According to surveillance data from the Centers for Disease Control and Prevention (CDC), mortality from drug overdose has steadily increased since the dawn of the new millennium. More than 600,000 overdose deaths were reported from 2000 to 2016. According to the CDC, the first wave began with increased prescribing of opioids in the 1990s and then though the pill mills until approximately 2010. The second wave began shortly thereafter with increased overdose deaths involving heroin as the cost of prescription opioids increased when the pill mills were shut down. The third wave began in 2013 with increased overdose deaths involving synthetic opioids – particularly when illicitly manufactured fentanyl was first used as an additive to Mexican heroin. The illicitly manufactured opioid market continues to change, and is still found in combination with heroin, counterfeit “look-alike opioid prescription medication, spiked marijuana, and now cocaine.

In spite of this changing data, legally prescribed opioid use remains the focus of the most recent opioid “epidemic”. To wit, approximately 63% of the 52,404 overdose deaths in 2015 involved an opioid—but which one? By 2016, the trend was clear– heroin and fentanyl killed the majority of the 42,000 people who overdosed in 2016, more than any year on record. Further, 40% of opioid overdose deaths involved a prescription opioid. This does tell us whether the prescription opioid was attained legally or illegally. Pop star Prince died from an overdose of counterfeit oxycodone tablets, spiked with fentanyl.

Although various strategies have been introduced to address the crisis, including implementation of the CDC Guideline for Prescribing Opioids for Chronic Pain, as well as efforts to improve prescription drug monitoring programs and better access to treatment for opioid use disorder.

Figure 1 CDC Clinical Guidelines for Physicians Prescribing Opioids (CDC 2017):

These recommendations from the CDC are excellent but without adequate training for physicians who deal with chronic pain or addiction on a regular basis, they will likely not produce the change we hope for—and for good reason.  The fear of suspicion and retribution from governing bodies who monitor prescription opioids and all scheduled medications have kept physicians from prescribing these drugs for their patients who need them. Many will recall the latter days of the pill mills, with surveillance videos of sketchy looking characters carrying trash bags full of hydrocodone and oxycodone out of a doctor’s office as part of a covert sting operation–followed by the physician in handcuffs being “perp walked” on the nightly news. These images became iconic in the American psyche and have changed medical practice. Yet for the millions of Americans who suffer from legitimate chronic, non-cancer pain, this is a frightening prospect. Why? Because for most pain patients, opioids have provided a viable means to a quality of life.

The facts are clear; patients with legitimate chronic pain who are cared for by boarded pain or addiction specialists do not abuse their opioid pain medication. In fact, recent data reveal that only between 4 and 10 percent of these patients will ever misuse or abuse their medication. Most of these individuals could not work, achieve self-efficacy, or have any quality of life without the pain relief opioids provide them. We all wish that alternatives were available—but they are not. As the baby boomers are living longer and have more wear and tear and injuries that require expert pain management, there is a legitimate need for these medications—until some alternative to opioids are found. Understandably, many pain patients and their doctors are afraid that government overreach, designed to stop drug dealers and drug addicts, will rob them of the little quality of life they have because opioids provide a temporary respite from severe pain.

In truth, the DEA has done a good job of shutting down the pill mills and most states now allow physicians to access each patient’s pharmacy records online. This process has also shut down “doctor shopping” for controlled substances and takes less than a minute to review all prescriptions for controlled substances for a single patient. Perhaps the epidemic of chronic pain should be the focus of our research efforts.

So why are people still dying from opioid overdose? The CDC report reveals part of the answer. As the pill mills shut down, the price of illicit prescription opioids increased substantially. In response, the Mexican cartel, which was losing billions due to legalized marijuana, flooded the US with cheap, powerful heroin. It was cheap and powerful because the cartel was spiking it with homemade fentanyl, which is approximately 100 times more potent that morphine. It is heroin and fentanyl that are killing thousands of Americans each month.

Cannabis and Pain

Is marijuana really a reasonable alternative to opioids for opioid addicts or for chronic pain? Maybe, but the science is woefully silent on the topic. What little science exists remains inconclusive. The recent JAMA article shows epidemiological trends among Medicare Part D recipients and state Medicaid recipients. The analysis attempts to statistically correlate states with liberal marijuana laws and a decrease in the number of opioid prescriptions written between 2010 and 2015.

Why Does This Matter?

Correlation is not causation. The conclusions reached by this investigation suggest that merely the decline of filling prescriptions for opioids by elderly infirmed adults is due to liberalized, legal access to cannabis, which is quite a reach in logic. This conclusion assumes these same adults voluntarily switched from their opioids to medical marijuana for pain control.  In truth, there are hundreds of variants, including hordes of untrained and anxious physicians who live in fear that prescribing opioids sends a red flag to licensing boards and invites increased scrutiny and potential retribution. Plus, any physician who believes in evidence-based medicine is unlikely to prescribe medical marijuana for pain. At present, the research does not support this practice.

Double blind, placebo-controlled comparisons between medical marijuana and legally prescribed opioids for debilitating non-cancer pain syndromes will provide the science necessary to determine the efficacy and safety of marijuana as a medication for chronic pain.

Yes, it is feasible that the endocannabinoid system may provide new therapeutics for pain and other disease. However, the well-established risks associated with THC must be accounted for. It hard to believe that elderly patients would choose to be stoned for 3-5 hours and experience the cognitive “dulling” and short-term memory deficits over an opioid that if anything, gives them some energy, plus the best pain relief known.

The recent approval of the Cannabidiol (CBD) based medication Epiolidex by an FDA subcommittee, for treating two debilitating seizures disorders, has provided a model for assessing efficacy and risk for cannabis-based medicines. CBD is non-addictive and non-psychoactive.  Until similar scientific scrutiny proves safety and efficacy of THC products, they should be considered harmful.

Reference
Bradford AC, Bradford WD, Abraham A,  Bagwell Adams G . Association Between US State Medical Cannabis Laws and Opioid Prescribing in the Medicare Part D Population. JAMA Intern Med. 2018 Apr 2. doi: 10.1001/jamainternmed.2018.0266. [Epub ahead of print]

According to surveillance data from the Centers for Disease Control and Prevention (CDC), mortality from drug overdose has steadily increased since the dawn of the new millennium. More than 600,000 overdose deaths were reported from 2000 to 2016. According to the CDC, the first wave began with increased prescribing of opioids in the 1990s and then though the pill mills until approximately 2010. The second wave began shortly thereafter with increased overdose deaths involving heroin as the cost of prescription opioids increased when the pill mills were shut down. The third wave began in 2013 with increased overdose deaths involving synthetic opioids – particularly when illicitly manufactured fentanyl was first used as an additive to Mexican heroin. The illicitly manufactured opioid market continues to change, and is still found in combination with heroin, counterfeit “look-alike opioid prescription medication, spiked marijuana, and now cocaine.

In spite of this changing data, legally prescribed opioid use remains the focus of the most recent opioid “epidemic”. To wit, approximately 63% of the 52,404 overdose deaths in 2015 involved an opioid—but which one? By 2016, the trend was clear– heroin and fentanyl killed the majority of the 42,000 people who overdosed in 2016, more than any year on record. Further, 40% of opioid overdose deaths involved a prescription opioid. This does tell us whether the prescription opioid was attained legally or illegally. Pop star Prince died from an overdose of counterfeit oxycodone tablets, spiked with fentanyl.

Although various strategies have been introduced to address the crisis, including implementation of the CDC Guideline for Prescribing Opioids for Chronic Pain, as well as efforts to improve prescription drug monitoring programs and better access to treatment for opioid use disorder.

Figure 1 CDC Clinical Guidelines for Physicians Prescribing Opioids (CDC 2017):

These recommendations from the CDC are excellent but without adequate training for physicians who deal with chronic pain or addiction on a regular basis, they will likely not produce the change we hope for—and for good reason.  The fear of suspicion and retribution from governing bodies who monitor prescription opioids and all scheduled medications have kept physicians from prescribing these drugs for their patients who need them. Many will recall the latter days of the pill mills, with surveillance videos of sketchy looking characters carrying trash bags full of hydrocodone and oxycodone out of a doctor’s office as part of a covert sting operation–followed by the physician in handcuffs being “perp walked” on the nightly news. These images became iconic in the American psyche and have changed medical practice. Yet for the millions of Americans who suffer from legitimate chronic, non-cancer pain, this is a frightening prospect. Why? Because for most pain patients, opioids have provided a viable means to a quality of life.

The facts are clear; patients with legitimate chronic pain who are cared for by boarded pain or addiction specialists do not abuse their opioid pain medication. In fact, recent data reveal that only between 4 and 10 percent of these patients will ever misuse or abuse their medication. Most of these individuals could not work, achieve self-efficacy, or have any quality of life without the pain relief opioids provide them. We all wish that alternatives were available—but they are not. As the baby boomers are living longer and have more wear and tear and injuries that require expert pain management, there is a legitimate need for these medications—until some alternative to opioids are found. Understandably, many pain patients and their doctors are afraid that government overreach, designed to stop drug dealers and drug addicts, will rob them of the little quality of life they have because opioids provide a temporary respite from severe pain.

In truth, the DEA has done a good job of shutting down the pill mills and most states now allow physicians to access each patient’s pharmacy records online. This process has also shut down “doctor shopping” for controlled substances and takes less than a minute to review all prescriptions for controlled substances for a single patient. Perhaps the epidemic of chronic pain should be the focus of our research efforts.

So why are people still dying from opioid overdose? The CDC report reveals part of the answer. As the pill mills shut down, the price of illicit prescription opioids increased substantially. In response, the Mexican cartel, which was losing billions due to legalized marijuana, flooded the US with cheap, powerful heroin. It was cheap and powerful because the cartel was spiking it with homemade fentanyl, which is approximately 100 times more potent that morphine. It is heroin and fentanyl that are killing thousands of Americans each month.

Cannabis and Pain

Is marijuana really a reasonable alternative to opioids for opioid addicts or for chronic pain? Maybe, but the science is woefully silent on the topic. What little science exists remains inconclusive. The recent JAMA article shows epidemiological trends among Medicare Part D recipients and state Medicaid recipients. The analysis attempts to statistically correlate states with liberal marijuana laws and a decrease in the number of opioid prescriptions written between 2010 and 2015.

Why Does This Matter?

Correlation is not causation. The conclusions reached by this investigation suggest that merely the decline of filling prescriptions for opioids by elderly infirmed adults is due to liberalized, legal access to cannabis, which is quite a reach in logic. This conclusion assumes these same adults voluntarily switched from their opioids to medical marijuana for pain control.  In truth, there are hundreds of variants, including hordes of untrained and anxious physicians who live in fear that prescribing opioids sends a red flag to licensing boards and invites increased scrutiny and potential retribution. Plus, any physician who believes in evidence-based medicine is unlikely to prescribe medical marijuana for pain. At present, the research does not support this practice.

Double blind, placebo-controlled comparisons between medical marijuana and legally prescribed opioids for debilitating non-cancer pain syndromes will provide the science necessary to determine the efficacy and safety of marijuana as a medication for chronic pain.

Yes, it is feasible that the endocannabinoid system may provide new therapeutics for pain and other disease. However, the well-established risks associated with THC must be accounted for. It hard to believe that elderly patients would choose to be stoned for 3-5 hours and experience the cognitive “dulling” and short-term memory deficits over an opioid that if anything, gives them some energy, plus the best pain relief known.

The recent approval of the Cannabidiol (CBD) based medication Epiolidex by an FDA subcommittee, for treating two debilitating seizures disorders, has provided a model for assessing efficacy and risk for cannabis-based medicines. CBD is non-addictive and non-psychoactive.  Until similar scientific scrutiny proves safety and efficacy of THC products, they should be considered harmful.

Reference
Bradford AC, Bradford WD, Abraham A,  Bagwell Adams G . Association Between US State Medical Cannabis Laws and Opioid Prescribing in the Medicare Part D Population. JAMA Intern Med. 2018 Apr 2. doi: 10.1001/jamainternmed.2018.0266. [Epub ahead of print]

According to surveillance data from the Centers for Disease Control and Prevention (CDC), mortality from drug overdose has steadily increased since the dawn of the new millennium. More than 600,000 overdose deaths were reported from 2000 to 2016. According to the CDC, the first wave began with increased prescribing of opioids in the 1990s and then though the pill mills until approximately 2010. The second wave began shortly thereafter with increased overdose deaths involving heroin as the cost of prescription opioids increased when the pill mills were shut down. The third wave began in 2013 with increased overdose deaths involving synthetic opioids – particularly when illicitly manufactured fentanyl was first used as an additive to Mexican heroin. The illicitly manufactured opioid market continues to change, and is still found in combination with heroin, counterfeit “look-alike opioid prescription medication, spiked marijuana, and now cocaine.

In spite of this changing data, legally prescribed opioid use remains the focus of the most recent opioid “epidemic”. To wit, approximately 63% of the 52,404 overdose deaths in 2015 involved an opioid—but which one? By 2016, the trend was clear– heroin and fentanyl killed the majority of the 42,000 people who overdosed in 2016, more than any year on record. Further, 40% of opioid overdose deaths involved a prescription opioid. This does tell us whether the prescription opioid was attained legally or illegally. Pop star Prince died from an overdose of counterfeit oxycodone tablets, spiked with fentanyl.

Although various strategies have been introduced to address the crisis, including implementation of the CDC Guideline for Prescribing Opioids for Chronic Pain, as well as efforts to improve prescription drug monitoring programs and better access to treatment for opioid use disorder.

Figure 1 CDC Clinical Guidelines for Physicians Prescribing Opioids (CDC 2017):

These recommendations from the CDC are excellent but without adequate training for physicians who deal with chronic pain or addiction on a regular basis, they will likely not produce the change we hope for—and for good reason.  The fear of suspicion and retribution from governing bodies who monitor prescription opioids and all scheduled medications have kept physicians from prescribing these drugs for their patients who need them. Many will recall the latter days of the pill mills, with surveillance videos of sketchy looking characters carrying trash bags full of hydrocodone and oxycodone out of a doctor’s office as part of a covert sting operation–followed by the physician in handcuffs being “perp walked” on the nightly news. These images became iconic in the American psyche and have changed medical practice. Yet for the millions of Americans who suffer from legitimate chronic, non-cancer pain, this is a frightening prospect. Why? Because for most pain patients, opioids have provided a viable means to a quality of life.

The facts are clear; patients with legitimate chronic pain who are cared for by boarded pain or addiction specialists do not abuse their opioid pain medication. In fact, recent data reveal that only between 4 and 10 percent of these patients will ever misuse or abuse their medication. Most of these individuals could not work, achieve self-efficacy, or have any quality of life without the pain relief opioids provide them. We all wish that alternatives were available—but they are not. As the baby boomers are living longer and have more wear and tear and injuries that require expert pain management, there is a legitimate need for these medications—until some alternative to opioids are found. Understandably, many pain patients and their doctors are afraid that government overreach, designed to stop drug dealers and drug addicts, will rob them of the little quality of life they have because opioids provide a temporary respite from severe pain.

In truth, the DEA has done a good job of shutting down the pill mills and most states now allow physicians to access each patient’s pharmacy records online. This process has also shut down “doctor shopping” for controlled substances and takes less than a minute to review all prescriptions for controlled substances for a single patient. Perhaps the epidemic of chronic pain should be the focus of our research efforts.

So why are people still dying from opioid overdose? The CDC report reveals part of the answer. As the pill mills shut down, the price of illicit prescription opioids increased substantially. In response, the Mexican cartel, which was losing billions due to legalized marijuana, flooded the US with cheap, powerful heroin. It was cheap and powerful because the cartel was spiking it with homemade fentanyl, which is approximately 100 times more potent that morphine. It is heroin and fentanyl that are killing thousands of Americans each month.

Cannabis and Pain

Is marijuana really a reasonable alternative to opioids for opioid addicts or for chronic pain? Maybe, but the science is woefully silent on the topic. What little science exists remains inconclusive. The recent JAMA article shows epidemiological trends among Medicare Part D recipients and state Medicaid recipients. The analysis attempts to statistically correlate states with liberal marijuana laws and a decrease in the number of opioid prescriptions written between 2010 and 2015.

Why Does This Matter?

Correlation is not causation. The conclusions reached by this investigation suggest that merely the decline of filling prescriptions for opioids by elderly infirmed adults is due to liberalized, legal access to cannabis, which is quite a reach in logic. This conclusion assumes these same adults voluntarily switched from their opioids to medical marijuana for pain control.  In truth, there are hundreds of variants, including hordes of untrained and anxious physicians who live in fear that prescribing opioids sends a red flag to licensing boards and invites increased scrutiny and potential retribution. Plus, any physician who believes in evidence-based medicine is unlikely to prescribe medical marijuana for pain. At present, the research does not support this practice.

Double blind, placebo-controlled comparisons between medical marijuana and legally prescribed opioids for debilitating non-cancer pain syndromes will provide the science necessary to determine the efficacy and safety of marijuana as a medication for chronic pain.

Yes, it is feasible that the endocannabinoid system may provide new therapeutics for pain and other disease. However, the well-established risks associated with THC must be accounted for. It hard to believe that elderly patients would choose to be stoned for 3-5 hours and experience the cognitive “dulling” and short-term memory deficits over an opioid that if anything, gives them some energy, plus the best pain relief known.

The recent approval of the Cannabidiol (CBD) based medication Epiolidex by an FDA subcommittee, for treating two debilitating seizures disorders, has provided a model for assessing efficacy and risk for cannabis-based medicines. CBD is non-addictive and non-psychoactive.  Until similar scientific scrutiny proves safety and efficacy of THC products, they should be considered harmful.

Reference
Bradford AC, Bradford WD, Abraham A,  Bagwell Adams G . Association Between US State Medical Cannabis Laws and Opioid Prescribing in the Medicare Part D Population. JAMA Intern Med. 2018 Apr 2. doi: 10.1001/jamainternmed.2018.0266. [Epub ahead of print]

Data from a VA report on its nursing homesshow that the VA’s 132 community living centers compare closely with 15,487 private-sector nursing homes even though the VA on average cares for sicker patients, with a higher proportion of conditions such as spinal cord injury, PTSD, and combat injury: 25.6% of VA nursing homes rated 5 stars (the highest rating), as did 28.7% of private-sector facilities.

The VA report notes that VA nursing homes do not refuse service to any eligible veteran. The fact that they often house residents with more complex medical needs than private-sector facilities will accept “makes achieving good quality ratings more challenging,” the VA says. VA nursing homes at times rate lower than private-sector facilities on specific metrics such as pain and type of treatment.

But the VA has a significantly lower percentage of 1-star (lowest rated) facilities. Moreover, 60 of the VA’s nursing homes improved their quality score in the past year. The report also says VA nursing homes have a higher staff-to-resident ratio than private-sector facilities, meaning residents in VA facilities get more direct attention

Data from a VA report on its nursing homesshow that the VA’s 132 community living centers compare closely with 15,487 private-sector nursing homes even though the VA on average cares for sicker patients, with a higher proportion of conditions such as spinal cord injury, PTSD, and combat injury: 25.6% of VA nursing homes rated 5 stars (the highest rating), as did 28.7% of private-sector facilities.

The VA report notes that VA nursing homes do not refuse service to any eligible veteran. The fact that they often house residents with more complex medical needs than private-sector facilities will accept “makes achieving good quality ratings more challenging,” the VA says. VA nursing homes at times rate lower than private-sector facilities on specific metrics such as pain and type of treatment.

But the VA has a significantly lower percentage of 1-star (lowest rated) facilities. Moreover, 60 of the VA’s nursing homes improved their quality score in the past year. The report also says VA nursing homes have a higher staff-to-resident ratio than private-sector facilities, meaning residents in VA facilities get more direct attention

Data from a VA report on its nursing homesshow that the VA’s 132 community living centers compare closely with 15,487 private-sector nursing homes even though the VA on average cares for sicker patients, with a higher proportion of conditions such as spinal cord injury, PTSD, and combat injury: 25.6% of VA nursing homes rated 5 stars (the highest rating), as did 28.7% of private-sector facilities.

The VA report notes that VA nursing homes do not refuse service to any eligible veteran. The fact that they often house residents with more complex medical needs than private-sector facilities will accept “makes achieving good quality ratings more challenging,” the VA says. VA nursing homes at times rate lower than private-sector facilities on specific metrics such as pain and type of treatment.

But the VA has a significantly lower percentage of 1-star (lowest rated) facilities. Moreover, 60 of the VA’s nursing homes improved their quality score in the past year. The report also says VA nursing homes have a higher staff-to-resident ratio than private-sector facilities, meaning residents in VA facilities get more direct attention

Photo from UAB

Children may have an increased risk of premature death decades after allogeneic hematopoietic stem cell transplant (allo-HSCT), according to a study published in JAMA Oncology.

The leading causes of death in the patients studied were infection and chronic graft-vs-host disease (GVHD), patients’ primary disease, and subsequent cancers.

“This study shows that, while we are able to save the life of the child during their cancer treatment, we need to continue to provide proactive follow-up care with these types of patients throughout the rest of their life, as they are still an at-risk population,” said study author Smita Bhatia, MBBS, of the University of Alabama at Birmingham (UAB).

“The high intensity of therapeutic exposures at a young age lends itself to cause morbidities and organ compromise once they reach adulthood.”

Dr Bhatia and her colleagues conducted this retrospective study of children who underwent allo-HSCT between January 1, 1974, and December 31, 2010, and were followed until December 31, 2016.

The study included 1388 patients who lived 2 years or more after transplant. Their median age at transplant was 14.6 years (range, 0-21). The majority of patients were non-Hispanic white (70.7%), and most were male (59.7%).

Patients underwent allo-HSCT to treat acute lymphoblastic leukemia (ALL, 25.1%), acute myeloid leukemia (AML) or myelodysplastic syndromes (MDS, 23.5%), inborn errors of metabolism (13.8%), severe aplastic anemia (SAA, 10.6%), Fanconi anemia (8.3%), chronic myelogenous leukemia (CML, 6.5%), immune disorders (4%), sickle cell disease or thalassemia (1.9%), and other diseases.

Most patients had a related donor (57.9%), and most received a bone marrow transplant (73.4%).

The most common component of conditioning was cyclophosphamide (80.5%), followed by total body irradiation (TBI, 64.3%). About half of patients (49.8%) received both cyclophosphamide and TBI, and nearly a quarter (23.5%) received busulfan and cyclophosphamide.

Outcomes

The researchers found that allo-HSCT recipients had a 14.4-fold greater risk of premature death than the general population.

The team said the absolute excess risk of all-cause mortality was 12.0 per 1000 person-years, and relative mortality remained elevated 25 years or more after transplant (standardized mortality ratio, 2.9).

At a median follow-up of 14.9 years (range, 2.0 to 41.2), 295 patients had died. The 20-year overall survival rate was 79.3%.

The cause of death was available for 82.7% of patients (244/295), and some of these patients had more than 1 cause listed. Causes of death included:

• Infection and/or chronic GVHD—49.6%
• Primary disease—24.6%
• Subsequent malignant neoplasm—18.4%
• Cardiac disease—9.8%
• Pulmonary disease—7.8%
• External causes—2.9%
• Other causes—18.0%.

The hazard of all-cause late mortality was higher among patients who were older at transplant (hazard ratio [HR], 1.03; P=0.004) and those who had a high risk of relapse at transplant (HR, 1.95; P<0.001).

Compared to patients treated for ALL, the hazard of all-cause late mortality was lower among patients with AML/MDS (HR, 0.72; P=0.04), CML (HR, 0.53; P=0.02), Fanconi anemia (HR, 0.49; P=0.03), immune disorders (HR, 0.32; P=0.006), and SAA (HR, 0.33; P<0.001).

The hazard of all-cause late mortality was lower for patients who received conditioning with busulfan and cyclophosphamide (HR, 0.62; P=0.03) than for those who received TBI and cyclophosphamide.

Compared to patients treated for ALL, the hazard of relapse-related mortality was lower among patients with AML/MDS (HR, 0.39; P=0.01) and SAA (HR, 0.09; P=0.03), and the hazard of non-relapse mortality was lower for patients with SAA (HR, 0.36; P=0.004) and immune disorders (HR, 0.14; P=0.009).

The hazard of non-relapse mortality was higher for patients who were older at transplant (HR, 1.03; P=0.03), patients who received peripheral blood stem cells rather than bone marrow (HR, 2.39; P=0.01), and patients who had a high risk of relapse at transplant (HR, 2.05; P<0.001).

Photo from UAB

Children may have an increased risk of premature death decades after allogeneic hematopoietic stem cell transplant (allo-HSCT), according to a study published in JAMA Oncology.

The leading causes of death in the patients studied were infection and chronic graft-vs-host disease (GVHD), patients’ primary disease, and subsequent cancers.

“This study shows that, while we are able to save the life of the child during their cancer treatment, we need to continue to provide proactive follow-up care with these types of patients throughout the rest of their life, as they are still an at-risk population,” said study author Smita Bhatia, MBBS, of the University of Alabama at Birmingham (UAB).

“The high intensity of therapeutic exposures at a young age lends itself to cause morbidities and organ compromise once they reach adulthood.”

Dr Bhatia and her colleagues conducted this retrospective study of children who underwent allo-HSCT between January 1, 1974, and December 31, 2010, and were followed until December 31, 2016.

The study included 1388 patients who lived 2 years or more after transplant. Their median age at transplant was 14.6 years (range, 0-21). The majority of patients were non-Hispanic white (70.7%), and most were male (59.7%).

Patients underwent allo-HSCT to treat acute lymphoblastic leukemia (ALL, 25.1%), acute myeloid leukemia (AML) or myelodysplastic syndromes (MDS, 23.5%), inborn errors of metabolism (13.8%), severe aplastic anemia (SAA, 10.6%), Fanconi anemia (8.3%), chronic myelogenous leukemia (CML, 6.5%), immune disorders (4%), sickle cell disease or thalassemia (1.9%), and other diseases.

Most patients had a related donor (57.9%), and most received a bone marrow transplant (73.4%).

The most common component of conditioning was cyclophosphamide (80.5%), followed by total body irradiation (TBI, 64.3%). About half of patients (49.8%) received both cyclophosphamide and TBI, and nearly a quarter (23.5%) received busulfan and cyclophosphamide.

Outcomes

The researchers found that allo-HSCT recipients had a 14.4-fold greater risk of premature death than the general population.

The team said the absolute excess risk of all-cause mortality was 12.0 per 1000 person-years, and relative mortality remained elevated 25 years or more after transplant (standardized mortality ratio, 2.9).

At a median follow-up of 14.9 years (range, 2.0 to 41.2), 295 patients had died. The 20-year overall survival rate was 79.3%.

The cause of death was available for 82.7% of patients (244/295), and some of these patients had more than 1 cause listed. Causes of death included:

• Infection and/or chronic GVHD—49.6%
• Primary disease—24.6%
• Subsequent malignant neoplasm—18.4%
• Cardiac disease—9.8%
• Pulmonary disease—7.8%
• External causes—2.9%
• Other causes—18.0%.

The hazard of all-cause late mortality was higher among patients who were older at transplant (hazard ratio [HR], 1.03; P=0.004) and those who had a high risk of relapse at transplant (HR, 1.95; P<0.001).

Compared to patients treated for ALL, the hazard of all-cause late mortality was lower among patients with AML/MDS (HR, 0.72; P=0.04), CML (HR, 0.53; P=0.02), Fanconi anemia (HR, 0.49; P=0.03), immune disorders (HR, 0.32; P=0.006), and SAA (HR, 0.33; P<0.001).

The hazard of all-cause late mortality was lower for patients who received conditioning with busulfan and cyclophosphamide (HR, 0.62; P=0.03) than for those who received TBI and cyclophosphamide.

Compared to patients treated for ALL, the hazard of relapse-related mortality was lower among patients with AML/MDS (HR, 0.39; P=0.01) and SAA (HR, 0.09; P=0.03), and the hazard of non-relapse mortality was lower for patients with SAA (HR, 0.36; P=0.004) and immune disorders (HR, 0.14; P=0.009).

The hazard of non-relapse mortality was higher for patients who were older at transplant (HR, 1.03; P=0.03), patients who received peripheral blood stem cells rather than bone marrow (HR, 2.39; P=0.01), and patients who had a high risk of relapse at transplant (HR, 2.05; P<0.001).

Photo from UAB

Children may have an increased risk of premature death decades after allogeneic hematopoietic stem cell transplant (allo-HSCT), according to a study published in JAMA Oncology.

The leading causes of death in the patients studied were infection and chronic graft-vs-host disease (GVHD), patients’ primary disease, and subsequent cancers.

“This study shows that, while we are able to save the life of the child during their cancer treatment, we need to continue to provide proactive follow-up care with these types of patients throughout the rest of their life, as they are still an at-risk population,” said study author Smita Bhatia, MBBS, of the University of Alabama at Birmingham (UAB).

“The high intensity of therapeutic exposures at a young age lends itself to cause morbidities and organ compromise once they reach adulthood.”

Dr Bhatia and her colleagues conducted this retrospective study of children who underwent allo-HSCT between January 1, 1974, and December 31, 2010, and were followed until December 31, 2016.

The study included 1388 patients who lived 2 years or more after transplant. Their median age at transplant was 14.6 years (range, 0-21). The majority of patients were non-Hispanic white (70.7%), and most were male (59.7%).

Patients underwent allo-HSCT to treat acute lymphoblastic leukemia (ALL, 25.1%), acute myeloid leukemia (AML) or myelodysplastic syndromes (MDS, 23.5%), inborn errors of metabolism (13.8%), severe aplastic anemia (SAA, 10.6%), Fanconi anemia (8.3%), chronic myelogenous leukemia (CML, 6.5%), immune disorders (4%), sickle cell disease or thalassemia (1.9%), and other diseases.

Most patients had a related donor (57.9%), and most received a bone marrow transplant (73.4%).

The most common component of conditioning was cyclophosphamide (80.5%), followed by total body irradiation (TBI, 64.3%). About half of patients (49.8%) received both cyclophosphamide and TBI, and nearly a quarter (23.5%) received busulfan and cyclophosphamide.

Outcomes

The researchers found that allo-HSCT recipients had a 14.4-fold greater risk of premature death than the general population.

The team said the absolute excess risk of all-cause mortality was 12.0 per 1000 person-years, and relative mortality remained elevated 25 years or more after transplant (standardized mortality ratio, 2.9).

At a median follow-up of 14.9 years (range, 2.0 to 41.2), 295 patients had died. The 20-year overall survival rate was 79.3%.

The cause of death was available for 82.7% of patients (244/295), and some of these patients had more than 1 cause listed. Causes of death included:

• Infection and/or chronic GVHD—49.6%
• Primary disease—24.6%
• Subsequent malignant neoplasm—18.4%
• Cardiac disease—9.8%
• Pulmonary disease—7.8%
• External causes—2.9%
• Other causes—18.0%.

The hazard of all-cause late mortality was higher among patients who were older at transplant (hazard ratio [HR], 1.03; P=0.004) and those who had a high risk of relapse at transplant (HR, 1.95; P<0.001).

Compared to patients treated for ALL, the hazard of all-cause late mortality was lower among patients with AML/MDS (HR, 0.72; P=0.04), CML (HR, 0.53; P=0.02), Fanconi anemia (HR, 0.49; P=0.03), immune disorders (HR, 0.32; P=0.006), and SAA (HR, 0.33; P<0.001).

The hazard of all-cause late mortality was lower for patients who received conditioning with busulfan and cyclophosphamide (HR, 0.62; P=0.03) than for those who received TBI and cyclophosphamide.

Compared to patients treated for ALL, the hazard of relapse-related mortality was lower among patients with AML/MDS (HR, 0.39; P=0.01) and SAA (HR, 0.09; P=0.03), and the hazard of non-relapse mortality was lower for patients with SAA (HR, 0.36; P=0.004) and immune disorders (HR, 0.14; P=0.009).

The hazard of non-relapse mortality was higher for patients who were older at transplant (HR, 1.03; P=0.03), patients who received peripheral blood stem cells rather than bone marrow (HR, 2.39; P=0.01), and patients who had a high risk of relapse at transplant (HR, 2.05; P<0.001).

Risky or higher alcohol consumption while breastfeeding could be associated with poorer cognitive outcomes in children, according to a longitudinal cohort study.

©Maxim Tupikov/iStockphoto.com

SOURCE: Gibson L et al. Pediatrics 2018 Jul 30. doi: 10.1542/peds.2017-4266.

Risky or higher alcohol consumption while breastfeeding could be associated with poorer cognitive outcomes in children, according to a longitudinal cohort study.

©Maxim Tupikov/iStockphoto.com

SOURCE: Gibson L et al. Pediatrics 2018 Jul 30. doi: 10.1542/peds.2017-4266.

Risky or higher alcohol consumption while breastfeeding could be associated with poorer cognitive outcomes in children, according to a longitudinal cohort study.

©Maxim Tupikov/iStockphoto.com

SOURCE: Gibson L et al. Pediatrics 2018 Jul 30. doi: 10.1542/peds.2017-4266.

General pediatricians and subspecialists need to provide early and ongoing counseling about infertility and sexual dysfunction for at-risk patients, the American Academy of Pediatrics (AAP) has said in its first-ever clinical report on how to address these potentially sensitive topics.

Examples of pediatric populations at risk for infertility/and or sexual dysfunction include those with hematologic and oncologic disorders such as genitourinary cancer, genetic disorders such as Down syndrome, rheumatologic disorders such as rheumatoid arthritis, and endocrine disorders such as diabetes.

Counseling should include discussion of possible management and psychosocial support options for patients who have conditions or who need treatments that might impair reproductive capacity or sexual functioning, according to the policy statement, published July 30 in Pediatrics.

“We want children to feel safe asking questions, as a lack of information can lead to inaccurate beliefs or distress over time, through young adulthood,” Leena Nahata, MD, a pediatric physician in the endocrinology division at Nationwide Children’s Hospital, Columbus, Ohio, and her coauthors, wrote in an AAP statement.

The policy statement lists five specific recommendations for counseling at-risk pediatric populations on fertility and sexual function:

1. Early discussion is essential, and should start either with parents in infancy, or at the soonest time point where the patient could be affected.

2. “Developmentally sensitive approaches” should be used to deliver complete information about patients’ conditions, accounting for changes in patients’ concerns, perspectives, and comprehension level as they mature.

3. Evidence-based interventions and recommendations should be used, and when evidence is not available, that information needs to be shared with families to facilitate decision-making.

4. Interdisciplinary teams need strategies to discuss risks and interventions in a “direct but sensitive manner” allowing time for questions and considerations; teams also should identify which provider will discuss each risk and potential intervention, and when those discussions will occur.

5. Documentation of discussions and their outcomes are critical to ensure clear communication between health care providers and smooth transition to adult care.

Although team physicians have the best grasp of relevant medical issues, behavioral health specialists are “best equipped” to comprehend cultural, developmental, and family psychosocial issues, and to engage children in decision making, according Dr. Nahata, also affiliated with the Ohio State University, Columbus, and her coauthors.

“By having ongoing discussions, we are more likely to establish a sense of safety and trust, while helping youth and family make informed decisions,” coauthor Amy C. Tishelman, PhD, of the departments of endocrinology and psychiatry, Boston Children’s Hospital and Harvard Medical School, Boston, said in the AAP statement announcing the new guidelines.

Gwendolyn P. Quinn, PhD, of the department of obstetrics and gynecology, New York University Langone Medical Center, served as a third coauthor of the report.

In the AAP statement, Dr. Quinn noted differences in child and adolescent counseling needs, stating that adolescents might express concerns about pregnancy or might need information on contraception to avoid sexually transmitted diseases.

By contrast, detailed discussions about sexual function or fertility might not be appropriate for younger children, who nevertheless might exhibit interest and curiosity in their bodies, and should be made comfortable to ask questions. Open-ended prompts such as “How are you feeling about your body?” could be helpful for children approaching adolescence, according to the policy statement.

Dr. Nahata, Dr. Quinn, and Dr. Tishelman reported that they had no financial relationships relevant to their report, no external funding, and no potential conflicts of interest to disclose.

SOURCE: Nahata L et al. Pediatrics. 2018 Jul 30. doi: 10.1542/peds.2018-1435.

General pediatricians and subspecialists need to provide early and ongoing counseling about infertility and sexual dysfunction for at-risk patients, the American Academy of Pediatrics (AAP) has said in its first-ever clinical report on how to address these potentially sensitive topics.

Examples of pediatric populations at risk for infertility/and or sexual dysfunction include those with hematologic and oncologic disorders such as genitourinary cancer, genetic disorders such as Down syndrome, rheumatologic disorders such as rheumatoid arthritis, and endocrine disorders such as diabetes.

Counseling should include discussion of possible management and psychosocial support options for patients who have conditions or who need treatments that might impair reproductive capacity or sexual functioning, according to the policy statement, published July 30 in Pediatrics.

“We want children to feel safe asking questions, as a lack of information can lead to inaccurate beliefs or distress over time, through young adulthood,” Leena Nahata, MD, a pediatric physician in the endocrinology division at Nationwide Children’s Hospital, Columbus, Ohio, and her coauthors, wrote in an AAP statement.

The policy statement lists five specific recommendations for counseling at-risk pediatric populations on fertility and sexual function:

1. Early discussion is essential, and should start either with parents in infancy, or at the soonest time point where the patient could be affected.

2. “Developmentally sensitive approaches” should be used to deliver complete information about patients’ conditions, accounting for changes in patients’ concerns, perspectives, and comprehension level as they mature.

3. Evidence-based interventions and recommendations should be used, and when evidence is not available, that information needs to be shared with families to facilitate decision-making.

4. Interdisciplinary teams need strategies to discuss risks and interventions in a “direct but sensitive manner” allowing time for questions and considerations; teams also should identify which provider will discuss each risk and potential intervention, and when those discussions will occur.

5. Documentation of discussions and their outcomes are critical to ensure clear communication between health care providers and smooth transition to adult care.

Although team physicians have the best grasp of relevant medical issues, behavioral health specialists are “best equipped” to comprehend cultural, developmental, and family psychosocial issues, and to engage children in decision making, according Dr. Nahata, also affiliated with the Ohio State University, Columbus, and her coauthors.

“By having ongoing discussions, we are more likely to establish a sense of safety and trust, while helping youth and family make informed decisions,” coauthor Amy C. Tishelman, PhD, of the departments of endocrinology and psychiatry, Boston Children’s Hospital and Harvard Medical School, Boston, said in the AAP statement announcing the new guidelines.

Gwendolyn P. Quinn, PhD, of the department of obstetrics and gynecology, New York University Langone Medical Center, served as a third coauthor of the report.

In the AAP statement, Dr. Quinn noted differences in child and adolescent counseling needs, stating that adolescents might express concerns about pregnancy or might need information on contraception to avoid sexually transmitted diseases.

By contrast, detailed discussions about sexual function or fertility might not be appropriate for younger children, who nevertheless might exhibit interest and curiosity in their bodies, and should be made comfortable to ask questions. Open-ended prompts such as “How are you feeling about your body?” could be helpful for children approaching adolescence, according to the policy statement.

Dr. Nahata, Dr. Quinn, and Dr. Tishelman reported that they had no financial relationships relevant to their report, no external funding, and no potential conflicts of interest to disclose.

SOURCE: Nahata L et al. Pediatrics. 2018 Jul 30. doi: 10.1542/peds.2018-1435.

General pediatricians and subspecialists need to provide early and ongoing counseling about infertility and sexual dysfunction for at-risk patients, the American Academy of Pediatrics (AAP) has said in its first-ever clinical report on how to address these potentially sensitive topics.

Examples of pediatric populations at risk for infertility/and or sexual dysfunction include those with hematologic and oncologic disorders such as genitourinary cancer, genetic disorders such as Down syndrome, rheumatologic disorders such as rheumatoid arthritis, and endocrine disorders such as diabetes.

Counseling should include discussion of possible management and psychosocial support options for patients who have conditions or who need treatments that might impair reproductive capacity or sexual functioning, according to the policy statement, published July 30 in Pediatrics.

“We want children to feel safe asking questions, as a lack of information can lead to inaccurate beliefs or distress over time, through young adulthood,” Leena Nahata, MD, a pediatric physician in the endocrinology division at Nationwide Children’s Hospital, Columbus, Ohio, and her coauthors, wrote in an AAP statement.

The policy statement lists five specific recommendations for counseling at-risk pediatric populations on fertility and sexual function:

1. Early discussion is essential, and should start either with parents in infancy, or at the soonest time point where the patient could be affected.

2. “Developmentally sensitive approaches” should be used to deliver complete information about patients’ conditions, accounting for changes in patients’ concerns, perspectives, and comprehension level as they mature.

3. Evidence-based interventions and recommendations should be used, and when evidence is not available, that information needs to be shared with families to facilitate decision-making.

4. Interdisciplinary teams need strategies to discuss risks and interventions in a “direct but sensitive manner” allowing time for questions and considerations; teams also should identify which provider will discuss each risk and potential intervention, and when those discussions will occur.

5. Documentation of discussions and their outcomes are critical to ensure clear communication between health care providers and smooth transition to adult care.

Although team physicians have the best grasp of relevant medical issues, behavioral health specialists are “best equipped” to comprehend cultural, developmental, and family psychosocial issues, and to engage children in decision making, according Dr. Nahata, also affiliated with the Ohio State University, Columbus, and her coauthors.

“By having ongoing discussions, we are more likely to establish a sense of safety and trust, while helping youth and family make informed decisions,” coauthor Amy C. Tishelman, PhD, of the departments of endocrinology and psychiatry, Boston Children’s Hospital and Harvard Medical School, Boston, said in the AAP statement announcing the new guidelines.

Gwendolyn P. Quinn, PhD, of the department of obstetrics and gynecology, New York University Langone Medical Center, served as a third coauthor of the report.

In the AAP statement, Dr. Quinn noted differences in child and adolescent counseling needs, stating that adolescents might express concerns about pregnancy or might need information on contraception to avoid sexually transmitted diseases.

By contrast, detailed discussions about sexual function or fertility might not be appropriate for younger children, who nevertheless might exhibit interest and curiosity in their bodies, and should be made comfortable to ask questions. Open-ended prompts such as “How are you feeling about your body?” could be helpful for children approaching adolescence, according to the policy statement.

Dr. Nahata, Dr. Quinn, and Dr. Tishelman reported that they had no financial relationships relevant to their report, no external funding, and no potential conflicts of interest to disclose.

SOURCE: Nahata L et al. Pediatrics. 2018 Jul 30. doi: 10.1542/peds.2018-1435.

LAKE TAHOE, CALIF. – Among children and adolescents, vitiligo appears to predominately affect nonwhite boys and girls between the ages of 10 and 17 years, results from a large cross-sectional analysis demonstrated.

Doug Brunk/MDedge News

During an interview at the annual meeting of the Society for Pediatric Dermatology, lead study author Jessica Haber, MD, said that, while it’s known vitiligo can have its onset in childhood, there have been no population-based analyses in the United States specific to children and adolescents with the condition.

“We wanted to examine disease burden in the U.S. specifically, because we have such a diverse population,” said Dr. Haber, a second-year resident in the department of dermatology at Northwell Health, New York.

For the study, she and her associates used IBM’s Explorys research analytics platform to conduct a cross-sectional analysis of more than 55 million unique patients across all census regions of the United States. There were 1,630 vitiligo cases identified from a total of 4,242,400 pediatric patients, for an overall standard prevalence of 0.04%, or 40.1 per 100,000 children and adolescents. The proportion of female and male patients with vitiligo was similar (49.1% and 50.9%, respectively), and nearly three-fourths (72.3%) were 10 years of age or older.

The researchers observed no significant difference in the prevalence of vitiligo between males and females (40.2 per 100,000 vs. 40 per 100,000, respectively). The standardized prevalence of vitiligo was greatest in pediatric patients who were of “other” races and ethnicities (including Asian, Hispanic, multiracial, and other; 69.1 per 100,000), followed by African Americans (51.5 per 100,000) and whites (37.9 per 100,000). There were too few vitiligo cases among biracial patients to determine standardized estimates, but the crude prevalence was greatest in this group (68.7 per 100,000).

Two factors could contribute to the increased prevalence of vitiligo observed in nonwhite children and adolescents, Dr. Haber said. One is selection bias.

“It has been reported that both children and adults with higher Fitzpatrick skin types tend to have increased morbidity of their vitiligo, so it may be a selection bias that these patients are seeking out treatment for their disease,” she said. “Also, according to recent research in the medical literature, increased melanin production may be a risk factor for the development of vitiligo (J Am Acad Dermatol. 2017;77[1]:1-13). That might explain some of our findings, as well.”

While the study findings “don’t necessarily change clinical practice, it is good for us to have a sense of the burden of disease in the pediatric patient population of vitiligo, and to be aware that this is a disease that predominately affects non-Caucasian children and adolescents,” Dr. Haber concluded.

She reported having no financial disclosures.

[email protected]

LAKE TAHOE, CALIF. – Among children and adolescents, vitiligo appears to predominately affect nonwhite boys and girls between the ages of 10 and 17 years, results from a large cross-sectional analysis demonstrated.

Doug Brunk/MDedge News

During an interview at the annual meeting of the Society for Pediatric Dermatology, lead study author Jessica Haber, MD, said that, while it’s known vitiligo can have its onset in childhood, there have been no population-based analyses in the United States specific to children and adolescents with the condition.

“We wanted to examine disease burden in the U.S. specifically, because we have such a diverse population,” said Dr. Haber, a second-year resident in the department of dermatology at Northwell Health, New York.

For the study, she and her associates used IBM’s Explorys research analytics platform to conduct a cross-sectional analysis of more than 55 million unique patients across all census regions of the United States. There were 1,630 vitiligo cases identified from a total of 4,242,400 pediatric patients, for an overall standard prevalence of 0.04%, or 40.1 per 100,000 children and adolescents. The proportion of female and male patients with vitiligo was similar (49.1% and 50.9%, respectively), and nearly three-fourths (72.3%) were 10 years of age or older.

The researchers observed no significant difference in the prevalence of vitiligo between males and females (40.2 per 100,000 vs. 40 per 100,000, respectively). The standardized prevalence of vitiligo was greatest in pediatric patients who were of “other” races and ethnicities (including Asian, Hispanic, multiracial, and other; 69.1 per 100,000), followed by African Americans (51.5 per 100,000) and whites (37.9 per 100,000). There were too few vitiligo cases among biracial patients to determine standardized estimates, but the crude prevalence was greatest in this group (68.7 per 100,000).

Two factors could contribute to the increased prevalence of vitiligo observed in nonwhite children and adolescents, Dr. Haber said. One is selection bias.

“It has been reported that both children and adults with higher Fitzpatrick skin types tend to have increased morbidity of their vitiligo, so it may be a selection bias that these patients are seeking out treatment for their disease,” she said. “Also, according to recent research in the medical literature, increased melanin production may be a risk factor for the development of vitiligo (J Am Acad Dermatol. 2017;77[1]:1-13). That might explain some of our findings, as well.”

While the study findings “don’t necessarily change clinical practice, it is good for us to have a sense of the burden of disease in the pediatric patient population of vitiligo, and to be aware that this is a disease that predominately affects non-Caucasian children and adolescents,” Dr. Haber concluded.

She reported having no financial disclosures.

[email protected]

LAKE TAHOE, CALIF. – Among children and adolescents, vitiligo appears to predominately affect nonwhite boys and girls between the ages of 10 and 17 years, results from a large cross-sectional analysis demonstrated.

Doug Brunk/MDedge News

During an interview at the annual meeting of the Society for Pediatric Dermatology, lead study author Jessica Haber, MD, said that, while it’s known vitiligo can have its onset in childhood, there have been no population-based analyses in the United States specific to children and adolescents with the condition.

“We wanted to examine disease burden in the U.S. specifically, because we have such a diverse population,” said Dr. Haber, a second-year resident in the department of dermatology at Northwell Health, New York.

For the study, she and her associates used IBM’s Explorys research analytics platform to conduct a cross-sectional analysis of more than 55 million unique patients across all census regions of the United States. There were 1,630 vitiligo cases identified from a total of 4,242,400 pediatric patients, for an overall standard prevalence of 0.04%, or 40.1 per 100,000 children and adolescents. The proportion of female and male patients with vitiligo was similar (49.1% and 50.9%, respectively), and nearly three-fourths (72.3%) were 10 years of age or older.

The researchers observed no significant difference in the prevalence of vitiligo between males and females (40.2 per 100,000 vs. 40 per 100,000, respectively). The standardized prevalence of vitiligo was greatest in pediatric patients who were of “other” races and ethnicities (including Asian, Hispanic, multiracial, and other; 69.1 per 100,000), followed by African Americans (51.5 per 100,000) and whites (37.9 per 100,000). There were too few vitiligo cases among biracial patients to determine standardized estimates, but the crude prevalence was greatest in this group (68.7 per 100,000).

Two factors could contribute to the increased prevalence of vitiligo observed in nonwhite children and adolescents, Dr. Haber said. One is selection bias.

“It has been reported that both children and adults with higher Fitzpatrick skin types tend to have increased morbidity of their vitiligo, so it may be a selection bias that these patients are seeking out treatment for their disease,” she said. “Also, according to recent research in the medical literature, increased melanin production may be a risk factor for the development of vitiligo (J Am Acad Dermatol. 2017;77[1]:1-13). That might explain some of our findings, as well.”

While the study findings “don’t necessarily change clinical practice, it is good for us to have a sense of the burden of disease in the pediatric patient population of vitiligo, and to be aware that this is a disease that predominately affects non-Caucasian children and adolescents,” Dr. Haber concluded.

She reported having no financial disclosures.

[email protected]

SAN DIEGO – Fatigue increases anterior cruciate ligament injury risk in adolescent athletes, results from a field-based drop-jump study demonstrate.

Doug Brunk/MDedge News

“The number of ACL reconstructions that occur annually are on the rise, particularly in high school and adolescent aged athletes,” lead study author Mohsin S. Fidai, MD, said at the annual meeting of the American Orthopaedic Society for Sports Medicine. “About 70% of these are accounted for by noncontact injuries, the majority of which occur during jump landing. A number of risk factors that have previously been implicated in ACL injury include genetics and anatomy, but a modifiable risk factor is landing biomechanics.”

In 2005, researchers led by Timothy E. Hewett, PhD, determined biomechanical measures of neuromuscular control that might pose certain athletes to be at risk for ACL injury, particularly knee abduction and dynamic knee valgus during a drop-jump test (Am J Sports Med. 2005;33[4]:492-501). “Historically, these studies have required the use of sophisticated computer technology, which can be cumbersome from a time and cost perspective,” said Dr. Fidai, a third-year orthopedic surgery resident at Henry Ford Health System, Detroit.

In a more recent analysis, researchers validated a field-based drop vertical jump screening test for ACL injury (Phys Sportmed. 2016;44[1]:46-52). The sensitivity was 95%, the specificity was 46%, and it had a strong inter-rater reliability (k = 0.92; P less than .05).

The purpose of the current study was to evaluate the effect of fatigue on ACL injury risk using a field-based drop-jump test. “We hypothesized that fatigue would lead to greater dynamic knee valgus during a drop-jump test,” Dr. Fidai said. “We also wanted to identify individual characteristics which may place athletes at increased risk for ACL injury.”

The researchers recruited 85 athletes who competed in track and field, basketball, volleyball, and soccer. More than half (55%) were female, and the mean age was 15.4 years. They excluded athletes with any previous or current lower extremity injuries or neuromuscular deficits. Each athlete performed a maximum vertical jump, followed by a drop-jump test.

“We then fatigued all of our athletes with a standardized high-intensity fatigue protocol, and had each athlete perform another maximum vertical jump and drop-jump test,” Dr. Fidai said. “All drop-jumps were video recorded and sent to a number of orthopedic surgery residents, athletic trainers, and physical therapists for review.”

Of the 85 athletes, nearly half (45%) showed an increased risk for ACL injury after high-intensity aerobic activity. In addition, 68% of study participants were identified as having a medium or high risk for injury following the aerobic activity, compared with 44% at baseline. “When looking at fatigue, it seems to have a dose-dependent response,” Dr. Fidai noted. “In the group of athletes with higher levels of fatigue, there is a significantly increased risk, compared with their counterparts with lower levels of fatigue.”

Specifically, 14 of the 22 athletes who demonstrated over 20% fatigue showed an increased ACL injury risk. Subgroup analysis revealed that female athletes and those older than age 15 were more likely to demonstrate an increased injury risk.

“The findings of this study advocate for changes to current neuromuscular training programs to incorporate fatigue resistance, as well as to raise awareness amongst physical therapists, athletic trainers, coaches, and athletes about the effect of fatigue on ACL injury risk,” Dr. Fidai concluded. “We can target vulnerable athletes, particularly female athletes, in an effort to negate some of those effects.”

The study’s principal investigator was Eric C. Makhni, MD. Dr. Makhni, an orthopedic surgeon in West Bloomfield, Mich., disclosed that he is a paid consultant for Smith & Nephew and that he receives publishing royalties from Springer. Dr. Fidai reported having no financial disclosures.

[email protected]

SAN DIEGO – Fatigue increases anterior cruciate ligament injury risk in adolescent athletes, results from a field-based drop-jump study demonstrate.

Doug Brunk/MDedge News

“The number of ACL reconstructions that occur annually are on the rise, particularly in high school and adolescent aged athletes,” lead study author Mohsin S. Fidai, MD, said at the annual meeting of the American Orthopaedic Society for Sports Medicine. “About 70% of these are accounted for by noncontact injuries, the majority of which occur during jump landing. A number of risk factors that have previously been implicated in ACL injury include genetics and anatomy, but a modifiable risk factor is landing biomechanics.”

In 2005, researchers led by Timothy E. Hewett, PhD, determined biomechanical measures of neuromuscular control that might pose certain athletes to be at risk for ACL injury, particularly knee abduction and dynamic knee valgus during a drop-jump test (Am J Sports Med. 2005;33[4]:492-501). “Historically, these studies have required the use of sophisticated computer technology, which can be cumbersome from a time and cost perspective,” said Dr. Fidai, a third-year orthopedic surgery resident at Henry Ford Health System, Detroit.

In a more recent analysis, researchers validated a field-based drop vertical jump screening test for ACL injury (Phys Sportmed. 2016;44[1]:46-52). The sensitivity was 95%, the specificity was 46%, and it had a strong inter-rater reliability (k = 0.92; P less than .05).

The purpose of the current study was to evaluate the effect of fatigue on ACL injury risk using a field-based drop-jump test. “We hypothesized that fatigue would lead to greater dynamic knee valgus during a drop-jump test,” Dr. Fidai said. “We also wanted to identify individual characteristics which may place athletes at increased risk for ACL injury.”

The researchers recruited 85 athletes who competed in track and field, basketball, volleyball, and soccer. More than half (55%) were female, and the mean age was 15.4 years. They excluded athletes with any previous or current lower extremity injuries or neuromuscular deficits. Each athlete performed a maximum vertical jump, followed by a drop-jump test.

“We then fatigued all of our athletes with a standardized high-intensity fatigue protocol, and had each athlete perform another maximum vertical jump and drop-jump test,” Dr. Fidai said. “All drop-jumps were video recorded and sent to a number of orthopedic surgery residents, athletic trainers, and physical therapists for review.”

Of the 85 athletes, nearly half (45%) showed an increased risk for ACL injury after high-intensity aerobic activity. In addition, 68% of study participants were identified as having a medium or high risk for injury following the aerobic activity, compared with 44% at baseline. “When looking at fatigue, it seems to have a dose-dependent response,” Dr. Fidai noted. “In the group of athletes with higher levels of fatigue, there is a significantly increased risk, compared with their counterparts with lower levels of fatigue.”

Specifically, 14 of the 22 athletes who demonstrated over 20% fatigue showed an increased ACL injury risk. Subgroup analysis revealed that female athletes and those older than age 15 were more likely to demonstrate an increased injury risk.

“The findings of this study advocate for changes to current neuromuscular training programs to incorporate fatigue resistance, as well as to raise awareness amongst physical therapists, athletic trainers, coaches, and athletes about the effect of fatigue on ACL injury risk,” Dr. Fidai concluded. “We can target vulnerable athletes, particularly female athletes, in an effort to negate some of those effects.”

The study’s principal investigator was Eric C. Makhni, MD. Dr. Makhni, an orthopedic surgeon in West Bloomfield, Mich., disclosed that he is a paid consultant for Smith & Nephew and that he receives publishing royalties from Springer. Dr. Fidai reported having no financial disclosures.

[email protected]

SAN DIEGO – Fatigue increases anterior cruciate ligament injury risk in adolescent athletes, results from a field-based drop-jump study demonstrate.

Doug Brunk/MDedge News

“The number of ACL reconstructions that occur annually are on the rise, particularly in high school and adolescent aged athletes,” lead study author Mohsin S. Fidai, MD, said at the annual meeting of the American Orthopaedic Society for Sports Medicine. “About 70% of these are accounted for by noncontact injuries, the majority of which occur during jump landing. A number of risk factors that have previously been implicated in ACL injury include genetics and anatomy, but a modifiable risk factor is landing biomechanics.”

In 2005, researchers led by Timothy E. Hewett, PhD, determined biomechanical measures of neuromuscular control that might pose certain athletes to be at risk for ACL injury, particularly knee abduction and dynamic knee valgus during a drop-jump test (Am J Sports Med. 2005;33[4]:492-501). “Historically, these studies have required the use of sophisticated computer technology, which can be cumbersome from a time and cost perspective,” said Dr. Fidai, a third-year orthopedic surgery resident at Henry Ford Health System, Detroit.

In a more recent analysis, researchers validated a field-based drop vertical jump screening test for ACL injury (Phys Sportmed. 2016;44[1]:46-52). The sensitivity was 95%, the specificity was 46%, and it had a strong inter-rater reliability (k = 0.92; P less than .05).

The purpose of the current study was to evaluate the effect of fatigue on ACL injury risk using a field-based drop-jump test. “We hypothesized that fatigue would lead to greater dynamic knee valgus during a drop-jump test,” Dr. Fidai said. “We also wanted to identify individual characteristics which may place athletes at increased risk for ACL injury.”

The researchers recruited 85 athletes who competed in track and field, basketball, volleyball, and soccer. More than half (55%) were female, and the mean age was 15.4 years. They excluded athletes with any previous or current lower extremity injuries or neuromuscular deficits. Each athlete performed a maximum vertical jump, followed by a drop-jump test.

“We then fatigued all of our athletes with a standardized high-intensity fatigue protocol, and had each athlete perform another maximum vertical jump and drop-jump test,” Dr. Fidai said. “All drop-jumps were video recorded and sent to a number of orthopedic surgery residents, athletic trainers, and physical therapists for review.”

Of the 85 athletes, nearly half (45%) showed an increased risk for ACL injury after high-intensity aerobic activity. In addition, 68% of study participants were identified as having a medium or high risk for injury following the aerobic activity, compared with 44% at baseline. “When looking at fatigue, it seems to have a dose-dependent response,” Dr. Fidai noted. “In the group of athletes with higher levels of fatigue, there is a significantly increased risk, compared with their counterparts with lower levels of fatigue.”

Specifically, 14 of the 22 athletes who demonstrated over 20% fatigue showed an increased ACL injury risk. Subgroup analysis revealed that female athletes and those older than age 15 were more likely to demonstrate an increased injury risk.

“The findings of this study advocate for changes to current neuromuscular training programs to incorporate fatigue resistance, as well as to raise awareness amongst physical therapists, athletic trainers, coaches, and athletes about the effect of fatigue on ACL injury risk,” Dr. Fidai concluded. “We can target vulnerable athletes, particularly female athletes, in an effort to negate some of those effects.”

The study’s principal investigator was Eric C. Makhni, MD. Dr. Makhni, an orthopedic surgeon in West Bloomfield, Mich., disclosed that he is a paid consultant for Smith & Nephew and that he receives publishing royalties from Springer. Dr. Fidai reported having no financial disclosures.

[email protected]

SAN DIEGO – Patients who received a corticosteroid injection within 6 months prior to rotator cuff repair were more likely to undergo a revision rotator cuff surgery within the following 3 years, results from a large database study show.

“Corticosteroid injections are frequently utilized in the nonoperative management of rotator cuff tears,” researchers led by Sophia A. Traven, MD, wrote in an abstract presented during a poster session at the annual meeting of the American Orthopaedic Society for Sports Medicine. “However, recent literature suggests that injections may reduce biomechanical strengths of tendons and ligaments in animal models.”

In an effort to examine the effect of preoperative shoulder injections on the rate of revision cuff repair following arthroscopic rotator cuff repair, the researchers retrospectively reviewed MarketScan claims data between 2010 and 2014 to identify 4,959 patients with an ICD-9 diagnosis of a rotator cuff tear with subsequent arthroscopic rotator cuff repair (CPT 29827).

They used multivariable logistic regression to compare the odds of reoperation between groups, while controlling for certain demographic and comorbid variables, including age and gender, tobacco use, diabetes, and the Charlson comorbidity index score.

Dr. Traven, an orthopedic surgeon at the Medical University of South Carolina, Charleston, and her associates reported that 392 of the 4,959 patients required rotator cuff repair revision within the following 3 years. Compared with those who did not require revision, those who did were older (a mean age of 53 vs. 49 years, respectively), more likely to be smokers (7% vs. 4%), and more likely to receive any injection prior to rotator cuff repair (36% vs 25%; P less than .0001 for all associations).

The risk for revision rotator cuff repair was highest for patients who received an injection 3-6 months before the primary rotator cuff repair (odds ratio, 1.822), followed by those who received an injection 0-3 months before the primary repair (OR, 1.375), and those who received an injection 6-12 months before the primary repair (OR, 1.237).

“The risk of revision rotator cuff repair remains elevated for 6 months following a shoulder injection,” the researchers concluded in their poster. “Consideration should therefore be given to minimizing preoperative injections in patients who may require rotator cuff repair.”

They reported having no financial disclosures.

[email protected]

SAN DIEGO – Patients who received a corticosteroid injection within 6 months prior to rotator cuff repair were more likely to undergo a revision rotator cuff surgery within the following 3 years, results from a large database study show.

“Corticosteroid injections are frequently utilized in the nonoperative management of rotator cuff tears,” researchers led by Sophia A. Traven, MD, wrote in an abstract presented during a poster session at the annual meeting of the American Orthopaedic Society for Sports Medicine. “However, recent literature suggests that injections may reduce biomechanical strengths of tendons and ligaments in animal models.”

In an effort to examine the effect of preoperative shoulder injections on the rate of revision cuff repair following arthroscopic rotator cuff repair, the researchers retrospectively reviewed MarketScan claims data between 2010 and 2014 to identify 4,959 patients with an ICD-9 diagnosis of a rotator cuff tear with subsequent arthroscopic rotator cuff repair (CPT 29827).

They used multivariable logistic regression to compare the odds of reoperation between groups, while controlling for certain demographic and comorbid variables, including age and gender, tobacco use, diabetes, and the Charlson comorbidity index score.

Dr. Traven, an orthopedic surgeon at the Medical University of South Carolina, Charleston, and her associates reported that 392 of the 4,959 patients required rotator cuff repair revision within the following 3 years. Compared with those who did not require revision, those who did were older (a mean age of 53 vs. 49 years, respectively), more likely to be smokers (7% vs. 4%), and more likely to receive any injection prior to rotator cuff repair (36% vs 25%; P less than .0001 for all associations).

The risk for revision rotator cuff repair was highest for patients who received an injection 3-6 months before the primary rotator cuff repair (odds ratio, 1.822), followed by those who received an injection 0-3 months before the primary repair (OR, 1.375), and those who received an injection 6-12 months before the primary repair (OR, 1.237).

“The risk of revision rotator cuff repair remains elevated for 6 months following a shoulder injection,” the researchers concluded in their poster. “Consideration should therefore be given to minimizing preoperative injections in patients who may require rotator cuff repair.”

They reported having no financial disclosures.

[email protected]

SAN DIEGO – Patients who received a corticosteroid injection within 6 months prior to rotator cuff repair were more likely to undergo a revision rotator cuff surgery within the following 3 years, results from a large database study show.

“Corticosteroid injections are frequently utilized in the nonoperative management of rotator cuff tears,” researchers led by Sophia A. Traven, MD, wrote in an abstract presented during a poster session at the annual meeting of the American Orthopaedic Society for Sports Medicine. “However, recent literature suggests that injections may reduce biomechanical strengths of tendons and ligaments in animal models.”

In an effort to examine the effect of preoperative shoulder injections on the rate of revision cuff repair following arthroscopic rotator cuff repair, the researchers retrospectively reviewed MarketScan claims data between 2010 and 2014 to identify 4,959 patients with an ICD-9 diagnosis of a rotator cuff tear with subsequent arthroscopic rotator cuff repair (CPT 29827).

They used multivariable logistic regression to compare the odds of reoperation between groups, while controlling for certain demographic and comorbid variables, including age and gender, tobacco use, diabetes, and the Charlson comorbidity index score.

Dr. Traven, an orthopedic surgeon at the Medical University of South Carolina, Charleston, and her associates reported that 392 of the 4,959 patients required rotator cuff repair revision within the following 3 years. Compared with those who did not require revision, those who did were older (a mean age of 53 vs. 49 years, respectively), more likely to be smokers (7% vs. 4%), and more likely to receive any injection prior to rotator cuff repair (36% vs 25%; P less than .0001 for all associations).

The risk for revision rotator cuff repair was highest for patients who received an injection 3-6 months before the primary rotator cuff repair (odds ratio, 1.822), followed by those who received an injection 0-3 months before the primary repair (OR, 1.375), and those who received an injection 6-12 months before the primary repair (OR, 1.237).

“The risk of revision rotator cuff repair remains elevated for 6 months following a shoulder injection,” the researchers concluded in their poster. “Consideration should therefore be given to minimizing preoperative injections in patients who may require rotator cuff repair.”

They reported having no financial disclosures.

[email protected]

SAN DIEGO – When it comes to soft tissue recovery modalities for elite athletes beyond rest, recovery, and retaining movement efficiency, not all options are created equal.

In fact, the science for most supplemental recovery modalities stems from cohort studies examining physiologic response – not high-level randomized clinical trials, Chuck Thigpen, PhD, said at the annual meeting of the American Orthopaedic Society for Sports Medicine.

“We should be very careful when we discuss overtraining and overload,” said Dr. Thigpen, senior director of practice innovation and analytics for ATI Physical Therapy, Greenville, S.C. “In fact, we need training load to create an anabolic response, so then the question is, how do we manage that load? I would suggest that it’s not overtraining, but underrecovery after a load that results in increasing fatigue, decreased performance, and potential increased injury risk.”

One option for soft tissue recovery is whole body vibration, for which the athlete stands, sits, or lies on a machine with a vibrating platform, while he or she performs static or isotonic exercise. “With this modality, you get a rapid co-contraction of muscle, which increases muscle preactivation,” said Dr. Thigpen, who is also directs the program in observational clinical research in orthopedics at the Greenville, S.C.–based Center for Effectiveness Research in Orthopaedics. “It has demonstrated increased blood flow as well as increased motor neuron excitability. There seems to be some physiologic benefit coming potentially from muscle waste removal (lactate) and nutrient delivery, as well as decreasing subsequent inhibition.”

In terms of parameters, benefits have been observed when athletes perform one or two sets of a static stretch or contact massage on a body vibration machine for a minute or so at a frequency of 30-50 Hz. “The application is what becomes challenging,” Dr. Thigpen said. “Where are you going to work this in? Is it a pre or post activity? Recent evidence implicates use during halftime may maintain strength and power. However, most of the work that has been done with vibration has been as an adjunct to exercise and not really in terms of recovery.”

Massage is another popular recovery tool, and most elite sports team have a masseuse on staff. Soft tissue manipulation creates release of oxytocin and other neurotransmitters, some central nervous system response, and increased blood flow to the treated area, but it also influences the athlete’s general disposition.

“There’s something about laying hands on somebody that seems to affect a person’s mood state,” Dr. Thigpen said. “Some studies have reported better perceived recovery status, even though the physiologic markers are about the same. Therefore, I would classify body vibration and massage in the same bucket. They seem to work; they seem to have some perceived benefit.”

Another soft tissue recovery option, compression therapy, has been shown to increase the local pressure gradient of the impacted area, thereby increasing progressive venous return and creating some muscle splinting (or protective muscle spasms). “Compression therapy seems to clear the system and get some waste removal, as well as increase nutrient delivery,” Dr. Thigpen said. “A couple of studies have looked at the ultrastructure of the muscle concurrently after using compression garments. The nice thing is that you can put them on right after the activity. They should be worn for 24 hours.”

Another way to get compression therapy is to use compression devices; it is recommended that they are worn for 15-minute intervals for up to 4 hours after intense physical activity, depending on the device. “You see some of the same benefits that you see with compression garments,” he said.

Dr. Thigpen went on to discuss cryotherapy such as cold-water immersion in a tub, which has a long history of use in muscle recovery. In fact, many basic science studies have demonstrated a reduction of inflammatory markers and other immunologic responses after its use. “Cryotherapy is thought to create an acute decrease in blood flow and a concurrent increase in blood flow after you remove it, which creates the release of these neurotransmitters and immunosuppressants that seem to be helpful in the healing process,” he explained.

“The thought is, because of the decreased pain reduction, the waste removal, and the change in oxidative stress, this would be beneficial.” For example, cold water immersion in a tub four times over a 72-hour period has been found to decrease soreness and increase athletic performance on the backside. “That seems to be helpful in recovery, as an adjunct to heavy resistance training or eccentric and plyometric training,” he said.

Neuromuscular electrical stimulation has been shown to provide some analgesic effect to sore muscles via afferent stimulation, but the primary mechanism is contractile via the motor unit. Typically, neuromuscular electrical stimulation consists of about a 20-minute application to affected muscles, “and you can do multiple applications per day interspersed with periods of high-intensity training to restore the neuromuscular profile during the recovery period,” Dr. Thigpen said.

He reported having no financial disclosures.

[email protected]

SAN DIEGO – When it comes to soft tissue recovery modalities for elite athletes beyond rest, recovery, and retaining movement efficiency, not all options are created equal.

In fact, the science for most supplemental recovery modalities stems from cohort studies examining physiologic response – not high-level randomized clinical trials, Chuck Thigpen, PhD, said at the annual meeting of the American Orthopaedic Society for Sports Medicine.

“We should be very careful when we discuss overtraining and overload,” said Dr. Thigpen, senior director of practice innovation and analytics for ATI Physical Therapy, Greenville, S.C. “In fact, we need training load to create an anabolic response, so then the question is, how do we manage that load? I would suggest that it’s not overtraining, but underrecovery after a load that results in increasing fatigue, decreased performance, and potential increased injury risk.”

One option for soft tissue recovery is whole body vibration, for which the athlete stands, sits, or lies on a machine with a vibrating platform, while he or she performs static or isotonic exercise. “With this modality, you get a rapid co-contraction of muscle, which increases muscle preactivation,” said Dr. Thigpen, who is also directs the program in observational clinical research in orthopedics at the Greenville, S.C.–based Center for Effectiveness Research in Orthopaedics. “It has demonstrated increased blood flow as well as increased motor neuron excitability. There seems to be some physiologic benefit coming potentially from muscle waste removal (lactate) and nutrient delivery, as well as decreasing subsequent inhibition.”

In terms of parameters, benefits have been observed when athletes perform one or two sets of a static stretch or contact massage on a body vibration machine for a minute or so at a frequency of 30-50 Hz. “The application is what becomes challenging,” Dr. Thigpen said. “Where are you going to work this in? Is it a pre or post activity? Recent evidence implicates use during halftime may maintain strength and power. However, most of the work that has been done with vibration has been as an adjunct to exercise and not really in terms of recovery.”

Massage is another popular recovery tool, and most elite sports team have a masseuse on staff. Soft tissue manipulation creates release of oxytocin and other neurotransmitters, some central nervous system response, and increased blood flow to the treated area, but it also influences the athlete’s general disposition.

“There’s something about laying hands on somebody that seems to affect a person’s mood state,” Dr. Thigpen said. “Some studies have reported better perceived recovery status, even though the physiologic markers are about the same. Therefore, I would classify body vibration and massage in the same bucket. They seem to work; they seem to have some perceived benefit.”

Another soft tissue recovery option, compression therapy, has been shown to increase the local pressure gradient of the impacted area, thereby increasing progressive venous return and creating some muscle splinting (or protective muscle spasms). “Compression therapy seems to clear the system and get some waste removal, as well as increase nutrient delivery,” Dr. Thigpen said. “A couple of studies have looked at the ultrastructure of the muscle concurrently after using compression garments. The nice thing is that you can put them on right after the activity. They should be worn for 24 hours.”

Another way to get compression therapy is to use compression devices; it is recommended that they are worn for 15-minute intervals for up to 4 hours after intense physical activity, depending on the device. “You see some of the same benefits that you see with compression garments,” he said.

Dr. Thigpen went on to discuss cryotherapy such as cold-water immersion in a tub, which has a long history of use in muscle recovery. In fact, many basic science studies have demonstrated a reduction of inflammatory markers and other immunologic responses after its use. “Cryotherapy is thought to create an acute decrease in blood flow and a concurrent increase in blood flow after you remove it, which creates the release of these neurotransmitters and immunosuppressants that seem to be helpful in the healing process,” he explained.

“The thought is, because of the decreased pain reduction, the waste removal, and the change in oxidative stress, this would be beneficial.” For example, cold water immersion in a tub four times over a 72-hour period has been found to decrease soreness and increase athletic performance on the backside. “That seems to be helpful in recovery, as an adjunct to heavy resistance training or eccentric and plyometric training,” he said.

Neuromuscular electrical stimulation has been shown to provide some analgesic effect to sore muscles via afferent stimulation, but the primary mechanism is contractile via the motor unit. Typically, neuromuscular electrical stimulation consists of about a 20-minute application to affected muscles, “and you can do multiple applications per day interspersed with periods of high-intensity training to restore the neuromuscular profile during the recovery period,” Dr. Thigpen said.

He reported having no financial disclosures.

[email protected]

SAN DIEGO – When it comes to soft tissue recovery modalities for elite athletes beyond rest, recovery, and retaining movement efficiency, not all options are created equal.

In fact, the science for most supplemental recovery modalities stems from cohort studies examining physiologic response – not high-level randomized clinical trials, Chuck Thigpen, PhD, said at the annual meeting of the American Orthopaedic Society for Sports Medicine.

“We should be very careful when we discuss overtraining and overload,” said Dr. Thigpen, senior director of practice innovation and analytics for ATI Physical Therapy, Greenville, S.C. “In fact, we need training load to create an anabolic response, so then the question is, how do we manage that load? I would suggest that it’s not overtraining, but underrecovery after a load that results in increasing fatigue, decreased performance, and potential increased injury risk.”

One option for soft tissue recovery is whole body vibration, for which the athlete stands, sits, or lies on a machine with a vibrating platform, while he or she performs static or isotonic exercise. “With this modality, you get a rapid co-contraction of muscle, which increases muscle preactivation,” said Dr. Thigpen, who is also directs the program in observational clinical research in orthopedics at the Greenville, S.C.–based Center for Effectiveness Research in Orthopaedics. “It has demonstrated increased blood flow as well as increased motor neuron excitability. There seems to be some physiologic benefit coming potentially from muscle waste removal (lactate) and nutrient delivery, as well as decreasing subsequent inhibition.”

In terms of parameters, benefits have been observed when athletes perform one or two sets of a static stretch or contact massage on a body vibration machine for a minute or so at a frequency of 30-50 Hz. “The application is what becomes challenging,” Dr. Thigpen said. “Where are you going to work this in? Is it a pre or post activity? Recent evidence implicates use during halftime may maintain strength and power. However, most of the work that has been done with vibration has been as an adjunct to exercise and not really in terms of recovery.”

Massage is another popular recovery tool, and most elite sports team have a masseuse on staff. Soft tissue manipulation creates release of oxytocin and other neurotransmitters, some central nervous system response, and increased blood flow to the treated area, but it also influences the athlete’s general disposition.

“There’s something about laying hands on somebody that seems to affect a person’s mood state,” Dr. Thigpen said. “Some studies have reported better perceived recovery status, even though the physiologic markers are about the same. Therefore, I would classify body vibration and massage in the same bucket. They seem to work; they seem to have some perceived benefit.”

Another soft tissue recovery option, compression therapy, has been shown to increase the local pressure gradient of the impacted area, thereby increasing progressive venous return and creating some muscle splinting (or protective muscle spasms). “Compression therapy seems to clear the system and get some waste removal, as well as increase nutrient delivery,” Dr. Thigpen said. “A couple of studies have looked at the ultrastructure of the muscle concurrently after using compression garments. The nice thing is that you can put them on right after the activity. They should be worn for 24 hours.”

Another way to get compression therapy is to use compression devices; it is recommended that they are worn for 15-minute intervals for up to 4 hours after intense physical activity, depending on the device. “You see some of the same benefits that you see with compression garments,” he said.

Dr. Thigpen went on to discuss cryotherapy such as cold-water immersion in a tub, which has a long history of use in muscle recovery. In fact, many basic science studies have demonstrated a reduction of inflammatory markers and other immunologic responses after its use. “Cryotherapy is thought to create an acute decrease in blood flow and a concurrent increase in blood flow after you remove it, which creates the release of these neurotransmitters and immunosuppressants that seem to be helpful in the healing process,” he explained.

“The thought is, because of the decreased pain reduction, the waste removal, and the change in oxidative stress, this would be beneficial.” For example, cold water immersion in a tub four times over a 72-hour period has been found to decrease soreness and increase athletic performance on the backside. “That seems to be helpful in recovery, as an adjunct to heavy resistance training or eccentric and plyometric training,” he said.

Neuromuscular electrical stimulation has been shown to provide some analgesic effect to sore muscles via afferent stimulation, but the primary mechanism is contractile via the motor unit. Typically, neuromuscular electrical stimulation consists of about a 20-minute application to affected muscles, “and you can do multiple applications per day interspersed with periods of high-intensity training to restore the neuromuscular profile during the recovery period,” Dr. Thigpen said.

He reported having no financial disclosures.

[email protected]

Treatment with isavuconazole resolved or substantially improved invasive fungal disease among seven of eight patients receiving concomitant ibrutinib, according to the results of a small two-center study.

The combination “was well-tolerated overall,” wrote Kaelyn C. Cummins of Brigham and Women’s Hospital, together with her associates there and at the Dana-Farber Cancer Institute, Boston. Their letter to the editor was published in Leukemia & Lymphoma.

Although ibrutinib is considered less immunosuppressive than conventional chemotherapy, it has been tied to invasive fungal infections, even in seemingly low-risk patients. The preferred treatment, voriconazole, is a very strong inhibitor of cytochrome P450 systems, of which ibrutinib is a substrate. For this study, the researchers queried the pharmacy databases of their institutions to identify adults who received concomitant isavuconazole (200 mg per day) and ibrutinib between 2015 and 2018. Drug exposures were confirmed by medical record review.

Four patients experienced clinical and radiologic resolution of invasive aspergillosis, fusariosis, mucormycosis, or phaeohyphomycosis. Another three had clinical and radiologic improvement of confirmed or probable aspergillosis or histoplasmosis. One of these patients underwent five debridements for central nervous system invasive aspergillosis but had 8 months of clinical improvement between debridements. This patient’s fungal isolate remained susceptible to isavuconazole throughout treatment. The patient who did not respond at all to isavuconazole had invasive aspergillosis with recurrent brain abscesses. The fungal isolate remained susceptible to isavuconazole, and the patient switched to long-term voriconazole therapy after stopping ibrutinib.

Several adverse events occurred while patients were on concomitant therapy. One patient developed paroxysmal atrial fibrillation that persisted after stopping ibrutinib. Another had worsening of preexisting thrombocytopenia. Among four patients with electrocardiogram data, two had transient QTc prolongation. No patient died within 12 weeks of starting concomitant therapy. Two patients eventually died after their cancer progressed.

The median age of the patients was 60 years (range, 38-76 years). Five were men. Six had chronic lymphocytic leukemia (CLL) and two had marginal zone lymphoma. Two CLL patients were on ibrutinib monotherapy, two also received rituximab, one also received umbralisib, and one also received obinutuzumab. One patient with marginal zone lymphoma was on ibrutinib monotherapy, and the other received concomitant rituximab, gemcitabine, dexamethasone, and cisplatin.

Researchers should study the mechanisms by which [Bruton’s tyrosine kinase] inhibitors might increase susceptibility to fungal infections among patients with lymphoma or CLL, said Ms. Cummins and her associates. Because the CYP3A enzyme system also metabolizes PI3K and BCL-2 inhibitors, their results “could be more broadly applicable.”

Ms. Cummins had no disclosures.

SOURCE: Cummins KC et al. Leuk. Lymphoma 2018 Jul 24. doi: 10.1080/10428194.2018.1485913.

Treatment with isavuconazole resolved or substantially improved invasive fungal disease among seven of eight patients receiving concomitant ibrutinib, according to the results of a small two-center study.

The combination “was well-tolerated overall,” wrote Kaelyn C. Cummins of Brigham and Women’s Hospital, together with her associates there and at the Dana-Farber Cancer Institute, Boston. Their letter to the editor was published in Leukemia & Lymphoma.

Although ibrutinib is considered less immunosuppressive than conventional chemotherapy, it has been tied to invasive fungal infections, even in seemingly low-risk patients. The preferred treatment, voriconazole, is a very strong inhibitor of cytochrome P450 systems, of which ibrutinib is a substrate. For this study, the researchers queried the pharmacy databases of their institutions to identify adults who received concomitant isavuconazole (200 mg per day) and ibrutinib between 2015 and 2018. Drug exposures were confirmed by medical record review.

Four patients experienced clinical and radiologic resolution of invasive aspergillosis, fusariosis, mucormycosis, or phaeohyphomycosis. Another three had clinical and radiologic improvement of confirmed or probable aspergillosis or histoplasmosis. One of these patients underwent five debridements for central nervous system invasive aspergillosis but had 8 months of clinical improvement between debridements. This patient’s fungal isolate remained susceptible to isavuconazole throughout treatment. The patient who did not respond at all to isavuconazole had invasive aspergillosis with recurrent brain abscesses. The fungal isolate remained susceptible to isavuconazole, and the patient switched to long-term voriconazole therapy after stopping ibrutinib.

Several adverse events occurred while patients were on concomitant therapy. One patient developed paroxysmal atrial fibrillation that persisted after stopping ibrutinib. Another had worsening of preexisting thrombocytopenia. Among four patients with electrocardiogram data, two had transient QTc prolongation. No patient died within 12 weeks of starting concomitant therapy. Two patients eventually died after their cancer progressed.

The median age of the patients was 60 years (range, 38-76 years). Five were men. Six had chronic lymphocytic leukemia (CLL) and two had marginal zone lymphoma. Two CLL patients were on ibrutinib monotherapy, two also received rituximab, one also received umbralisib, and one also received obinutuzumab. One patient with marginal zone lymphoma was on ibrutinib monotherapy, and the other received concomitant rituximab, gemcitabine, dexamethasone, and cisplatin.

Researchers should study the mechanisms by which [Bruton’s tyrosine kinase] inhibitors might increase susceptibility to fungal infections among patients with lymphoma or CLL, said Ms. Cummins and her associates. Because the CYP3A enzyme system also metabolizes PI3K and BCL-2 inhibitors, their results “could be more broadly applicable.”

Ms. Cummins had no disclosures.

SOURCE: Cummins KC et al. Leuk. Lymphoma 2018 Jul 24. doi: 10.1080/10428194.2018.1485913.

Treatment with isavuconazole resolved or substantially improved invasive fungal disease among seven of eight patients receiving concomitant ibrutinib, according to the results of a small two-center study.

The combination “was well-tolerated overall,” wrote Kaelyn C. Cummins of Brigham and Women’s Hospital, together with her associates there and at the Dana-Farber Cancer Institute, Boston. Their letter to the editor was published in Leukemia & Lymphoma.

Although ibrutinib is considered less immunosuppressive than conventional chemotherapy, it has been tied to invasive fungal infections, even in seemingly low-risk patients. The preferred treatment, voriconazole, is a very strong inhibitor of cytochrome P450 systems, of which ibrutinib is a substrate. For this study, the researchers queried the pharmacy databases of their institutions to identify adults who received concomitant isavuconazole (200 mg per day) and ibrutinib between 2015 and 2018. Drug exposures were confirmed by medical record review.

Four patients experienced clinical and radiologic resolution of invasive aspergillosis, fusariosis, mucormycosis, or phaeohyphomycosis. Another three had clinical and radiologic improvement of confirmed or probable aspergillosis or histoplasmosis. One of these patients underwent five debridements for central nervous system invasive aspergillosis but had 8 months of clinical improvement between debridements. This patient’s fungal isolate remained susceptible to isavuconazole throughout treatment. The patient who did not respond at all to isavuconazole had invasive aspergillosis with recurrent brain abscesses. The fungal isolate remained susceptible to isavuconazole, and the patient switched to long-term voriconazole therapy after stopping ibrutinib.

Several adverse events occurred while patients were on concomitant therapy. One patient developed paroxysmal atrial fibrillation that persisted after stopping ibrutinib. Another had worsening of preexisting thrombocytopenia. Among four patients with electrocardiogram data, two had transient QTc prolongation. No patient died within 12 weeks of starting concomitant therapy. Two patients eventually died after their cancer progressed.

The median age of the patients was 60 years (range, 38-76 years). Five were men. Six had chronic lymphocytic leukemia (CLL) and two had marginal zone lymphoma. Two CLL patients were on ibrutinib monotherapy, two also received rituximab, one also received umbralisib, and one also received obinutuzumab. One patient with marginal zone lymphoma was on ibrutinib monotherapy, and the other received concomitant rituximab, gemcitabine, dexamethasone, and cisplatin.

Researchers should study the mechanisms by which [Bruton’s tyrosine kinase] inhibitors might increase susceptibility to fungal infections among patients with lymphoma or CLL, said Ms. Cummins and her associates. Because the CYP3A enzyme system also metabolizes PI3K and BCL-2 inhibitors, their results “could be more broadly applicable.”

Ms. Cummins had no disclosures.

SOURCE: Cummins KC et al. Leuk. Lymphoma 2018 Jul 24. doi: 10.1080/10428194.2018.1485913.