To improve patient care and outcomes, leading dermatologists from the Cutis Editorial Board answered 5 questions on pediatric skin care. Here’s what we found.

Do you recommend sunscreen in babies younger than 6 months?

More than half (64%) of dermatologists we surveyed do not recommend using sunscreens in babies younger than 6 months; they should stay out of the sun. They recommended sun-protective clothing, hats, and sunglasses in this age group.

Expert Commentary
Provided by Shari R. Lipner, MD, PhD (New York, New York)

Babies younger than 6 months are still developing barrier functionality and have a higher surface area to body weight ratio compared to older children and adults. There is decreased UV light barrier protection and increased risk for systemic drug absorption. Therefore, it is best to avoid sunscreen in babies younger than 6 months. Instead, I recommend avoiding sunlight during peak hours, keeping babies in the shade, and dressing them in sun-protective clothing and hats.

Next page: Bathing and eczema

What advice do you give parents/guardians on bathing for babies with eczema?

Two-thirds of dermatologists (68%) indicated that moisturizers should be applied after bathing babies with eczema. More than half (64%) suggested using fragrance-free cleansers. Results varied on the frequency of bathing; 32% said bathe once daily for short periods with warm water, and 41% suggested to reduce bathing to a few nights a week.

Expert Commentary
Provided by Shari R. Lipner, MD, PhD (New York, New York)

Dry skin is a characteristic feature of atopic dermatitis. We now know that skin barrier dysfunction, such as filaggrin deficiency, contributes to the pathophysiology in some patients. In addition, a paucity of stratum corneum and intercellular lipids increases transepidermal water loss. Therefore, emollients containing humectants to augment stratum corneum hydration and occludents to reduce evaporation are extremely helpful in maintenance treatment of atopic dermatitis.

Next page: Nonsteroidal agents

Do you prescribe nonsteroidal agents for children younger than 2 years?

Almost two-thirds (64%) of dermatologists do prescribe nonsteroidal agents for children younger than 2 years.

If yes, which nonsteroidal agents do you prescribe for children?

Of those dermatologists who indicated that they do prescribe nonsteroidal agents for children younger than 2 years, almost half (45%) prescribe pimecrolimus, while 36% prescribe crisaborole or tacrolimus.

Expert Commentary
Provided by Shari R. Lipner, MD, PhD (New York, New York)

We have limited options for US Food and Drug Administration (FDA)–approved therapies for atopic dermatitis in children younger than 2 years. The risks of adverse effects also are higher in younger children compared to older children and adults, particularly hypothalamic-pituitary-adrenal suppression with corticosteroids. Pimecrolimus was the most common nonsteroidal prescribed in this group. It should be noted that pimecrolimus is not FDA approved for use in children younger than 2 years; however, 2 phase 3 studies were conducted with 436 infants aged 3 months to 23 months and they demonstrated safety and efficacy.

Next page: Procedures in adolescents

Which procedures do you perform on adolescents?
Forty-one percent of dermatologists surveyed indicated that they do not perform procedures on adolescents. Of those that do, 32% use laser hair removal or chemical peels in adolescents, while only 23% each use light therapy for acne or onabotulinumtoxinA for hyperhidrosis. Pulsed dye laser use was reported in only 18% of dermatologists.

Expert Commentary
Provided by Shari R. Lipner, MD, PhD (New York, New York)

The results of this survey are a reflection of the relatively recent trends in dermatology training. Now that there is board certification in pediatric dermatology, many dermatologists now refer to pediatric dermatologists for children who need or want procedures.

Next page: More tips from derms

More Tips From Dermatologists

The dermatologists we polled had the following advice for their peers:

Keep the regimen as simple as possible and make sure your skin care advice is culturally relevant.—Craig Burkhart, MD (Chapel Hill, North Carolina)

Please, avoid direct sun exposure as much as possible by wearing protective garments and finding shades in the outside.—Jisun Cha, MD (New Brunswick, New Jersey)

Good habits start early. Teach children how to care for their skin and they will carry that practice with them over the course of their  lifetime, and hopefully pass it on.—James Q. Del Rosso, DO (Las Vegas, Nevada)

About This Survey
The survey was fielded electronically to Cutis Editorial Board Members within the United States from September 13, 2018, to October 4, 2018. A total of 22 usable responses were received.

To improve patient care and outcomes, leading dermatologists from the Cutis Editorial Board answered 5 questions on pediatric skin care. Here’s what we found.

Do you recommend sunscreen in babies younger than 6 months?

More than half (64%) of dermatologists we surveyed do not recommend using sunscreens in babies younger than 6 months; they should stay out of the sun. They recommended sun-protective clothing, hats, and sunglasses in this age group.

Expert Commentary
Provided by Shari R. Lipner, MD, PhD (New York, New York)

Babies younger than 6 months are still developing barrier functionality and have a higher surface area to body weight ratio compared to older children and adults. There is decreased UV light barrier protection and increased risk for systemic drug absorption. Therefore, it is best to avoid sunscreen in babies younger than 6 months. Instead, I recommend avoiding sunlight during peak hours, keeping babies in the shade, and dressing them in sun-protective clothing and hats.

Next page: Bathing and eczema

What advice do you give parents/guardians on bathing for babies with eczema?

Two-thirds of dermatologists (68%) indicated that moisturizers should be applied after bathing babies with eczema. More than half (64%) suggested using fragrance-free cleansers. Results varied on the frequency of bathing; 32% said bathe once daily for short periods with warm water, and 41% suggested to reduce bathing to a few nights a week.

Expert Commentary
Provided by Shari R. Lipner, MD, PhD (New York, New York)

Dry skin is a characteristic feature of atopic dermatitis. We now know that skin barrier dysfunction, such as filaggrin deficiency, contributes to the pathophysiology in some patients. In addition, a paucity of stratum corneum and intercellular lipids increases transepidermal water loss. Therefore, emollients containing humectants to augment stratum corneum hydration and occludents to reduce evaporation are extremely helpful in maintenance treatment of atopic dermatitis.

Next page: Nonsteroidal agents

Do you prescribe nonsteroidal agents for children younger than 2 years?

Almost two-thirds (64%) of dermatologists do prescribe nonsteroidal agents for children younger than 2 years.

If yes, which nonsteroidal agents do you prescribe for children?

Of those dermatologists who indicated that they do prescribe nonsteroidal agents for children younger than 2 years, almost half (45%) prescribe pimecrolimus, while 36% prescribe crisaborole or tacrolimus.

Expert Commentary
Provided by Shari R. Lipner, MD, PhD (New York, New York)

We have limited options for US Food and Drug Administration (FDA)–approved therapies for atopic dermatitis in children younger than 2 years. The risks of adverse effects also are higher in younger children compared to older children and adults, particularly hypothalamic-pituitary-adrenal suppression with corticosteroids. Pimecrolimus was the most common nonsteroidal prescribed in this group. It should be noted that pimecrolimus is not FDA approved for use in children younger than 2 years; however, 2 phase 3 studies were conducted with 436 infants aged 3 months to 23 months and they demonstrated safety and efficacy.

Next page: Procedures in adolescents

Which procedures do you perform on adolescents?
Forty-one percent of dermatologists surveyed indicated that they do not perform procedures on adolescents. Of those that do, 32% use laser hair removal or chemical peels in adolescents, while only 23% each use light therapy for acne or onabotulinumtoxinA for hyperhidrosis. Pulsed dye laser use was reported in only 18% of dermatologists.

Expert Commentary
Provided by Shari R. Lipner, MD, PhD (New York, New York)

The results of this survey are a reflection of the relatively recent trends in dermatology training. Now that there is board certification in pediatric dermatology, many dermatologists now refer to pediatric dermatologists for children who need or want procedures.

Next page: More tips from derms

More Tips From Dermatologists

The dermatologists we polled had the following advice for their peers:

Keep the regimen as simple as possible and make sure your skin care advice is culturally relevant.—Craig Burkhart, MD (Chapel Hill, North Carolina)

Please, avoid direct sun exposure as much as possible by wearing protective garments and finding shades in the outside.—Jisun Cha, MD (New Brunswick, New Jersey)

Good habits start early. Teach children how to care for their skin and they will carry that practice with them over the course of their  lifetime, and hopefully pass it on.—James Q. Del Rosso, DO (Las Vegas, Nevada)

About This Survey
The survey was fielded electronically to Cutis Editorial Board Members within the United States from September 13, 2018, to October 4, 2018. A total of 22 usable responses were received.

To improve patient care and outcomes, leading dermatologists from the Cutis Editorial Board answered 5 questions on pediatric skin care. Here’s what we found.

Do you recommend sunscreen in babies younger than 6 months?

More than half (64%) of dermatologists we surveyed do not recommend using sunscreens in babies younger than 6 months; they should stay out of the sun. They recommended sun-protective clothing, hats, and sunglasses in this age group.

Expert Commentary
Provided by Shari R. Lipner, MD, PhD (New York, New York)

Babies younger than 6 months are still developing barrier functionality and have a higher surface area to body weight ratio compared to older children and adults. There is decreased UV light barrier protection and increased risk for systemic drug absorption. Therefore, it is best to avoid sunscreen in babies younger than 6 months. Instead, I recommend avoiding sunlight during peak hours, keeping babies in the shade, and dressing them in sun-protective clothing and hats.

Next page: Bathing and eczema

What advice do you give parents/guardians on bathing for babies with eczema?

Two-thirds of dermatologists (68%) indicated that moisturizers should be applied after bathing babies with eczema. More than half (64%) suggested using fragrance-free cleansers. Results varied on the frequency of bathing; 32% said bathe once daily for short periods with warm water, and 41% suggested to reduce bathing to a few nights a week.

Expert Commentary
Provided by Shari R. Lipner, MD, PhD (New York, New York)

Dry skin is a characteristic feature of atopic dermatitis. We now know that skin barrier dysfunction, such as filaggrin deficiency, contributes to the pathophysiology in some patients. In addition, a paucity of stratum corneum and intercellular lipids increases transepidermal water loss. Therefore, emollients containing humectants to augment stratum corneum hydration and occludents to reduce evaporation are extremely helpful in maintenance treatment of atopic dermatitis.

Next page: Nonsteroidal agents

Do you prescribe nonsteroidal agents for children younger than 2 years?

Almost two-thirds (64%) of dermatologists do prescribe nonsteroidal agents for children younger than 2 years.

If yes, which nonsteroidal agents do you prescribe for children?

Of those dermatologists who indicated that they do prescribe nonsteroidal agents for children younger than 2 years, almost half (45%) prescribe pimecrolimus, while 36% prescribe crisaborole or tacrolimus.

Expert Commentary
Provided by Shari R. Lipner, MD, PhD (New York, New York)

We have limited options for US Food and Drug Administration (FDA)–approved therapies for atopic dermatitis in children younger than 2 years. The risks of adverse effects also are higher in younger children compared to older children and adults, particularly hypothalamic-pituitary-adrenal suppression with corticosteroids. Pimecrolimus was the most common nonsteroidal prescribed in this group. It should be noted that pimecrolimus is not FDA approved for use in children younger than 2 years; however, 2 phase 3 studies were conducted with 436 infants aged 3 months to 23 months and they demonstrated safety and efficacy.

Next page: Procedures in adolescents

Which procedures do you perform on adolescents?
Forty-one percent of dermatologists surveyed indicated that they do not perform procedures on adolescents. Of those that do, 32% use laser hair removal or chemical peels in adolescents, while only 23% each use light therapy for acne or onabotulinumtoxinA for hyperhidrosis. Pulsed dye laser use was reported in only 18% of dermatologists.

Expert Commentary
Provided by Shari R. Lipner, MD, PhD (New York, New York)

The results of this survey are a reflection of the relatively recent trends in dermatology training. Now that there is board certification in pediatric dermatology, many dermatologists now refer to pediatric dermatologists for children who need or want procedures.

Next page: More tips from derms

More Tips From Dermatologists

The dermatologists we polled had the following advice for their peers:

Keep the regimen as simple as possible and make sure your skin care advice is culturally relevant.—Craig Burkhart, MD (Chapel Hill, North Carolina)

Please, avoid direct sun exposure as much as possible by wearing protective garments and finding shades in the outside.—Jisun Cha, MD (New Brunswick, New Jersey)

Good habits start early. Teach children how to care for their skin and they will carry that practice with them over the course of their  lifetime, and hopefully pass it on.—James Q. Del Rosso, DO (Las Vegas, Nevada)

About This Survey
The survey was fielded electronically to Cutis Editorial Board Members within the United States from September 13, 2018, to October 4, 2018. A total of 22 usable responses were received.

What do Queen Silvia of Sweden, Pope Francis, and the first director of the National Institute on Drug Abuse (NIDA) have in common? They all share a deep and sobering commitment to fighting the global disease of addiction.

Robert L. DuPont, MD, has written a beautiful and surprisingly spiritual guide into the American addiction epidemic. He is the author of “The Selfish Brain: Learning From Addiction” (Center City, Minn.: Hazelden, 2000) and with his newest publication, “Chemical Slavery: Understanding Addiction and Stopping the Drug Epidemic” (Institute for Behavior and Health, 2018), he writes a clear-eyed tome detailing the history of drug and alcohol use within the United States and the current state of America’s drug epidemic.

Dr. DuPont is well known within the American addiction community as NIDA’s first director and as the second drug czar, under two presidents, Richard M. Nixon and Gerald R. Ford. His breadth of experience, spanning 50-plus years, dates from his early career with the District of Columbia Department of Corrections, into his work in public policy on drugs and alcohol. This experience infuses his book with the hard science of addiction and the common-sense compassion required to shepherd people into recovery. One of us has worked with and been influenced by him since the 1970s. The other, also an addiction psychiatrist, finished this book both invigorated and compelled to say thank you to Dr. DuPont and his life’s work! He remains relevant, insightful, and always optimistic about the future of addiction treatment.
 

Harm reduction explored

The book begins with a cogent history of drug and alcohol use in America. Dr. DuPont details this as well as the public policies that have evolved to address them. He weaves into our national history reasoning behind why, as a “mass consumer” culture, we are more prone to addiction than ever before. The loss of cultural and societal pressures has a role to play in the rise along with genetics and environmental stress. The adolescent brain is prominently discussed throughout this first section as a highly vulnerable organ that can lead to lifelong addiction if primed early by addictive chemicals.

Dr. DuPont addresses the biology of addiction, delving into both the biological mechanisms within the brain, making those details accessible and understandable – to a practicing physician as well as a family member or patient struggling with addiction.

He also addresses harm reduction, a fairly new concept within the field. Harm reduction has taken on more prominence with localities across the country providing people with addictions with safe places and clean needles to continue their substance use without risks of serious or life-threatening diseases and crime. He challenges the idea that harm reduction is active recovery from substance addiction. Instead, he opines that harm reduction must be tethered to and must lead to real recovery work or it risks becoming an organizational enabling of the addict’s behavior.

Dr. DuPont pulls no punches with his language. He uses words such as “fatal,” “addict,” and “alcoholic.” He addresses the concerns by some in the field that those kinds of words are harsh, derogatory, and prejudicial by calling out addiction as a disease hallmarked primarily by loss of control and by dishonesty. To shun those words is to perpetuate the disease, delaying life-saving treatment.

Compassion is a theme throughout. He says we must stigmatize the addiction but not the addict. He advocates for real consequences to addictive behaviors as a key to getting addicted physicians and others with this disease into recovery. Treatment works, but we also have studied specific approaches that work and why.¹ His writing conveys a genuine empathy for his patients and argues that treatment is delayed when serious and negative consequences for patients are removed.
 

Focus on prevention

A clear passion for prevention is evident within his chapters on youth addiction. For adolescents, Dr. DuPont presents a “One Choice approach,” which requires complete abstinence from alcohol, tobacco, and marijuana. He also presents science showing that patients younger than age 21 will have a greater risk of developing lifelong and debilitating addictions if they use these chemicals prior to this age. His emphasis for the One Choice approach carries ramifications throughout the primary care, pediatric, and family practice communities.

Dr. DuPont is nothing if not an optimist. Though he clearly defines addiction as an often-fatal disease, he remains positive about the future of addiction treatment, both with changes in public policy and with advancements in the medicine of addiction. He makes a compelling argument regarding Sweden’s approach to the drug problem, citing Queen Silvia’s lifelong commitment to prevent, control, and treat drug and alcohol addiction. Sweden’s model is, indeed, intriguing, and that country’s outcomes present a strong argument for the marriage of the criminal justice system with medical intervention – an approach that the United States has adopted only in a patchwork fashion.

Courtesy Dr. Jorandby

The book describes controversies throughout, such as Dr. DuPont’s furtherance of our work on how best to treat dual disorders.² He is not impressed with the self-medication hypothesis as well as the dive into the U.S. national medical marijuana experiment. We had looked at college students having new-onset memory or attention-deficit/hyperactivity problems, only to find that it was likely psychostimulant seeking to reverse marijuana effects.³ Physicians, families, and patients would be well served to review his arguments on the clear definition of “medicine” with regard to marijuana and the risks taken when we medicalize a known addictive chemical. He tackles the push for legalization as well, and the risks of increased societal acceptance and commercialization power that comes with this. He has led the field in thinking about the role of early drug exposure, brain training, and hijacking in the addictive process. This gateway hypothesis can occur whether the first teen drugs are cannabis or tobacco⁴ or alcohol.

Dr. DuPont finishes his work with a detailed biography, in which he addresses his family history of addiction, and his own overuse of alcohol in his late teens and early 20s as well as a confession of onetime use of marijuana during medical school. He always has led the field in trying to explain the disease of addiction, intervention, treatment, and recovery. But this self-reflection and brutal honesty is refreshing and in step with themes in his book, which promote the idea of recovery as an embrace of honesty, in mind, body, and spirit.
 

Dr. Jorandby trained in addiction psychiatry at Yale University, New Haven, Conn., and works as an addiction psychiatrist with Amen Clinics in Washington. Dr. Gold is the 17th Distinguished Alumni Professor at the University of Florida, Gainesville, and professor of psychiatry (adjunct) at Washington University in St. Louis.

References

1. J Subst Abuse Treat. 2009 Mar;36(2):159-71.

2. J Addict Dis. 2007;26 Suppl 1:13-23.

3. Am J Psychiatry. 2007 Jun;164(6):973.

4. J Addict Dis. 2003;22(3):51-62.

What do Queen Silvia of Sweden, Pope Francis, and the first director of the National Institute on Drug Abuse (NIDA) have in common? They all share a deep and sobering commitment to fighting the global disease of addiction.

Robert L. DuPont, MD, has written a beautiful and surprisingly spiritual guide into the American addiction epidemic. He is the author of “The Selfish Brain: Learning From Addiction” (Center City, Minn.: Hazelden, 2000) and with his newest publication, “Chemical Slavery: Understanding Addiction and Stopping the Drug Epidemic” (Institute for Behavior and Health, 2018), he writes a clear-eyed tome detailing the history of drug and alcohol use within the United States and the current state of America’s drug epidemic.

Dr. DuPont is well known within the American addiction community as NIDA’s first director and as the second drug czar, under two presidents, Richard M. Nixon and Gerald R. Ford. His breadth of experience, spanning 50-plus years, dates from his early career with the District of Columbia Department of Corrections, into his work in public policy on drugs and alcohol. This experience infuses his book with the hard science of addiction and the common-sense compassion required to shepherd people into recovery. One of us has worked with and been influenced by him since the 1970s. The other, also an addiction psychiatrist, finished this book both invigorated and compelled to say thank you to Dr. DuPont and his life’s work! He remains relevant, insightful, and always optimistic about the future of addiction treatment.
 

Harm reduction explored

The book begins with a cogent history of drug and alcohol use in America. Dr. DuPont details this as well as the public policies that have evolved to address them. He weaves into our national history reasoning behind why, as a “mass consumer” culture, we are more prone to addiction than ever before. The loss of cultural and societal pressures has a role to play in the rise along with genetics and environmental stress. The adolescent brain is prominently discussed throughout this first section as a highly vulnerable organ that can lead to lifelong addiction if primed early by addictive chemicals.

Dr. DuPont addresses the biology of addiction, delving into both the biological mechanisms within the brain, making those details accessible and understandable – to a practicing physician as well as a family member or patient struggling with addiction.

He also addresses harm reduction, a fairly new concept within the field. Harm reduction has taken on more prominence with localities across the country providing people with addictions with safe places and clean needles to continue their substance use without risks of serious or life-threatening diseases and crime. He challenges the idea that harm reduction is active recovery from substance addiction. Instead, he opines that harm reduction must be tethered to and must lead to real recovery work or it risks becoming an organizational enabling of the addict’s behavior.

Dr. DuPont pulls no punches with his language. He uses words such as “fatal,” “addict,” and “alcoholic.” He addresses the concerns by some in the field that those kinds of words are harsh, derogatory, and prejudicial by calling out addiction as a disease hallmarked primarily by loss of control and by dishonesty. To shun those words is to perpetuate the disease, delaying life-saving treatment.

Compassion is a theme throughout. He says we must stigmatize the addiction but not the addict. He advocates for real consequences to addictive behaviors as a key to getting addicted physicians and others with this disease into recovery. Treatment works, but we also have studied specific approaches that work and why.¹ His writing conveys a genuine empathy for his patients and argues that treatment is delayed when serious and negative consequences for patients are removed.
 

Focus on prevention

A clear passion for prevention is evident within his chapters on youth addiction. For adolescents, Dr. DuPont presents a “One Choice approach,” which requires complete abstinence from alcohol, tobacco, and marijuana. He also presents science showing that patients younger than age 21 will have a greater risk of developing lifelong and debilitating addictions if they use these chemicals prior to this age. His emphasis for the One Choice approach carries ramifications throughout the primary care, pediatric, and family practice communities.

Dr. DuPont is nothing if not an optimist. Though he clearly defines addiction as an often-fatal disease, he remains positive about the future of addiction treatment, both with changes in public policy and with advancements in the medicine of addiction. He makes a compelling argument regarding Sweden’s approach to the drug problem, citing Queen Silvia’s lifelong commitment to prevent, control, and treat drug and alcohol addiction. Sweden’s model is, indeed, intriguing, and that country’s outcomes present a strong argument for the marriage of the criminal justice system with medical intervention – an approach that the United States has adopted only in a patchwork fashion.

Courtesy Dr. Jorandby

The book describes controversies throughout, such as Dr. DuPont’s furtherance of our work on how best to treat dual disorders.² He is not impressed with the self-medication hypothesis as well as the dive into the U.S. national medical marijuana experiment. We had looked at college students having new-onset memory or attention-deficit/hyperactivity problems, only to find that it was likely psychostimulant seeking to reverse marijuana effects.³ Physicians, families, and patients would be well served to review his arguments on the clear definition of “medicine” with regard to marijuana and the risks taken when we medicalize a known addictive chemical. He tackles the push for legalization as well, and the risks of increased societal acceptance and commercialization power that comes with this. He has led the field in thinking about the role of early drug exposure, brain training, and hijacking in the addictive process. This gateway hypothesis can occur whether the first teen drugs are cannabis or tobacco⁴ or alcohol.

Dr. DuPont finishes his work with a detailed biography, in which he addresses his family history of addiction, and his own overuse of alcohol in his late teens and early 20s as well as a confession of onetime use of marijuana during medical school. He always has led the field in trying to explain the disease of addiction, intervention, treatment, and recovery. But this self-reflection and brutal honesty is refreshing and in step with themes in his book, which promote the idea of recovery as an embrace of honesty, in mind, body, and spirit.
 

Dr. Jorandby trained in addiction psychiatry at Yale University, New Haven, Conn., and works as an addiction psychiatrist with Amen Clinics in Washington. Dr. Gold is the 17th Distinguished Alumni Professor at the University of Florida, Gainesville, and professor of psychiatry (adjunct) at Washington University in St. Louis.

References

1. J Subst Abuse Treat. 2009 Mar;36(2):159-71.

2. J Addict Dis. 2007;26 Suppl 1:13-23.

3. Am J Psychiatry. 2007 Jun;164(6):973.

4. J Addict Dis. 2003;22(3):51-62.

What do Queen Silvia of Sweden, Pope Francis, and the first director of the National Institute on Drug Abuse (NIDA) have in common? They all share a deep and sobering commitment to fighting the global disease of addiction.

Robert L. DuPont, MD, has written a beautiful and surprisingly spiritual guide into the American addiction epidemic. He is the author of “The Selfish Brain: Learning From Addiction” (Center City, Minn.: Hazelden, 2000) and with his newest publication, “Chemical Slavery: Understanding Addiction and Stopping the Drug Epidemic” (Institute for Behavior and Health, 2018), he writes a clear-eyed tome detailing the history of drug and alcohol use within the United States and the current state of America’s drug epidemic.

Dr. DuPont is well known within the American addiction community as NIDA’s first director and as the second drug czar, under two presidents, Richard M. Nixon and Gerald R. Ford. His breadth of experience, spanning 50-plus years, dates from his early career with the District of Columbia Department of Corrections, into his work in public policy on drugs and alcohol. This experience infuses his book with the hard science of addiction and the common-sense compassion required to shepherd people into recovery. One of us has worked with and been influenced by him since the 1970s. The other, also an addiction psychiatrist, finished this book both invigorated and compelled to say thank you to Dr. DuPont and his life’s work! He remains relevant, insightful, and always optimistic about the future of addiction treatment.
 

Harm reduction explored

The book begins with a cogent history of drug and alcohol use in America. Dr. DuPont details this as well as the public policies that have evolved to address them. He weaves into our national history reasoning behind why, as a “mass consumer” culture, we are more prone to addiction than ever before. The loss of cultural and societal pressures has a role to play in the rise along with genetics and environmental stress. The adolescent brain is prominently discussed throughout this first section as a highly vulnerable organ that can lead to lifelong addiction if primed early by addictive chemicals.

Dr. DuPont addresses the biology of addiction, delving into both the biological mechanisms within the brain, making those details accessible and understandable – to a practicing physician as well as a family member or patient struggling with addiction.

He also addresses harm reduction, a fairly new concept within the field. Harm reduction has taken on more prominence with localities across the country providing people with addictions with safe places and clean needles to continue their substance use without risks of serious or life-threatening diseases and crime. He challenges the idea that harm reduction is active recovery from substance addiction. Instead, he opines that harm reduction must be tethered to and must lead to real recovery work or it risks becoming an organizational enabling of the addict’s behavior.

Dr. DuPont pulls no punches with his language. He uses words such as “fatal,” “addict,” and “alcoholic.” He addresses the concerns by some in the field that those kinds of words are harsh, derogatory, and prejudicial by calling out addiction as a disease hallmarked primarily by loss of control and by dishonesty. To shun those words is to perpetuate the disease, delaying life-saving treatment.

Compassion is a theme throughout. He says we must stigmatize the addiction but not the addict. He advocates for real consequences to addictive behaviors as a key to getting addicted physicians and others with this disease into recovery. Treatment works, but we also have studied specific approaches that work and why.¹ His writing conveys a genuine empathy for his patients and argues that treatment is delayed when serious and negative consequences for patients are removed.
 

Focus on prevention

A clear passion for prevention is evident within his chapters on youth addiction. For adolescents, Dr. DuPont presents a “One Choice approach,” which requires complete abstinence from alcohol, tobacco, and marijuana. He also presents science showing that patients younger than age 21 will have a greater risk of developing lifelong and debilitating addictions if they use these chemicals prior to this age. His emphasis for the One Choice approach carries ramifications throughout the primary care, pediatric, and family practice communities.

Dr. DuPont is nothing if not an optimist. Though he clearly defines addiction as an often-fatal disease, he remains positive about the future of addiction treatment, both with changes in public policy and with advancements in the medicine of addiction. He makes a compelling argument regarding Sweden’s approach to the drug problem, citing Queen Silvia’s lifelong commitment to prevent, control, and treat drug and alcohol addiction. Sweden’s model is, indeed, intriguing, and that country’s outcomes present a strong argument for the marriage of the criminal justice system with medical intervention – an approach that the United States has adopted only in a patchwork fashion.

Courtesy Dr. Jorandby

The book describes controversies throughout, such as Dr. DuPont’s furtherance of our work on how best to treat dual disorders.² He is not impressed with the self-medication hypothesis as well as the dive into the U.S. national medical marijuana experiment. We had looked at college students having new-onset memory or attention-deficit/hyperactivity problems, only to find that it was likely psychostimulant seeking to reverse marijuana effects.³ Physicians, families, and patients would be well served to review his arguments on the clear definition of “medicine” with regard to marijuana and the risks taken when we medicalize a known addictive chemical. He tackles the push for legalization as well, and the risks of increased societal acceptance and commercialization power that comes with this. He has led the field in thinking about the role of early drug exposure, brain training, and hijacking in the addictive process. This gateway hypothesis can occur whether the first teen drugs are cannabis or tobacco⁴ or alcohol.

Dr. DuPont finishes his work with a detailed biography, in which he addresses his family history of addiction, and his own overuse of alcohol in his late teens and early 20s as well as a confession of onetime use of marijuana during medical school. He always has led the field in trying to explain the disease of addiction, intervention, treatment, and recovery. But this self-reflection and brutal honesty is refreshing and in step with themes in his book, which promote the idea of recovery as an embrace of honesty, in mind, body, and spirit.
 

Dr. Jorandby trained in addiction psychiatry at Yale University, New Haven, Conn., and works as an addiction psychiatrist with Amen Clinics in Washington. Dr. Gold is the 17th Distinguished Alumni Professor at the University of Florida, Gainesville, and professor of psychiatry (adjunct) at Washington University in St. Louis.

References

1. J Subst Abuse Treat. 2009 Mar;36(2):159-71.

2. J Addict Dis. 2007;26 Suppl 1:13-23.

3. Am J Psychiatry. 2007 Jun;164(6):973.

4. J Addict Dis. 2003;22(3):51-62.

CHICAGO—The Children’s Hospital of Philadelphia Infant Test of Neuromuscular Disorders (CHOP-INTEND) was designed to track motor function in patients with spinal muscular atrophy type 1 (SMA1), but the test may not be sensitive to advances in motor function made by patients who receive an investigational gene-replacement therapy, researchers said at the 47th Annual Meeting of the Child Neurology Society.

AVXS-101 is an adeno-associated virus serotype 9 (AAV9)-based gene-replacement therapy that contains a copy of the SMN1 gene. AVXS-101 crosses the blood–brain barrier and is meant to treat the deletion or loss of function of the SMN1 gene in patients with SMA. The treatment may result in sustained SMN protein expression with a one-time dose.

Researchers conducted a phase I, open-label, dose-escalation study to study the treatment. Fifteen patients received AVXS-101 intravenously, and 12 participants received the proposed therapeutic dose.

“Patients treated with AVXS-101 achieved and maintained motor milestones unprecedented in the natural history of SMA1,” said Linda P. Lowes, PT, PhD, Principal Investigator for the Center for Gene Therapy at Nationwide Children’s Hospital in Columbus, Ohio, and Associate Professor of Pediatrics at Ohio State University, and colleagues. “CHOP-INTEND is a reliable tool for detecting early treatment impact, but appears insensitive to further motor function gains among AVXS-101–treated children as they age and develop.”

CHICAGO—The Children’s Hospital of Philadelphia Infant Test of Neuromuscular Disorders (CHOP-INTEND) was designed to track motor function in patients with spinal muscular atrophy type 1 (SMA1), but the test may not be sensitive to advances in motor function made by patients who receive an investigational gene-replacement therapy, researchers said at the 47th Annual Meeting of the Child Neurology Society.

AVXS-101 is an adeno-associated virus serotype 9 (AAV9)-based gene-replacement therapy that contains a copy of the SMN1 gene. AVXS-101 crosses the blood–brain barrier and is meant to treat the deletion or loss of function of the SMN1 gene in patients with SMA. The treatment may result in sustained SMN protein expression with a one-time dose.

Researchers conducted a phase I, open-label, dose-escalation study to study the treatment. Fifteen patients received AVXS-101 intravenously, and 12 participants received the proposed therapeutic dose.

“Patients treated with AVXS-101 achieved and maintained motor milestones unprecedented in the natural history of SMA1,” said Linda P. Lowes, PT, PhD, Principal Investigator for the Center for Gene Therapy at Nationwide Children’s Hospital in Columbus, Ohio, and Associate Professor of Pediatrics at Ohio State University, and colleagues. “CHOP-INTEND is a reliable tool for detecting early treatment impact, but appears insensitive to further motor function gains among AVXS-101–treated children as they age and develop.”

CHICAGO—The Children’s Hospital of Philadelphia Infant Test of Neuromuscular Disorders (CHOP-INTEND) was designed to track motor function in patients with spinal muscular atrophy type 1 (SMA1), but the test may not be sensitive to advances in motor function made by patients who receive an investigational gene-replacement therapy, researchers said at the 47th Annual Meeting of the Child Neurology Society.

AVXS-101 is an adeno-associated virus serotype 9 (AAV9)-based gene-replacement therapy that contains a copy of the SMN1 gene. AVXS-101 crosses the blood–brain barrier and is meant to treat the deletion or loss of function of the SMN1 gene in patients with SMA. The treatment may result in sustained SMN protein expression with a one-time dose.

Researchers conducted a phase I, open-label, dose-escalation study to study the treatment. Fifteen patients received AVXS-101 intravenously, and 12 participants received the proposed therapeutic dose.

“Patients treated with AVXS-101 achieved and maintained motor milestones unprecedented in the natural history of SMA1,” said Linda P. Lowes, PT, PhD, Principal Investigator for the Center for Gene Therapy at Nationwide Children’s Hospital in Columbus, Ohio, and Associate Professor of Pediatrics at Ohio State University, and colleagues. “CHOP-INTEND is a reliable tool for detecting early treatment impact, but appears insensitive to further motor function gains among AVXS-101–treated children as they age and develop.”

Annual ultrasound screening of asymptomatic women at risk of epithelial ovarian cancer can lead to lower staging of cancer at detection and improved survival, compared with no screening, according to a prospective clinical trial that followed more than 46,000 women over 2 decades.

“The findings of this study support the concept that a major predictor of ovarian cancer survival is stage at detection,” said John R. van Nagell Jr., MD, of the University of Kentucky–Markey Cancer Center, Lexington, and his coauthors. “The 10-year survival of women whose ovarian cancer was detected at an early stage (I or II) was 35% higher than that of women diagnosed with stage III cancer.” Study results were published in the November issue of Obstetrics & Gynecology.

The study evaluated 46,101 women enrolled in the University of Kentucky Ovarian Cancer Screening Trial over 30.5 years. Trial participants, all of whom had annual ultrasound screening, were age 50 and older, or 25 and older with a family history of ovarian cancer. Overall, 23% and 44% of the women had a family history of either ovarian or breast cancer, respectively. Women in the study had an average of seven scans each. The unscreened comparator group was women with ovarian cancer referred to the UK Markey Cancer Center.

The study detected 71 cases of invasive epithelial ovarian cancers and 17 epithelial ovarian tumors of low malignant potential. None of the women with these tumors had a recurrence. Among the invasive cancers, the majority were either stage I (42%) or II (21%), and none were stage IV. The median age of these patients was 66 years. Of the low-malignancy tumors, 27% were stage I and 73% stage II, with none stage III or IV. A total of 699 women (1.5%) with persistent ovarian tumors had surgery.

Screened women also had improved survival compared to unscreened women: 86% vs. 45% at 5 years, 68% vs. 31% at 10 years (P less than .001).

However, the study also showed a high overall incidence rate for ovarian cancer, including false-positive and false-negative cases, compared with National Cancer Institute reports in the Kentucky state cancer profile: 271 per 100,000 vs. 10.4/100,000.

The study also looked at the economics of annual screening. “Ovarian screening reduced the 10-year mortality by 37% and produced 416 life years gained,” Dr. van Nagell and his coauthors said. Based on an estimated cost of $56 for each transvaginal ultrasound scan, that translates into a cost of $40,731 for each life year gained.

One concern of screening ultrasound is the high false-positive rate. “Although the sensitivity of transvaginal ultrasonography in detecting an ovarian abnormality is high, it has been unreliable in differentiating benign from malignant ovarian tumors,” they said. While they noted the accuracy of assessing malignancy has improved, the risk of complications in women who have surgery for benign tumors is an ongoing concern. “Additional research is necessary to identify high-risk populations who will benefit most from screening.”

Dr. van Nagell and his coauthors reported having no financial relationships. The study was supported by research grants from the Kentucky Department of Health and Human Services and the Telford Foundation.

SOURCE: Van Nagell JR Jr et al. Obstet Gynecol. 2018 Nov;132[5]:1091-100. doi: 10.1097/AOG.0000000000002921.

Annual ultrasound screening of asymptomatic women at risk of epithelial ovarian cancer can lead to lower staging of cancer at detection and improved survival, compared with no screening, according to a prospective clinical trial that followed more than 46,000 women over 2 decades.

“The findings of this study support the concept that a major predictor of ovarian cancer survival is stage at detection,” said John R. van Nagell Jr., MD, of the University of Kentucky–Markey Cancer Center, Lexington, and his coauthors. “The 10-year survival of women whose ovarian cancer was detected at an early stage (I or II) was 35% higher than that of women diagnosed with stage III cancer.” Study results were published in the November issue of Obstetrics & Gynecology.

The study evaluated 46,101 women enrolled in the University of Kentucky Ovarian Cancer Screening Trial over 30.5 years. Trial participants, all of whom had annual ultrasound screening, were age 50 and older, or 25 and older with a family history of ovarian cancer. Overall, 23% and 44% of the women had a family history of either ovarian or breast cancer, respectively. Women in the study had an average of seven scans each. The unscreened comparator group was women with ovarian cancer referred to the UK Markey Cancer Center.

The study detected 71 cases of invasive epithelial ovarian cancers and 17 epithelial ovarian tumors of low malignant potential. None of the women with these tumors had a recurrence. Among the invasive cancers, the majority were either stage I (42%) or II (21%), and none were stage IV. The median age of these patients was 66 years. Of the low-malignancy tumors, 27% were stage I and 73% stage II, with none stage III or IV. A total of 699 women (1.5%) with persistent ovarian tumors had surgery.

Screened women also had improved survival compared to unscreened women: 86% vs. 45% at 5 years, 68% vs. 31% at 10 years (P less than .001).

However, the study also showed a high overall incidence rate for ovarian cancer, including false-positive and false-negative cases, compared with National Cancer Institute reports in the Kentucky state cancer profile: 271 per 100,000 vs. 10.4/100,000.

The study also looked at the economics of annual screening. “Ovarian screening reduced the 10-year mortality by 37% and produced 416 life years gained,” Dr. van Nagell and his coauthors said. Based on an estimated cost of $56 for each transvaginal ultrasound scan, that translates into a cost of $40,731 for each life year gained.

One concern of screening ultrasound is the high false-positive rate. “Although the sensitivity of transvaginal ultrasonography in detecting an ovarian abnormality is high, it has been unreliable in differentiating benign from malignant ovarian tumors,” they said. While they noted the accuracy of assessing malignancy has improved, the risk of complications in women who have surgery for benign tumors is an ongoing concern. “Additional research is necessary to identify high-risk populations who will benefit most from screening.”

Dr. van Nagell and his coauthors reported having no financial relationships. The study was supported by research grants from the Kentucky Department of Health and Human Services and the Telford Foundation.

SOURCE: Van Nagell JR Jr et al. Obstet Gynecol. 2018 Nov;132[5]:1091-100. doi: 10.1097/AOG.0000000000002921.

Annual ultrasound screening of asymptomatic women at risk of epithelial ovarian cancer can lead to lower staging of cancer at detection and improved survival, compared with no screening, according to a prospective clinical trial that followed more than 46,000 women over 2 decades.

“The findings of this study support the concept that a major predictor of ovarian cancer survival is stage at detection,” said John R. van Nagell Jr., MD, of the University of Kentucky–Markey Cancer Center, Lexington, and his coauthors. “The 10-year survival of women whose ovarian cancer was detected at an early stage (I or II) was 35% higher than that of women diagnosed with stage III cancer.” Study results were published in the November issue of Obstetrics & Gynecology.

The study evaluated 46,101 women enrolled in the University of Kentucky Ovarian Cancer Screening Trial over 30.5 years. Trial participants, all of whom had annual ultrasound screening, were age 50 and older, or 25 and older with a family history of ovarian cancer. Overall, 23% and 44% of the women had a family history of either ovarian or breast cancer, respectively. Women in the study had an average of seven scans each. The unscreened comparator group was women with ovarian cancer referred to the UK Markey Cancer Center.

The study detected 71 cases of invasive epithelial ovarian cancers and 17 epithelial ovarian tumors of low malignant potential. None of the women with these tumors had a recurrence. Among the invasive cancers, the majority were either stage I (42%) or II (21%), and none were stage IV. The median age of these patients was 66 years. Of the low-malignancy tumors, 27% were stage I and 73% stage II, with none stage III or IV. A total of 699 women (1.5%) with persistent ovarian tumors had surgery.

Screened women also had improved survival compared to unscreened women: 86% vs. 45% at 5 years, 68% vs. 31% at 10 years (P less than .001).

However, the study also showed a high overall incidence rate for ovarian cancer, including false-positive and false-negative cases, compared with National Cancer Institute reports in the Kentucky state cancer profile: 271 per 100,000 vs. 10.4/100,000.

The study also looked at the economics of annual screening. “Ovarian screening reduced the 10-year mortality by 37% and produced 416 life years gained,” Dr. van Nagell and his coauthors said. Based on an estimated cost of $56 for each transvaginal ultrasound scan, that translates into a cost of $40,731 for each life year gained.

One concern of screening ultrasound is the high false-positive rate. “Although the sensitivity of transvaginal ultrasonography in detecting an ovarian abnormality is high, it has been unreliable in differentiating benign from malignant ovarian tumors,” they said. While they noted the accuracy of assessing malignancy has improved, the risk of complications in women who have surgery for benign tumors is an ongoing concern. “Additional research is necessary to identify high-risk populations who will benefit most from screening.”

Dr. van Nagell and his coauthors reported having no financial relationships. The study was supported by research grants from the Kentucky Department of Health and Human Services and the Telford Foundation.

SOURCE: Van Nagell JR Jr et al. Obstet Gynecol. 2018 Nov;132[5]:1091-100. doi: 10.1097/AOG.0000000000002921.

Patients typically switch from carbamazepine (CBZ) or oxcarbazepine (OXC) to eslicarbazepine acetate (ESL) for at least 1 of 3 reasons: tolerability, simpler dosing, and/or efficacy. Since no evidence-based recommendations exist regarding the switching schedule, expert opinions may prove helpful for practitioners. In this supplement, expert epileptologists and clinical trialists share their experience about switching patients from CBZ or OXC to ESL.

Supplement

Click here or on the image below to read the supplement

Podcasts

Dr. Elinor Ben-Menachem discusses the case of a 28-year-old man with focal onset epilepsy who was switched from CBZ to ESL.

Dr. Toufic Fakhoury discusses the case of a 34-year-old female who became seizure-free after switching from OXC to ESL.

Dr. Mohamad Koubeissi discusses the case of a 22-year-old man with intractable epilepsy who was switched from OXC to ESL.

Dr. John Stern discusses the case of a 48-year-woman with tonic-clonic seizures who was switched from CBZ to ESL.

Dr. James Wheless discusses the case of an 8-year-old male who found relief having switched from OXC to ESL.

About the Faculty

Patients typically switch from carbamazepine (CBZ) or oxcarbazepine (OXC) to eslicarbazepine acetate (ESL) for at least 1 of 3 reasons: tolerability, simpler dosing, and/or efficacy. Since no evidence-based recommendations exist regarding the switching schedule, expert opinions may prove helpful for practitioners. In this supplement, expert epileptologists and clinical trialists share their experience about switching patients from CBZ or OXC to ESL.

Supplement

Click here or on the image below to read the supplement

Podcasts

Dr. Elinor Ben-Menachem discusses the case of a 28-year-old man with focal onset epilepsy who was switched from CBZ to ESL.

Dr. Toufic Fakhoury discusses the case of a 34-year-old female who became seizure-free after switching from OXC to ESL.

Dr. Mohamad Koubeissi discusses the case of a 22-year-old man with intractable epilepsy who was switched from OXC to ESL.

Dr. John Stern discusses the case of a 48-year-woman with tonic-clonic seizures who was switched from CBZ to ESL.

Dr. James Wheless discusses the case of an 8-year-old male who found relief having switched from OXC to ESL.

About the Faculty

Patients typically switch from carbamazepine (CBZ) or oxcarbazepine (OXC) to eslicarbazepine acetate (ESL) for at least 1 of 3 reasons: tolerability, simpler dosing, and/or efficacy. Since no evidence-based recommendations exist regarding the switching schedule, expert opinions may prove helpful for practitioners. In this supplement, expert epileptologists and clinical trialists share their experience about switching patients from CBZ or OXC to ESL.

Supplement

Click here or on the image below to read the supplement

Podcasts

Dr. Elinor Ben-Menachem discusses the case of a 28-year-old man with focal onset epilepsy who was switched from CBZ to ESL.

Dr. Toufic Fakhoury discusses the case of a 34-year-old female who became seizure-free after switching from OXC to ESL.

Dr. Mohamad Koubeissi discusses the case of a 22-year-old man with intractable epilepsy who was switched from OXC to ESL.

Dr. John Stern discusses the case of a 48-year-woman with tonic-clonic seizures who was switched from CBZ to ESL.

Dr. James Wheless discusses the case of an 8-year-old male who found relief having switched from OXC to ESL.

About the Faculty

In episode 27, Lorenzo Norris, MD, welcomes Carl C. Bell, MD, for part 2 of 2 of a conversation of fetal alcohol spectrum disorder at the 2018 annual IPS Mental Health Services Conference. And later, Dr. Renee Kohanski discusses the time and the tide.

In episode 27, Lorenzo Norris, MD, welcomes Carl C. Bell, MD, for part 2 of 2 of a conversation of fetal alcohol spectrum disorder at the 2018 annual IPS Mental Health Services Conference. And later, Dr. Renee Kohanski discusses the time and the tide.

In episode 27, Lorenzo Norris, MD, welcomes Carl C. Bell, MD, for part 2 of 2 of a conversation of fetal alcohol spectrum disorder at the 2018 annual IPS Mental Health Services Conference. And later, Dr. Renee Kohanski discusses the time and the tide.

The weight loss drug lorcaserin has neither risk nor benefit for cardiovascular adverse events. Also today, increased risk for suicide among adults who harm themselves, banning corporal punishment may reduce violence in youth, and a formula that scores the quality of a diet is validated.
 

The weight loss drug lorcaserin has neither risk nor benefit for cardiovascular adverse events. Also today, increased risk for suicide among adults who harm themselves, banning corporal punishment may reduce violence in youth, and a formula that scores the quality of a diet is validated.
 

The weight loss drug lorcaserin has neither risk nor benefit for cardiovascular adverse events. Also today, increased risk for suicide among adults who harm themselves, banning corporal punishment may reduce violence in youth, and a formula that scores the quality of a diet is validated.
 

In 2017, 7 states reported an adult obesity prevalence at or above 35%, up from 5 states in 2016. In 2012, obesity prevalence was lower than 35% in all states. The new data, from the Behavioral Risk Factor Surveillance System, are detailed in the CDC’s 2017 Adult Obesity Prevalence Maps,  www.cdc.gov/obesity/data/prevalence-maps.html.

The highest levels were in Alabama, Arkansas, Iowa, Louisiana, Mississippi, Oklahoma, and West Virginia. The lowest prevalence was 22.6% in Colorado. Adults aged 45 to54 years were twice as likely as young adults to report obesity (36% vs 17%). Non-Hispanic blacks had the highest prevalence (39%), followed by Hispanics (32.4%), and non-Hispanic whites (29.3%). When education was factored in, adults without a high school degree had the highest prevalence at 35.6%; high school graduates, 32.9%; adults with some college, 31.9%; and college graduates, 22.7%.

Maps showing obesity levels overall, as well as by race and ethnicity, are also available for 2011 through 2016.

In 2017, 7 states reported an adult obesity prevalence at or above 35%, up from 5 states in 2016. In 2012, obesity prevalence was lower than 35% in all states. The new data, from the Behavioral Risk Factor Surveillance System, are detailed in the CDC’s 2017 Adult Obesity Prevalence Maps,  www.cdc.gov/obesity/data/prevalence-maps.html.

The highest levels were in Alabama, Arkansas, Iowa, Louisiana, Mississippi, Oklahoma, and West Virginia. The lowest prevalence was 22.6% in Colorado. Adults aged 45 to54 years were twice as likely as young adults to report obesity (36% vs 17%). Non-Hispanic blacks had the highest prevalence (39%), followed by Hispanics (32.4%), and non-Hispanic whites (29.3%). When education was factored in, adults without a high school degree had the highest prevalence at 35.6%; high school graduates, 32.9%; adults with some college, 31.9%; and college graduates, 22.7%.

Maps showing obesity levels overall, as well as by race and ethnicity, are also available for 2011 through 2016.

In 2017, 7 states reported an adult obesity prevalence at or above 35%, up from 5 states in 2016. In 2012, obesity prevalence was lower than 35% in all states. The new data, from the Behavioral Risk Factor Surveillance System, are detailed in the CDC’s 2017 Adult Obesity Prevalence Maps,  www.cdc.gov/obesity/data/prevalence-maps.html.

The highest levels were in Alabama, Arkansas, Iowa, Louisiana, Mississippi, Oklahoma, and West Virginia. The lowest prevalence was 22.6% in Colorado. Adults aged 45 to54 years were twice as likely as young adults to report obesity (36% vs 17%). Non-Hispanic blacks had the highest prevalence (39%), followed by Hispanics (32.4%), and non-Hispanic whites (29.3%). When education was factored in, adults without a high school degree had the highest prevalence at 35.6%; high school graduates, 32.9%; adults with some college, 31.9%; and college graduates, 22.7%.

Maps showing obesity levels overall, as well as by race and ethnicity, are also available for 2011 through 2016.

Photo by Neil Osterweil

BOSTON—Even the most vigilant hospitals experience transfusion errors and problems with blood storage, according to researchers.

A review of data from 32 U.S. hospitals showed that pediatric transfusions were associated with a higher rate of safety problems than adult transfusions, with errors differing by age group.

The most common error in the pediatric population was failure to follow protocol, and the most common error in the adult population was that scheduled transfusions were not performed.

Sarah Vossoughi, MD, of Columbia University and New York–Presbyterian Hospital in New York, described these findings at AABB 2018 (abstract QT4).

To evaluate patient safety events related to blood transfusions, Dr. Vossoughi and her colleagues reviewed data on events reported by three children’s hospitals and 29 adult hospitals. Events were reported to either the AABB Center for Patient Safety or the medical center’s own adverse event reporting system from January 2010 through September 2017.

The researchers identified a total of 1,806 reports associated with approximately 1,088,884 transfusions.

There were 249 reports associated with 99,064 pediatric transfusions and 1,577 reports associated with 989,820 adult transfusions. So the reporting rate was 251 per 100,000 transfusions for the pediatric population and 157 per 100,000 transfusions for the adult population (P<0.001).

The most common error for pediatric patients—failure to follow the transfusion protocol—made up 31% of the pediatric errors.

“In a lot of the pediatric hospitals, it’s kind of like the Wild West,” Dr. Vossoughi said. “People say, ‘Well, I know it’s the hospital policy, but this child is special, so I’m going to do it this way, this time.’ That seems to be a culture in pediatrics, whereas, on the adult side, [clinicians] seem to be much less likely to just deviate from the protocol.”

Among adults, the most common error was “transfusion not performed,” which accounted for 43% of the adult errors. Dr. Vossoughi said transfusions may be skipped due to a bungled patient hand-off during a shift change or when a patient is being moved from one unit to another.

“The next day, they’ll check the patient’s CBC [complete blood count] and realize that the patient didn’t respond to the infusion that it turned out they never got, and then the product will be found on the floor, expired,” Dr. Vossoughi said.

She and her colleagues also found that 20% of pediatric errors and 24% of adult errors were associated with incorrect storage of blood products on the patient floor.

“It’s very common for blood banks to find platelets in the refrigerator,” Dr. Vossoughi said. “It doesn’t matter how old you are or what type of hospital you’re at. Everyone’s putting platelets in the fridge.”

Dr. Vossoughi and her colleagues believe these findings could help inpatient blood management programs target education and interventions to providers who commit similar errors.

“If you know that a particular provider group has problems following the protocol, maybe you can make the protocol a little simpler to follow or make the checklist less cumbersome, and then maybe they’ll follow them more often,” Dr. Vossoughi said.

This research was supported by the AABB Center for Patient Safety and University of Vermont Medical Center. The researchers reported no conflicts of interest.

Photo by Neil Osterweil

BOSTON—Even the most vigilant hospitals experience transfusion errors and problems with blood storage, according to researchers.

A review of data from 32 U.S. hospitals showed that pediatric transfusions were associated with a higher rate of safety problems than adult transfusions, with errors differing by age group.

The most common error in the pediatric population was failure to follow protocol, and the most common error in the adult population was that scheduled transfusions were not performed.

Sarah Vossoughi, MD, of Columbia University and New York–Presbyterian Hospital in New York, described these findings at AABB 2018 (abstract QT4).

To evaluate patient safety events related to blood transfusions, Dr. Vossoughi and her colleagues reviewed data on events reported by three children’s hospitals and 29 adult hospitals. Events were reported to either the AABB Center for Patient Safety or the medical center’s own adverse event reporting system from January 2010 through September 2017.

The researchers identified a total of 1,806 reports associated with approximately 1,088,884 transfusions.

There were 249 reports associated with 99,064 pediatric transfusions and 1,577 reports associated with 989,820 adult transfusions. So the reporting rate was 251 per 100,000 transfusions for the pediatric population and 157 per 100,000 transfusions for the adult population (P<0.001).

The most common error for pediatric patients—failure to follow the transfusion protocol—made up 31% of the pediatric errors.

“In a lot of the pediatric hospitals, it’s kind of like the Wild West,” Dr. Vossoughi said. “People say, ‘Well, I know it’s the hospital policy, but this child is special, so I’m going to do it this way, this time.’ That seems to be a culture in pediatrics, whereas, on the adult side, [clinicians] seem to be much less likely to just deviate from the protocol.”

Among adults, the most common error was “transfusion not performed,” which accounted for 43% of the adult errors. Dr. Vossoughi said transfusions may be skipped due to a bungled patient hand-off during a shift change or when a patient is being moved from one unit to another.

“The next day, they’ll check the patient’s CBC [complete blood count] and realize that the patient didn’t respond to the infusion that it turned out they never got, and then the product will be found on the floor, expired,” Dr. Vossoughi said.

She and her colleagues also found that 20% of pediatric errors and 24% of adult errors were associated with incorrect storage of blood products on the patient floor.

“It’s very common for blood banks to find platelets in the refrigerator,” Dr. Vossoughi said. “It doesn’t matter how old you are or what type of hospital you’re at. Everyone’s putting platelets in the fridge.”

Dr. Vossoughi and her colleagues believe these findings could help inpatient blood management programs target education and interventions to providers who commit similar errors.

“If you know that a particular provider group has problems following the protocol, maybe you can make the protocol a little simpler to follow or make the checklist less cumbersome, and then maybe they’ll follow them more often,” Dr. Vossoughi said.

This research was supported by the AABB Center for Patient Safety and University of Vermont Medical Center. The researchers reported no conflicts of interest.

Photo by Neil Osterweil

BOSTON—Even the most vigilant hospitals experience transfusion errors and problems with blood storage, according to researchers.

A review of data from 32 U.S. hospitals showed that pediatric transfusions were associated with a higher rate of safety problems than adult transfusions, with errors differing by age group.

The most common error in the pediatric population was failure to follow protocol, and the most common error in the adult population was that scheduled transfusions were not performed.

Sarah Vossoughi, MD, of Columbia University and New York–Presbyterian Hospital in New York, described these findings at AABB 2018 (abstract QT4).

To evaluate patient safety events related to blood transfusions, Dr. Vossoughi and her colleagues reviewed data on events reported by three children’s hospitals and 29 adult hospitals. Events were reported to either the AABB Center for Patient Safety or the medical center’s own adverse event reporting system from January 2010 through September 2017.

The researchers identified a total of 1,806 reports associated with approximately 1,088,884 transfusions.

There were 249 reports associated with 99,064 pediatric transfusions and 1,577 reports associated with 989,820 adult transfusions. So the reporting rate was 251 per 100,000 transfusions for the pediatric population and 157 per 100,000 transfusions for the adult population (P<0.001).

The most common error for pediatric patients—failure to follow the transfusion protocol—made up 31% of the pediatric errors.

“In a lot of the pediatric hospitals, it’s kind of like the Wild West,” Dr. Vossoughi said. “People say, ‘Well, I know it’s the hospital policy, but this child is special, so I’m going to do it this way, this time.’ That seems to be a culture in pediatrics, whereas, on the adult side, [clinicians] seem to be much less likely to just deviate from the protocol.”

Among adults, the most common error was “transfusion not performed,” which accounted for 43% of the adult errors. Dr. Vossoughi said transfusions may be skipped due to a bungled patient hand-off during a shift change or when a patient is being moved from one unit to another.

“The next day, they’ll check the patient’s CBC [complete blood count] and realize that the patient didn’t respond to the infusion that it turned out they never got, and then the product will be found on the floor, expired,” Dr. Vossoughi said.

She and her colleagues also found that 20% of pediatric errors and 24% of adult errors were associated with incorrect storage of blood products on the patient floor.

“It’s very common for blood banks to find platelets in the refrigerator,” Dr. Vossoughi said. “It doesn’t matter how old you are or what type of hospital you’re at. Everyone’s putting platelets in the fridge.”

Dr. Vossoughi and her colleagues believe these findings could help inpatient blood management programs target education and interventions to providers who commit similar errors.

“If you know that a particular provider group has problems following the protocol, maybe you can make the protocol a little simpler to follow or make the checklist less cumbersome, and then maybe they’ll follow them more often,” Dr. Vossoughi said.

This research was supported by the AABB Center for Patient Safety and University of Vermont Medical Center. The researchers reported no conflicts of interest.

Ali Bazarbachi, MD, PhD

DUBROVNIK, CROATIA—Hematopoietic stem cell transplant (HSCT) can be hit-or-miss in patients with peripheral T-cell lymphomas (PTCLs), according to a speaker at Leukemia and Lymphoma: Europe and the USA, Linking Knowledge and Practice.

Ali Bazarbachi, MD, PhD, of the American University of Beirut in Lebanon, noted that the success of HSCT varies according to the subtype of PTCL and the type of transplant.

For example, autologous (auto) HSCT given as frontline consolidation can be considered the standard of care for PTCL-not otherwise specified (NOS), angioimmunoblastic T-cell lymphoma (AITL), and certain patients with anaplastic large-cell lymphoma (ALCL), according to Dr. Bazarbachi.

On the other hand, auto-HSCT should never be used in patients with adult T-cell leukemia/lymphoma (ATLL).

Both auto-HSCT and allogeneic (allo) HSCT are options for patients with non-localized, extranodal natural killer T-cell lymphoma (ENKTL), nasal type, but only at certain times.

State of PTCL treatment

Dr. Bazarbachi began his presentation by pointing out that patients with newly diagnosed PTCL are no longer treated like patients with B-cell lymphoma, but treatment outcomes in PTCL still leave a lot to be desired.

He noted that, with any of the chemotherapy regimens used, typically, about a third of patients are primary refractory, a third relapse, and a quarter are cured. Only two forms of PTCL are frequently curable—localized ENKTL and ALK-positive ALCL.

Current treatment strategies for PTCL do include HSCT, but recommendations vary. Dr. Bazarbachi made the following recommendations, supported by evidence from clinical trials.

HSCT in PTCL-NOS, AITL, and ALCL

For patients with PTCL-NOS, AITL, or ALK-negative, non-DUSP22 ALCL, auto-HSCT as frontline consolidation can be considered the standard of care in patients who responded to induction, Dr. Bazarbachi said.

In a study published in 2012¹, high-dose chemotherapy and auto-HSCT as consolidation improved 5-year overall survival—compared to previous results with CHOP²—in patients with ALK-negative ALCL, AITL, PTCL-NOS, and enteropathy-associated T-cell lymphoma.

Allo-HSCT may also be an option for frontline consolidation in patients with PTCL-NOS, AITL, or ALK-negative, non-DUSP22 ALCL, according to Dr. Bazarbachi.

“Allo-transplant is not dead in this indication,” he said. “But it should be either part of a clinical trial or [given] to some selected patients—those with persistent bone marrow involvement, very young patients, or patients with primary refractory disease.”

Results from the COMPLETE study³ showed improved survival in patients who received consolidation with auto- or allo-HSCT, as compared to patients who did not receive a transplant.

COMPLETE patients with AITL or PTCL-NOS had improvements in progression-free and overall survival with HSCT. The survival advantage was “less evident” in patients with ALCL, the researchers said, but this trial included both ALK-negative and ALK-positive patients.

Dr. Bazarbachi noted that allo- and auto-HSCT can be options after relapse in patients with PTCL-NOS, AITL, or ALK-negative, non-DUSP22 ALCL.

However, chemosensitive patients who have relapsed should only receive auto-HSCT if they did not receive it frontline. Patients who have already undergone auto-HSCT can receive allo-HSCT, Dr. Bazarbachi said.

He added that refractory patients should not undergo auto-HSCT and should receive allo-HSCT only within the context of a clinical trial.

HSCT in ATLL

Dr. Bazarbachi noted that ATLL has a dismal prognosis, but allo-HSCT as frontline consolidation is potentially curative.^4,5 It is most effective in patients who have achieved a complete or partial response to induction.

However, allo-HSCT should not be given as consolidation to ATLL patients who have received prior mogamulizumab. These patients have an increased risk of morbidity and mortality if they undergo allo-HSCT.

Allo-HSCT should not be given to refractory ATLL patients, although it may be an option for relapsed patients.

Dr. Bazarbachi stressed that ATLL patients should not receive auto-HSCT at any time—as frontline consolidation, after relapse, or if they have refractory disease.

Auto-HSCT “does not work in this disease,” he said. In a study published in 2014⁵, all four ATLL patients who underwent auto-HSCT “rapidly” died.

HSCT in ENKTL

Dr. Bazarbachi said frontline consolidation with auto-HSCT should be considered the standard of care for patients with non-localized ENKTL, nasal type.

Auto-HSCT has been shown to improve survival in these patients⁶, and it is most effective when patients have achieved a complete response to induction.

Allo-HSCT is also an option for frontline consolidation in patients with non-localized ENKTL, nasal type, Dr. Bazarbachi said.

He added that chemosensitive patients who have relapsed can receive allo-HSCT, but they should only receive auto-HSCT if they did not receive it in the frontline setting. Both types of transplant should take place when patients are in complete remission.

Patients with refractory, non-localized ENKTL, nasal type should not receive auto-HSCT, but allo-HSCT is an option, Dr. Bazarbachi said.

He did not declare any conflicts of interest.

1. d’Amore F et al. J Clin Oncol. 2012 Sep 1;30(25):3093-9. doi: 10.1200/JCO.2011.40.2719

2. AbouYabis AN et al. ISRN Hematol. 2011 Jun 16. doi:  10.5402/2011/623924

3. Park SI et al. Blood 2017 130:342

4. Ishida T et al. Blood 2012 Aug 23;120(8):1734-41. doi: 10.1182/blood-2012-03-414490

5. Bazarbachi A et al. Bone Marrow Transplant. 2014 Oct;49(10):1266-8. doi: 10.1038/bmt.2014.143

6. Lee J et al. Biol Blood Marrow Transplant. 2008 Dec;14(12):1356-64. doi: 10.1016/j.bbmt.2008.09.014

Ali Bazarbachi, MD, PhD

DUBROVNIK, CROATIA—Hematopoietic stem cell transplant (HSCT) can be hit-or-miss in patients with peripheral T-cell lymphomas (PTCLs), according to a speaker at Leukemia and Lymphoma: Europe and the USA, Linking Knowledge and Practice.

Ali Bazarbachi, MD, PhD, of the American University of Beirut in Lebanon, noted that the success of HSCT varies according to the subtype of PTCL and the type of transplant.

For example, autologous (auto) HSCT given as frontline consolidation can be considered the standard of care for PTCL-not otherwise specified (NOS), angioimmunoblastic T-cell lymphoma (AITL), and certain patients with anaplastic large-cell lymphoma (ALCL), according to Dr. Bazarbachi.

On the other hand, auto-HSCT should never be used in patients with adult T-cell leukemia/lymphoma (ATLL).

Both auto-HSCT and allogeneic (allo) HSCT are options for patients with non-localized, extranodal natural killer T-cell lymphoma (ENKTL), nasal type, but only at certain times.

State of PTCL treatment

Dr. Bazarbachi began his presentation by pointing out that patients with newly diagnosed PTCL are no longer treated like patients with B-cell lymphoma, but treatment outcomes in PTCL still leave a lot to be desired.

He noted that, with any of the chemotherapy regimens used, typically, about a third of patients are primary refractory, a third relapse, and a quarter are cured. Only two forms of PTCL are frequently curable—localized ENKTL and ALK-positive ALCL.

Current treatment strategies for PTCL do include HSCT, but recommendations vary. Dr. Bazarbachi made the following recommendations, supported by evidence from clinical trials.

HSCT in PTCL-NOS, AITL, and ALCL

For patients with PTCL-NOS, AITL, or ALK-negative, non-DUSP22 ALCL, auto-HSCT as frontline consolidation can be considered the standard of care in patients who responded to induction, Dr. Bazarbachi said.

In a study published in 2012¹, high-dose chemotherapy and auto-HSCT as consolidation improved 5-year overall survival—compared to previous results with CHOP²—in patients with ALK-negative ALCL, AITL, PTCL-NOS, and enteropathy-associated T-cell lymphoma.

Allo-HSCT may also be an option for frontline consolidation in patients with PTCL-NOS, AITL, or ALK-negative, non-DUSP22 ALCL, according to Dr. Bazarbachi.

“Allo-transplant is not dead in this indication,” he said. “But it should be either part of a clinical trial or [given] to some selected patients—those with persistent bone marrow involvement, very young patients, or patients with primary refractory disease.”

Results from the COMPLETE study³ showed improved survival in patients who received consolidation with auto- or allo-HSCT, as compared to patients who did not receive a transplant.

COMPLETE patients with AITL or PTCL-NOS had improvements in progression-free and overall survival with HSCT. The survival advantage was “less evident” in patients with ALCL, the researchers said, but this trial included both ALK-negative and ALK-positive patients.

Dr. Bazarbachi noted that allo- and auto-HSCT can be options after relapse in patients with PTCL-NOS, AITL, or ALK-negative, non-DUSP22 ALCL.

However, chemosensitive patients who have relapsed should only receive auto-HSCT if they did not receive it frontline. Patients who have already undergone auto-HSCT can receive allo-HSCT, Dr. Bazarbachi said.

He added that refractory patients should not undergo auto-HSCT and should receive allo-HSCT only within the context of a clinical trial.

HSCT in ATLL

Dr. Bazarbachi noted that ATLL has a dismal prognosis, but allo-HSCT as frontline consolidation is potentially curative.^4,5 It is most effective in patients who have achieved a complete or partial response to induction.

However, allo-HSCT should not be given as consolidation to ATLL patients who have received prior mogamulizumab. These patients have an increased risk of morbidity and mortality if they undergo allo-HSCT.

Allo-HSCT should not be given to refractory ATLL patients, although it may be an option for relapsed patients.

Dr. Bazarbachi stressed that ATLL patients should not receive auto-HSCT at any time—as frontline consolidation, after relapse, or if they have refractory disease.

Auto-HSCT “does not work in this disease,” he said. In a study published in 2014⁵, all four ATLL patients who underwent auto-HSCT “rapidly” died.

HSCT in ENKTL

Dr. Bazarbachi said frontline consolidation with auto-HSCT should be considered the standard of care for patients with non-localized ENKTL, nasal type.

Auto-HSCT has been shown to improve survival in these patients⁶, and it is most effective when patients have achieved a complete response to induction.

Allo-HSCT is also an option for frontline consolidation in patients with non-localized ENKTL, nasal type, Dr. Bazarbachi said.

He added that chemosensitive patients who have relapsed can receive allo-HSCT, but they should only receive auto-HSCT if they did not receive it in the frontline setting. Both types of transplant should take place when patients are in complete remission.

Patients with refractory, non-localized ENKTL, nasal type should not receive auto-HSCT, but allo-HSCT is an option, Dr. Bazarbachi said.

He did not declare any conflicts of interest.

1. d’Amore F et al. J Clin Oncol. 2012 Sep 1;30(25):3093-9. doi: 10.1200/JCO.2011.40.2719

2. AbouYabis AN et al. ISRN Hematol. 2011 Jun 16. doi:  10.5402/2011/623924

3. Park SI et al. Blood 2017 130:342

4. Ishida T et al. Blood 2012 Aug 23;120(8):1734-41. doi: 10.1182/blood-2012-03-414490

5. Bazarbachi A et al. Bone Marrow Transplant. 2014 Oct;49(10):1266-8. doi: 10.1038/bmt.2014.143

6. Lee J et al. Biol Blood Marrow Transplant. 2008 Dec;14(12):1356-64. doi: 10.1016/j.bbmt.2008.09.014

Ali Bazarbachi, MD, PhD

DUBROVNIK, CROATIA—Hematopoietic stem cell transplant (HSCT) can be hit-or-miss in patients with peripheral T-cell lymphomas (PTCLs), according to a speaker at Leukemia and Lymphoma: Europe and the USA, Linking Knowledge and Practice.

Ali Bazarbachi, MD, PhD, of the American University of Beirut in Lebanon, noted that the success of HSCT varies according to the subtype of PTCL and the type of transplant.

For example, autologous (auto) HSCT given as frontline consolidation can be considered the standard of care for PTCL-not otherwise specified (NOS), angioimmunoblastic T-cell lymphoma (AITL), and certain patients with anaplastic large-cell lymphoma (ALCL), according to Dr. Bazarbachi.

On the other hand, auto-HSCT should never be used in patients with adult T-cell leukemia/lymphoma (ATLL).

Both auto-HSCT and allogeneic (allo) HSCT are options for patients with non-localized, extranodal natural killer T-cell lymphoma (ENKTL), nasal type, but only at certain times.

State of PTCL treatment

Dr. Bazarbachi began his presentation by pointing out that patients with newly diagnosed PTCL are no longer treated like patients with B-cell lymphoma, but treatment outcomes in PTCL still leave a lot to be desired.

He noted that, with any of the chemotherapy regimens used, typically, about a third of patients are primary refractory, a third relapse, and a quarter are cured. Only two forms of PTCL are frequently curable—localized ENKTL and ALK-positive ALCL.

Current treatment strategies for PTCL do include HSCT, but recommendations vary. Dr. Bazarbachi made the following recommendations, supported by evidence from clinical trials.

HSCT in PTCL-NOS, AITL, and ALCL

For patients with PTCL-NOS, AITL, or ALK-negative, non-DUSP22 ALCL, auto-HSCT as frontline consolidation can be considered the standard of care in patients who responded to induction, Dr. Bazarbachi said.

In a study published in 2012¹, high-dose chemotherapy and auto-HSCT as consolidation improved 5-year overall survival—compared to previous results with CHOP²—in patients with ALK-negative ALCL, AITL, PTCL-NOS, and enteropathy-associated T-cell lymphoma.

Allo-HSCT may also be an option for frontline consolidation in patients with PTCL-NOS, AITL, or ALK-negative, non-DUSP22 ALCL, according to Dr. Bazarbachi.

“Allo-transplant is not dead in this indication,” he said. “But it should be either part of a clinical trial or [given] to some selected patients—those with persistent bone marrow involvement, very young patients, or patients with primary refractory disease.”

Results from the COMPLETE study³ showed improved survival in patients who received consolidation with auto- or allo-HSCT, as compared to patients who did not receive a transplant.

COMPLETE patients with AITL or PTCL-NOS had improvements in progression-free and overall survival with HSCT. The survival advantage was “less evident” in patients with ALCL, the researchers said, but this trial included both ALK-negative and ALK-positive patients.

Dr. Bazarbachi noted that allo- and auto-HSCT can be options after relapse in patients with PTCL-NOS, AITL, or ALK-negative, non-DUSP22 ALCL.

However, chemosensitive patients who have relapsed should only receive auto-HSCT if they did not receive it frontline. Patients who have already undergone auto-HSCT can receive allo-HSCT, Dr. Bazarbachi said.

He added that refractory patients should not undergo auto-HSCT and should receive allo-HSCT only within the context of a clinical trial.

HSCT in ATLL

Dr. Bazarbachi noted that ATLL has a dismal prognosis, but allo-HSCT as frontline consolidation is potentially curative.^4,5 It is most effective in patients who have achieved a complete or partial response to induction.

However, allo-HSCT should not be given as consolidation to ATLL patients who have received prior mogamulizumab. These patients have an increased risk of morbidity and mortality if they undergo allo-HSCT.

Allo-HSCT should not be given to refractory ATLL patients, although it may be an option for relapsed patients.

Dr. Bazarbachi stressed that ATLL patients should not receive auto-HSCT at any time—as frontline consolidation, after relapse, or if they have refractory disease.

Auto-HSCT “does not work in this disease,” he said. In a study published in 2014⁵, all four ATLL patients who underwent auto-HSCT “rapidly” died.

HSCT in ENKTL

Dr. Bazarbachi said frontline consolidation with auto-HSCT should be considered the standard of care for patients with non-localized ENKTL, nasal type.

Auto-HSCT has been shown to improve survival in these patients⁶, and it is most effective when patients have achieved a complete response to induction.

Allo-HSCT is also an option for frontline consolidation in patients with non-localized ENKTL, nasal type, Dr. Bazarbachi said.

He added that chemosensitive patients who have relapsed can receive allo-HSCT, but they should only receive auto-HSCT if they did not receive it in the frontline setting. Both types of transplant should take place when patients are in complete remission.

Patients with refractory, non-localized ENKTL, nasal type should not receive auto-HSCT, but allo-HSCT is an option, Dr. Bazarbachi said.

He did not declare any conflicts of interest.

1. d’Amore F et al. J Clin Oncol. 2012 Sep 1;30(25):3093-9. doi: 10.1200/JCO.2011.40.2719

2. AbouYabis AN et al. ISRN Hematol. 2011 Jun 16. doi:  10.5402/2011/623924

3. Park SI et al. Blood 2017 130:342

4. Ishida T et al. Blood 2012 Aug 23;120(8):1734-41. doi: 10.1182/blood-2012-03-414490

5. Bazarbachi A et al. Bone Marrow Transplant. 2014 Oct;49(10):1266-8. doi: 10.1038/bmt.2014.143

6. Lee J et al. Biol Blood Marrow Transplant. 2008 Dec;14(12):1356-64. doi: 10.1016/j.bbmt.2008.09.014