but it's a relatively minor issue," Burns said. The occurrence is extremely rare, and vaccine-derived viruses rarely spread from the immunocompromised individual to the community, she said.
Scientists are studying the use of antiviral drugs to stop the replication of vaccine-derived virus in immunocompromised patients, Burns said.
But the key to defending against vaccine-derived viruses is immunization, because immunized individuals are protected, she said.
"We will have to keep our guard up for some time to come," Burns said.
The study had no commercial funding. Authors reported no relevant financial interests.
  • Reviewed by F. Perry Wilson, MD, MSCE Assistant Professor, Section of Nephrology, Yale School of Medicine and Dorothy Caputo, MA, BSN, RN, Nurse Planner
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Amgen's PCSK9 Drug Wins FDA Approval

Repatha will be available next week


As expected, the FDA granted marketing approval on Thursday to evolocumab (Repatha), the second in a new class of lipid-lowering drugs -- PCSK9 inhibitors -- to become available in the U.S.
Drug-maker Amgen said evolocumab will be availabe in the U.S. next week.
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As with alirocumab (Praluent), which was approved in July, evolocumab was approved for use in patients who fail to achieve LDL cholesterol lowering through diet and maximally-tolerated statin therapy in adults who require additional LDL cholesterol lowering, including patients with heterozygous or homozygous familial hypercholesterolemia.
The FDA's Endocrinologic and Metabolic Drugs Advisory Committee voted 11-4 in favor of approval for evolocumab, Amgen's entry in the PCSK9 derby, although there was some concern that clinical trials of the drug were short term -- the longest exposure to the drug was 7 months -- thus the panel said that outcomes studies should continue.
But for patients with homozygous familial hypercholesterolemia, the FDA advisors were unanimous in their support of evolocumab.
Sanofi and Regeneron Pharmaceuticals set the wholesale acquisition price for alirocumab on the U.S. market at $1,120 every 28 days for both the 75 mg and 150 mg doses, a price that was higher than anticipated by market watchers. Steven D. Pearson, MD, president of the Institute for Clinical and Economic Review (ICER), an independent nonprofit research institute in Boston focused on comparative effectiveness and cost effectiveness, told MedPage Today that he anticipated that payers would negotiate for a lower price.
Amgen said the U.S. Wholesale Acquisition Cost (WAC) price of Repatha is $542.31 for one 140 mg single-use prefilled SureClick autoinjector or prefilled syringe, or $14,100 annually for the every two weeks administration.
The company said it would make a single monthly injection available next year. “Until then, Amgen anticipates monthly administration predominately for HoFH patients. Actual costs to patients, payers and health systems are anticipated to be lower as WAC pricing does not reflect discounts or rebates. Out-of-pocket costs to patients will vary depending on insurance status and eligibility for patient assistance.”
Anthony C. Hooper, executive vice president of Global Commercial Operations addressed the cost issue saying, “… we will be working with payers and other purchasers to provide innovative pricing programs linking the net price of Repatha to the expected LDL cholesterol reductions and anticipated appropriate patient utilization. By partnering with payers to implement these programs, we can help ensure that all appropriate patients who could benefit from Repatha will have access to this important new therapy.”
Evolocumab made headlines last spring when results of the LAPLACE-2 trial and the DESCARTES trial were presented at the American College of Cardiology and simultaneously published by The New England Journal of Medicine.
LAPLACE-2, which used a complicated randomization scheme, demonstrated dramatic reductions in LDL whether injected once a month or twice a month. It was also effective if given on top of a statin or ezetimibe, or administered as monotherapy.
In the DESCARTES trial, the monoclonal antibody cut LDL by a placebo-adjusted 48% to 62% from baseline across patient populations ranging from background management with diet alone to high-dose atorvastatin (Lipitor) plus ezetimibe (all P<0.001).
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Can Tomatoes Trigger Gout?

Some support for patient claims seen in new study

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Action Points

  • Many patients with gout assert that eating tomatoes prompts disease flares, and a new study by researchers in New Zealand offered some limited corroboration.
  • Note that a positive association with serum urate per serving of tomatoes per week was seen in data pooled from three cohorts with largely North American-European ancestry.
Many patients with gout assert that eating tomatoes prompts disease flares, and a new study by researchers in New Zealand offered some limited corroboration.
In a survey of 2,051 New Zealanders -- where gout is more common than anywhere else in the world -- 20.2% of individuals reported that tomatoes triggered their attacks, which was topped only by seafood (62.5%), alcohol (47.1%), and red meat (35.2%), according to Tony R. Merriman, PhD, of the University of Otago in Dunedin, and colleagues.
Moreover, a positive association with serum urate per serving of tomatoes per week was seen in data pooled from three cohorts with largely North American-European ancestry (beta 0.664, 95% CI 0.194 to 1.133, P=0.006), the researchers reported online in BMC Musculoskeletal Disorders.
But only one of these cohorts, the Atherosclerosis Risk in Communities, showed a significant association when analyzed individually (beta 0.907, 95% CI 0.264 to 1.550, P=0.006). It was not confirmed in the Cardiovascular Health Study (beta 0.216, 95% CI -1.341 to 1.772, P=0.786) or the Framingham Heart Study (beta 0.428, 95% CI -0.337 to 1.193, P=0.273).
"This is one in a long series of studies [from] researchers trying to confirm what gout patients tell them about food and drink as triggers of their gout flares," said N. Lawrence Edwards, MD, of the University of Florida in Gainesville, who was not involved in the research.
"However, the whole role of foods in the management of gout is more history than actual and practical," Edwards told MedPage Today.
"The problem is people trying to control their gout by diet alone. It doesn't work. People can't go on a restrictive enough diet so that their uric acid will be lowered to the point that they're not at risk of gout flares. What they need to do is go on pharmacologic therapy with the standard drugs -- allopurinol, febuxostat, probenecid -- to lower their uric acid. If they stay on that therapy, they aren't going to be susceptible to flares even if they have dietary indiscretions," said Edwards, who is chair of the Gout & Uric Acid Education Society.
Nonetheless, he said,"Gout has a long history of having triggers for disease. Any given individual with gout usually can come up with a list of things that they think will set their disease off," he said.
Case-control studies have linked alcohol and purine-rich foods as gout triggers, and these foods also have been shown to raise serum urate levels, "consistent with the hypothesis that they trigger acute gout attacks," according to Merriman and colleagues.
"People with gout also self-report food avoidances that have not been substantiated by the medical literature -- these avoidances include tomatoes and tomato products," Merriman's group wrote.
Therefore, to see if evidence backed this popular conception about tomatoes, he and his colleagues surveyed several ethnic groups in New Zealand, and found greater likelihood of self-reporting tomatoes as gout triggers compared with individuals of European ancestry:
  • New Zealand Pacific Islanders, odds ratio 1.48 (95% CI 1.02 to 2.18, P=0.04)
  • Ngati Porou Maori, OR 2.58 (95% CI 1.69 to 3.93, P=1 x 10-5)
  • New Zealand Maori, OR 1.98 (95% CI 1.32 to 2.97, P=8.8 x 10-4)
But these groups also were more likely than Europeans to report any trigger for gout, with odds ratios ranging from 1.91 to 3.87, even after adjustment for disease severity and frequency of attacks.
"It is possible that self-recognition of attack triggers is a reflection of a greater community familiarity with gout due to a higher prevalence and longer disease history in Pacific Island and Maori populations," Merriman and colleagues noted.
"This is a very unusual population of patients who have truly terrible gout," Edwards commented.
"It's extremely prevalent, and it's harder to treat because of more consequences and comorbidities, so it's difficult to extrapolate these data to primarily European ancestry populations such as in the United States," he said.
"Whilst our data cannot support the claim that tomato consumption is a trigger of gout attacks, we provide support for the hypothesis that tomato consumption may trigger gout attacks through increasing serum urate," Merriman's group argued.
A potential mechanism for this effect is through the actions of glutamate, found in high levels in tomatoes, which can "stimulate or amplify the synthesis of urate by acting as a nitrogen donor in the purine synthesis pathway," they suggested.
"Further research into the relationship between gout (and onset of gout attacks) and tomatoes needs to be conducted," they concluded.
But the elevation in serum urate was small, according to Edwards, at 0.7 μmol/L -1 per one serving of tomatoes per week, compared with an increase of 2.3 μmol/L -1 per single serving of alcohol and 2.4 μmol/L -1 per serving of seafood per week.
"This increase could easily be overcome with uric acid lowering therapies," he said.
The authors reported no financial disclosures.
  • Reviewed by Robert Jasmer, MD Associate Clinical Professor of Medicine, University of California, San Francisco
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Arthritis Tx Self-Monitoring Can Cut Healthcare Use

Patient safety and disease control were not compromised




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  • by Pauline Anderson
    Contributing Writer, MedPage Today

Action Points

  • A model of care in which patients with rheumatoid arthritis or psoriatic arthritis monitored their own therapy reduced the use of outpatient services by about half while maintaining clinical and psychosocial well-being.
  • Note that despite fewer appointments, this new service was not inferior to standard practice regarding disease activity, pain, fatigue, quality of life, or mood.
A model of care in which patients with rheumatoid arthritis (RA) or psoriatic arthritis (PsA) monitored their own therapy reduced the use of outpatient services by about half while maintaining clinical and psychosocial well-being, according to a U.K. study.
Compared with those in the control group, the intervention group initiated 54.6% fewer appointments with their clinical nurse specialist (P<0.0001) compared with controls, reported Stanton Newman, DPhil, of the School of Health Sciences at City University in London, and colleagues.
In addition, they attended 6.8% fewer rheumatologist appointments compared with control group participants, and initiated 38.8% fewer arthritis-related primary care appointments, although these latter results weren't statistically significant (P=0.23 and P=0.07, respectively), the researchers reported in Annals of the Rheumatic Diseases.
Recent decades have seen a considerable increase in the utilization of rheumatology healthcare services, as drug therapy has become more complex and monitoring needs more demanding. Some relief has been seen with the introduction of nurse-led care, but the system remains overburdened and patients continue to experience lengthy waiting times for appointments.
One approach to minimizing this could be through reducing unnecessary appointments, "through the use of patient-initiated services, in which patients are encouraged to take an active role in initiating their own care," Newman and colleagues noted.
"This approach is supported by more than 40% of patients with arthritis, who feel they should be able to decide how frequently they need a check-up and want to take responsibility for organizing their own disease-modifying anti-rheumatic drug [DMARD] monitoring appointments," they wrote.
To explore the feasibility and safety of this, the researchers enrolled 100 patients with RA or PsA whose treatment was stable, defined as at least 6 months of methotrexate plus another 3 months if patients were receiving a self-injecting anti-tumor necrosis factor agent.
These patients were randomized to either an intervention or control group. Those in the intervention group received training on identifying safe or normal ranges of relevant blood levels, side effects, and symptoms. They learned to interpret markers of inflammation (C-reactive protein and erythrocyte sedimentation rate), hemoglobin, white blood cell counts, liver function tests, platelets, and neutrophils.
The intervention group continued to receive routine care from their rheumatologists and routine blood monitoring every 4 to 6 weeks depending on their methotrexate dose.
The control group received standard care, which typically consisted of a blood test every 4-6 weeks, and outpatient appointments with their clinical nurse specialist every 3 months and rheumatologist every 6 months.
The intervention group had a total of 231 telephone consultations, of which 74.7% were initiated appropriately by the patient in response to their lab results, and 25.3% were initiated by the clinical nurse specialist when abnormal blood results were detected but not acted on by the patient. Two patients in the intervention group who were deemed unable to safely self-monitor were removed from the trial.
Despite fewer appointments, this new service was not inferior to standard practice regarding disease activity, pain, fatigue, quality of life, or mood, the study found.
"These results suggest that this model of care could be implemented without compromising the clinical or psychological well-being of patients with either RA or PsA on methotrexate," the authors wrote.
It could be that a large proportion of follow-up appointments in nurse-led DMARD monitoring clinics are made habitually, and may not be clinically necessary, they added.
A parallel reduction in primary care visits is "encouraging" as this indicates that patients weren't redirecting their care but felt better able to manage their arthritis themselves, the authors commented.
Further studies are needed to understand how these reductions translate into cost saving.
A limitation of the study was that data were not available on the length of each phone call, the number of calls control group participants made to the nurse helpline, or the use by any study participant of services such as physiotherapy, occupational therapy, or podiatry.
Moreover, a third of eligible patients did not consent to the study, preferring to have regularly scheduled face-to-face appointments with their clinical nurse specialist.
The study was funded by University College London Hospital Charity's Otto Beit Fund and the Shipley-Rudge Fund. One co-author disclosed a relevant relationship with the Shipley-Rudge Fund.
Newman and co-authors disclosed no relevant relationships with industry.
  • Reviewed by Robert Jasmer, MD Associate Clinical Professor of Medicine, University of California, San Francisco and Dorothy Caputo, MA, BSN, RN, Nurse Planner
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Stroke Rounds: Recurrent Stroke Risk High for Childhood Cancer Survivors

Second strokes occur at double the rate seen in the general population





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  • by Salynn Boyles
    Contributing Writer

  • This article is a collaboration between MedPage Today® and:
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Action Points

  • Note that this observational cohort study found a high rate of recurrent stroke among childhood cancer survivors who had suffered a first stroke.
  • Be aware that cranial irradiation was a powerful risk factor for recurrent stroke.
Survivors of childhood cancer who suffer strokes during young adulthood have a high risk of recurrent stroke for decades to come, especially when they have been treated with high-dose cranial radiation, researchers reported.
The analysis of data from the retrospective Childhood Cancer Survivor Study (CCSS) revealed a 2-fold greater risk of recurrent stroke in survivors of childhood cancer, compared to the general population matched for age.
Having a history of cranial radiation (≥50 Gy) was associated with a three-fold increase in recurrent stroke risk, Heather Fullerton, MD, of the University of California San Francisco, and colleagues wrote online in Neurology. Hypertension and older age at first stroke were also associated with an increased risk for recurrent stroke.
The study is the first large analysis of recurrent stroke rates among survivors of childhood cancer, and the findings have important implications for the medical follow-up of this population.
Current screening guidelines do not include a recommendation for routine vascular disease assessment, the researchers noted.
"A better understanding of risk factors for stroke, and the underlying mechanism, creates opportunities for primary and secondary stroke prevention," they wrote. "A role for accelerated atherosclerosis suggests particularly low-hanging fruit for risk modification in this population: the early identification and treatment of modifiable atherosclerotic risk factors like hypertension."
Median Age at Second Stroke was 32
The CCSS includes 14,358 cancer survivors diagnosed between 1970 and 1986 before the age of 21 who had survived for 5 years or more following their cancer diagnosis. The study cohort has been followed since 1994.
A total of 443 surveyed survivors reported a first stroke. To assess the rate of recurrent stroke, the researchers sent a second survey to these study participants asking them to confirm their first stroke and report any subsequent strokes.
Among 329 respondents (74% response rate), 271 confirmed a first stroke at a median age of 19 years, and 70 reported a second stroke at a median age of 32 years. The median time from cancer diagnosis to first stroke was 10 years (interquartile range 21 years) and the most common cancer type among participants who had strokes were brain tumors (44%) and leukemia (22%).
The median time from cancer diagnosis to second stroke was 23 years (IQR 19 years).
Independent predictors of stroke recurrence (revealed using multivariate Cox proportional hazard model analysis) included:
  • Cranial radiation therapy dose of ≥50 Gy (versus none, hazard ratio 4.4, 95% CI 1.4 to 13.7)
  • Hypertension (HR 1.9, 95% CI 1.0 to 3.5)
  • Older age at first stroke (HR 6.4, 95% CI 1.8 to 23 for age ≥40 versus age 0-17 years)
  • 10 year cumulative incidence of late recurrent stroke was 21% (95% CI 16 to 27%) overall and 33% (95% CI 21 to 44%) among participants treated with ≥50 Gy of cranial radiation therapy
The majority of the participants who had strokes had received cranial radiation, although 22% had received neither cranial nor neck radiation. Stroke survivors who had not received cranial radiation had a recurrent stroke risk of 11% at 10 years.
Radiation May Accelerate Vessel Disease
"The cumulative rate of recurrent stroke in the general population of young adults (≤50 years of age) has been estimated at approximately 10% by 10 years after a first ischemic stroke," the researchers wrote. "In our cohort of childhood cancer survivors, the first strokes tended to occur in young adulthood, but the recurrent stroke rate was, overall, double that for young adults in general."
Potential study limitations cited by the researchers included the fact that the stroke data were self reported, the exclusion of children who died within the first 5 years following their cancer diagnosis, and the lack of access to vascular imaging data.
Neck radiation is a known risk factor for vascular disease, and the researchers suggested that cranial radiation may increase stroke risk by accelerating intracranial atherosclerosis development.
In a previous analysis of the CCSS data, hypertension and black race were found to be independent predictors of first stroke risk in childhood cancer survivors. Another CCSS analysis, published in 2014, found survivors of childhood cancer to have an increased risk for premature aging and early onset cardiovascular disease.
"This (study) lends further support to the hypothesis that early onset atherosclerosis is on the causal pathway from cranial radiation to ischemic stroke, and suggests that earlier screening for modifiable atherosclerotic risk factors could be an avenue for improving both cardiovascular and cerebrovascular outcomes," the researchers wrote.
From the American Heart Association:
The research was funded by the National Cancer Institute, Cancer Center Support, and the American Lebanese-Syrian Associated Charities.
The researchers reported no relevant relationships with industry.
  • Reviewed by F. Perry Wilson, MD, MSCE Assistant Professor, Section of Nephrology, Yale School of Medicine and Dorothy Caputo, MA, BSN, RN, Nurse Planner
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‘The Milk and Cookie Disease’ Epidemic: How Much Candy Is Your Child Drinking?

By Everyday Health Guest Columnist
Published May 2, 2014
IMG_0448By Julie L. Wei, MD, Special to Everyday Health
As an Ear Nose and Throat (ENT) surgeon who sees up to 30 kids per day, I’m all too familiar with the illnesses that affect our children. So much so, that I’ve come up with a new name for such childhood maladies — Milk and Cookie Disease (MCD).
MCD consists of ear, nose, and throat complaints that mimic actual infections and illness as a result of sugar and dairy consumption before bedtime.

A Sugary Scourge: Sinus Symptoms

When my family moved to Orlando last June after 10 wonderful years in Kansas City, I was unsure of the prevalence of Milk and Cookie Disease in Florida. In addition to enjoying a busy surgery practice, I had had the pleasure of helping Kansas and Missouri children and families end their chronic suffering from cough, runny nose, stuffy nose, recurrent croup, sinus infections, breathing difficulties, sore throats, and other problems. I was determined to continue my practice in Orlando and Central Florida.
Thousands of children have these sinus symptoms in the absence of fever or positive strep tests, and are still able to go to school even though they are “sick.”  I have met and treated countless children who, despite seeing many specialists and being treated with numerous nasal steroid sprays, allergy medications, inhalers, and other medications, are still somehow unable to completely get rid of their chronic symptoms — the essence of Milk and Cookie Disease.
So it is bittersweet for me to report that MCD is alive and well here in Florida. I am confident that it is prevalent across our nation and probably affecting almost every child. Why? Because so many of our children are not only addicted to sugar, but are also drinking their weight in sugar! Literally!

You Are What You Drink – and Eat – at Bedtime

For several years I have been telling families that drinking milk before bed is REALLY bad for a child or anyone after 12 months of age. Why? Imagine milk sitting at 96.8 degrees Fahrenheit for a few hours, mixed with some stomach acid.  It will probably curdle and form yogurt-like clumps, and it can reflux back up to the child’s throat.  Drinking milk with sugary snacks is a common evening and bedtime routine for American children.
I have spent years observing that when kids stop consuming sugar and dairy in the evenings and before bed, many are completely “cured” of their ENT symptoms. Even if they are not cured, at least it makes it clear to someone like me what their real medical problems may be.
My goal is to increase parents’ awareness that late-night dairy and sugar are also the probable culprits in their kids’ indigestion. Along with ENT and digestive problems, excessive sugar intake leads to obesity, followed by high blood pressure, and even diabetes.

Adding Up the Sugar Totals

I believe MCD is a crisis, a serious epidemic facing our children.  Once I started asking parents about their children’s diets the problem became clear. So many children are eating and drinking more sugar than most of us would deem healthy. I asked parents to fill out a questionnaire about it:
What does your child consume throughout the day on most days?  Check all that apply:
  • Danimal or some type of yogurt drink
  • Go-gurt
  • Cheese “stick”
  • Apple juice
  • Lemonade
  • Sweet tea
  • Soda
  • Orange juice and any other juice
  • Gatorade
  • Capri-Sun
Now repeat for what they get at daycare or in preschool…
Every day, in almost every clinic appointment, I check the above list and then I add up the items to get the approximate number of grams of added sugar a child is consuming in a given day.
Many of the children I meet eat and drink between 150 to 200 grams of added sugar a day, and that’s only counting juices and flavored milk! The human digestive system was never meant to process so much sugar, which means that your child’s stomach needs even more time to get this stuff out of the stomach into the intestines.  So while that fermenting sugar and processed liquid sits around in the stomach (and gets more rancid with each passing moment) it can come back up and cause symptoms that can mislead doctors into treating asthma, allergies, or whatever else we think may be wrong.

The Sugar-Water Diet

Every child in America is at risk because they’re unknowingly consuming a ridiculous and eventually life-threatening amount of sugar every day in “innocent” liquids that are pretty much just sugar water  –   juice boxes, pouches, lemonade, sodas, and fortified “water.”
Every day I meet parents who tell me that their 3, 5, 8, or 12 year old “won’t drink water” or will not eat “fruits and vegetables.”  This generation of parents has lost to the food industry and stopped being in charge of their child’s eating and drinking habits. Every day I tell families, “If your child won’t drink water now, he or she will probably not drink water over sugary drinks for the next 90 years…”
Moving and exercising is important, but let’s be clear. No child can move faster and exercise enough to burn all the calories consumed by guzzling these sugary drinks (see my chart below). Until the government and FDA step in and regulate conveniently packaged, highly processed drinks with falsely reassuring labels like “No Sugar Added,” and “100% juice,”  our only choice is to tell every parent to boycott and stop this epidemic, and teach our children to make better choices.

Make Better Choices

We are all too busy to think about how much added sugar our children are drinking every day, but this is what we MUST get busy thinking about.  Save a child. Model and encourage good eating and drinking behavior. Take your kids to the grocery store and look at the food labels together to choose items lower in sugar whenever possible. Cook at home. Eat well. And please, drink nature’s perfect drink: water.
I’m pleased to report that I’ve shared my career epiphany with countless families who are implementing these suggestions, and many have seen their children recover into the healthy bodies they were born with and minimize chronic medication use. Less time spent seeing doctors is more time for fun, learning, and living a fulfilled and great life.
Nutrition IS the only comprehensive solution, and when partnered with appropriately prescribed medications and surgeries, is what America needs – and we needed it yesterday. Help your children be healthy, today and every day, by reducing their liquid sugar intake, avoiding milk and cookies before bedtime, and working on living A Healthier Wei.

candyFINALInfographic
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Thứ Năm, 27 tháng 8, 2015

Transient Newborn Hypoglycemia Tied to Poor Academics


  • by Molly Walker
    Contributing Writer

  • This article is a collaboration between MedPage Today® and:
    Medpage Today

Action Points

  • Newborns with low glucose levels may have low achievement test scores once they are in grade school.
  • Note that currently, the American Academy of Pediatrics recommends only screening for glucose levels in infants small for gestational age, infants born to mothers with diabetes, and late preterm infants.
Newborns with low glucose levels may have low achievement test scores once they are in grade school, according to a small, population-based study.
Jeffrey R. Kaiser, MD, of Baylor College of Medicine in Houston, and colleagues found that transient hypoglycemia (<35 mg/dL) in a newborn was associated with the decreased likelihood of proficiency on literary achievement testing (adjusted odds ratio 0.49, 95% CI 0.28 to 0.83) and mathematics achievement testing (adjusted OR 0.49, 95% CI 0.29 to 0.82) as a fourth grader.
Even when employing higher cutoffs for transient hypoglycemia (<40 mg/dL and <45 mg/dL), similar results were observed for deficiencies in literary scores (OR 0.43, 95% CI 0.28 to 0.67 and OR 0.62, 9% CI 0.45 to 0.85, respectively) and math scores (OR 0.51, CI 0.29 to 0.82 and OR 0.78, CI 0.57 to 1.08, respectively), they wrote in JAMA Pediatrics.
Currently, the American Academy of Pediatrics (AAP) recommends only screening for glucose levels in infants small for gestational age, infants born to mothers with diabetes, and late preterm infants.
Kaiser characterized the results of his group's study as preliminary data, and emphasized that these early results should not change current practice.
"This is an important study because it's the first that says maybe there's something out there, but we have to be very cautious and not just change things based upon one study," he told MedPage Today. "Until somebody else replicates our study, we should still do things the way the AAP recommends."
Jay Reeve, PhD, and assistant professor, department of psychology at Florida State University in Tallahassee, said that from a child development standpoint, the results did not come as a complete surprise. Previous studies have demonstrated the link between adequate early nutrition, including consistent blood sugar levels, and academic achievement.
"We need to continue to pay close attention to the health of very young children, perhaps even upping our game with universal screening, since infant health can have such profound long-term consequences on child development," Reeve, who was not involved in the study, told MedPage Today via e-mail.
"I see relations also to the Adverse Childhood Experiences studies, which demonstrated pretty incontrovertibly that the elevated cortisol levels associated with anxiety have major, long term impacts on behavioral health when experienced repeatedly in childhood," added Reeve, who is also president and CEO of the Apalachee Center in Tallahassee.
Kaiser explained that the impetus for the study was a discussion about the University of Arkansas in Little Rock, where glucose levels in newborns were routinely checked during the first 3 hours of life. The institution had been doing this since the 1970s, but was considering stopping the practice after calling 10 major hospitals around the country who "laughed" at them, according to Kaiser.
"So I'm ... thinking to myself 'Wait a second, we have data from 40 to 50 years of babies with glucose levels,'" Kaiser told MedPage Today. "Instead of stopping [the practice], I raised my hand and said 'Hey, we've got to study this.'"
Using testing data from the No Child Left Behind initiative, his group matched 72% of infant data from 1998 to state achievement test scores 10 years later.
The authors used logistic regression models to determine this association, and controlled for gestational age, race, sex, multifetal gestation, insurance status, maternal educational level and socioeconomic status, and gravidity.
They found that increased probability of test proficiency was associated with female sex, singleton birth, full-term status, white and other race, private insurance, maternal education level exceeding high school, and primiparous birth.
Overall, transient hypoglycemia only occurred in a relatively small portion of all newborns. Less than 20% (19.3%) of newborns had a glucose level <45 mg/dL, with 10.3% registering <35 mg/dL and 6.4% at <35 mg/dL.
A smaller portion of hypoglycemic newborns (<30 mg/dL) were proficient in both fourth-grade literacy and math testing compared to normoglycemic newborns (≥35 mg/dL). The literacy test proficiency rate was 57% for normoglycemic newborns and 32% for hypoglycemic newborns, and 64% and 46% for math, respectively.
The researchers matched data from 1,395 newborns, with a mean gestational age of 36.8 weeks. Demographic characteristics of the sample were 94.7% black or white race and 50.3% male and a large majority (81.5%) with Medicaid or no insurance. There were 4.9% of mothers with diabetes mellitus. Infants with prolonged hypoglycemia, congenital anomalies, or chromosomal abnormalities were excluded.
Limitations to the study included its retrospective observational nature, and that glucose concentrations were collected at the discretion of bedside nurses. The authors also noted that information about signs of hypoglycemia was inconsistently available from medical records and that they could not account for potential confounders, such as 10 years of environmental influences, that may have contributed to test scores.
In an accompanying editorial, Christopher J.D. McKinlay, MBchB, PhD, and Jane E. Harding, MBchB, DPhil, both of the University of Auckland in New Zealand, pointed out there were no data on breastfeeding and that the duration of transitional hypoglycemia was brief. They also warned of the potential adverse effects for universal screening, such as pain-induced stress from repeated heal lancing.
"In the absence of evidence from randomized controlled trials (RCTs), clinicians should follow published guidelines [...] which recommend glucose screening only in at-risk infants," they wrote. "However, the data presented by Kaiser and colleagues emphasize that neonatal hypoglycemia is not a trivial matter."
Kaiser agreed, saying that the next steps would be to do an RCT assessing treatment outcomes for infants with low sugar levels. He also hoped that another hospital would replicate this study to see if the results were similar.
"We need another study or two to say 'We found the same thing,' and then perhaps, we'll start screening all newborns for low sugars," Kaiser stated.
Kaiser and co-authors disclosed no relevant relationships with industry.
Harding disclosed being an investigator on the Children with Hypoglycaemia and Their Later Development (CHYLD) Study.
McKinlay and Harding disclosed no relevant relationships with industry.
  • Reviewed by Robert Jasmer, MD Associate Clinical Professor of Medicine, University of California, San Francisco and Dorothy Caputo, MA, BSN, RN, Nurse Planner
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Alzheimer's Disease: Gene Therapy May Promote Neuronal Growth

Early results from a small trial show promise

by Kristina Fiore

  • Staff Writer, MedPage Today

Action Points

  • Note that this proof of concept study demonstrated that gene therapy targeted towards nerve growth factor leads to increased neuronal growth in patients with early Alzheimer's disease.
  • Be aware that cognitive performance was not the subject of this study.
A gene therapy that boosts nerve growth factor (NGF) production in cholinergic neurons was safe and appeared to promote neuronal growth in a small study of patients with early Alzheimer's disease, researchers reported.
All 10 patients in the trial -- which started in 2001 -- showed a trophic response to the growth factor delivered via gene therapy, Mark Tuszynski, MD, PhD, of the University of California San Diego and the San Diego Veterans Affairs clinic, and colleagues reported online in JAMA Neurology.
"In every case, all cholinergic neurons showed growth," Tuszynski told MedPage Today. "We consistently achieved [growth] in every patient who had the procedure."
Tuszynski's group appears to be doing the only gene therapy for Alzheimer's disease. Most therapeutic efforts in the field have focused on the accumulation of amyloid in the brain, but after several failed trials of antibodies targeting accumulation of that protein, researchers have begun to ask whether it's time to explore other therapeutic targets.
NGF gene therapy instead attempts to directly target the neurodegeneration that manifests clinical symptoms. It does not target amyloid.
Tuszynski said his group chose NGF because it stimulates the cholinergic neurons that are impaired so early on in the Alzheimer's disease process. The protein helps to prevent cell death and neurodegeneration.
But why gene therapy instead of just delivering NGF? It's important to keep potent growth factors under control to thwart potential side effects, Tuszynski said.
"It's a better way to go [since] it's simple, efficient, and now we know it's safe," he told MedPage Today, adding that it's also a matter of convenience. "In theory, you could give it once in a person's lifetime and be done. They won't have to take medications."
For their trial, the researchers enrolled 10 patients with early Alzheimer's in what was the first attempt at gene delivery to slow neurodegeneration.
The first eight patients had ex vivo gene therapy, which involves inserting NGF genes into skin fibroblasts and implanting those altered cells into the brain. The final two patients had in vivo gene therapy, in which an adeno-associated viral vector serotype 2 (AAV2) carrying NGF genes were injected into the brain.
The researchers autopsied all 10 brains after patients died. They found that the neurons responded to the therapy in all patients, as evidenced by axonal sprouting toward the NGF source, neuronal hypertrophy, and activation of cell signaling.
Although there are concerns about systemic effects of growth factors in the body, the researchers reported no serious adverse events.
"This is the largest opportunity to date to show that at an anatomical level, [gene therapy delivering NGF] is safe," Tuszynski said. "Growth factors are very potent in the nervous system, and if they're broadly distributed, they can cause off-target adverse effects. But we saw none in these 10 patients."
One patient survived 7 years, and there was evidence that the implanted NGF genes continued to be expressed at that time, he added.
Some researchers not involved in the study told MedPage Today that the data provide encouraging support for the potential of gene therapies that deliver growth factors, but that large clinical trials are needed to see whether this therapy has a meaningful clinical effect.
Others were quick to applaud the work for moving beyond amyloid and into other targets that likely play a role in the Alzheimer's disease process.
"The cholinergic basal forebrain appears to be one of the earliest tangled areas, and [neurofibrillary] tangling may index oxidative stress, inflammation, mitochondrial decline, and perhaps other metabolically undesirable aspects of aging that are being accelerated in the Alzheimer's brain," Douglas Watt, PhD, of the Alzheimer's center at Quincy Medical Center in Boston who was not involved in the study, told MedPage Today.
"From this perspective, it does make sense that nerve growth factor may counter-balance whatever is going on to create early tangling in these cholinergic regions," Watt said.
He added that the "clear implication" of the research is that researchers "really shouldn't be looking at treatments in isolation but in combination."
That includes "anti-inflammatory, pro-plasticity, mitigating sex steroid declines, promoting insulin sensitivity in the brain, correcting circadian imbalances, promoting better mitochondrial function, proving dietary patterns, improving aerobic fitness, reducing social stress and social isolation, etc.," Watt said. "And yet we've had decades of applying single factor therapies in relationship to Alzheimer's disease -- and the vast majority of these have shown minimal to no benefit at all."
Tuszynski noted that a phase 2 multicenter randomized sham-surgery-controlled trial of AAV2-NGF gene delivery is completed and will publish soon.
He and his group also published work on gene therapy with brain-derived neurotrophic factor (BDNF) targeting cortical neurons in animal models in Nature Medicine in 2009, and they are now slated to start human clinical trials in 12 to 18 months, he added.
Tuszynski is the founder of Ceregene but has no present financial interest in the company.
  • Reviewed by F. Perry Wilson, MD, MSCE Assistant Professor, Section of Nephrology, Yale School of Medicine and Dorothy Caputo, MA, BSN, RN, Nurse Planner
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Mental Health Needs Rise for College Students: Psychiatric Times and Neurology Times

Also, accelerations in cognitive decline after stroke may last for years

by Neurology Times and Psychiatric Times Staff


A recent report documents an increase in mental health issues among college students, with demand for services outstripping available resources. Researchers at Harvard discuss the trends.
A stroke may exacerbate cognitive decline, not only directly after, but also years later, a study reveals.
Hallucinations look different in the brains of patients with schizophrenia and bipolar disorder, according to new research that could help clinicians better distinguish the two disorders.
Another soldier death linked to suicide -- is the Army no longer interested in psychiatric medicine?
Surgery may offer relief for people with migraines, especially patients who are not helped by less invasive interventions, recent research suggests.
This weekly news roundup is brought to our readers by our partners at Neurology Times and Psychiatric Times, which are a part of UBM Medica. (Free registration is required.)
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Pain by the Numbers

NIH study: chronic pain afflicts more than 25 million Americans


by Rachel Gotbaum

  • Kaiser Health News

In one of the largest population studies on pain to date, researchers with the National Institutes of Health estimate that nearly 40 million Americans experience severe pain and more than 25 million have pain every day.
Those with severe pain were more likely to have worse health status, use more health care, and suffer from more disability than those with less severe pain.
"There are so many people in the severe pain category that something has to be done," said Richard Nahin, the lead author of the analysis and lead epidemiologist for the National Center for Complementary and Integrative Health, the arm of the NIH that funded the study. "If people are in the most severe category of pain, whatever treatment they are getting may be inadequate."
Published in The Journal of Pain earlier this month, the study is an analysis of 2012 data from the National Health Interview Survey. It follows a comprehensive 2011 Institute of Medicine report on pain.
The analysis examined pain differences among ethnic groups. For example, Hispanics and Asians are less likely to report pain.
"If you are dealing with a minority group that doesn't speak English, you need to pay greater attention to eliciting what they mean when they say they have mild pain or severe pain," Nahin said.
The authors of the analysis hope their work will help inform greater research and better treatment options for people in pain.
"We're doing a lot of research on the mechanism of pain and potential medications. The problem is there is no silver bullet," said David Shurtleff, deputy director of NCCIH. "These data are giving us a better understanding of the pain conditions in the United States. We now can understand how sub-populations across age and across ethnic groups are experiencing pain."
Shurtleff said that pain is a challenge to treat because it is not just about what happens to a person physically. Emotional and cognitive factors come into play as well. "Our major focus is on symptom management for pain," he said. "It's not necessarily [one] medication or behavioral intervention. It's likely to be an integrative approach using multiple strategies to help patients alleviate their pain."
Paul Gileno, who has had chronic pain since he broke his back 12 years ago, is doing just that. Gileno, who founded the U.S. Pain Foundation advocacy group, uses acupuncture, meditation, and changes to his diet to manage his pain. He is now able to take fewer painkillers, he said.
"You need to keep trying these different modalities because you never want to give up hoping that your pain can be reduced or go away," he says.
Gileno endured multiple surgeries and has tried many different pain medicines, but he still lives with pain every day.
"After I saw the last neurologist and the last doctor and they said, 'Listen we've done everything we can do and I don't think your pain is going to go away,' I had to come to terms that I would have chronic pain for the rest of my life," said Gileno. "Pain comes with a lot of baggage. It comes with depression. It comes with feeling judged and you feel less of a person. You become very isolated."
Untreated pain is something Dr. Sean Morrison sees in many of his patients. He is a geriatrician and director of Palliative Care at Mount Sinai Hospital in New York.
"Pain causes a tremendous amount of suffering," said Morrison. "It has huge economic costs, because of people who cannot work ... And it has a significant impact on caregivers who are caring for people who have pain."
As more effective treatments are developed for a greater number of diseases, a growing number of people will suffer from pain as a side-effect, he said.
"Many of the cancer drugs we use now result in permanent nerve injury and resulting neuropathic pain which is very difficult to treat," he said.
Another of Morrison's frustrations is the growing level of scrutiny physicians and pharmacists are under as they treat pain. The law enforcement crackdown on prescription drug abuse appears to be making it harder for legitimate pain patients to get the medicines they need.
"What's happening is that the same drug is being used appropriately by group of patients and inappropriately in a large segment of the population," Morrison said. "What we've seen is people in pain are the unintended victims of the war on drugs."
NIH is in the process of finalizing a National Pain Strategy to coordinate efforts among different agencies to prevent, treat, manage, and study pain.
This article, which first appeared Aug. 24, 2015, was reprinted from kaiserhealthnews.org with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonprofit, nonpartisan health policy research and communication organization not affiliated with Kaiser Permanente.
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Speedy Adrenaline Reduces Cardiac Arrest Mortality in Young Kids

Each minute of delay cut survival chance by 5% 

by Salynn Boyles

  • Contributing Writer

  • This article is a collaboration between MedPage Today® and:
    Medpage Today

Action Points

  • Note that this observational study found that, among children with non-shockable in-hospital cardiac arrest, earlier epinephrine administration was associated with better overall survival.
  • Be aware that no randomized trial of epinephrine administration exists, but the weight of evidence makes such a study unethical to perform.
Timely use of epinephrine was associated with increased survival among hospitalized children in nonshockable rhythm cardiac arrest, researchers reported.
Delayed adrenaline administration was associated with worse survival and other outcomes in the pediatric in-hospital cardiac arrest setting, the analysis of data from the American Heart Association's "Get With the Guidelines-Resuscitation" registry (GWTG-R) confirmed.
Multivariable analysis revealed that longer time to epinephrine administration was associated with lower risk of survival to discharge (multivariable-adjusted risk ratio per minute delay, 0.95, 95% CI 0.93 to 0.98), according to Lars W. Anderson, MD, of Beth Israel Deaconess Medical Center, Boston, and colleagues writing in the August 25 issue of the Journal of the American Medical Association.
Children in nonshockable cardiac arrest who did not receive epinephrine within 5 minutes of the event had a lower likelihood of survival than children who did (21% survival versus 33.1%; multiple adjusted RR 0.75, 95% CI 0.60 to 0.93; P=0.01).
Delays in epinephrine administration were also associated with worse outcomes on secondary measures, including return of spontaneous circulation (ROSC), survival at 24 hours, and neurological impairment.
"These associations remained when accounting for multiple predetermined potentially confounding patient, event, and hospital characteristics and in multiple difference sensitivity analyses," the researchers wrote. "Although the observational design precludes ascertainment of causality, the strong association with outcomes suggests that early epinephrine may be beneficial in pediatric cardiac arrest."
As many as 16,000 children in the U.S. suffer cardiac arrest each year -- mostly in a hospital setting -- and their survival rate is poor.
"An initial rhythm of pulseless electrical activity or asystole (i.e., a nonshockable rhythm) is most common and carries a significant mortality, with 25% to 40% of patients surviving to hospital discharge," Anderson and colleagues wrote.
They noted that despite improvements in in-hospital resuscitation efforts, there remain few evidence-based interventions for nonshockable pediatric cardiac arrest besides supportive care.
Delayed epinephrine administration has been associated with worse outcomes in the adult in-hospital nonshockable cardiac arrest setting, but the impact of delayed administration in the pediatric setting has not been known.
"To our knowledge, no randomized trial comparing epinephrine with placebo has been conducted in this population, and the ethics of such a trial may currently be questionable," the researchers wrote.
The AHA's 2010 pediatric advanced life support (PALS) guidelines recommend giving epinephrine at 0.01 mg/kg (maximum, 1 mg) as soon as vascular or intraosseous access is obtained, followed by repeat administration every 3 to 5 minutes for patients with nonshockable rhythm.
The analysis of GWTG-R data identified 1,558 pediatric cardiac arrest patients, with a median age of 9 months (interquartile range 13 days to 5 years).
Slightly less than one-third of these patients (31.3%) survived to hospital discharge. The median time to first epinephrine dose was 1 minute (IQR 0-4; range 0-20; mean 2.6 minutes). Median time to chest compression was 0 minutes (IQR 0-0).
A total of 993 (63.7%) patients had return of spontaneous circulation, and 745 (47.8%) were alive 24 hours after the event. Just 217 (15.6%) had a documented favorable neurological outcome at hospital discharge.
In an editorial published with the study, Robert Tasker, MD, and Adrienne Randolph, MD, of Boston Children's Hospital, wrote that the study confirms the poor prognosis of children who suffer nonshockable in-hospital cardiac arrest, noting that less than a third of children survived to hospital discharge and fewer than 1 in 5 survived with favorable neurocognitive outcomes.
"Given there will never be a randomized clinical trial and that epinephrine is listed in the PALS guidelines as the next step after CPR for nonshockable rhythms, these new data provide fairly strong evidence that following the guidelines with regards to epinephrine dosing and timing is best practice, with this study likely providing an AHA Class I strength of recommendation," they wrote.
They added that the new findings support the current recommendations, but questions remain about the optimal timing of adrenaline administration.
"It is not known if epinephrine should be given within 2 minutes, as a good number of patients did not receive the drug at all and had ROSC in that time," they wrote.
From the American Heart Association:
The researchers were funded by the National Heart, Lung, and Blood Institute and the American Heart Association.
The researchers disclosed no relevant relationships with industry.
  • Reviewed by F. Perry Wilson, MD, MSCE Assistant Professor, Section of Nephrology, Yale School of Medicine and Dorothy Caputo, MA, BSN, RN, Nurse Planner
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Women, Minorities Still Underrepresented in Medicine

Wide variation seen among specialties

by Megan Brooks

NEW YORK (Reuters Health) -- Continued efforts are needed to increase the number of women and minorities in graduate medical education (GME) to ensure a diverse US physician workforce, say the authors of a research letter published today.
"Diversifying the physician workforce has been discussed as requisite to addressing health disparities and inequities. Minority physicians continue to provide the majority of care for underserved and non-English speaking populations," first author Dr. Curtiland Deville of Johns Hopkins University told Reuters Health by email.
Using publicly reported data, the researchers determined that in 2012, there were 16,835 medical school graduates, of which 48.3% were women and 15.3% were minority groups (including 7.4% Hispanic and 6.8% black).
There were 115,111 trainees in GME in 2012, of which 46.1% were women and 13.8% were minority groups (7.5% Hispanic and 5.8% black).
Of the 688,468 practicing physicians in 2012, 30.1% were women and 9.2% were members of underrepresented minorities, including 5.2% who were Hispanic and 3.8% who were black.
In 2012, women accounted for 82.4% of trainees in obstetrics and gynecology and for 74.5% of pediatrics trainees, but only 13.8% of trainees in orthopedics. Women also accounted for more than 50% of GME trainees in dermatology (64.4%), family medicine (55.2%), pathology (54.6%), and psychiatry (54.5%).
Among black trainees, family medicine (7.5%) and obstetrics and gynecology (10.3%) were top picks, while otolaryngology (2.2%) was least favorite. Among Hispanic trainees, top picks were psychiatry (9.3%), family medicine (9%), obstetrics and gynecology, and pediatrics (each 8.7%), while ophthalmology (3.6%) was least favorite.
"Our study shows that while representation is increased in certain specialties for females, Blacks, and Hispanics, it remains largely unchanged in others," Dr. Deville told Reuters Health.
"Efforts have been made to increase the available pipeline of diverse medical school graduates with perhaps the assumption that this increased diversity will translate downstream to all specialties. Our study shows that this is not the case. There remain some specialties such as radiology, orthopedics, and otolaryngology, with disproportionate underrepresentation of women and minorities," he noted.
What's needed to increase diversity in GME?
"First is the need to increase the available pipeline of diverse medical students," Dr. Deville said. "This is especially the case for Blacks, Hispanics, and other underrepresented groups. In parallel, is the need to ensure that female, black, and Hispanic medical students are exposed, prepared, and engaged to join all medical specialties. As the country becomes increasingly diverse, the physician workforce should mirror that diversity in all fields to ensure improved health equity and reduce health disparities," he said.
The study was published online August 24 in JAMA Internal Medicine.
In a commentary published with the paper, Dr. Laura E. Riley of Massachusetts General Hospital in Boston says this study calls attention "yet again to the continued underrepresentation of women and minority groups in medicine."
"Ensuring a diverse physician workforce will require the continuing attention of medical school leadership and health care systems, and interventions to provide opportunities for diverse physicians to join the leadership ranks. Increasing physician diversity is yet another opportunity to improve the quality of care for all of our patients, particularly the most disadvantaged and those with a disproportionate burden of disease," Dr. Riley writes.
In an interview with Reuters Health, Marc Nivet, chief diversity officer at the Association of American Medical Colleges (AAMC), said this is "an important paper primarily because, in my mind, it calls to question if we need to be doing more research to figure out why women remain predominantly in three specialties, family medicine, pediatrics, and OBGYN. Is that based on choice or are they in some way being relegated to those particular fields, or not being given advice to go into orthopedics or surgery specialties. Is there gender bias at play?"
Nivet said the study also confirms that minorities are more likely to go into primary care. "We've had this rationale of wanting minorities to go into primary care and go and serve the underserved. But I think we need to appreciate the fact that we also need more minority surgeons and more minority psychiatrists and dermatologists, etc. Again, is there steering going on or is it choice?"
"We need to be sure that all students that have the talent, capacity, and desire to go into medicine have the opportunity to do so because we need them for sure," Nivet said.
He added, "I do think there is a role for hospitals and medical schools to make sure that their environments are as inclusive as possible. A minority or a woman shouldn't look at a particular field like orthopedics and say, 'Well, that's not for me.' There should be training that's happening for the graduate medical education leaders (and) for the faculty members of institutions to make sure that they are exposing all students to different opportunities so they can make the right choice for themselves."
SOURCE: http://bit.ly/1hWztB8 http://bit.ly/1JrNtJ2
JAMA Intern Med 2015.
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RheumNow: Better Zoster Vaccine Options on the Horizon


Impressive efficacy seen in phase III trial

by Arthur Kavanaugh MD


A recent article about a new herpes zoster vaccine should be of great interest to rheumatologists as well as to all clinicians who use immunosuppressive medications. The investigators reported results from a phase III study of a vaccine comprised of a key protein from the varicella zoster virus, conjugated to an adjuvant in order to boost immunogenicity.
The vaccine, given intramuscularly twice over 2 months, showed impressive efficacy. Thus, over an average followup just over 3 years, 6 of the 7,698 persons receiving the vaccine developed herpes zoster (0.3/1,000 person-years) compared to 210 of the 7,713 persons receiving placebo vaccination (9.1/1,000 person-years) -- that's nearly a 97% reduction.
Tolerability appears to be good, with injection reactions being more common among persons receiving the vaccine. Immunogenicity results (specific cell mediated or antibody responses) were not reported. Of note, vaccine efficacy appeared to be maintained across age cohorts, with comparable levels of protection among persons 50 to 59 years of age compared to older persons. This is relevant as the live-attenuated vaccine currently available for adults (Zostavax) has been shown to have lesser efficacy among older persons.
Rheumatologists and others prescribing immune-modifying medications are often between a rock and a hard place when it comes to herpes zoster. Shingles is not uncommon among patients with autoimmune systemic inflammatory diseases, and almost all experienced clinicians know firsthand how devastating shingles can be. So, vaccination would be a useful strategy. However, current guidelines call for withholding many effective medications, including biologic agents, before, during, and after vaccination.
When faced with a patient with active disease, the clinician must choose: adhere to a 'treat to target' strategy and commence highly effective therapy immediately, or delay therapy while arranging for herpes zoster vaccination. Neither choice is ideal. Hopefully, if this conjugate vaccine becomes available, doctors can work towards both goals concomitantly.
There is still data that rheumatologists would be eager to learn about the new vaccine. How effective is it specifically among patients with immune diseases? What impact might the various types of medications patients may be taking, alone and in combination, have upon the efficacy of the vaccine? What will the new vaccine cost? The last issue is relevant, as the costs to the patient of the current vaccine have impacted its utilization. Nevertheless, this is an important topic and further developments are eagerly awaited.
Arthur Kavanaugh, MD, is professor of medicine at the University of California San Diego School of Medicine. In addition, he is director of the Center for Innovative Therapy in the UCSD Division of Rheumatology, Allergy, and Immunology. A version of this article first appeared on RheumNow, a news, information and commentary site dedicated to the field of rheumatology. Register to receive their free rheumatology newsletter.
Kavanaugh declared he had no relevant conflicts of interest.
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Ultrasound-Based Vasculitis Diagnosis May Save Vision


Fast-track outpatient clinic for giant cell arteritis also cuts inpatient days





Action Points

  • The implementation of a "fast-track" clinic with rapid ultrasound assessment for patients with suspected giant cell arteritis led to a dramatic decrease in permanent visual impairment.
  • Note that the diagnostic program involved patient evaluation with color Doppler ultrasound within 24 hours of presentation, followed by immediate treatment with corticosteroids for positive findings.
The implementation of a "fast-track" clinic with rapid ultrasound assessment for patients with suspected giant cell arteritis led to a dramatic decrease in permanent visual impairment, a Norwegian study found.
Among 32 patients evaluated conventionally using biopsy of the temporal artery and 43 assessed with the fast-track ultrasound approach, 18 patients -- nine patients in each group -- experienced visual disturbances typical of giant cell arteritis, such as diplopia, blurred vision, and amaurosis fugax, according to Andreas P. Diamantopoulos, MD, PhD, of the Hospital of Southern Norway Trust in Kristiansand, and colleagues.
Yet six patients in the conventional group (21.5%) experienced permanent visual loss compared with only one assessed with the fast track ultrasound approach (2.4%), with what was an 88% lower rate (RR 0.12, 95% CI 0.01 to 0.97, P=0.01), the researchers reported online in Rheumatology.
"Our data indicate that the fast-track clinic including a rapid assessment by ultrasonography may significantly reduce the risk of permanent visual impairment in giant cell arteritis patients," they observed.
Giant cell arteritis is the most common of the primary vasculitides, most often affecting individuals older than 50. One in five patients are thought to experience irreversible vision loss, and high-dose steroids are the treatment of choice.
The gold standard for diagnosing the condition has been biopsy of the temporal artery, with confirmation being provided by a positive response to corticosteroid therapy.
However, the inflammation of the artery typically is segmental and so can be missed if the biopsy needle is inserted in areas unaffected by the vasculitic process.
In addition, delay in obtaining the biopsy is common and clinicians may hesitate to prescribe corticosteroids in high doses to older patients, yet speed is of the utmost importance as vision loss can occur rapidly.
"The fast-track approach has been introduced in several fields in medicine with remarkable success in reducing mortality, morbidity, and inpatient days of care. Rapid initiation of treatment improves outcomes in rheumatoid arthritis through the utilization of the window of opportunity," the researchers noted.
Reports of the successful use of ultrasound for the noninvasive diagnosis of giant cell arteritis have emerged over the past decade, and in 2012 Diamantopoulos and colleagues began implementing a diagnostic program involving patient evaluation with color Doppler ultrasound within 24 hours of presentation, followed by immediate treatment with corticosteroids for positive findings.
The ultrasound assessment included examination of the superficial temporal arteries, the frontal and parietal branches, and the axillary and common carotid arteries, with a hypoechoic ring (halo sign) surrounding a vessel in any of these arteries being considered a positive result.
To compare the results of the fast-track approach and conventional diagnosis, the researchers analyzed outcomes for patients seen in their clinic before and after the implementation date of 2012, including 75 patients seen from April 2010 to October 2014.
Patients' mean age was 74, and twice as many women as men were affected.
The most common visual disturbances were amaurosis fugax in 22%, anterior ischemic optic neuropathy in 22%, blurred vision in 16%, and diplopia in 12%.
The mean number of days spent in the hospital among the conventional care group was 3.6, compared with 0.6 day in the fast-track group, for a mean difference of 3 days (P<0.0005).
The Norwegian Ministry of Finance estimated that the cost of daily inpatient care was 12,433 Norwegian krone ($1,512).
"Thus, implementation of the fast track clinic reduced the cost of inpatient care by ~37,300 Norwegian krone per patient, a total reduction for all the 42 giant cell arteritis patients assessed in the fast-track clinic of 1,566,558 Norwegian krone [$191,138]," the researchers determined.
"The implementation of an innovative technique combined with quick evaluation can lead to a significant decrease of one of the most feared complications of the giant cell arteritis disease. Furthermore, the fast track clinic seems to be more cost effective by reducing the need for inpatient days of care," they wrote.
Limitations of the study included its retrospective design and small number of patients.
"Further observational studies are warranted in order to confirm these encouraging and promising data," Diamantopoulos and colleagues concluded.
Agder Medforsk, a nonprofit scientific organization, supplied the ultrasound equipment (Siemens Acuson S2000).
Diamantopoulos and co-authors disclosed no relevant relationships with industry.
  • Reviewed by Robert Jasmer, MD Associate Clinical Professor of Medicine, University of California, San Francisco and Dorothy Caputo, MA, BSN, RN, Nurse Planner
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