Sensitivity and area under the curve (AUC) analyses of thermography that is combined with diagnostic software demonstrate “the efficacy of the tool for breast cancer screening,” concludes an observational, comparative study from India published online Oct. 1 in JCO Global Oncology, a publication of the American Society of Clinical Oncology.

Siva Teja Kakileti of Niramai Health Analytix, Koramangala, Bangalore, India, and colleagues said that the product, Thermalytix, is potentially a good fit for low- and middle-income countries because it is portable and provides automated quantitative analysis of thermal images – and thus can be conducted by technicians with “minimal training.”

Conventional thermography involves manual interpretation of complex thermal images, which “often results in erroneous results owing to subjectivity,” said the study authors.

That manual interpretation of thermal images might involve looking at 200 color shades, which is “high cognitive overload for the thermographer,” explained Mr. Kakileti in an interview.

However, an American mammography expert who was approached for comment dismissed thermography – even with the new twist of software-aided diagnostic scoring by Thermalytix – as wholly inappropriate for the detection of early breast cancer, owing to inherent limitations.

“Thermal imaging of any type has no value in finding early breast cancer,” Daniel Kopans, MD, of Harvard University and Massachusetts General Hospital, both in Boston, said in an interview. He said that thermal imaging only detects heat on the skin and perhaps a few millimeters beneath the skin and thus misses deeper cancers, the heat from which is carried away by the vascular system.

The new study included 470 women who presented for breast screening at two centers in Bangalore, India. A total of 238 women had symptoms such as breast lump, nipple discharge, skin changes, or breast pain; the remaining 232 women were asymptomatic.

All participants underwent a Thermalytix test and one or more standard-of-care tests for breast cancer screening (such as mammography, ultrasonography, biopsy, fine-needle aspiration, or elastography). A total of 78 women, or 16.6% of the group overall, were diagnosed with a malignancy. For the overall group of 470 women, Thermalytix had a sensitivity of 91.02% (symptomatic, 89.85%; asymptomatic,100%) and a specificity of 82.39% (symptomatic, 69.04%; asymptomatic, 92.41%) in detection of breast malignancy. Thermalytix showed an overall AUC of 0.90, with an AUC of 0.82 for symptomatic and 0.98 for asymptomatic women.

The study authors characterized both the sensitivity and AUC as “high.”

The results from the study, which the authors characterized as preliminary, encouraged the study sponsor, Niramai, to start planning a large-scale, multicountry trial.

But Dr. Kopans, who serves as a consultant to DART, which produces digital breast tomosynthesis units in China, suggested that this research will be fruitless. “Thermal imaging seems to raise its head every few years since it is passive, but it does not work and is a waste of money,” Dr. Kopans reiterated.

“Its use can be dangerous by dissuading women from being screened with mammography, which has been proven to save lives,” he stressed.
 

Thermalytix compared with mammography

Investigators also compared screening results in the subset of 242 women who underwent both Thermalytix and mammography. Results showed that Thermalytix had a higher sensitivity than did mammography (91.23% vs. 85.96%), but mammography had a higher specificity than Thermalytix did (94.05% vs. 68.65%).

In the asymptomatic group who underwent both tests (n = 95), four cancers were detected, and Thermalytix demonstrated superior sensitivity than mammography (100% vs. 50%), Mr. Kakileti and colleagues state.
 

Thermalytix evaluates vascularity variations too

In the subset of 228 women who did not undergo mammography (owing to dense breasts, younger age, or other reasons), Thermalytix detected tumors in all but 3 of 21 patients who went on to be diagnosed with breast cancer. The authors state that, because their artificial intelligence–based analysis uses vascularity, as well as temperature variations on the skin, to complement hot-spot detection, it is able to detect small lesions.

In the current study, 24 malignant tumors were less than 2 cm in diameter, and Thermalytix was able to identify 17 of the tumors as positive, for a 71% sensitivity rate for T1 tumors. This compared with a 68% sensitivity rate for mammography for detecting the same T1 tumors. Thermalytix also showed promising results in women younger than 40 years, for whom screening mammography is not usually recommended. The automated test picked up all 11 tumors eventually diagnosed in this younger cohort.

“Thermalytix is a portable, noninvasive, radiation-free test that has shown promising results in this preliminary study,” the investigators wrote, “[and] it can be an affordable and scalable method of screening in remote areas,” they added.

“We believe that Thermalytix ... is poised to be a promising modality for breast cancer screening,” Mr. Kakileti and colleagues summarized.
 

The FDA warns about thermography in place of mammography

The US Food and Drug Administration fairly recently warned against the use of thermography as an alternative to mammography for breast cancer screening or diagnosis, noting that it has received reports that facilities where thermography is offered often provide false information about the technology that can mislead patients into believing that it is either an alternative to or a better option than mammography.

Dr. Kopans says that other groups have invested in thermography research. “The Israelis spent millions working on a similar approach that didn’t work,” he commented.

The new software from Thermalytix, which is derived from artificial intelligence, is a “gimmick,” says the Boston radiologist. “If the basic information is not there, a computer cannot find it,” he stated, referring to what he believes are deeper-tissue tumors that are inaccessible to heat-detecting technology.

Mr. Kakileti is an employee of Nirami Health Analytix and owns stock and has filed patents with the company. Other investigators are also employed by the same company or receive research and other funding or have patents filed by the company as well. Dr. Kopans serves as a consultant to DART, which produces digital breast tomosynthesis units in China.
 

A version of this article originally appeared on Medscape.com.

Sensitivity and area under the curve (AUC) analyses of thermography that is combined with diagnostic software demonstrate “the efficacy of the tool for breast cancer screening,” concludes an observational, comparative study from India published online Oct. 1 in JCO Global Oncology, a publication of the American Society of Clinical Oncology.

Siva Teja Kakileti of Niramai Health Analytix, Koramangala, Bangalore, India, and colleagues said that the product, Thermalytix, is potentially a good fit for low- and middle-income countries because it is portable and provides automated quantitative analysis of thermal images – and thus can be conducted by technicians with “minimal training.”

Conventional thermography involves manual interpretation of complex thermal images, which “often results in erroneous results owing to subjectivity,” said the study authors.

That manual interpretation of thermal images might involve looking at 200 color shades, which is “high cognitive overload for the thermographer,” explained Mr. Kakileti in an interview.

However, an American mammography expert who was approached for comment dismissed thermography – even with the new twist of software-aided diagnostic scoring by Thermalytix – as wholly inappropriate for the detection of early breast cancer, owing to inherent limitations.

“Thermal imaging of any type has no value in finding early breast cancer,” Daniel Kopans, MD, of Harvard University and Massachusetts General Hospital, both in Boston, said in an interview. He said that thermal imaging only detects heat on the skin and perhaps a few millimeters beneath the skin and thus misses deeper cancers, the heat from which is carried away by the vascular system.

The new study included 470 women who presented for breast screening at two centers in Bangalore, India. A total of 238 women had symptoms such as breast lump, nipple discharge, skin changes, or breast pain; the remaining 232 women were asymptomatic.

All participants underwent a Thermalytix test and one or more standard-of-care tests for breast cancer screening (such as mammography, ultrasonography, biopsy, fine-needle aspiration, or elastography). A total of 78 women, or 16.6% of the group overall, were diagnosed with a malignancy. For the overall group of 470 women, Thermalytix had a sensitivity of 91.02% (symptomatic, 89.85%; asymptomatic,100%) and a specificity of 82.39% (symptomatic, 69.04%; asymptomatic, 92.41%) in detection of breast malignancy. Thermalytix showed an overall AUC of 0.90, with an AUC of 0.82 for symptomatic and 0.98 for asymptomatic women.

The study authors characterized both the sensitivity and AUC as “high.”

The results from the study, which the authors characterized as preliminary, encouraged the study sponsor, Niramai, to start planning a large-scale, multicountry trial.

But Dr. Kopans, who serves as a consultant to DART, which produces digital breast tomosynthesis units in China, suggested that this research will be fruitless. “Thermal imaging seems to raise its head every few years since it is passive, but it does not work and is a waste of money,” Dr. Kopans reiterated.

“Its use can be dangerous by dissuading women from being screened with mammography, which has been proven to save lives,” he stressed.
 

Thermalytix compared with mammography

Investigators also compared screening results in the subset of 242 women who underwent both Thermalytix and mammography. Results showed that Thermalytix had a higher sensitivity than did mammography (91.23% vs. 85.96%), but mammography had a higher specificity than Thermalytix did (94.05% vs. 68.65%).

In the asymptomatic group who underwent both tests (n = 95), four cancers were detected, and Thermalytix demonstrated superior sensitivity than mammography (100% vs. 50%), Mr. Kakileti and colleagues state.
 

Thermalytix evaluates vascularity variations too

In the subset of 228 women who did not undergo mammography (owing to dense breasts, younger age, or other reasons), Thermalytix detected tumors in all but 3 of 21 patients who went on to be diagnosed with breast cancer. The authors state that, because their artificial intelligence–based analysis uses vascularity, as well as temperature variations on the skin, to complement hot-spot detection, it is able to detect small lesions.

In the current study, 24 malignant tumors were less than 2 cm in diameter, and Thermalytix was able to identify 17 of the tumors as positive, for a 71% sensitivity rate for T1 tumors. This compared with a 68% sensitivity rate for mammography for detecting the same T1 tumors. Thermalytix also showed promising results in women younger than 40 years, for whom screening mammography is not usually recommended. The automated test picked up all 11 tumors eventually diagnosed in this younger cohort.

“Thermalytix is a portable, noninvasive, radiation-free test that has shown promising results in this preliminary study,” the investigators wrote, “[and] it can be an affordable and scalable method of screening in remote areas,” they added.

“We believe that Thermalytix ... is poised to be a promising modality for breast cancer screening,” Mr. Kakileti and colleagues summarized.
 

The FDA warns about thermography in place of mammography

The US Food and Drug Administration fairly recently warned against the use of thermography as an alternative to mammography for breast cancer screening or diagnosis, noting that it has received reports that facilities where thermography is offered often provide false information about the technology that can mislead patients into believing that it is either an alternative to or a better option than mammography.

Dr. Kopans says that other groups have invested in thermography research. “The Israelis spent millions working on a similar approach that didn’t work,” he commented.

The new software from Thermalytix, which is derived from artificial intelligence, is a “gimmick,” says the Boston radiologist. “If the basic information is not there, a computer cannot find it,” he stated, referring to what he believes are deeper-tissue tumors that are inaccessible to heat-detecting technology.

Mr. Kakileti is an employee of Nirami Health Analytix and owns stock and has filed patents with the company. Other investigators are also employed by the same company or receive research and other funding or have patents filed by the company as well. Dr. Kopans serves as a consultant to DART, which produces digital breast tomosynthesis units in China.
 

A version of this article originally appeared on Medscape.com.

Sensitivity and area under the curve (AUC) analyses of thermography that is combined with diagnostic software demonstrate “the efficacy of the tool for breast cancer screening,” concludes an observational, comparative study from India published online Oct. 1 in JCO Global Oncology, a publication of the American Society of Clinical Oncology.

Siva Teja Kakileti of Niramai Health Analytix, Koramangala, Bangalore, India, and colleagues said that the product, Thermalytix, is potentially a good fit for low- and middle-income countries because it is portable and provides automated quantitative analysis of thermal images – and thus can be conducted by technicians with “minimal training.”

Conventional thermography involves manual interpretation of complex thermal images, which “often results in erroneous results owing to subjectivity,” said the study authors.

That manual interpretation of thermal images might involve looking at 200 color shades, which is “high cognitive overload for the thermographer,” explained Mr. Kakileti in an interview.

However, an American mammography expert who was approached for comment dismissed thermography – even with the new twist of software-aided diagnostic scoring by Thermalytix – as wholly inappropriate for the detection of early breast cancer, owing to inherent limitations.

“Thermal imaging of any type has no value in finding early breast cancer,” Daniel Kopans, MD, of Harvard University and Massachusetts General Hospital, both in Boston, said in an interview. He said that thermal imaging only detects heat on the skin and perhaps a few millimeters beneath the skin and thus misses deeper cancers, the heat from which is carried away by the vascular system.

The new study included 470 women who presented for breast screening at two centers in Bangalore, India. A total of 238 women had symptoms such as breast lump, nipple discharge, skin changes, or breast pain; the remaining 232 women were asymptomatic.

All participants underwent a Thermalytix test and one or more standard-of-care tests for breast cancer screening (such as mammography, ultrasonography, biopsy, fine-needle aspiration, or elastography). A total of 78 women, or 16.6% of the group overall, were diagnosed with a malignancy. For the overall group of 470 women, Thermalytix had a sensitivity of 91.02% (symptomatic, 89.85%; asymptomatic,100%) and a specificity of 82.39% (symptomatic, 69.04%; asymptomatic, 92.41%) in detection of breast malignancy. Thermalytix showed an overall AUC of 0.90, with an AUC of 0.82 for symptomatic and 0.98 for asymptomatic women.

The study authors characterized both the sensitivity and AUC as “high.”

The results from the study, which the authors characterized as preliminary, encouraged the study sponsor, Niramai, to start planning a large-scale, multicountry trial.

But Dr. Kopans, who serves as a consultant to DART, which produces digital breast tomosynthesis units in China, suggested that this research will be fruitless. “Thermal imaging seems to raise its head every few years since it is passive, but it does not work and is a waste of money,” Dr. Kopans reiterated.

“Its use can be dangerous by dissuading women from being screened with mammography, which has been proven to save lives,” he stressed.
 

Thermalytix compared with mammography

Investigators also compared screening results in the subset of 242 women who underwent both Thermalytix and mammography. Results showed that Thermalytix had a higher sensitivity than did mammography (91.23% vs. 85.96%), but mammography had a higher specificity than Thermalytix did (94.05% vs. 68.65%).

In the asymptomatic group who underwent both tests (n = 95), four cancers were detected, and Thermalytix demonstrated superior sensitivity than mammography (100% vs. 50%), Mr. Kakileti and colleagues state.
 

Thermalytix evaluates vascularity variations too

In the subset of 228 women who did not undergo mammography (owing to dense breasts, younger age, or other reasons), Thermalytix detected tumors in all but 3 of 21 patients who went on to be diagnosed with breast cancer. The authors state that, because their artificial intelligence–based analysis uses vascularity, as well as temperature variations on the skin, to complement hot-spot detection, it is able to detect small lesions.

In the current study, 24 malignant tumors were less than 2 cm in diameter, and Thermalytix was able to identify 17 of the tumors as positive, for a 71% sensitivity rate for T1 tumors. This compared with a 68% sensitivity rate for mammography for detecting the same T1 tumors. Thermalytix also showed promising results in women younger than 40 years, for whom screening mammography is not usually recommended. The automated test picked up all 11 tumors eventually diagnosed in this younger cohort.

“Thermalytix is a portable, noninvasive, radiation-free test that has shown promising results in this preliminary study,” the investigators wrote, “[and] it can be an affordable and scalable method of screening in remote areas,” they added.

“We believe that Thermalytix ... is poised to be a promising modality for breast cancer screening,” Mr. Kakileti and colleagues summarized.
 

The FDA warns about thermography in place of mammography

The US Food and Drug Administration fairly recently warned against the use of thermography as an alternative to mammography for breast cancer screening or diagnosis, noting that it has received reports that facilities where thermography is offered often provide false information about the technology that can mislead patients into believing that it is either an alternative to or a better option than mammography.

Dr. Kopans says that other groups have invested in thermography research. “The Israelis spent millions working on a similar approach that didn’t work,” he commented.

The new software from Thermalytix, which is derived from artificial intelligence, is a “gimmick,” says the Boston radiologist. “If the basic information is not there, a computer cannot find it,” he stated, referring to what he believes are deeper-tissue tumors that are inaccessible to heat-detecting technology.

Mr. Kakileti is an employee of Nirami Health Analytix and owns stock and has filed patents with the company. Other investigators are also employed by the same company or receive research and other funding or have patents filed by the company as well. Dr. Kopans serves as a consultant to DART, which produces digital breast tomosynthesis units in China.
 

A version of this article originally appeared on Medscape.com.

COVID-19 cases are surging in rural places across the Mountain States and Midwest, and when it hits health care workers, ready reinforcements aren’t easy to find.

In Montana, pandemic-induced staffing shortages have shuttered a clinic in the state’s capital, led a northwestern regional hospital to ask employees exposed to COVID-19 to continue to work and emptied a health department 400 miles to the east.

“Just one more person out and we wouldn’t be able to keep the surgeries going,” said Dr. Shelly Harkins, MD, chief medical officer of St. Peter’s Health in Helena, a city of roughly 32,000 where cases continue to spread. “When the virus is just all around you, it’s almost impossible to not be deemed a contact at some point. One case can take out a whole team of people in a blink of an eye.”

In North Dakota, where cases per resident are growing faster than any other state, hospitals may once again curtail elective surgeries and possibly seek government aid to hire more nurses if the situation gets worse, North Dakota Hospital Association President Tim Blasl said.

“How long can we run at this rate with the workforce that we have?” Blasl said. “You can have all the licensed beds you want, but if you don’t have anybody to staff those beds, it doesn’t do you any good.”

The northern Rocky Mountains, Great Plains and Upper Midwest are seeing the highest surge of COVID-19 cases in the nation, as some residents have ignored recommendations for curtailing the virus, such as wearing masks and avoiding large gatherings. Montana, Idaho, Utah, Wyoming, North Dakota, South Dakota, Nebraska, Iowa, and Wisconsin have recently ranked among the top 10 U.S. states in confirmed cases per 100,000 residents over a 7-day period, according to an analysis  by the New York Times.

Such coronavirus infections – and the quarantines that occur because of them – are exacerbating the health care worker shortage that existed in these states well before the pandemic. Unlike in the nation’s metropolitan hubs, these outbreaks are scattered across hundreds of miles. And even in these states’ biggest cities, the ranks of medical professionals are in short supply. Specialists and registered nurses are sometimes harder to track down than ventilators, N95 masks or hospital beds. Without enough care providers, patients may not be able to get the medical attention they need.

Hospitals have asked staffers to cover extra shifts and learn new skills. They have brought in temporary workers from other parts of the country and transferred some patients to less-crowded hospitals. But, at St. Peter’s Health, if the hospital’s one kidney doctor gets sick or is told to quarantine, Dr. Harkins doesn’t expect to find a backup.

“We make a point to not have excessive staff because we have an obligation to keep the cost of health care down for a community – we just don’t have a lot of slack in our rope,” Dr. Harkins said. “What we don’t account for is a mass exodus of staff for 14 days.”

Some hospitals are already at patient capacity or are nearly there. That’s not just because of the growing number of COVID-19 patients. Elective surgeries have resumed, and medical emergencies don’t pause for a pandemic.

Some Montana hospitals formed agreements with local affiliates early in the pandemic to share staff if one came up short. But now that the disease is spreading fast – and widely – the hope is that their needs don’t peak all at once.

Montana state officials keep a list of primarily in-state volunteer workers ready to travel to towns with shortages of contact tracers, nurses and more. But during a press conference on Oct. 15, Democratic Gov. Steve Bullock said the state had exhausted that database, and its nationwide request for National Guard medical staffing hadn’t brought in new workers.

“If you are a registered nurse, licensed practical nurse, paramedic, EMT, CNA or contact tracer, and are able to join our workforce, please do consider joining our team,” Gov. Bullock said.

This month, Kalispell Regional Medical Center in northwestern Montana even stopped quarantining COVID-exposed staff who remain asymptomatic, a change allowed by Centers for Disease Control and Prevention guidelines for health facilities facing staffing shortages.

“That’s very telling for what staffing is going through right now,” said Andrea Lueck, a registered nurse at the center. “We’re so tight that employees are called off of quarantine.”

Financial pressure early in the pandemic led the hospital to furlough staff, but it had to bring most of them back to work because it needs those bodies more than ever. The regional hub is based in Flathead County, which has recorded the state’s second-highest number of active COVID-19 cases.

Mellody Sharpton, a hospital spokesperson, said hospital workers who are exposed to someone infected with the virus are tested within three to five days and monitored for symptoms. The hospital is also pulling in new workers, with 25 traveling health professionals on hand and another 25 temporary ones on the way.

But Ms. Sharpton said the best way to conserve the hospital’s workforce is to stop the disease surge in the community.

Earlier in the pandemic, Central Montana Medical Center in Lewistown, a town of fewer than 6,000, experienced an exodus of part-time workers or those close to retirement who decided their jobs weren’t worth the risk. The facility recently secured two traveling workers, but both backed out because they couldn’t find housing. And, so far, roughly 40 of the hospital’s 322 employees have missed work for reasons connected to COVID-19.

“We’re at a critical staffing shortage and have been since the beginning of COVID,” said Joanie Slaybaugh, Central Montana Medical Center’s director of human resources. “We’re small enough, everybody feels an obligation to protect themselves and to protect each other. But it doesn’t take much to take out our staff.”

Roosevelt County, where roughly 11,000 live on the northeastern edge of Montana, had one of the nation’s highest rates of new cases as of Oct. 15. But by the end of the month, the county health department will lose half of its registered nurses as one person is about to retire and another was hired through a grant that’s ending. That leaves only one registered nurse aside from its director, Patty Presser. The health department already had to close earlier during the pandemic because of COVID exposure and not enough staffers to cover the gap. Now, if Ms. Presser can’t find nurse replacements in time, she hopes volunteers will step in, though she added they typically stay for only a few weeks.

“I need someone to do immunizations for my community, and you don’t become an immunization nurse in 14 days,” she said. “We don’t have the workforce here to deal with this virus, not even right now, and then I’m going to have my best two people go.”

Back in Helena, Dr. Harkins said St. Peter’s Health had to close a specialty outpatient clinic that treats chronic diseases for two weeks at the end of September because the entire staff had to quarantine.

Now the hospital is considering having doctors take turns spending a week working from home, so that if another wave of quarantines hits in the hospital, at least one untainted person can be brought back to work. But that won’t help for some specialties, like the hospital’s sole kidney doctor.

Every time Dr. Harkins’ phone rings, she said, she takes a breath and hopes it’s not another case that will force a whole division to close.

“Because I think immediately of the hundreds of people that need that service and won’t have it for 14 days,” she said.

Kaiser Health News is a nonprofit news service covering health issues. It is an editorially independent program of KFF (Kaiser Family Foundation), which is not affiliated with Kaiser Permanente.

COVID-19 cases are surging in rural places across the Mountain States and Midwest, and when it hits health care workers, ready reinforcements aren’t easy to find.

In Montana, pandemic-induced staffing shortages have shuttered a clinic in the state’s capital, led a northwestern regional hospital to ask employees exposed to COVID-19 to continue to work and emptied a health department 400 miles to the east.

“Just one more person out and we wouldn’t be able to keep the surgeries going,” said Dr. Shelly Harkins, MD, chief medical officer of St. Peter’s Health in Helena, a city of roughly 32,000 where cases continue to spread. “When the virus is just all around you, it’s almost impossible to not be deemed a contact at some point. One case can take out a whole team of people in a blink of an eye.”

In North Dakota, where cases per resident are growing faster than any other state, hospitals may once again curtail elective surgeries and possibly seek government aid to hire more nurses if the situation gets worse, North Dakota Hospital Association President Tim Blasl said.

“How long can we run at this rate with the workforce that we have?” Blasl said. “You can have all the licensed beds you want, but if you don’t have anybody to staff those beds, it doesn’t do you any good.”

The northern Rocky Mountains, Great Plains and Upper Midwest are seeing the highest surge of COVID-19 cases in the nation, as some residents have ignored recommendations for curtailing the virus, such as wearing masks and avoiding large gatherings. Montana, Idaho, Utah, Wyoming, North Dakota, South Dakota, Nebraska, Iowa, and Wisconsin have recently ranked among the top 10 U.S. states in confirmed cases per 100,000 residents over a 7-day period, according to an analysis  by the New York Times.

Such coronavirus infections – and the quarantines that occur because of them – are exacerbating the health care worker shortage that existed in these states well before the pandemic. Unlike in the nation’s metropolitan hubs, these outbreaks are scattered across hundreds of miles. And even in these states’ biggest cities, the ranks of medical professionals are in short supply. Specialists and registered nurses are sometimes harder to track down than ventilators, N95 masks or hospital beds. Without enough care providers, patients may not be able to get the medical attention they need.

Hospitals have asked staffers to cover extra shifts and learn new skills. They have brought in temporary workers from other parts of the country and transferred some patients to less-crowded hospitals. But, at St. Peter’s Health, if the hospital’s one kidney doctor gets sick or is told to quarantine, Dr. Harkins doesn’t expect to find a backup.

“We make a point to not have excessive staff because we have an obligation to keep the cost of health care down for a community – we just don’t have a lot of slack in our rope,” Dr. Harkins said. “What we don’t account for is a mass exodus of staff for 14 days.”

Some hospitals are already at patient capacity or are nearly there. That’s not just because of the growing number of COVID-19 patients. Elective surgeries have resumed, and medical emergencies don’t pause for a pandemic.

Some Montana hospitals formed agreements with local affiliates early in the pandemic to share staff if one came up short. But now that the disease is spreading fast – and widely – the hope is that their needs don’t peak all at once.

Montana state officials keep a list of primarily in-state volunteer workers ready to travel to towns with shortages of contact tracers, nurses and more. But during a press conference on Oct. 15, Democratic Gov. Steve Bullock said the state had exhausted that database, and its nationwide request for National Guard medical staffing hadn’t brought in new workers.

“If you are a registered nurse, licensed practical nurse, paramedic, EMT, CNA or contact tracer, and are able to join our workforce, please do consider joining our team,” Gov. Bullock said.

This month, Kalispell Regional Medical Center in northwestern Montana even stopped quarantining COVID-exposed staff who remain asymptomatic, a change allowed by Centers for Disease Control and Prevention guidelines for health facilities facing staffing shortages.

“That’s very telling for what staffing is going through right now,” said Andrea Lueck, a registered nurse at the center. “We’re so tight that employees are called off of quarantine.”

Financial pressure early in the pandemic led the hospital to furlough staff, but it had to bring most of them back to work because it needs those bodies more than ever. The regional hub is based in Flathead County, which has recorded the state’s second-highest number of active COVID-19 cases.

Mellody Sharpton, a hospital spokesperson, said hospital workers who are exposed to someone infected with the virus are tested within three to five days and monitored for symptoms. The hospital is also pulling in new workers, with 25 traveling health professionals on hand and another 25 temporary ones on the way.

But Ms. Sharpton said the best way to conserve the hospital’s workforce is to stop the disease surge in the community.

Earlier in the pandemic, Central Montana Medical Center in Lewistown, a town of fewer than 6,000, experienced an exodus of part-time workers or those close to retirement who decided their jobs weren’t worth the risk. The facility recently secured two traveling workers, but both backed out because they couldn’t find housing. And, so far, roughly 40 of the hospital’s 322 employees have missed work for reasons connected to COVID-19.

“We’re at a critical staffing shortage and have been since the beginning of COVID,” said Joanie Slaybaugh, Central Montana Medical Center’s director of human resources. “We’re small enough, everybody feels an obligation to protect themselves and to protect each other. But it doesn’t take much to take out our staff.”

Roosevelt County, where roughly 11,000 live on the northeastern edge of Montana, had one of the nation’s highest rates of new cases as of Oct. 15. But by the end of the month, the county health department will lose half of its registered nurses as one person is about to retire and another was hired through a grant that’s ending. That leaves only one registered nurse aside from its director, Patty Presser. The health department already had to close earlier during the pandemic because of COVID exposure and not enough staffers to cover the gap. Now, if Ms. Presser can’t find nurse replacements in time, she hopes volunteers will step in, though she added they typically stay for only a few weeks.

“I need someone to do immunizations for my community, and you don’t become an immunization nurse in 14 days,” she said. “We don’t have the workforce here to deal with this virus, not even right now, and then I’m going to have my best two people go.”

Back in Helena, Dr. Harkins said St. Peter’s Health had to close a specialty outpatient clinic that treats chronic diseases for two weeks at the end of September because the entire staff had to quarantine.

Now the hospital is considering having doctors take turns spending a week working from home, so that if another wave of quarantines hits in the hospital, at least one untainted person can be brought back to work. But that won’t help for some specialties, like the hospital’s sole kidney doctor.

Every time Dr. Harkins’ phone rings, she said, she takes a breath and hopes it’s not another case that will force a whole division to close.

“Because I think immediately of the hundreds of people that need that service and won’t have it for 14 days,” she said.

Kaiser Health News is a nonprofit news service covering health issues. It is an editorially independent program of KFF (Kaiser Family Foundation), which is not affiliated with Kaiser Permanente.

COVID-19 cases are surging in rural places across the Mountain States and Midwest, and when it hits health care workers, ready reinforcements aren’t easy to find.

In Montana, pandemic-induced staffing shortages have shuttered a clinic in the state’s capital, led a northwestern regional hospital to ask employees exposed to COVID-19 to continue to work and emptied a health department 400 miles to the east.

“Just one more person out and we wouldn’t be able to keep the surgeries going,” said Dr. Shelly Harkins, MD, chief medical officer of St. Peter’s Health in Helena, a city of roughly 32,000 where cases continue to spread. “When the virus is just all around you, it’s almost impossible to not be deemed a contact at some point. One case can take out a whole team of people in a blink of an eye.”

In North Dakota, where cases per resident are growing faster than any other state, hospitals may once again curtail elective surgeries and possibly seek government aid to hire more nurses if the situation gets worse, North Dakota Hospital Association President Tim Blasl said.

“How long can we run at this rate with the workforce that we have?” Blasl said. “You can have all the licensed beds you want, but if you don’t have anybody to staff those beds, it doesn’t do you any good.”

The northern Rocky Mountains, Great Plains and Upper Midwest are seeing the highest surge of COVID-19 cases in the nation, as some residents have ignored recommendations for curtailing the virus, such as wearing masks and avoiding large gatherings. Montana, Idaho, Utah, Wyoming, North Dakota, South Dakota, Nebraska, Iowa, and Wisconsin have recently ranked among the top 10 U.S. states in confirmed cases per 100,000 residents over a 7-day period, according to an analysis  by the New York Times.

Such coronavirus infections – and the quarantines that occur because of them – are exacerbating the health care worker shortage that existed in these states well before the pandemic. Unlike in the nation’s metropolitan hubs, these outbreaks are scattered across hundreds of miles. And even in these states’ biggest cities, the ranks of medical professionals are in short supply. Specialists and registered nurses are sometimes harder to track down than ventilators, N95 masks or hospital beds. Without enough care providers, patients may not be able to get the medical attention they need.

Hospitals have asked staffers to cover extra shifts and learn new skills. They have brought in temporary workers from other parts of the country and transferred some patients to less-crowded hospitals. But, at St. Peter’s Health, if the hospital’s one kidney doctor gets sick or is told to quarantine, Dr. Harkins doesn’t expect to find a backup.

“We make a point to not have excessive staff because we have an obligation to keep the cost of health care down for a community – we just don’t have a lot of slack in our rope,” Dr. Harkins said. “What we don’t account for is a mass exodus of staff for 14 days.”

Some hospitals are already at patient capacity or are nearly there. That’s not just because of the growing number of COVID-19 patients. Elective surgeries have resumed, and medical emergencies don’t pause for a pandemic.

Some Montana hospitals formed agreements with local affiliates early in the pandemic to share staff if one came up short. But now that the disease is spreading fast – and widely – the hope is that their needs don’t peak all at once.

Montana state officials keep a list of primarily in-state volunteer workers ready to travel to towns with shortages of contact tracers, nurses and more. But during a press conference on Oct. 15, Democratic Gov. Steve Bullock said the state had exhausted that database, and its nationwide request for National Guard medical staffing hadn’t brought in new workers.

“If you are a registered nurse, licensed practical nurse, paramedic, EMT, CNA or contact tracer, and are able to join our workforce, please do consider joining our team,” Gov. Bullock said.

This month, Kalispell Regional Medical Center in northwestern Montana even stopped quarantining COVID-exposed staff who remain asymptomatic, a change allowed by Centers for Disease Control and Prevention guidelines for health facilities facing staffing shortages.

“That’s very telling for what staffing is going through right now,” said Andrea Lueck, a registered nurse at the center. “We’re so tight that employees are called off of quarantine.”

Financial pressure early in the pandemic led the hospital to furlough staff, but it had to bring most of them back to work because it needs those bodies more than ever. The regional hub is based in Flathead County, which has recorded the state’s second-highest number of active COVID-19 cases.

Mellody Sharpton, a hospital spokesperson, said hospital workers who are exposed to someone infected with the virus are tested within three to five days and monitored for symptoms. The hospital is also pulling in new workers, with 25 traveling health professionals on hand and another 25 temporary ones on the way.

But Ms. Sharpton said the best way to conserve the hospital’s workforce is to stop the disease surge in the community.

Earlier in the pandemic, Central Montana Medical Center in Lewistown, a town of fewer than 6,000, experienced an exodus of part-time workers or those close to retirement who decided their jobs weren’t worth the risk. The facility recently secured two traveling workers, but both backed out because they couldn’t find housing. And, so far, roughly 40 of the hospital’s 322 employees have missed work for reasons connected to COVID-19.

“We’re at a critical staffing shortage and have been since the beginning of COVID,” said Joanie Slaybaugh, Central Montana Medical Center’s director of human resources. “We’re small enough, everybody feels an obligation to protect themselves and to protect each other. But it doesn’t take much to take out our staff.”

Roosevelt County, where roughly 11,000 live on the northeastern edge of Montana, had one of the nation’s highest rates of new cases as of Oct. 15. But by the end of the month, the county health department will lose half of its registered nurses as one person is about to retire and another was hired through a grant that’s ending. That leaves only one registered nurse aside from its director, Patty Presser. The health department already had to close earlier during the pandemic because of COVID exposure and not enough staffers to cover the gap. Now, if Ms. Presser can’t find nurse replacements in time, she hopes volunteers will step in, though she added they typically stay for only a few weeks.

“I need someone to do immunizations for my community, and you don’t become an immunization nurse in 14 days,” she said. “We don’t have the workforce here to deal with this virus, not even right now, and then I’m going to have my best two people go.”

Back in Helena, Dr. Harkins said St. Peter’s Health had to close a specialty outpatient clinic that treats chronic diseases for two weeks at the end of September because the entire staff had to quarantine.

Now the hospital is considering having doctors take turns spending a week working from home, so that if another wave of quarantines hits in the hospital, at least one untainted person can be brought back to work. But that won’t help for some specialties, like the hospital’s sole kidney doctor.

Every time Dr. Harkins’ phone rings, she said, she takes a breath and hopes it’s not another case that will force a whole division to close.

“Because I think immediately of the hundreds of people that need that service and won’t have it for 14 days,” she said.

Kaiser Health News is a nonprofit news service covering health issues. It is an editorially independent program of KFF (Kaiser Family Foundation), which is not affiliated with Kaiser Permanente.

Highlights of new updated guidelines for cardiopulmonary resuscitation and emergency cardiovascular care from the American Heart Association include management of opioid-related emergencies; discussion of health disparities; and a new emphasis on physical, social, and emotional recovery after resuscitation.

© American Heart Association, Inc.

The AHA is also exploring digital territory to improve CPR outcomes. The guidelines encourage use of mobile phone technology to summon trained laypeople to individuals requiring CPR, and an adaptive learning suite will be available online for personalized CPR instruction, with lessons catered to individual needs and knowledge levels.

These novel approaches reflect an ongoing effort by the AHA to ensure that the guidelines evolve rapidly with science and technology, reported Raina Merchant, MD, chair of the AHA Emergency Cardiovascular Care Committee and associate professor of emergency medicine at the University of Pennsylvania, Philadelphia, and colleagues. In 2015, the committee shifted from 5-year updates to a continuous online review process, citing a need for more immediate implementation of practice-altering data, they wrote in Circulation.

And new approaches do appear to save lives, at least in a hospital setting.

Since 2004, in-hospital cardiac arrest outcomes have been improving, but similar gains have yet to be realized for out-of-hospital cardiac arrest.

“Much of the variation in survival rates is thought to be due to the strength of the Chain of Survival, the [five] critical actions that must occur in rapid succession to maximize the chance of survival from cardiac arrest,” the committee wrote.
 

Update adds sixth link to Chains of Survival: Recovery

“Recovery expectations and survivorship plans that address treatment, surveillance, and rehabilitation need to be provided to cardiac arrest survivors and their caregivers at hospital discharge to address the sequelae of cardiac arrest and optimize transitions of care to independent physical, social, emotional, and role function,” the committee wrote.

Dr. Merchant and colleagues identified three “critically important” recommendations for both cardiac arrest survivors and caregivers during the recovery process: structured psychological assessment; multimodal rehabilitation assessment and treatment; and comprehensive, multidisciplinary discharge planning.

The recovery process is now part of all four Chains of Survival, which are specific to in-hospital and out-of-hospital arrest for adults and children.
 

New advice on opioid overdoses and bystander training

Among instances of out-of-hospital cardiac arrest, the committee noted that opioid overdoses are “sharply on the rise,” leading to new, scenario-specific recommendations. Among them, the committee encouraged lay rescuers and trained responders to activate emergency response systems immediately while awaiting improvements with naloxone and other interventions. They also suggested that, for individuals in known or suspected cardiac arrest, high-quality CPR, including compressions and ventilation, should be prioritized over naloxone administration.

In a broader discussion, the committee identified disparities in CPR training, which could explain lower rates of bystander CPR and poorer outcomes among certain demographics, such as black and Hispanic populations, as well as those with lower socioeconomic status.

“Targeting training efforts should consider barriers such as language, financial considerations, and poor access to information,” the committee wrote.

While low bystander CPR in these areas may be improved through mobile phone technology that alerts trained laypeople to individuals in need, the committee noted that this approach may be impacted by cultural and geographic factors. To date, use of mobile devices to improve bystander intervention rates has been demonstrated through “uniformly positive data,” but never in North America.

According to the guidelines, bystander intervention rates may also be improved through video-based learning, which is as effective as in-person, instructor-led training.

This led the AHA to create an online adaptive learning platform, which the organization describes as a “digital resuscitation portfolio” that connects programs and courses such as the Resuscitation Quality Improvement program and the HeartCode blended learning course.

“It will cover all of the guideline changes,” said Monica Sales, communications manager at the AHA. “It’s really groundbreaking because it’s the first time that we’re able to kind of close that gap between new science and new products.”

The online content also addresses CPR considerations for COVID-19, which were first addressed by interim CPR guidance published by the AHA in April.

According to Alexis Topjian, MD, coauthor of the present guidelines and pediatric critical care medicine physician at Children’s Hospital of Philadelphia, CPR awareness is more important now than ever.

“The major message [of the guidelines] is that high-quality CPR saves lives,” she said. “So push hard, and push fast. You have the power in your hands to make a difference, more so than ever during this pandemic.”

Concerning coronavirus precautions, Dr. Topjian noted that roughly 70% of out-of-hospital CPR events involve people who know each other, so most bystanders have already been exposed to the person in need, thereby reducing the concern of infection.

When asked about performing CPR on strangers, Dr. Topjian remained encouraging, though she noted that decision making may be informed by local coronavirus rates.

“It’s always a personal choice,” she said.
 

More for clinicians

For clinicians, Dr. Topjian highlighted several recommendations, including use of epinephrine as soon as possible during CPR, preferential use of a cuffed endotracheal tube, continuous EEG monitoring during and after cardiac arrest, and rapid intervention for clinical seizures and of nonconvulsive status epilepticus.

From a pediatric perspective, Dr. Topjian pointed out a change in breathing rate for infants and children who are receiving CPR or rescue breathing with a pulse, from 12-20 breaths/min to 20-30 breaths/min. While not a new recommendation, Dr. Topjian also pointed out the lifesaving benefit of early defibrillation among pediatric patients.

The guidelines were funded by the American Heart Association. The investigators disclosed additional relationships with BTG Pharmaceuticals, Zoll Foundation, the National Institutes of Health, and others.

SOURCE: American Heart Association. Circulation. 2020 Oct 20. Suppl 2.

Highlights of new updated guidelines for cardiopulmonary resuscitation and emergency cardiovascular care from the American Heart Association include management of opioid-related emergencies; discussion of health disparities; and a new emphasis on physical, social, and emotional recovery after resuscitation.

© American Heart Association, Inc.

The AHA is also exploring digital territory to improve CPR outcomes. The guidelines encourage use of mobile phone technology to summon trained laypeople to individuals requiring CPR, and an adaptive learning suite will be available online for personalized CPR instruction, with lessons catered to individual needs and knowledge levels.

These novel approaches reflect an ongoing effort by the AHA to ensure that the guidelines evolve rapidly with science and technology, reported Raina Merchant, MD, chair of the AHA Emergency Cardiovascular Care Committee and associate professor of emergency medicine at the University of Pennsylvania, Philadelphia, and colleagues. In 2015, the committee shifted from 5-year updates to a continuous online review process, citing a need for more immediate implementation of practice-altering data, they wrote in Circulation.

And new approaches do appear to save lives, at least in a hospital setting.

Since 2004, in-hospital cardiac arrest outcomes have been improving, but similar gains have yet to be realized for out-of-hospital cardiac arrest.

“Much of the variation in survival rates is thought to be due to the strength of the Chain of Survival, the [five] critical actions that must occur in rapid succession to maximize the chance of survival from cardiac arrest,” the committee wrote.
 

Update adds sixth link to Chains of Survival: Recovery

“Recovery expectations and survivorship plans that address treatment, surveillance, and rehabilitation need to be provided to cardiac arrest survivors and their caregivers at hospital discharge to address the sequelae of cardiac arrest and optimize transitions of care to independent physical, social, emotional, and role function,” the committee wrote.

Dr. Merchant and colleagues identified three “critically important” recommendations for both cardiac arrest survivors and caregivers during the recovery process: structured psychological assessment; multimodal rehabilitation assessment and treatment; and comprehensive, multidisciplinary discharge planning.

The recovery process is now part of all four Chains of Survival, which are specific to in-hospital and out-of-hospital arrest for adults and children.
 

New advice on opioid overdoses and bystander training

Among instances of out-of-hospital cardiac arrest, the committee noted that opioid overdoses are “sharply on the rise,” leading to new, scenario-specific recommendations. Among them, the committee encouraged lay rescuers and trained responders to activate emergency response systems immediately while awaiting improvements with naloxone and other interventions. They also suggested that, for individuals in known or suspected cardiac arrest, high-quality CPR, including compressions and ventilation, should be prioritized over naloxone administration.

In a broader discussion, the committee identified disparities in CPR training, which could explain lower rates of bystander CPR and poorer outcomes among certain demographics, such as black and Hispanic populations, as well as those with lower socioeconomic status.

“Targeting training efforts should consider barriers such as language, financial considerations, and poor access to information,” the committee wrote.

While low bystander CPR in these areas may be improved through mobile phone technology that alerts trained laypeople to individuals in need, the committee noted that this approach may be impacted by cultural and geographic factors. To date, use of mobile devices to improve bystander intervention rates has been demonstrated through “uniformly positive data,” but never in North America.

According to the guidelines, bystander intervention rates may also be improved through video-based learning, which is as effective as in-person, instructor-led training.

This led the AHA to create an online adaptive learning platform, which the organization describes as a “digital resuscitation portfolio” that connects programs and courses such as the Resuscitation Quality Improvement program and the HeartCode blended learning course.

“It will cover all of the guideline changes,” said Monica Sales, communications manager at the AHA. “It’s really groundbreaking because it’s the first time that we’re able to kind of close that gap between new science and new products.”

The online content also addresses CPR considerations for COVID-19, which were first addressed by interim CPR guidance published by the AHA in April.

According to Alexis Topjian, MD, coauthor of the present guidelines and pediatric critical care medicine physician at Children’s Hospital of Philadelphia, CPR awareness is more important now than ever.

“The major message [of the guidelines] is that high-quality CPR saves lives,” she said. “So push hard, and push fast. You have the power in your hands to make a difference, more so than ever during this pandemic.”

Concerning coronavirus precautions, Dr. Topjian noted that roughly 70% of out-of-hospital CPR events involve people who know each other, so most bystanders have already been exposed to the person in need, thereby reducing the concern of infection.

When asked about performing CPR on strangers, Dr. Topjian remained encouraging, though she noted that decision making may be informed by local coronavirus rates.

“It’s always a personal choice,” she said.
 

More for clinicians

For clinicians, Dr. Topjian highlighted several recommendations, including use of epinephrine as soon as possible during CPR, preferential use of a cuffed endotracheal tube, continuous EEG monitoring during and after cardiac arrest, and rapid intervention for clinical seizures and of nonconvulsive status epilepticus.

From a pediatric perspective, Dr. Topjian pointed out a change in breathing rate for infants and children who are receiving CPR or rescue breathing with a pulse, from 12-20 breaths/min to 20-30 breaths/min. While not a new recommendation, Dr. Topjian also pointed out the lifesaving benefit of early defibrillation among pediatric patients.

The guidelines were funded by the American Heart Association. The investigators disclosed additional relationships with BTG Pharmaceuticals, Zoll Foundation, the National Institutes of Health, and others.

SOURCE: American Heart Association. Circulation. 2020 Oct 20. Suppl 2.

Highlights of new updated guidelines for cardiopulmonary resuscitation and emergency cardiovascular care from the American Heart Association include management of opioid-related emergencies; discussion of health disparities; and a new emphasis on physical, social, and emotional recovery after resuscitation.

© American Heart Association, Inc.

The AHA is also exploring digital territory to improve CPR outcomes. The guidelines encourage use of mobile phone technology to summon trained laypeople to individuals requiring CPR, and an adaptive learning suite will be available online for personalized CPR instruction, with lessons catered to individual needs and knowledge levels.

These novel approaches reflect an ongoing effort by the AHA to ensure that the guidelines evolve rapidly with science and technology, reported Raina Merchant, MD, chair of the AHA Emergency Cardiovascular Care Committee and associate professor of emergency medicine at the University of Pennsylvania, Philadelphia, and colleagues. In 2015, the committee shifted from 5-year updates to a continuous online review process, citing a need for more immediate implementation of practice-altering data, they wrote in Circulation.

And new approaches do appear to save lives, at least in a hospital setting.

Since 2004, in-hospital cardiac arrest outcomes have been improving, but similar gains have yet to be realized for out-of-hospital cardiac arrest.

“Much of the variation in survival rates is thought to be due to the strength of the Chain of Survival, the [five] critical actions that must occur in rapid succession to maximize the chance of survival from cardiac arrest,” the committee wrote.
 

Update adds sixth link to Chains of Survival: Recovery

“Recovery expectations and survivorship plans that address treatment, surveillance, and rehabilitation need to be provided to cardiac arrest survivors and their caregivers at hospital discharge to address the sequelae of cardiac arrest and optimize transitions of care to independent physical, social, emotional, and role function,” the committee wrote.

Dr. Merchant and colleagues identified three “critically important” recommendations for both cardiac arrest survivors and caregivers during the recovery process: structured psychological assessment; multimodal rehabilitation assessment and treatment; and comprehensive, multidisciplinary discharge planning.

The recovery process is now part of all four Chains of Survival, which are specific to in-hospital and out-of-hospital arrest for adults and children.
 

New advice on opioid overdoses and bystander training

Among instances of out-of-hospital cardiac arrest, the committee noted that opioid overdoses are “sharply on the rise,” leading to new, scenario-specific recommendations. Among them, the committee encouraged lay rescuers and trained responders to activate emergency response systems immediately while awaiting improvements with naloxone and other interventions. They also suggested that, for individuals in known or suspected cardiac arrest, high-quality CPR, including compressions and ventilation, should be prioritized over naloxone administration.

In a broader discussion, the committee identified disparities in CPR training, which could explain lower rates of bystander CPR and poorer outcomes among certain demographics, such as black and Hispanic populations, as well as those with lower socioeconomic status.

“Targeting training efforts should consider barriers such as language, financial considerations, and poor access to information,” the committee wrote.

While low bystander CPR in these areas may be improved through mobile phone technology that alerts trained laypeople to individuals in need, the committee noted that this approach may be impacted by cultural and geographic factors. To date, use of mobile devices to improve bystander intervention rates has been demonstrated through “uniformly positive data,” but never in North America.

According to the guidelines, bystander intervention rates may also be improved through video-based learning, which is as effective as in-person, instructor-led training.

This led the AHA to create an online adaptive learning platform, which the organization describes as a “digital resuscitation portfolio” that connects programs and courses such as the Resuscitation Quality Improvement program and the HeartCode blended learning course.

“It will cover all of the guideline changes,” said Monica Sales, communications manager at the AHA. “It’s really groundbreaking because it’s the first time that we’re able to kind of close that gap between new science and new products.”

The online content also addresses CPR considerations for COVID-19, which were first addressed by interim CPR guidance published by the AHA in April.

According to Alexis Topjian, MD, coauthor of the present guidelines and pediatric critical care medicine physician at Children’s Hospital of Philadelphia, CPR awareness is more important now than ever.

“The major message [of the guidelines] is that high-quality CPR saves lives,” she said. “So push hard, and push fast. You have the power in your hands to make a difference, more so than ever during this pandemic.”

Concerning coronavirus precautions, Dr. Topjian noted that roughly 70% of out-of-hospital CPR events involve people who know each other, so most bystanders have already been exposed to the person in need, thereby reducing the concern of infection.

When asked about performing CPR on strangers, Dr. Topjian remained encouraging, though she noted that decision making may be informed by local coronavirus rates.

“It’s always a personal choice,” she said.
 

More for clinicians

For clinicians, Dr. Topjian highlighted several recommendations, including use of epinephrine as soon as possible during CPR, preferential use of a cuffed endotracheal tube, continuous EEG monitoring during and after cardiac arrest, and rapid intervention for clinical seizures and of nonconvulsive status epilepticus.

From a pediatric perspective, Dr. Topjian pointed out a change in breathing rate for infants and children who are receiving CPR or rescue breathing with a pulse, from 12-20 breaths/min to 20-30 breaths/min. While not a new recommendation, Dr. Topjian also pointed out the lifesaving benefit of early defibrillation among pediatric patients.

The guidelines were funded by the American Heart Association. The investigators disclosed additional relationships with BTG Pharmaceuticals, Zoll Foundation, the National Institutes of Health, and others.

SOURCE: American Heart Association. Circulation. 2020 Oct 20. Suppl 2.

Topics include:

Long-Term Impact of COVID-19 on the Practice of Gastroenterology and Endoscopy
John I. Allen, MD, MBA, AGAF

Consolidation Trends in Gastroenterology
Michael Weinstein, MD, AGAF

IBD Management Amid COVID-19
Kim L. Isaacs, MD, AGAF

Racial and Social Disparities in Gastroenterology
Sandra M. Quezada, MD, MS

Impending Physician Shortages in Gastroenterology
Michael Weinstein, MD, AGAF

Recommendations for Colonoscopy and the Management of Large Polyps
Aasma Shaukat, MD, MPH, AGAF

Nonalcoholic Steatohepatitis (NASH): Identifying Patients with High-Risk Disease
Brent Tetri, MD, AGAF

Esophageal Adenocarcinoma: Geographical Clustering and Time Trends
Joel Rubenstein, MD, MSc

Read the Issue

Topics include:

Long-Term Impact of COVID-19 on the Practice of Gastroenterology and Endoscopy
John I. Allen, MD, MBA, AGAF

Consolidation Trends in Gastroenterology
Michael Weinstein, MD, AGAF

IBD Management Amid COVID-19
Kim L. Isaacs, MD, AGAF

Racial and Social Disparities in Gastroenterology
Sandra M. Quezada, MD, MS

Impending Physician Shortages in Gastroenterology
Michael Weinstein, MD, AGAF

Recommendations for Colonoscopy and the Management of Large Polyps
Aasma Shaukat, MD, MPH, AGAF

Nonalcoholic Steatohepatitis (NASH): Identifying Patients with High-Risk Disease
Brent Tetri, MD, AGAF

Esophageal Adenocarcinoma: Geographical Clustering and Time Trends
Joel Rubenstein, MD, MSc

Read the Issue

Topics include:

Long-Term Impact of COVID-19 on the Practice of Gastroenterology and Endoscopy
John I. Allen, MD, MBA, AGAF

Consolidation Trends in Gastroenterology
Michael Weinstein, MD, AGAF

IBD Management Amid COVID-19
Kim L. Isaacs, MD, AGAF

Racial and Social Disparities in Gastroenterology
Sandra M. Quezada, MD, MS

Impending Physician Shortages in Gastroenterology
Michael Weinstein, MD, AGAF

Recommendations for Colonoscopy and the Management of Large Polyps
Aasma Shaukat, MD, MPH, AGAF

Nonalcoholic Steatohepatitis (NASH): Identifying Patients with High-Risk Disease
Brent Tetri, MD, AGAF

Esophageal Adenocarcinoma: Geographical Clustering and Time Trends
Joel Rubenstein, MD, MSc

Read the Issue

Sugary and artificially sweetened drinks are each associated with an increased risk of developing cardiovascular disease, according to results from a large prospective cohort study.

© Irochka/Fotolia.com

However, the design of that study fails to take into account other sources of dietary sugar, according to one expert.

In a research letter published online Oct. 26 in the Journal of the American College of Cardiology, Eloi Chazelas, a PhD candidate at Sorbonne Paris Nord University in Paris, and colleagues, shared results from nearly 105,000 subjects (79% women, mean age 43 at baseline, median follow up 6.6 years) enrolled in the NutriNet-Santé cohort study.

In this observational study, which began recruiting in 2009, dietary patterns are self-reported by subjects, while health outcomes are validated by investigators.

Mr. Chazelas and his colleagues identified 1,379 first incident cases of stroke, transient ischemic attack, myocardial infarction, acute coronary syndrome, and angioplasty in the cohort during 2009-2019. Cases that occurred during the first 3 years’ follow up were excluded from the analysis, to avoid potential reverse causality bias.

After adjustment for a wide range of dietary, demographic and health confounders, the investigators found that high consumers of sugary drinks or artificially sweetened drinks saw 20% and 32% higher risk of such events, respectively, compared with people who reported drinking neither beverage type (hazard ratio: 1.20; 95% confidence interval 1.04-1.40, P for trend < .0009 and HR: 1.32; 95% CI, 1.00-1.73, P for trend < .03).

Sugary drinks were defined as containing 5% or more of sugars, including natural fruit juices. The high consumers in the study had a median intake of 185 mL per day of sugary drinks, or 176 mL per day for artificially sweetened drinks. Natural noncaloric sweeteners such as Stevia were included in the artificially sweetened group.

The findings, Mr. Chazelas and colleagues wrote in their analysis, add to evidence that artificially sweetened beverages “might not be a healthy substitute for sugary drinks.” While research has suggested that artificial sweeteners induce glucose intolerance by disturbing gut microbiota, they noted, more and bigger studies are needed to understand the mechanisms by which they might bear on cardiovascular disease risk.

Robert A. Vogel, MD, of the University of Colorado Denver, urged caution in interpreting the researchers’ results. In an interview, Dr. Vogel, a preventive cardiologist, said that it is “notoriously difficult” to evaluate what a food or food group does to the body outside of a carefully controlled trial. What little randomized trial evidence exists comparing the health effects of artificially sweetened and sugary drinks includes a 2012 trial in children that found diet drinks associated with reductions in body fat – if anything a positive indication for heart health.

SOURCE: Chazelas et al. JACC 2020;76(18):2175-80.

Sugary and artificially sweetened drinks are each associated with an increased risk of developing cardiovascular disease, according to results from a large prospective cohort study.

© Irochka/Fotolia.com

However, the design of that study fails to take into account other sources of dietary sugar, according to one expert.

In a research letter published online Oct. 26 in the Journal of the American College of Cardiology, Eloi Chazelas, a PhD candidate at Sorbonne Paris Nord University in Paris, and colleagues, shared results from nearly 105,000 subjects (79% women, mean age 43 at baseline, median follow up 6.6 years) enrolled in the NutriNet-Santé cohort study.

In this observational study, which began recruiting in 2009, dietary patterns are self-reported by subjects, while health outcomes are validated by investigators.

Mr. Chazelas and his colleagues identified 1,379 first incident cases of stroke, transient ischemic attack, myocardial infarction, acute coronary syndrome, and angioplasty in the cohort during 2009-2019. Cases that occurred during the first 3 years’ follow up were excluded from the analysis, to avoid potential reverse causality bias.

After adjustment for a wide range of dietary, demographic and health confounders, the investigators found that high consumers of sugary drinks or artificially sweetened drinks saw 20% and 32% higher risk of such events, respectively, compared with people who reported drinking neither beverage type (hazard ratio: 1.20; 95% confidence interval 1.04-1.40, P for trend < .0009 and HR: 1.32; 95% CI, 1.00-1.73, P for trend < .03).

Sugary drinks were defined as containing 5% or more of sugars, including natural fruit juices. The high consumers in the study had a median intake of 185 mL per day of sugary drinks, or 176 mL per day for artificially sweetened drinks. Natural noncaloric sweeteners such as Stevia were included in the artificially sweetened group.

The findings, Mr. Chazelas and colleagues wrote in their analysis, add to evidence that artificially sweetened beverages “might not be a healthy substitute for sugary drinks.” While research has suggested that artificial sweeteners induce glucose intolerance by disturbing gut microbiota, they noted, more and bigger studies are needed to understand the mechanisms by which they might bear on cardiovascular disease risk.

Robert A. Vogel, MD, of the University of Colorado Denver, urged caution in interpreting the researchers’ results. In an interview, Dr. Vogel, a preventive cardiologist, said that it is “notoriously difficult” to evaluate what a food or food group does to the body outside of a carefully controlled trial. What little randomized trial evidence exists comparing the health effects of artificially sweetened and sugary drinks includes a 2012 trial in children that found diet drinks associated with reductions in body fat – if anything a positive indication for heart health.

SOURCE: Chazelas et al. JACC 2020;76(18):2175-80.

Sugary and artificially sweetened drinks are each associated with an increased risk of developing cardiovascular disease, according to results from a large prospective cohort study.

© Irochka/Fotolia.com

However, the design of that study fails to take into account other sources of dietary sugar, according to one expert.

In a research letter published online Oct. 26 in the Journal of the American College of Cardiology, Eloi Chazelas, a PhD candidate at Sorbonne Paris Nord University in Paris, and colleagues, shared results from nearly 105,000 subjects (79% women, mean age 43 at baseline, median follow up 6.6 years) enrolled in the NutriNet-Santé cohort study.

In this observational study, which began recruiting in 2009, dietary patterns are self-reported by subjects, while health outcomes are validated by investigators.

Mr. Chazelas and his colleagues identified 1,379 first incident cases of stroke, transient ischemic attack, myocardial infarction, acute coronary syndrome, and angioplasty in the cohort during 2009-2019. Cases that occurred during the first 3 years’ follow up were excluded from the analysis, to avoid potential reverse causality bias.

After adjustment for a wide range of dietary, demographic and health confounders, the investigators found that high consumers of sugary drinks or artificially sweetened drinks saw 20% and 32% higher risk of such events, respectively, compared with people who reported drinking neither beverage type (hazard ratio: 1.20; 95% confidence interval 1.04-1.40, P for trend < .0009 and HR: 1.32; 95% CI, 1.00-1.73, P for trend < .03).

Sugary drinks were defined as containing 5% or more of sugars, including natural fruit juices. The high consumers in the study had a median intake of 185 mL per day of sugary drinks, or 176 mL per day for artificially sweetened drinks. Natural noncaloric sweeteners such as Stevia were included in the artificially sweetened group.

The findings, Mr. Chazelas and colleagues wrote in their analysis, add to evidence that artificially sweetened beverages “might not be a healthy substitute for sugary drinks.” While research has suggested that artificial sweeteners induce glucose intolerance by disturbing gut microbiota, they noted, more and bigger studies are needed to understand the mechanisms by which they might bear on cardiovascular disease risk.

Robert A. Vogel, MD, of the University of Colorado Denver, urged caution in interpreting the researchers’ results. In an interview, Dr. Vogel, a preventive cardiologist, said that it is “notoriously difficult” to evaluate what a food or food group does to the body outside of a carefully controlled trial. What little randomized trial evidence exists comparing the health effects of artificially sweetened and sugary drinks includes a 2012 trial in children that found diet drinks associated with reductions in body fat – if anything a positive indication for heart health.

SOURCE: Chazelas et al. JACC 2020;76(18):2175-80.

Physicians with difficult patient scenarios regularly bring their questions to the AGA Community (https://community.gastro.org) to seek advice from colleagues about therapy and disease management options, best practices, and diagnoses. The upgraded networking platform now features a newsfeed for difficult patient scenarios and regularly scheduled Roundtable discussions with experts in the field.

In case you missed it, here are some clinical discussions and Roundtables in the newsfeed this month:
 

• Initial results from the FMT National Registry (https://community.gastro.org/posts/22693)
• Practice update: Reducing rates of post endoscopy esophageal adenocarcinoma (https://community.gastro.org/posts/22805)
• Patient case: Eosinophilic gastrointestinal disease (https://community.gastro.org/posts/22743)
• Patient case: Repeat colonoscopy following splenic injury (https://community.gastro.org/posts/22739)
• Windows on Clinical GI Roundtables: Crohn’s disease and gastroparesis

View upcoming Roundtables in the community at https://community.gastro.org/discussions.
 

Physicians with difficult patient scenarios regularly bring their questions to the AGA Community (https://community.gastro.org) to seek advice from colleagues about therapy and disease management options, best practices, and diagnoses. The upgraded networking platform now features a newsfeed for difficult patient scenarios and regularly scheduled Roundtable discussions with experts in the field.

In case you missed it, here are some clinical discussions and Roundtables in the newsfeed this month:
 

• Initial results from the FMT National Registry (https://community.gastro.org/posts/22693)
• Practice update: Reducing rates of post endoscopy esophageal adenocarcinoma (https://community.gastro.org/posts/22805)
• Patient case: Eosinophilic gastrointestinal disease (https://community.gastro.org/posts/22743)
• Patient case: Repeat colonoscopy following splenic injury (https://community.gastro.org/posts/22739)
• Windows on Clinical GI Roundtables: Crohn’s disease and gastroparesis

View upcoming Roundtables in the community at https://community.gastro.org/discussions.
 

Physicians with difficult patient scenarios regularly bring their questions to the AGA Community (https://community.gastro.org) to seek advice from colleagues about therapy and disease management options, best practices, and diagnoses. The upgraded networking platform now features a newsfeed for difficult patient scenarios and regularly scheduled Roundtable discussions with experts in the field.

In case you missed it, here are some clinical discussions and Roundtables in the newsfeed this month:
 

• Initial results from the FMT National Registry (https://community.gastro.org/posts/22693)
• Practice update: Reducing rates of post endoscopy esophageal adenocarcinoma (https://community.gastro.org/posts/22805)
• Patient case: Eosinophilic gastrointestinal disease (https://community.gastro.org/posts/22743)
• Patient case: Repeat colonoscopy following splenic injury (https://community.gastro.org/posts/22739)
• Windows on Clinical GI Roundtables: Crohn’s disease and gastroparesis

View upcoming Roundtables in the community at https://community.gastro.org/discussions.
 

Key clinical point: Both rituximab and glatiramer acetate failed to stop disability progression in patients with secondary progressive multiple sclerosis (SPMS). They were equally effective in relapse control.

Major finding: The mean Expanded Disability Status Scale (EDSS) score increased from 3.05 to 4.14 in the rituximab group and from 3.22 to 4.60 in the glatiramer acetate group (P less than .001 for both). EDSS score showed no statistically significant difference between 2 groups (P = .071). Annualized relapse rate decreased in both groups with no significant difference between them (P = .534).

Study details: An open randomized clinical trial of 84 patients with SPMS assigned to receive rituximab (n = 43) or glatiramer acetate (n = 41) for 12 months.

Disclosures: The study was funded by vice-chancellor for research and technology of Isfahan University of Medical Sciences. The authors declared no conflicts of interest.

Citation: Cheshmavar M et al. Acta Neurol Scand. 2020 Sep 8. doi: 10.1111/ane.13344.

Key clinical point: Both rituximab and glatiramer acetate failed to stop disability progression in patients with secondary progressive multiple sclerosis (SPMS). They were equally effective in relapse control.

Major finding: The mean Expanded Disability Status Scale (EDSS) score increased from 3.05 to 4.14 in the rituximab group and from 3.22 to 4.60 in the glatiramer acetate group (P less than .001 for both). EDSS score showed no statistically significant difference between 2 groups (P = .071). Annualized relapse rate decreased in both groups with no significant difference between them (P = .534).

Study details: An open randomized clinical trial of 84 patients with SPMS assigned to receive rituximab (n = 43) or glatiramer acetate (n = 41) for 12 months.

Disclosures: The study was funded by vice-chancellor for research and technology of Isfahan University of Medical Sciences. The authors declared no conflicts of interest.

Citation: Cheshmavar M et al. Acta Neurol Scand. 2020 Sep 8. doi: 10.1111/ane.13344.

Key clinical point: Both rituximab and glatiramer acetate failed to stop disability progression in patients with secondary progressive multiple sclerosis (SPMS). They were equally effective in relapse control.

Major finding: The mean Expanded Disability Status Scale (EDSS) score increased from 3.05 to 4.14 in the rituximab group and from 3.22 to 4.60 in the glatiramer acetate group (P less than .001 for both). EDSS score showed no statistically significant difference between 2 groups (P = .071). Annualized relapse rate decreased in both groups with no significant difference between them (P = .534).

Study details: An open randomized clinical trial of 84 patients with SPMS assigned to receive rituximab (n = 43) or glatiramer acetate (n = 41) for 12 months.

Disclosures: The study was funded by vice-chancellor for research and technology of Isfahan University of Medical Sciences. The authors declared no conflicts of interest.

Citation: Cheshmavar M et al. Acta Neurol Scand. 2020 Sep 8. doi: 10.1111/ane.13344.

Key clinical point: Ofatumumab is associated with lower annualized relapse rates than teriflunomide in patients with relapsing multiple sclerosis (MS).

Major finding: Annualized relapse rates in the ofatumumab and teriflunomide groups were 0.11 and 0.22, respectively, in ASCLEPIOS I trial (difference, −0.11; P less than .001) and 0.10 and 0.25, respectively, in ASCLEPIOS II trial (difference, −0.15; P less than .001). The percentage of patients with disability worsening at 3 months and at 6 months was higher in the teriflunomide group, whereas the percentage of patients with disability improvement at 6 months was higher in ofatumumab group.

Study details: In 2 double-blind, double-dummy, phase 3 trials (ASCLEPIOS I and II), patients with relapsing MS were randomly assigned to receive subcutaneous ofatumumab (n = 946) or oral teriflunomide (n = 936) for up to 30 months and were followed for a median of 1.6 years.

Disclosures: The study was supported by Novartis Pharma. Dr. Hauser reported ties with various pharmaceutical companies and travel grant from Novartis.

Citation: Hauser SL et al. N Engl J Med. 2020 Aug 6. doi: 10.1056/NEJMoa1917246.

Key clinical point: Ofatumumab is associated with lower annualized relapse rates than teriflunomide in patients with relapsing multiple sclerosis (MS).

Major finding: Annualized relapse rates in the ofatumumab and teriflunomide groups were 0.11 and 0.22, respectively, in ASCLEPIOS I trial (difference, −0.11; P less than .001) and 0.10 and 0.25, respectively, in ASCLEPIOS II trial (difference, −0.15; P less than .001). The percentage of patients with disability worsening at 3 months and at 6 months was higher in the teriflunomide group, whereas the percentage of patients with disability improvement at 6 months was higher in ofatumumab group.

Study details: In 2 double-blind, double-dummy, phase 3 trials (ASCLEPIOS I and II), patients with relapsing MS were randomly assigned to receive subcutaneous ofatumumab (n = 946) or oral teriflunomide (n = 936) for up to 30 months and were followed for a median of 1.6 years.

Disclosures: The study was supported by Novartis Pharma. Dr. Hauser reported ties with various pharmaceutical companies and travel grant from Novartis.

Citation: Hauser SL et al. N Engl J Med. 2020 Aug 6. doi: 10.1056/NEJMoa1917246.

Key clinical point: Ofatumumab is associated with lower annualized relapse rates than teriflunomide in patients with relapsing multiple sclerosis (MS).

Major finding: Annualized relapse rates in the ofatumumab and teriflunomide groups were 0.11 and 0.22, respectively, in ASCLEPIOS I trial (difference, −0.11; P less than .001) and 0.10 and 0.25, respectively, in ASCLEPIOS II trial (difference, −0.15; P less than .001). The percentage of patients with disability worsening at 3 months and at 6 months was higher in the teriflunomide group, whereas the percentage of patients with disability improvement at 6 months was higher in ofatumumab group.

Study details: In 2 double-blind, double-dummy, phase 3 trials (ASCLEPIOS I and II), patients with relapsing MS were randomly assigned to receive subcutaneous ofatumumab (n = 946) or oral teriflunomide (n = 936) for up to 30 months and were followed for a median of 1.6 years.

Disclosures: The study was supported by Novartis Pharma. Dr. Hauser reported ties with various pharmaceutical companies and travel grant from Novartis.

Citation: Hauser SL et al. N Engl J Med. 2020 Aug 6. doi: 10.1056/NEJMoa1917246.

Improved molecular characterization of mixed glioneuronal and neuronal tumors is driving the World Health Organization to update its classification system for pediatric brain tumors, and that will have far-reaching implications for how clinicians diagnose and manage these rare and often debilitating malignancies, a leading European researcher reported at the 2020 CNS-ICNA Conjoint Meeting, held virtually this year.

“These pediatric neuronal/glioneuronal tumors are quite heterogeneous in terms of the number of different tumors and subclasses of tumors going into these groups, but they have some molecular features in common,” said David T.W. Jones, PhD, of Hopp Children’s Cancer Center in Heidelberg, Germany. “Together they represent quite a sizable portion of all childhood brain tumors, so it’s important to recognize and understand them.”

Dr. Jones noted that updated WHO classifications would add six new descriptions to the category of mixed glioneuronal tumors and one to the list of neuronal tumors. A working group of the Consortium to Inform Molecular and Practical Approaches to CNS Tumor Taxonomy, known as cIMPACT-NOW, has recommended the expanded classifications for central nervous system tumors.

“The molecular understandings of pediatric neuro-glial tumors are critical in their management,” Roger Packer, MD, senior vice president of the Center for Neuroscience and Behavioral Health at Children’s National in Washington, said in an interview, especially as treatments targeting specific molecular structures emerge. “For those with tumors not amenable to safe, total resections, there’s little evidence that radiation or chemotherapy are effective, and molecular-targeted therapy, guided by the molecular genetic composition, increases the safe use of these new agents.”

Dr. Jones noted that “as a minimum” molecular diagnostics of pediatric low-grade glioneuronal and neuronal tumors should include a BRAF gene mutation and fusion status, as well as FGFR1 mutation plus fusion or rearrangement status.

“Ideally,” he added, “it should also have a broader copy number profile, whether that’s based on sequencing or SNP arrays or DNA methylation rate, a global DNA methylation profile to get those global molecular patterns, and also wider gene and RNA sequence to pick up some of those rarer alterations that may not be covered by targeted BRAF and FGFR1 mutations.”

The updated tumor classification will evolve to include novel tumor classes, as well as links or overlaps between the tumor classes and their characteristic underlying kinetic alterations, he noted. “Some of these profiling measures will actually be required to generate a fully WHO-compatible pathological diagnosis,” Dr. Jones said.

“This group of tumors are now just better molecularly characterized than it was 5 years ago, so in the last few years we’ve really made tremendous progress in understanding what alterations are driving some of these tumors,” he said. “That knowledge is now providing a basis for improved diagnosis and also for starting to plan more targeted treatment strategies.”

But, he added, there’s still a lot to learn about how these oncogenic mechanisms drive tumor pathogenesis. “What is the clinical costs when we really start getting down into defining these distinct molecular groups?” he said. “What are their different responses to treatment depending on different levels, where the MEKi [mitogen-activated protein kinase inhibitor] pathway might be activated and, for example, response to treatment of different subclasses of one tumor?”

Large, collaborative clinical studies will be needed to get those answers, he said.

“There are certainly some therapeutic opportunities arising in this group of tumors now, but in order to really translate those into a clinical benefit, we’re really going to need some careful planning of international studies because of the relative rarity of some of these groups,” he said.

Dr. Jones has no relevant financial relationships to disclose.

Improved molecular characterization of mixed glioneuronal and neuronal tumors is driving the World Health Organization to update its classification system for pediatric brain tumors, and that will have far-reaching implications for how clinicians diagnose and manage these rare and often debilitating malignancies, a leading European researcher reported at the 2020 CNS-ICNA Conjoint Meeting, held virtually this year.

“These pediatric neuronal/glioneuronal tumors are quite heterogeneous in terms of the number of different tumors and subclasses of tumors going into these groups, but they have some molecular features in common,” said David T.W. Jones, PhD, of Hopp Children’s Cancer Center in Heidelberg, Germany. “Together they represent quite a sizable portion of all childhood brain tumors, so it’s important to recognize and understand them.”

Dr. Jones noted that updated WHO classifications would add six new descriptions to the category of mixed glioneuronal tumors and one to the list of neuronal tumors. A working group of the Consortium to Inform Molecular and Practical Approaches to CNS Tumor Taxonomy, known as cIMPACT-NOW, has recommended the expanded classifications for central nervous system tumors.

“The molecular understandings of pediatric neuro-glial tumors are critical in their management,” Roger Packer, MD, senior vice president of the Center for Neuroscience and Behavioral Health at Children’s National in Washington, said in an interview, especially as treatments targeting specific molecular structures emerge. “For those with tumors not amenable to safe, total resections, there’s little evidence that radiation or chemotherapy are effective, and molecular-targeted therapy, guided by the molecular genetic composition, increases the safe use of these new agents.”

Dr. Jones noted that “as a minimum” molecular diagnostics of pediatric low-grade glioneuronal and neuronal tumors should include a BRAF gene mutation and fusion status, as well as FGFR1 mutation plus fusion or rearrangement status.

“Ideally,” he added, “it should also have a broader copy number profile, whether that’s based on sequencing or SNP arrays or DNA methylation rate, a global DNA methylation profile to get those global molecular patterns, and also wider gene and RNA sequence to pick up some of those rarer alterations that may not be covered by targeted BRAF and FGFR1 mutations.”

The updated tumor classification will evolve to include novel tumor classes, as well as links or overlaps between the tumor classes and their characteristic underlying kinetic alterations, he noted. “Some of these profiling measures will actually be required to generate a fully WHO-compatible pathological diagnosis,” Dr. Jones said.

“This group of tumors are now just better molecularly characterized than it was 5 years ago, so in the last few years we’ve really made tremendous progress in understanding what alterations are driving some of these tumors,” he said. “That knowledge is now providing a basis for improved diagnosis and also for starting to plan more targeted treatment strategies.”

But, he added, there’s still a lot to learn about how these oncogenic mechanisms drive tumor pathogenesis. “What is the clinical costs when we really start getting down into defining these distinct molecular groups?” he said. “What are their different responses to treatment depending on different levels, where the MEKi [mitogen-activated protein kinase inhibitor] pathway might be activated and, for example, response to treatment of different subclasses of one tumor?”

Large, collaborative clinical studies will be needed to get those answers, he said.

“There are certainly some therapeutic opportunities arising in this group of tumors now, but in order to really translate those into a clinical benefit, we’re really going to need some careful planning of international studies because of the relative rarity of some of these groups,” he said.

Dr. Jones has no relevant financial relationships to disclose.

Improved molecular characterization of mixed glioneuronal and neuronal tumors is driving the World Health Organization to update its classification system for pediatric brain tumors, and that will have far-reaching implications for how clinicians diagnose and manage these rare and often debilitating malignancies, a leading European researcher reported at the 2020 CNS-ICNA Conjoint Meeting, held virtually this year.

“These pediatric neuronal/glioneuronal tumors are quite heterogeneous in terms of the number of different tumors and subclasses of tumors going into these groups, but they have some molecular features in common,” said David T.W. Jones, PhD, of Hopp Children’s Cancer Center in Heidelberg, Germany. “Together they represent quite a sizable portion of all childhood brain tumors, so it’s important to recognize and understand them.”

Dr. Jones noted that updated WHO classifications would add six new descriptions to the category of mixed glioneuronal tumors and one to the list of neuronal tumors. A working group of the Consortium to Inform Molecular and Practical Approaches to CNS Tumor Taxonomy, known as cIMPACT-NOW, has recommended the expanded classifications for central nervous system tumors.

“The molecular understandings of pediatric neuro-glial tumors are critical in their management,” Roger Packer, MD, senior vice president of the Center for Neuroscience and Behavioral Health at Children’s National in Washington, said in an interview, especially as treatments targeting specific molecular structures emerge. “For those with tumors not amenable to safe, total resections, there’s little evidence that radiation or chemotherapy are effective, and molecular-targeted therapy, guided by the molecular genetic composition, increases the safe use of these new agents.”

Dr. Jones noted that “as a minimum” molecular diagnostics of pediatric low-grade glioneuronal and neuronal tumors should include a BRAF gene mutation and fusion status, as well as FGFR1 mutation plus fusion or rearrangement status.

“Ideally,” he added, “it should also have a broader copy number profile, whether that’s based on sequencing or SNP arrays or DNA methylation rate, a global DNA methylation profile to get those global molecular patterns, and also wider gene and RNA sequence to pick up some of those rarer alterations that may not be covered by targeted BRAF and FGFR1 mutations.”

The updated tumor classification will evolve to include novel tumor classes, as well as links or overlaps between the tumor classes and their characteristic underlying kinetic alterations, he noted. “Some of these profiling measures will actually be required to generate a fully WHO-compatible pathological diagnosis,” Dr. Jones said.

“This group of tumors are now just better molecularly characterized than it was 5 years ago, so in the last few years we’ve really made tremendous progress in understanding what alterations are driving some of these tumors,” he said. “That knowledge is now providing a basis for improved diagnosis and also for starting to plan more targeted treatment strategies.”

But, he added, there’s still a lot to learn about how these oncogenic mechanisms drive tumor pathogenesis. “What is the clinical costs when we really start getting down into defining these distinct molecular groups?” he said. “What are their different responses to treatment depending on different levels, where the MEKi [mitogen-activated protein kinase inhibitor] pathway might be activated and, for example, response to treatment of different subclasses of one tumor?”

Large, collaborative clinical studies will be needed to get those answers, he said.

“There are certainly some therapeutic opportunities arising in this group of tumors now, but in order to really translate those into a clinical benefit, we’re really going to need some careful planning of international studies because of the relative rarity of some of these groups,” he said.

Dr. Jones has no relevant financial relationships to disclose.

Key clinical point: Natalizumab is effective on the inflammatory phase of relapsing-remitting multiple sclerosis (RRMS). The frequency of poor outcomes is low and are predicted by disease activity criteria.

Major finding: At 10 years, the cumulative probabilities for secondary progressive multiple sclerosis (SPMS) conversion, Expanded Disability Status Scale (EDSS) worsening, reaching EDSS-4 and EDSS-6 were 23.7%, 30.4%, 25.1%, and 12.4%, respectively with natalizumab. The mean reduction in annualized relapsed rate at 10 years was 97.5% (P less than .0001). Factors predictive of disability at the long-term were not reaching ‘no evidence of disease activity’ (NEDA)-3, MRI worsening, increased EDSS score, and to a lesser extent the occurrence of relapse.

Study details: TYSTEN was a real-life observational study that assessed 770 patients with RRMS starting Natalizumab between 2007 and 2012. The mean follow-up duration was 97.2 months and mean treatment duration for natalizumab was 66 months.

Disclosures: The study received no funding. The presenting author had no disclosures. Some of his coinvestigators reported ties with Biogen Idec.

Citation: Bigaut K et al. Mult Scler. 2020 Jul 9. doi: 10.1177/1352458520936239.

Key clinical point: Natalizumab is effective on the inflammatory phase of relapsing-remitting multiple sclerosis (RRMS). The frequency of poor outcomes is low and are predicted by disease activity criteria.

Major finding: At 10 years, the cumulative probabilities for secondary progressive multiple sclerosis (SPMS) conversion, Expanded Disability Status Scale (EDSS) worsening, reaching EDSS-4 and EDSS-6 were 23.7%, 30.4%, 25.1%, and 12.4%, respectively with natalizumab. The mean reduction in annualized relapsed rate at 10 years was 97.5% (P less than .0001). Factors predictive of disability at the long-term were not reaching ‘no evidence of disease activity’ (NEDA)-3, MRI worsening, increased EDSS score, and to a lesser extent the occurrence of relapse.

Study details: TYSTEN was a real-life observational study that assessed 770 patients with RRMS starting Natalizumab between 2007 and 2012. The mean follow-up duration was 97.2 months and mean treatment duration for natalizumab was 66 months.

Disclosures: The study received no funding. The presenting author had no disclosures. Some of his coinvestigators reported ties with Biogen Idec.

Citation: Bigaut K et al. Mult Scler. 2020 Jul 9. doi: 10.1177/1352458520936239.

Key clinical point: Natalizumab is effective on the inflammatory phase of relapsing-remitting multiple sclerosis (RRMS). The frequency of poor outcomes is low and are predicted by disease activity criteria.

Major finding: At 10 years, the cumulative probabilities for secondary progressive multiple sclerosis (SPMS) conversion, Expanded Disability Status Scale (EDSS) worsening, reaching EDSS-4 and EDSS-6 were 23.7%, 30.4%, 25.1%, and 12.4%, respectively with natalizumab. The mean reduction in annualized relapsed rate at 10 years was 97.5% (P less than .0001). Factors predictive of disability at the long-term were not reaching ‘no evidence of disease activity’ (NEDA)-3, MRI worsening, increased EDSS score, and to a lesser extent the occurrence of relapse.

Study details: TYSTEN was a real-life observational study that assessed 770 patients with RRMS starting Natalizumab between 2007 and 2012. The mean follow-up duration was 97.2 months and mean treatment duration for natalizumab was 66 months.

Disclosures: The study received no funding. The presenting author had no disclosures. Some of his coinvestigators reported ties with Biogen Idec.

Citation: Bigaut K et al. Mult Scler. 2020 Jul 9. doi: 10.1177/1352458520936239.