Bianca Nogrady

As a treatment for scalp psoriasis, the combination of a topical steroid and topical vitamin D was marginally better than topical steroids alone, but both approaches have a similar safety profile, according to a Cochrane review.

The systematic review included 59 randomized controlled trials of topical treatments for scalp psoriasis, representing a total of 11,561 participants of all ages, most of whom were followed for less than 6 months, according to Justin Schlager, MD, of the Charité – Universitätsmedizin Berlin, and coauthors (Cochrane Database of Systematic Reviews 2016. Issue 2. doi: 10.1002/14651858.CD009687.pub2).

Christine Langer-p?schel/Thinkstock

In the analysis, topical steroid monotherapy was significantly better than topical vitamin D for clearance, as assessed by the Investigator’s Global Assessment of Disease Severity (risk ratio, 1.82; 95% confidence interval, 1.52-2.18). But the combination of a topical steroid and vitamin D showed a small but statistically significant advantage over steroids alone (RR, 1.22; 95% CI, 1.08-1.36) and an even greater advantage over vitamin D alone (RR, 2.28; 95% CI, 1.87-2.78).

Similarly, for treatment response, the combination of a topical steroid and vitamin D showed the greatest benefit in terms of treatment response when compared with steroid monotherapy (RR, 1.15; 95% CI, 1.06-1.25) – an additional benefit the authors observed was small – and when compared with vitamin D alone (RR, 2.31; 95% CI, 1.75-3.04).

But for monotherapy, corticosteroids were more than twice as effective as vitamin D alone for treatment response (RR, 2.09; 95% CI, 1.80-2.41). The analysis also showed that corticosteroids of moderate, high, and very high potency were similarly effective.

Steroids were associated with a significantly lower risk of withdrawal because of adverse events than vitamin D (RR, 0.22; 95% CI, 0.11-0.42). Patients using topical steroids reported adverse events such as a burning sensation or irritation at the site of application, while patients taking vitamin D reported side effects such as pruritus, candidiasis, dermatitis, and erythema, although in both cases these were mostly limited to the application site.

The combination of vitamin D and topical steroid had a lower risk of withdrawals because of adverse events than vitamin D alone, but showed a similar rate to topical steroids alone.

“Given the similar safety profile and only slim benefit of the two-compound combination over the steroid alone, monotherapy with generic topical corticosteroids may be fully acceptable for short-term therapy,” the authors wrote. The authors noted that data on patients’ quality of life was poor across all the studies included in the analysis and called for future trials to address this gap, and more long-term assessments.

“Regardless of the type of psoriasis, up to 79% of people with the condition present with scalp involvement, which has frequently been the first site to show symptoms of the disease,” they pointed out.

Thirty of the 59 studies were either conducted or sponsored by the manufacturer of the study medication, and the authors described the overall quality of the studies as “moderate.” Thirty-three studies were double blind, 14 were single blind, two had “third-party” blinding, six were open-label, and four did not report blinding information.

The study was supported by the Universidade Federal de São Paulo, Brazil; the Universidade Federal do Rio Grande do Norte, Brazil; and the National Institute for Health Research, United Kingdom. Six authors and one clinical referee declared speakers’ fees, research grants, and funding from the pharmaceutical industry. One author had no conflicts of interest to disclose.

As a treatment for scalp psoriasis, the combination of a topical steroid and topical vitamin D was marginally better than topical steroids alone, but both approaches have a similar safety profile, according to a Cochrane review.

The systematic review included 59 randomized controlled trials of topical treatments for scalp psoriasis, representing a total of 11,561 participants of all ages, most of whom were followed for less than 6 months, according to Justin Schlager, MD, of the Charité – Universitätsmedizin Berlin, and coauthors (Cochrane Database of Systematic Reviews 2016. Issue 2. doi: 10.1002/14651858.CD009687.pub2).

Christine Langer-p?schel/Thinkstock

In the analysis, topical steroid monotherapy was significantly better than topical vitamin D for clearance, as assessed by the Investigator’s Global Assessment of Disease Severity (risk ratio, 1.82; 95% confidence interval, 1.52-2.18). But the combination of a topical steroid and vitamin D showed a small but statistically significant advantage over steroids alone (RR, 1.22; 95% CI, 1.08-1.36) and an even greater advantage over vitamin D alone (RR, 2.28; 95% CI, 1.87-2.78).

Similarly, for treatment response, the combination of a topical steroid and vitamin D showed the greatest benefit in terms of treatment response when compared with steroid monotherapy (RR, 1.15; 95% CI, 1.06-1.25) – an additional benefit the authors observed was small – and when compared with vitamin D alone (RR, 2.31; 95% CI, 1.75-3.04).

But for monotherapy, corticosteroids were more than twice as effective as vitamin D alone for treatment response (RR, 2.09; 95% CI, 1.80-2.41). The analysis also showed that corticosteroids of moderate, high, and very high potency were similarly effective.

Steroids were associated with a significantly lower risk of withdrawal because of adverse events than vitamin D (RR, 0.22; 95% CI, 0.11-0.42). Patients using topical steroids reported adverse events such as a burning sensation or irritation at the site of application, while patients taking vitamin D reported side effects such as pruritus, candidiasis, dermatitis, and erythema, although in both cases these were mostly limited to the application site.

The combination of vitamin D and topical steroid had a lower risk of withdrawals because of adverse events than vitamin D alone, but showed a similar rate to topical steroids alone.

“Given the similar safety profile and only slim benefit of the two-compound combination over the steroid alone, monotherapy with generic topical corticosteroids may be fully acceptable for short-term therapy,” the authors wrote. The authors noted that data on patients’ quality of life was poor across all the studies included in the analysis and called for future trials to address this gap, and more long-term assessments.

“Regardless of the type of psoriasis, up to 79% of people with the condition present with scalp involvement, which has frequently been the first site to show symptoms of the disease,” they pointed out.

Thirty of the 59 studies were either conducted or sponsored by the manufacturer of the study medication, and the authors described the overall quality of the studies as “moderate.” Thirty-three studies were double blind, 14 were single blind, two had “third-party” blinding, six were open-label, and four did not report blinding information.

The study was supported by the Universidade Federal de São Paulo, Brazil; the Universidade Federal do Rio Grande do Norte, Brazil; and the National Institute for Health Research, United Kingdom. Six authors and one clinical referee declared speakers’ fees, research grants, and funding from the pharmaceutical industry. One author had no conflicts of interest to disclose.

As a treatment for scalp psoriasis, the combination of a topical steroid and topical vitamin D was marginally better than topical steroids alone, but both approaches have a similar safety profile, according to a Cochrane review.

The systematic review included 59 randomized controlled trials of topical treatments for scalp psoriasis, representing a total of 11,561 participants of all ages, most of whom were followed for less than 6 months, according to Justin Schlager, MD, of the Charité – Universitätsmedizin Berlin, and coauthors (Cochrane Database of Systematic Reviews 2016. Issue 2. doi: 10.1002/14651858.CD009687.pub2).

Christine Langer-p?schel/Thinkstock

In the analysis, topical steroid monotherapy was significantly better than topical vitamin D for clearance, as assessed by the Investigator’s Global Assessment of Disease Severity (risk ratio, 1.82; 95% confidence interval, 1.52-2.18). But the combination of a topical steroid and vitamin D showed a small but statistically significant advantage over steroids alone (RR, 1.22; 95% CI, 1.08-1.36) and an even greater advantage over vitamin D alone (RR, 2.28; 95% CI, 1.87-2.78).

Similarly, for treatment response, the combination of a topical steroid and vitamin D showed the greatest benefit in terms of treatment response when compared with steroid monotherapy (RR, 1.15; 95% CI, 1.06-1.25) – an additional benefit the authors observed was small – and when compared with vitamin D alone (RR, 2.31; 95% CI, 1.75-3.04).

But for monotherapy, corticosteroids were more than twice as effective as vitamin D alone for treatment response (RR, 2.09; 95% CI, 1.80-2.41). The analysis also showed that corticosteroids of moderate, high, and very high potency were similarly effective.

Steroids were associated with a significantly lower risk of withdrawal because of adverse events than vitamin D (RR, 0.22; 95% CI, 0.11-0.42). Patients using topical steroids reported adverse events such as a burning sensation or irritation at the site of application, while patients taking vitamin D reported side effects such as pruritus, candidiasis, dermatitis, and erythema, although in both cases these were mostly limited to the application site.

The combination of vitamin D and topical steroid had a lower risk of withdrawals because of adverse events than vitamin D alone, but showed a similar rate to topical steroids alone.

“Given the similar safety profile and only slim benefit of the two-compound combination over the steroid alone, monotherapy with generic topical corticosteroids may be fully acceptable for short-term therapy,” the authors wrote. The authors noted that data on patients’ quality of life was poor across all the studies included in the analysis and called for future trials to address this gap, and more long-term assessments.

“Regardless of the type of psoriasis, up to 79% of people with the condition present with scalp involvement, which has frequently been the first site to show symptoms of the disease,” they pointed out.

Thirty of the 59 studies were either conducted or sponsored by the manufacturer of the study medication, and the authors described the overall quality of the studies as “moderate.” Thirty-three studies were double blind, 14 were single blind, two had “third-party” blinding, six were open-label, and four did not report blinding information.

The study was supported by the Universidade Federal de São Paulo, Brazil; the Universidade Federal do Rio Grande do Norte, Brazil; and the National Institute for Health Research, United Kingdom. Six authors and one clinical referee declared speakers’ fees, research grants, and funding from the pharmaceutical industry. One author had no conflicts of interest to disclose.

While euthanasia and physician-assisted suicide increasingly are being legalized around the world, there appears to be little evidence that vulnerable patients are being targeted by abuse of the practice, researchers say.

A review published in the July 5 edition of JAMA examined surveys and death certification studies from countries and jurisdictions where physician-assisted suicide, euthanasia or both have been legalized, to explore attitudes and practices.

©aga7ta/Thinkstock

Currently, physician-assisted suicide is legal in five U.S. states – California, Montana, Oregon, Vermont, and Washington – while euthanasia or physician-assisted suicide is legal in Belgium, Canada, Colombia, Luxembourg, the Netherlands, and Switzerland, (JAMA 2016;316:79-90. doi: 10.1001/jama.2016.8499).

The review found evidence suggesting that in the United States, physician-assisted suicide accounts for less than 0.4% of all deaths. In Belgium and the Netherlands, that prevalence is much higher; the most recent studies suggested that 4.6% of all deaths in Belgium and 2.9% of all deaths in the Netherlands can be attributed to euthanasia or physician-assisted suicide, and there is the suggestion that this proportion is increasing over time.

The authors also addressed the so-called “slippery slope” argument, which posits that legalization of euthanasia or physician-assisted suicide would see its expansion to include patients who had not explicitly requested it. They noted that the incidence of deaths resulting from administration of lethal drugs without explicit patient consent appeared to have declined from 0.8% of deaths in the Netherlands in 1990 to 0.2% of deaths in 2010.

Similarly in Belgium, these deaths without explicit patient consent were estimated to be around 3.2% of deaths before legalization and 1.7% of deaths in 2013, after legalization.

“There is much debate concerning performing euthanasia, physician-assisted suicide, or other life-ending procedures on patients with dementia or chronic mental illness, who are minors, who are just “tired of life,” or who are socioeconomically vulnerable,” wrote Dr. Ezekiel J. Emanuel, vice provost for global initiatives and professor and chair of the department of medical ethics and health policy medical ethics and health policy at the University of Pennsylvania in Philadelphia, and coauthors.

However they cited a survey of Dutch physicians which found that only 2% of requests for euthanasia or physician-assisted suicide were from patients with a psychiatric disease, 4% were from patients with dementia, and 3% were from patients with neither a serious physical or psychiatric disease.

“In the United States, the concern that minorities, the disabled, the poor, or other socioeconomically marginalized groups might be pressured to accept [physician-assisted suicide] does not seem to be borne out,” the authors wrote. “The demographic profile of patients in the United States who have received these interventions is white, well-educated, and well-insured.”

The majority of cases of physician-assisted suicide or euthanasia in the Netherlands and Belgium – 70% – occur in patients with cancer, and 6% are among individuals with a neurodegenerative disease.

The authors also examined changing attitudes among the general public and among physicians towards physician-assisted suicide and euthanasia. They found that public support has declined slightly in the United States, from 75% in 2005 to 64% in 2012, but pointed out that assessing attitudes was challenging because of “framing effects” in surveys.

“Support varies substantially depending on the wording of survey questions; the provision of details about the patients, their prognosis, their medical diagnosis, and symptoms; how the interventions are characterized; and whether the questions are focused on ethical acceptability, legalization, or some other endorsement.”

Support for euthanasia and physician-assisted suicide has increased in most Western European nations but has either plateaued or decreased in much of Central and Eastern Europe.

“These changes seem correlated with a strong decline in religiosity in Western Europe and an increase in religiosity in post-communist Eastern Europe,” the authors suggested.

Physician surveys experience the same framing issues, but the authors cited a 2014 Medscape survey of physicians in seven countries which found that 54% of U.S. respondents agreed that physician-assisted suicide should be allowed, compared with 47% of respondents in Germany and the U.K., 42% in Italy, 30% in France, and 36% in Spain.

No conflicts of interest were reported.

While euthanasia and physician-assisted suicide increasingly are being legalized around the world, there appears to be little evidence that vulnerable patients are being targeted by abuse of the practice, researchers say.

A review published in the July 5 edition of JAMA examined surveys and death certification studies from countries and jurisdictions where physician-assisted suicide, euthanasia or both have been legalized, to explore attitudes and practices.

©aga7ta/Thinkstock

Currently, physician-assisted suicide is legal in five U.S. states – California, Montana, Oregon, Vermont, and Washington – while euthanasia or physician-assisted suicide is legal in Belgium, Canada, Colombia, Luxembourg, the Netherlands, and Switzerland, (JAMA 2016;316:79-90. doi: 10.1001/jama.2016.8499).

The review found evidence suggesting that in the United States, physician-assisted suicide accounts for less than 0.4% of all deaths. In Belgium and the Netherlands, that prevalence is much higher; the most recent studies suggested that 4.6% of all deaths in Belgium and 2.9% of all deaths in the Netherlands can be attributed to euthanasia or physician-assisted suicide, and there is the suggestion that this proportion is increasing over time.

The authors also addressed the so-called “slippery slope” argument, which posits that legalization of euthanasia or physician-assisted suicide would see its expansion to include patients who had not explicitly requested it. They noted that the incidence of deaths resulting from administration of lethal drugs without explicit patient consent appeared to have declined from 0.8% of deaths in the Netherlands in 1990 to 0.2% of deaths in 2010.

Similarly in Belgium, these deaths without explicit patient consent were estimated to be around 3.2% of deaths before legalization and 1.7% of deaths in 2013, after legalization.

“There is much debate concerning performing euthanasia, physician-assisted suicide, or other life-ending procedures on patients with dementia or chronic mental illness, who are minors, who are just “tired of life,” or who are socioeconomically vulnerable,” wrote Dr. Ezekiel J. Emanuel, vice provost for global initiatives and professor and chair of the department of medical ethics and health policy medical ethics and health policy at the University of Pennsylvania in Philadelphia, and coauthors.

However they cited a survey of Dutch physicians which found that only 2% of requests for euthanasia or physician-assisted suicide were from patients with a psychiatric disease, 4% were from patients with dementia, and 3% were from patients with neither a serious physical or psychiatric disease.

“In the United States, the concern that minorities, the disabled, the poor, or other socioeconomically marginalized groups might be pressured to accept [physician-assisted suicide] does not seem to be borne out,” the authors wrote. “The demographic profile of patients in the United States who have received these interventions is white, well-educated, and well-insured.”

The majority of cases of physician-assisted suicide or euthanasia in the Netherlands and Belgium – 70% – occur in patients with cancer, and 6% are among individuals with a neurodegenerative disease.

The authors also examined changing attitudes among the general public and among physicians towards physician-assisted suicide and euthanasia. They found that public support has declined slightly in the United States, from 75% in 2005 to 64% in 2012, but pointed out that assessing attitudes was challenging because of “framing effects” in surveys.

“Support varies substantially depending on the wording of survey questions; the provision of details about the patients, their prognosis, their medical diagnosis, and symptoms; how the interventions are characterized; and whether the questions are focused on ethical acceptability, legalization, or some other endorsement.”

Support for euthanasia and physician-assisted suicide has increased in most Western European nations but has either plateaued or decreased in much of Central and Eastern Europe.

“These changes seem correlated with a strong decline in religiosity in Western Europe and an increase in religiosity in post-communist Eastern Europe,” the authors suggested.

Physician surveys experience the same framing issues, but the authors cited a 2014 Medscape survey of physicians in seven countries which found that 54% of U.S. respondents agreed that physician-assisted suicide should be allowed, compared with 47% of respondents in Germany and the U.K., 42% in Italy, 30% in France, and 36% in Spain.

No conflicts of interest were reported.

While euthanasia and physician-assisted suicide increasingly are being legalized around the world, there appears to be little evidence that vulnerable patients are being targeted by abuse of the practice, researchers say.

A review published in the July 5 edition of JAMA examined surveys and death certification studies from countries and jurisdictions where physician-assisted suicide, euthanasia or both have been legalized, to explore attitudes and practices.

©aga7ta/Thinkstock

Currently, physician-assisted suicide is legal in five U.S. states – California, Montana, Oregon, Vermont, and Washington – while euthanasia or physician-assisted suicide is legal in Belgium, Canada, Colombia, Luxembourg, the Netherlands, and Switzerland, (JAMA 2016;316:79-90. doi: 10.1001/jama.2016.8499).

The review found evidence suggesting that in the United States, physician-assisted suicide accounts for less than 0.4% of all deaths. In Belgium and the Netherlands, that prevalence is much higher; the most recent studies suggested that 4.6% of all deaths in Belgium and 2.9% of all deaths in the Netherlands can be attributed to euthanasia or physician-assisted suicide, and there is the suggestion that this proportion is increasing over time.

The authors also addressed the so-called “slippery slope” argument, which posits that legalization of euthanasia or physician-assisted suicide would see its expansion to include patients who had not explicitly requested it. They noted that the incidence of deaths resulting from administration of lethal drugs without explicit patient consent appeared to have declined from 0.8% of deaths in the Netherlands in 1990 to 0.2% of deaths in 2010.

Similarly in Belgium, these deaths without explicit patient consent were estimated to be around 3.2% of deaths before legalization and 1.7% of deaths in 2013, after legalization.

“There is much debate concerning performing euthanasia, physician-assisted suicide, or other life-ending procedures on patients with dementia or chronic mental illness, who are minors, who are just “tired of life,” or who are socioeconomically vulnerable,” wrote Dr. Ezekiel J. Emanuel, vice provost for global initiatives and professor and chair of the department of medical ethics and health policy medical ethics and health policy at the University of Pennsylvania in Philadelphia, and coauthors.

However they cited a survey of Dutch physicians which found that only 2% of requests for euthanasia or physician-assisted suicide were from patients with a psychiatric disease, 4% were from patients with dementia, and 3% were from patients with neither a serious physical or psychiatric disease.

“In the United States, the concern that minorities, the disabled, the poor, or other socioeconomically marginalized groups might be pressured to accept [physician-assisted suicide] does not seem to be borne out,” the authors wrote. “The demographic profile of patients in the United States who have received these interventions is white, well-educated, and well-insured.”

The majority of cases of physician-assisted suicide or euthanasia in the Netherlands and Belgium – 70% – occur in patients with cancer, and 6% are among individuals with a neurodegenerative disease.

The authors also examined changing attitudes among the general public and among physicians towards physician-assisted suicide and euthanasia. They found that public support has declined slightly in the United States, from 75% in 2005 to 64% in 2012, but pointed out that assessing attitudes was challenging because of “framing effects” in surveys.

“Support varies substantially depending on the wording of survey questions; the provision of details about the patients, their prognosis, their medical diagnosis, and symptoms; how the interventions are characterized; and whether the questions are focused on ethical acceptability, legalization, or some other endorsement.”

Support for euthanasia and physician-assisted suicide has increased in most Western European nations but has either plateaued or decreased in much of Central and Eastern Europe.

“These changes seem correlated with a strong decline in religiosity in Western Europe and an increase in religiosity in post-communist Eastern Europe,” the authors suggested.

Physician surveys experience the same framing issues, but the authors cited a 2014 Medscape survey of physicians in seven countries which found that 54% of U.S. respondents agreed that physician-assisted suicide should be allowed, compared with 47% of respondents in Germany and the U.K., 42% in Italy, 30% in France, and 36% in Spain.

No conflicts of interest were reported.

Consider melanoma-associated leukoderma (MAL) as a possible diagnosis in patients presenting with atypical vitiligo-like skin depigmentation that is refractory to standard treatment, advised the authors of a series of seven such cases.

In a research letter published online in the British Journal of Dermatology, Dr. H.E. Teulings and colleagues from the department of dermatology and the Netherlands Institute for Pigment Disorders at the University of Amsterdam, presented a retrospective analysis of seven patients diagnosed with MAL from 2009-2014, who had been initially diagnosed with nonsegmental vitiligo.

The authors defined MAL as “depigmentation that developed within 1 year before the detection of a primary melanoma or within 3 years before the detection of melanoma metastases with an unknown primary tumour.”

The five women and two men were white and were older (aged 45 to 72 years). They had experienced a sudden onset of highly progressive hypo- and depigmentation, which the authors described as often consisting of “round, patchy, confetti-like lesions” measuring 4-5 mm in diameter; most were scattered symmetrically over the trunk, extremities, and/or face (Br J Dermatol. 2016 Jun 7. doi: 10.1111/bjd.14790).

The authors noted that this presentation was unlike typical vitiligo, “which is often bilaterally distributed in an acrofacial pattern, or scattered symmetrically over the entire body with a predilection for extensor surfaces with a relatively early onset in life and a slowly evolving disease course over time.”

The lesions were also generally resistant to topical steroids and UV phototherapy, and six of the seven patients had no family history of vitiligo. The patients were either diagnosed with a primary melanoma at first presentation or were later diagnosed with metastatic melanoma. The majority responded well to immunotherapy, although one patient died.

“In conclusion, although MAL only constitutes a small percentage of patients presenting with vitiligo-like depigmentation, awareness of this phenomenon and correct diagnosis of these patients is crucial to limit further melanoma treatment delay,” the authors wrote. “Many dermatologists are not aware of the diagnosis MAL and may easily diagnose and treat these patients as having nonsegmental vitiligo, thereby overlooking the underlying (metastatic) melanoma,” they added.

Dr. Teulings is supported by a grant from the Dutch Cancer Society. The authors had no conflicts of interest to declare.

Consider melanoma-associated leukoderma (MAL) as a possible diagnosis in patients presenting with atypical vitiligo-like skin depigmentation that is refractory to standard treatment, advised the authors of a series of seven such cases.

In a research letter published online in the British Journal of Dermatology, Dr. H.E. Teulings and colleagues from the department of dermatology and the Netherlands Institute for Pigment Disorders at the University of Amsterdam, presented a retrospective analysis of seven patients diagnosed with MAL from 2009-2014, who had been initially diagnosed with nonsegmental vitiligo.

The authors defined MAL as “depigmentation that developed within 1 year before the detection of a primary melanoma or within 3 years before the detection of melanoma metastases with an unknown primary tumour.”

The five women and two men were white and were older (aged 45 to 72 years). They had experienced a sudden onset of highly progressive hypo- and depigmentation, which the authors described as often consisting of “round, patchy, confetti-like lesions” measuring 4-5 mm in diameter; most were scattered symmetrically over the trunk, extremities, and/or face (Br J Dermatol. 2016 Jun 7. doi: 10.1111/bjd.14790).

The authors noted that this presentation was unlike typical vitiligo, “which is often bilaterally distributed in an acrofacial pattern, or scattered symmetrically over the entire body with a predilection for extensor surfaces with a relatively early onset in life and a slowly evolving disease course over time.”

The lesions were also generally resistant to topical steroids and UV phototherapy, and six of the seven patients had no family history of vitiligo. The patients were either diagnosed with a primary melanoma at first presentation or were later diagnosed with metastatic melanoma. The majority responded well to immunotherapy, although one patient died.

“In conclusion, although MAL only constitutes a small percentage of patients presenting with vitiligo-like depigmentation, awareness of this phenomenon and correct diagnosis of these patients is crucial to limit further melanoma treatment delay,” the authors wrote. “Many dermatologists are not aware of the diagnosis MAL and may easily diagnose and treat these patients as having nonsegmental vitiligo, thereby overlooking the underlying (metastatic) melanoma,” they added.

Dr. Teulings is supported by a grant from the Dutch Cancer Society. The authors had no conflicts of interest to declare.

Consider melanoma-associated leukoderma (MAL) as a possible diagnosis in patients presenting with atypical vitiligo-like skin depigmentation that is refractory to standard treatment, advised the authors of a series of seven such cases.

In a research letter published online in the British Journal of Dermatology, Dr. H.E. Teulings and colleagues from the department of dermatology and the Netherlands Institute for Pigment Disorders at the University of Amsterdam, presented a retrospective analysis of seven patients diagnosed with MAL from 2009-2014, who had been initially diagnosed with nonsegmental vitiligo.

The authors defined MAL as “depigmentation that developed within 1 year before the detection of a primary melanoma or within 3 years before the detection of melanoma metastases with an unknown primary tumour.”

The five women and two men were white and were older (aged 45 to 72 years). They had experienced a sudden onset of highly progressive hypo- and depigmentation, which the authors described as often consisting of “round, patchy, confetti-like lesions” measuring 4-5 mm in diameter; most were scattered symmetrically over the trunk, extremities, and/or face (Br J Dermatol. 2016 Jun 7. doi: 10.1111/bjd.14790).

The authors noted that this presentation was unlike typical vitiligo, “which is often bilaterally distributed in an acrofacial pattern, or scattered symmetrically over the entire body with a predilection for extensor surfaces with a relatively early onset in life and a slowly evolving disease course over time.”

The lesions were also generally resistant to topical steroids and UV phototherapy, and six of the seven patients had no family history of vitiligo. The patients were either diagnosed with a primary melanoma at first presentation or were later diagnosed with metastatic melanoma. The majority responded well to immunotherapy, although one patient died.

“In conclusion, although MAL only constitutes a small percentage of patients presenting with vitiligo-like depigmentation, awareness of this phenomenon and correct diagnosis of these patients is crucial to limit further melanoma treatment delay,” the authors wrote. “Many dermatologists are not aware of the diagnosis MAL and may easily diagnose and treat these patients as having nonsegmental vitiligo, thereby overlooking the underlying (metastatic) melanoma,” they added.

Dr. Teulings is supported by a grant from the Dutch Cancer Society. The authors had no conflicts of interest to declare.

Premenopausal risk-reducing salpingo-oophorectomy becomes cost-effective in women who have a 4% or greater lifetime risk of ovarian cancer, according to a modeling study published online in the Journal of Medical Genetics.

The procedure, which is usually undertaken in women aged over 35 years who have completed their families, is available in the United Kingdom to women with a greater than 10% lifetime risk of ovarian cancer. However, the researchers, led by Dr. Ranjit Manchanda of Barts Cancer Institute at Queen Mary University of London, suggested that this threshold has not been tested for cost-effectiveness.

The decision analysis model evaluated lifetime costs as well as the effects of risk-reducing salpingo-oophorectomy in 40-year-old premenopausal women by comparing it with no procedure in women whose lifetime ovarian cancer risk ranged from 2%-10%. The final outcomes were development of breast cancer, ovarian cancer, and excess deaths from coronary heart disease, while cost-effectiveness was judged against the National Institute for Health and Care Excellence threshold of £20,000-£30,000 per quality-adjusted life-years (QALY).

Researchers found that premenopausal risk-reducing salpingo-oophorectomy was cost-effective in women with a 4% or greater lifetime risk of ovarian cancer, largely because of the reduction in their risk of breast cancer. At this level of risk, surgery gained 42.7 days of life-expectancy, with an incremental cost-effectiveness ratio of £19,536($26,186)/QALY.

Premenopausal risk-reducing salpingo-oophorectomy was not cost-effective at the baseline risk rate of 2%, with an incremental cost-effectiveness ratio of £46,480($62,267)/QALY and 19.9 days gain in life expectancy (J Med Genetics 2016 June 27. doi: 10.1136/jmedgenet-2016-103800).

The cost-effectiveness was predicated on the assumption of at least an 80% compliance rate with hormone therapy (HT) in women who underwent the procedure; without HT, the cost-effectiveness threshold increased to a lifetime risk of over 8.2%.

“Our results are of major significance for clinical practice and risk management in view of declining genetic testing costs and the improvements in estimating an individual’s OC risk,” the authors wrote.

“With routine clinical testing for certain moderate penetrance genes around the corner and lack of an effective OC screening programme, these findings are timely as it provides evidence supporting a surgical prevention strategy for ‘lower-risk’ (lifetime risk less than 10%) individuals,” noted Dr. Manchanda and colleagues.

They stressed that symptom levels after salpingo-oophorectomy, particularly for sexual function, were still higher even in women taking HT compared to those who hadn’t undergone salpingo-oophorectomy.

“This limitation needs to be discussed as part of informed consent for the surgical procedure and incorporated into [the risk-reducing salpingo-oophorectomy] decision-making process,” they wrote.

One author declared a financial interest in Abcodia, which has an interest in ovarian cancer screening and biomarkers for screening and risk prediction. No other conflicts of interest were declared.

Premenopausal risk-reducing salpingo-oophorectomy becomes cost-effective in women who have a 4% or greater lifetime risk of ovarian cancer, according to a modeling study published online in the Journal of Medical Genetics.

The procedure, which is usually undertaken in women aged over 35 years who have completed their families, is available in the United Kingdom to women with a greater than 10% lifetime risk of ovarian cancer. However, the researchers, led by Dr. Ranjit Manchanda of Barts Cancer Institute at Queen Mary University of London, suggested that this threshold has not been tested for cost-effectiveness.

The decision analysis model evaluated lifetime costs as well as the effects of risk-reducing salpingo-oophorectomy in 40-year-old premenopausal women by comparing it with no procedure in women whose lifetime ovarian cancer risk ranged from 2%-10%. The final outcomes were development of breast cancer, ovarian cancer, and excess deaths from coronary heart disease, while cost-effectiveness was judged against the National Institute for Health and Care Excellence threshold of £20,000-£30,000 per quality-adjusted life-years (QALY).

Researchers found that premenopausal risk-reducing salpingo-oophorectomy was cost-effective in women with a 4% or greater lifetime risk of ovarian cancer, largely because of the reduction in their risk of breast cancer. At this level of risk, surgery gained 42.7 days of life-expectancy, with an incremental cost-effectiveness ratio of £19,536($26,186)/QALY.

Premenopausal risk-reducing salpingo-oophorectomy was not cost-effective at the baseline risk rate of 2%, with an incremental cost-effectiveness ratio of £46,480($62,267)/QALY and 19.9 days gain in life expectancy (J Med Genetics 2016 June 27. doi: 10.1136/jmedgenet-2016-103800).

The cost-effectiveness was predicated on the assumption of at least an 80% compliance rate with hormone therapy (HT) in women who underwent the procedure; without HT, the cost-effectiveness threshold increased to a lifetime risk of over 8.2%.

“Our results are of major significance for clinical practice and risk management in view of declining genetic testing costs and the improvements in estimating an individual’s OC risk,” the authors wrote.

“With routine clinical testing for certain moderate penetrance genes around the corner and lack of an effective OC screening programme, these findings are timely as it provides evidence supporting a surgical prevention strategy for ‘lower-risk’ (lifetime risk less than 10%) individuals,” noted Dr. Manchanda and colleagues.

They stressed that symptom levels after salpingo-oophorectomy, particularly for sexual function, were still higher even in women taking HT compared to those who hadn’t undergone salpingo-oophorectomy.

“This limitation needs to be discussed as part of informed consent for the surgical procedure and incorporated into [the risk-reducing salpingo-oophorectomy] decision-making process,” they wrote.

One author declared a financial interest in Abcodia, which has an interest in ovarian cancer screening and biomarkers for screening and risk prediction. No other conflicts of interest were declared.

Premenopausal risk-reducing salpingo-oophorectomy becomes cost-effective in women who have a 4% or greater lifetime risk of ovarian cancer, according to a modeling study published online in the Journal of Medical Genetics.

The procedure, which is usually undertaken in women aged over 35 years who have completed their families, is available in the United Kingdom to women with a greater than 10% lifetime risk of ovarian cancer. However, the researchers, led by Dr. Ranjit Manchanda of Barts Cancer Institute at Queen Mary University of London, suggested that this threshold has not been tested for cost-effectiveness.

The decision analysis model evaluated lifetime costs as well as the effects of risk-reducing salpingo-oophorectomy in 40-year-old premenopausal women by comparing it with no procedure in women whose lifetime ovarian cancer risk ranged from 2%-10%. The final outcomes were development of breast cancer, ovarian cancer, and excess deaths from coronary heart disease, while cost-effectiveness was judged against the National Institute for Health and Care Excellence threshold of £20,000-£30,000 per quality-adjusted life-years (QALY).

Researchers found that premenopausal risk-reducing salpingo-oophorectomy was cost-effective in women with a 4% or greater lifetime risk of ovarian cancer, largely because of the reduction in their risk of breast cancer. At this level of risk, surgery gained 42.7 days of life-expectancy, with an incremental cost-effectiveness ratio of £19,536($26,186)/QALY.

Premenopausal risk-reducing salpingo-oophorectomy was not cost-effective at the baseline risk rate of 2%, with an incremental cost-effectiveness ratio of £46,480($62,267)/QALY and 19.9 days gain in life expectancy (J Med Genetics 2016 June 27. doi: 10.1136/jmedgenet-2016-103800).

The cost-effectiveness was predicated on the assumption of at least an 80% compliance rate with hormone therapy (HT) in women who underwent the procedure; without HT, the cost-effectiveness threshold increased to a lifetime risk of over 8.2%.

“Our results are of major significance for clinical practice and risk management in view of declining genetic testing costs and the improvements in estimating an individual’s OC risk,” the authors wrote.

“With routine clinical testing for certain moderate penetrance genes around the corner and lack of an effective OC screening programme, these findings are timely as it provides evidence supporting a surgical prevention strategy for ‘lower-risk’ (lifetime risk less than 10%) individuals,” noted Dr. Manchanda and colleagues.

They stressed that symptom levels after salpingo-oophorectomy, particularly for sexual function, were still higher even in women taking HT compared to those who hadn’t undergone salpingo-oophorectomy.

“This limitation needs to be discussed as part of informed consent for the surgical procedure and incorporated into [the risk-reducing salpingo-oophorectomy] decision-making process,” they wrote.

One author declared a financial interest in Abcodia, which has an interest in ovarian cancer screening and biomarkers for screening and risk prediction. No other conflicts of interest were declared.

Liraglutide is associated with a decreased risk of cardiovascular events, compared with placebo, in individuals with type 2 diabetes, according to results from the randomized, placebo-controlled, double-blind LEADER trial.

In the 9,340 patients with type 2 diabetes in LEADER, those treated with the glucagonlike peptide–1 (GLP-1) analogue liraglutide had a 13% lower risk of a composite outcome of death from cardiovascular causes, nonfatal myocardial infarction, or nonfatal stroke over a median follow-up of 3.8 years (hazard ratio, 0.87; 95% confidence interval, 0.78-0.97; P less than .001 for noninferiority; P = .01 for superiority).

This significant reduction in the primary outcome in LEADER (Liraglutide Effect and Action in Diabetes: Evaluation of Cardiovascular Outcome) makes liraglutide (Victoza) the second antihyperglycemic drug to be shown to reduce cardiovascular outcomes since the Food and Drug Administration mandated that all such agents be tested in such a way in 2008. The first was the sodium-glucose cotransporter–2 inhibitor empagliflozin, which reduced the risk of the composite endpoint of hospitalization for heart failure or death due to cardiovascular disease by 34% in the EMPA-REG OUTCOME trial (N Engl J Med. 2015;373:2117-28).

In LEADER, the rate of death from cardiovascular causes was 22% lower in the liraglutide group than in the placebo group (95% CI, 0.66-0.93; P = .007). However, the lower incidences of nonfatal MI, stroke, and hospitalization for heart failure in the liraglutide group did not reach statistical significance.

The participants in LEADER all had a hemoglobin A_1c level of 7.0%, and were either aged over 50 with at least one cardiovascular condition such as coronary heart disease, or aged over 60 with at least one cardiovascular risk factor such as hypertension or microalbuminuria.

The participants, who were recruited from 410 sites in 32 countries, were randomized to 1.8 mg or the maximum tolerated dose of subcutaneous liraglutide once daily or to equivalent placebo, in addition to standard care (N Engl J Med. 2016 June 13. doi: 10.1056/NEJMoa1603827).

“Although glycemic control is associated with reductions in the risk of microvascular complications, the macrovascular benefits of glycemic control are less certain,” wrote Dr. Steven P. Marso of the University of Texas Southwestern Medical Center, Dallas, and his coauthors.

“Furthermore, concern has been raised about the cardiovascular safety of antihyperglycemic therapies, [and] consequently, regulatory authorities have mandated cardiovascular safety assessments of new diabetes treatments.”

The study did see a significant interaction between liraglutide and renal function. Patients who had an estimated glomerular filtration rate (eGFR) of less than 60 mL/min per 1.73 m² showed more benefits from the liraglutide in terms of the primary outcomes than did those with an eGFR of at least 60 mL/min.

Individuals aged over 50 years with established cardiovascular disease also showed greater benefits in reductions in the primary outcome from liraglutide than did patients aged over 60 years with cardiovascular risk factors.

The authors commented that their findings contrast with those of the Lixisenatide in Acute Coronary Syndrome (ELIXA) trial using the shorter-acting and structurally dissimilar GLP-1 receptor agonist lixisenatide. This trial failed to show any cardiovascular benefit of the drug in patients with diabetes and a recent acute coronary syndrome, as did several other trials looking at cardiovascular outcomes in high-risk patients with type 2 diabetes treated with drugs including insulin, thiazolidinediones, and dipeptidyl peptidase–4 inhibitors.

“Our trial had greater statistical power and included patients with a higher baseline glycated hemoglobin level than did most previous studies,” the authors wrote. “However, no obvious single explanation in terms of either the study designs or the included populations is apparent to explain the divergent findings across this body of medical literature.

The study also examined the incidence of adverse events, finding a nonsignificantly higher overall rate of benign or malignant neoplasms with liraglutide, compared with placebo. However, there was a trend toward an increased risk of pancreatic cancer in those taking liraglutide, which approached statistical significance.

“There has been considerable interest in a potential association between the use of GLP-1 receptor agonists and pancreatitis and pancreatic cancer, although there is no consistent preclinical, pharmacovigilance, or epidemiologic evidence to date,” the authors commented.

The study was supported by Novo Nordisk and the National Institutes of Health. Several authors declared grants, consultancies and funding from the pharmaceutical industry, including from Novo Nordisk. Several authors are employees of Novo Nordisk, are on steering committees, and/or own shares in the company.

Liraglutide is associated with a decreased risk of cardiovascular events, compared with placebo, in individuals with type 2 diabetes, according to results from the randomized, placebo-controlled, double-blind LEADER trial.

In the 9,340 patients with type 2 diabetes in LEADER, those treated with the glucagonlike peptide–1 (GLP-1) analogue liraglutide had a 13% lower risk of a composite outcome of death from cardiovascular causes, nonfatal myocardial infarction, or nonfatal stroke over a median follow-up of 3.8 years (hazard ratio, 0.87; 95% confidence interval, 0.78-0.97; P less than .001 for noninferiority; P = .01 for superiority).

This significant reduction in the primary outcome in LEADER (Liraglutide Effect and Action in Diabetes: Evaluation of Cardiovascular Outcome) makes liraglutide (Victoza) the second antihyperglycemic drug to be shown to reduce cardiovascular outcomes since the Food and Drug Administration mandated that all such agents be tested in such a way in 2008. The first was the sodium-glucose cotransporter–2 inhibitor empagliflozin, which reduced the risk of the composite endpoint of hospitalization for heart failure or death due to cardiovascular disease by 34% in the EMPA-REG OUTCOME trial (N Engl J Med. 2015;373:2117-28).

In LEADER, the rate of death from cardiovascular causes was 22% lower in the liraglutide group than in the placebo group (95% CI, 0.66-0.93; P = .007). However, the lower incidences of nonfatal MI, stroke, and hospitalization for heart failure in the liraglutide group did not reach statistical significance.

The participants in LEADER all had a hemoglobin A_1c level of 7.0%, and were either aged over 50 with at least one cardiovascular condition such as coronary heart disease, or aged over 60 with at least one cardiovascular risk factor such as hypertension or microalbuminuria.

The participants, who were recruited from 410 sites in 32 countries, were randomized to 1.8 mg or the maximum tolerated dose of subcutaneous liraglutide once daily or to equivalent placebo, in addition to standard care (N Engl J Med. 2016 June 13. doi: 10.1056/NEJMoa1603827).

“Although glycemic control is associated with reductions in the risk of microvascular complications, the macrovascular benefits of glycemic control are less certain,” wrote Dr. Steven P. Marso of the University of Texas Southwestern Medical Center, Dallas, and his coauthors.

“Furthermore, concern has been raised about the cardiovascular safety of antihyperglycemic therapies, [and] consequently, regulatory authorities have mandated cardiovascular safety assessments of new diabetes treatments.”

The study did see a significant interaction between liraglutide and renal function. Patients who had an estimated glomerular filtration rate (eGFR) of less than 60 mL/min per 1.73 m² showed more benefits from the liraglutide in terms of the primary outcomes than did those with an eGFR of at least 60 mL/min.

Individuals aged over 50 years with established cardiovascular disease also showed greater benefits in reductions in the primary outcome from liraglutide than did patients aged over 60 years with cardiovascular risk factors.

The authors commented that their findings contrast with those of the Lixisenatide in Acute Coronary Syndrome (ELIXA) trial using the shorter-acting and structurally dissimilar GLP-1 receptor agonist lixisenatide. This trial failed to show any cardiovascular benefit of the drug in patients with diabetes and a recent acute coronary syndrome, as did several other trials looking at cardiovascular outcomes in high-risk patients with type 2 diabetes treated with drugs including insulin, thiazolidinediones, and dipeptidyl peptidase–4 inhibitors.

“Our trial had greater statistical power and included patients with a higher baseline glycated hemoglobin level than did most previous studies,” the authors wrote. “However, no obvious single explanation in terms of either the study designs or the included populations is apparent to explain the divergent findings across this body of medical literature.

The study also examined the incidence of adverse events, finding a nonsignificantly higher overall rate of benign or malignant neoplasms with liraglutide, compared with placebo. However, there was a trend toward an increased risk of pancreatic cancer in those taking liraglutide, which approached statistical significance.

“There has been considerable interest in a potential association between the use of GLP-1 receptor agonists and pancreatitis and pancreatic cancer, although there is no consistent preclinical, pharmacovigilance, or epidemiologic evidence to date,” the authors commented.

The study was supported by Novo Nordisk and the National Institutes of Health. Several authors declared grants, consultancies and funding from the pharmaceutical industry, including from Novo Nordisk. Several authors are employees of Novo Nordisk, are on steering committees, and/or own shares in the company.

Liraglutide is associated with a decreased risk of cardiovascular events, compared with placebo, in individuals with type 2 diabetes, according to results from the randomized, placebo-controlled, double-blind LEADER trial.

In the 9,340 patients with type 2 diabetes in LEADER, those treated with the glucagonlike peptide–1 (GLP-1) analogue liraglutide had a 13% lower risk of a composite outcome of death from cardiovascular causes, nonfatal myocardial infarction, or nonfatal stroke over a median follow-up of 3.8 years (hazard ratio, 0.87; 95% confidence interval, 0.78-0.97; P less than .001 for noninferiority; P = .01 for superiority).

This significant reduction in the primary outcome in LEADER (Liraglutide Effect and Action in Diabetes: Evaluation of Cardiovascular Outcome) makes liraglutide (Victoza) the second antihyperglycemic drug to be shown to reduce cardiovascular outcomes since the Food and Drug Administration mandated that all such agents be tested in such a way in 2008. The first was the sodium-glucose cotransporter–2 inhibitor empagliflozin, which reduced the risk of the composite endpoint of hospitalization for heart failure or death due to cardiovascular disease by 34% in the EMPA-REG OUTCOME trial (N Engl J Med. 2015;373:2117-28).

In LEADER, the rate of death from cardiovascular causes was 22% lower in the liraglutide group than in the placebo group (95% CI, 0.66-0.93; P = .007). However, the lower incidences of nonfatal MI, stroke, and hospitalization for heart failure in the liraglutide group did not reach statistical significance.

The participants in LEADER all had a hemoglobin A_1c level of 7.0%, and were either aged over 50 with at least one cardiovascular condition such as coronary heart disease, or aged over 60 with at least one cardiovascular risk factor such as hypertension or microalbuminuria.

The participants, who were recruited from 410 sites in 32 countries, were randomized to 1.8 mg or the maximum tolerated dose of subcutaneous liraglutide once daily or to equivalent placebo, in addition to standard care (N Engl J Med. 2016 June 13. doi: 10.1056/NEJMoa1603827).

“Although glycemic control is associated with reductions in the risk of microvascular complications, the macrovascular benefits of glycemic control are less certain,” wrote Dr. Steven P. Marso of the University of Texas Southwestern Medical Center, Dallas, and his coauthors.

“Furthermore, concern has been raised about the cardiovascular safety of antihyperglycemic therapies, [and] consequently, regulatory authorities have mandated cardiovascular safety assessments of new diabetes treatments.”

The study did see a significant interaction between liraglutide and renal function. Patients who had an estimated glomerular filtration rate (eGFR) of less than 60 mL/min per 1.73 m² showed more benefits from the liraglutide in terms of the primary outcomes than did those with an eGFR of at least 60 mL/min.

Individuals aged over 50 years with established cardiovascular disease also showed greater benefits in reductions in the primary outcome from liraglutide than did patients aged over 60 years with cardiovascular risk factors.

The authors commented that their findings contrast with those of the Lixisenatide in Acute Coronary Syndrome (ELIXA) trial using the shorter-acting and structurally dissimilar GLP-1 receptor agonist lixisenatide. This trial failed to show any cardiovascular benefit of the drug in patients with diabetes and a recent acute coronary syndrome, as did several other trials looking at cardiovascular outcomes in high-risk patients with type 2 diabetes treated with drugs including insulin, thiazolidinediones, and dipeptidyl peptidase–4 inhibitors.

“Our trial had greater statistical power and included patients with a higher baseline glycated hemoglobin level than did most previous studies,” the authors wrote. “However, no obvious single explanation in terms of either the study designs or the included populations is apparent to explain the divergent findings across this body of medical literature.

The study also examined the incidence of adverse events, finding a nonsignificantly higher overall rate of benign or malignant neoplasms with liraglutide, compared with placebo. However, there was a trend toward an increased risk of pancreatic cancer in those taking liraglutide, which approached statistical significance.

“There has been considerable interest in a potential association between the use of GLP-1 receptor agonists and pancreatitis and pancreatic cancer, although there is no consistent preclinical, pharmacovigilance, or epidemiologic evidence to date,” the authors commented.

The study was supported by Novo Nordisk and the National Institutes of Health. Several authors declared grants, consultancies and funding from the pharmaceutical industry, including from Novo Nordisk. Several authors are employees of Novo Nordisk, are on steering committees, and/or own shares in the company.