A minority of patients (43.5%) with an indication for breast cancer genetic risk evaluation actually received formal genetic counseling in clinical practice, according to an analysis of NCI Surveillance, Epidemiology, and End Results (SEER) data published in Journal of Clinical Oncology.

More expertise is required in genetic counseling, either formal counseling given by an expert, or by a cancer physician (physician-directed), wrote Steven J. Katz and his colleagues at the University of Michigan, Ann Arbor. With BRCA1/2-only testing, being replaced by multi-gene panel testing, further consideration and/or discussion of results and formulation of a management plan is required, they said.

In addition, younger women more often reported some type of counseling (odds ratio, 4.5;95% confidence interval, 2.6-8.0; 1.9;95% CI, 1.1-3.3; and 1.5;95% CI, 1.0-2.3 for women younger than 50 years of age, 50-59 years of age, and 60-69 years of age, respectively, versus those 70 years of age and older).

Patients’ assessment of the amount of information they received about whether to have testing was high, “whether they received formal genetic counseling or a physician-directed discussion only (80.8% v 79.4% stated information was ‘just right’; P = .58),” the researchers noted.

As high-throughput molecular testing becomes increasingly complex, personalizing and tailoring the information to a individual patients’ need is crucial, the authors said. They further suggest a multipronged strategy that will train oncologists to integrate genetic testing into clinical decision making; including timely testing of patients at an elevated risk.

The study was supported by Grant P01 CA163233 to the University of Michigan from the National Cancer Institute. Potential conflict of interests were reported by Lauren P. Wallner, PhD (GlaxoSmithKline); Monica Morrow, MD (Genomic Health); Reshma Jagsi, MD (Amgen and AbbVie); and Allison W. Kurian, MD (Myriad Genetics, Invitae, Ambry Genetics, Genomic Health, GeneDx/BioReference, Genentech (a member of the Roche Group).

SOURCE: Katz SJ et al. J Clin Oncol. 2018 Mar 12. doi: 10.1200/JCO.2017.76.2369.

A minority of patients (43.5%) with an indication for breast cancer genetic risk evaluation actually received formal genetic counseling in clinical practice, according to an analysis of NCI Surveillance, Epidemiology, and End Results (SEER) data published in Journal of Clinical Oncology.

More expertise is required in genetic counseling, either formal counseling given by an expert, or by a cancer physician (physician-directed), wrote Steven J. Katz and his colleagues at the University of Michigan, Ann Arbor. With BRCA1/2-only testing, being replaced by multi-gene panel testing, further consideration and/or discussion of results and formulation of a management plan is required, they said.

In addition, younger women more often reported some type of counseling (odds ratio, 4.5;95% confidence interval, 2.6-8.0; 1.9;95% CI, 1.1-3.3; and 1.5;95% CI, 1.0-2.3 for women younger than 50 years of age, 50-59 years of age, and 60-69 years of age, respectively, versus those 70 years of age and older).

Patients’ assessment of the amount of information they received about whether to have testing was high, “whether they received formal genetic counseling or a physician-directed discussion only (80.8% v 79.4% stated information was ‘just right’; P = .58),” the researchers noted.

As high-throughput molecular testing becomes increasingly complex, personalizing and tailoring the information to a individual patients’ need is crucial, the authors said. They further suggest a multipronged strategy that will train oncologists to integrate genetic testing into clinical decision making; including timely testing of patients at an elevated risk.

The study was supported by Grant P01 CA163233 to the University of Michigan from the National Cancer Institute. Potential conflict of interests were reported by Lauren P. Wallner, PhD (GlaxoSmithKline); Monica Morrow, MD (Genomic Health); Reshma Jagsi, MD (Amgen and AbbVie); and Allison W. Kurian, MD (Myriad Genetics, Invitae, Ambry Genetics, Genomic Health, GeneDx/BioReference, Genentech (a member of the Roche Group).

SOURCE: Katz SJ et al. J Clin Oncol. 2018 Mar 12. doi: 10.1200/JCO.2017.76.2369.

A minority of patients (43.5%) with an indication for breast cancer genetic risk evaluation actually received formal genetic counseling in clinical practice, according to an analysis of NCI Surveillance, Epidemiology, and End Results (SEER) data published in Journal of Clinical Oncology.

More expertise is required in genetic counseling, either formal counseling given by an expert, or by a cancer physician (physician-directed), wrote Steven J. Katz and his colleagues at the University of Michigan, Ann Arbor. With BRCA1/2-only testing, being replaced by multi-gene panel testing, further consideration and/or discussion of results and formulation of a management plan is required, they said.

In addition, younger women more often reported some type of counseling (odds ratio, 4.5;95% confidence interval, 2.6-8.0; 1.9;95% CI, 1.1-3.3; and 1.5;95% CI, 1.0-2.3 for women younger than 50 years of age, 50-59 years of age, and 60-69 years of age, respectively, versus those 70 years of age and older).

Patients’ assessment of the amount of information they received about whether to have testing was high, “whether they received formal genetic counseling or a physician-directed discussion only (80.8% v 79.4% stated information was ‘just right’; P = .58),” the researchers noted.

As high-throughput molecular testing becomes increasingly complex, personalizing and tailoring the information to a individual patients’ need is crucial, the authors said. They further suggest a multipronged strategy that will train oncologists to integrate genetic testing into clinical decision making; including timely testing of patients at an elevated risk.

The study was supported by Grant P01 CA163233 to the University of Michigan from the National Cancer Institute. Potential conflict of interests were reported by Lauren P. Wallner, PhD (GlaxoSmithKline); Monica Morrow, MD (Genomic Health); Reshma Jagsi, MD (Amgen and AbbVie); and Allison W. Kurian, MD (Myriad Genetics, Invitae, Ambry Genetics, Genomic Health, GeneDx/BioReference, Genentech (a member of the Roche Group).

SOURCE: Katz SJ et al. J Clin Oncol. 2018 Mar 12. doi: 10.1200/JCO.2017.76.2369.

Investigational agent fruquintinib holds promise as a third- or fourth-line treatment option for patients with advanced non–small-cell lung cancer (NSCLC), according to new findings published in the Journal of Clinical Oncology.

The median progression free survival (PFS) as evaluated by a blinded image central review committee and the study’s primary endpoint, was more than threefold higher than observed with placebo; 3.8 months (95% confidence interval, 2.8 to 4.6 months) with fruquintinib versus 1.1 months (95% CI, 1.0 to 1.9 months) with placebo (stratified HR was 0.34 (95% CI,0.20 to 0.57; P less than .001). PFS assessed by investigators was nearly identical.

Median overall survival, however, was numerically longer for patients in the placebo arm versus the fruquintinib arm (7.7 and 9.7 months in the fruquintinib and placebo groups; stratified HR, 0.70; 95% CI, 0.43 to 1.15; P = .152). The authors point out that overall survival is a secondary endpoint and the study was insufficiently powered to assess differences in overall survival.

“In patients with NSCLC who experienced treatment failure with two standard chemotherapies, fruquintinib may provide a clinically meaningful benefit, and further evidence of a statistically significant OS benefit of fruquintinib is expected from a phase 3 randomized study in this target population,” wrote Dr. Shun Lu of Shanghai Lung Cancer Center, Shanghai Chest Hospital, Jiao Tong University, Shanghai, China, and colleagues.

Fruquintinib is a highly selective inhibitor of VEGFR-1, -2 and -3 kinases, and showed promising activity against solid tumors, including NSCLC, in a phase 1 trial. The current phase 2 trial evaluated the efficacy and safety of single-agent fruquintinib in 91 patients with advanced nonsquamous NSCLC. All patients had experienced disease progression after two lines of standard chemotherapy, and were randomly assigned to be treated with either fruquintinib (n = 61) or placebo (n = 30).

At data cutoff for PFS analysis, a total of 46 patients (75.4%) in the fruquintinib group and 25 (83.3%) in the placebo group had experienced a PFS event. The median follow-up for survival was 28.0 months for fruquintinib and 25.4 months for the placebo group.

Both the 3- and 6-month survival rates were numerically higher for patients receiving fruquintinib group versus placebo (90.2% vs. 73.3% for 3-month survival and 67.2% vs. 58.8% for 6-month survival).

The results for other secondary endpoints showed a more favorable overall response rate for fruquintinib vs placebo (13.1% vs 0%; P = .041), as was the disease control rate (60.7% vs 13.3%; P less than .001).

Subgroup analyses favored PFS with fruquintinib, as it was significantly longer vs. placebo for all patient subsets except for those with brain metastases. The median overall survival also was numerically greater with fruquintinib among patients positive for EGFR mutations (8.4 vs. 5.5 months; HR, 0.58; 95% CI, 0.30-1.141 P =.11).

Treatment emergent adverse events were higher in the fruquintinib arm (100% vs. 90%), but most of these were grade 1/2 in both groups. The most common grade 3 and higher events observed with fruquintinib were hypertension (8.2%), hand-foot syndrome (4.9%), and proteinuria (4.9%).

SOURCE: Lu S. et al. J Clin Oncol. 2018 Mar. 12 doi: 10.1200/JCO.2017.76.7145.

Investigational agent fruquintinib holds promise as a third- or fourth-line treatment option for patients with advanced non–small-cell lung cancer (NSCLC), according to new findings published in the Journal of Clinical Oncology.

The median progression free survival (PFS) as evaluated by a blinded image central review committee and the study’s primary endpoint, was more than threefold higher than observed with placebo; 3.8 months (95% confidence interval, 2.8 to 4.6 months) with fruquintinib versus 1.1 months (95% CI, 1.0 to 1.9 months) with placebo (stratified HR was 0.34 (95% CI,0.20 to 0.57; P less than .001). PFS assessed by investigators was nearly identical.

Median overall survival, however, was numerically longer for patients in the placebo arm versus the fruquintinib arm (7.7 and 9.7 months in the fruquintinib and placebo groups; stratified HR, 0.70; 95% CI, 0.43 to 1.15; P = .152). The authors point out that overall survival is a secondary endpoint and the study was insufficiently powered to assess differences in overall survival.

“In patients with NSCLC who experienced treatment failure with two standard chemotherapies, fruquintinib may provide a clinically meaningful benefit, and further evidence of a statistically significant OS benefit of fruquintinib is expected from a phase 3 randomized study in this target population,” wrote Dr. Shun Lu of Shanghai Lung Cancer Center, Shanghai Chest Hospital, Jiao Tong University, Shanghai, China, and colleagues.

Fruquintinib is a highly selective inhibitor of VEGFR-1, -2 and -3 kinases, and showed promising activity against solid tumors, including NSCLC, in a phase 1 trial. The current phase 2 trial evaluated the efficacy and safety of single-agent fruquintinib in 91 patients with advanced nonsquamous NSCLC. All patients had experienced disease progression after two lines of standard chemotherapy, and were randomly assigned to be treated with either fruquintinib (n = 61) or placebo (n = 30).

At data cutoff for PFS analysis, a total of 46 patients (75.4%) in the fruquintinib group and 25 (83.3%) in the placebo group had experienced a PFS event. The median follow-up for survival was 28.0 months for fruquintinib and 25.4 months for the placebo group.

Both the 3- and 6-month survival rates were numerically higher for patients receiving fruquintinib group versus placebo (90.2% vs. 73.3% for 3-month survival and 67.2% vs. 58.8% for 6-month survival).

The results for other secondary endpoints showed a more favorable overall response rate for fruquintinib vs placebo (13.1% vs 0%; P = .041), as was the disease control rate (60.7% vs 13.3%; P less than .001).

Subgroup analyses favored PFS with fruquintinib, as it was significantly longer vs. placebo for all patient subsets except for those with brain metastases. The median overall survival also was numerically greater with fruquintinib among patients positive for EGFR mutations (8.4 vs. 5.5 months; HR, 0.58; 95% CI, 0.30-1.141 P =.11).

Treatment emergent adverse events were higher in the fruquintinib arm (100% vs. 90%), but most of these were grade 1/2 in both groups. The most common grade 3 and higher events observed with fruquintinib were hypertension (8.2%), hand-foot syndrome (4.9%), and proteinuria (4.9%).

SOURCE: Lu S. et al. J Clin Oncol. 2018 Mar. 12 doi: 10.1200/JCO.2017.76.7145.

Investigational agent fruquintinib holds promise as a third- or fourth-line treatment option for patients with advanced non–small-cell lung cancer (NSCLC), according to new findings published in the Journal of Clinical Oncology.

The median progression free survival (PFS) as evaluated by a blinded image central review committee and the study’s primary endpoint, was more than threefold higher than observed with placebo; 3.8 months (95% confidence interval, 2.8 to 4.6 months) with fruquintinib versus 1.1 months (95% CI, 1.0 to 1.9 months) with placebo (stratified HR was 0.34 (95% CI,0.20 to 0.57; P less than .001). PFS assessed by investigators was nearly identical.

Median overall survival, however, was numerically longer for patients in the placebo arm versus the fruquintinib arm (7.7 and 9.7 months in the fruquintinib and placebo groups; stratified HR, 0.70; 95% CI, 0.43 to 1.15; P = .152). The authors point out that overall survival is a secondary endpoint and the study was insufficiently powered to assess differences in overall survival.

“In patients with NSCLC who experienced treatment failure with two standard chemotherapies, fruquintinib may provide a clinically meaningful benefit, and further evidence of a statistically significant OS benefit of fruquintinib is expected from a phase 3 randomized study in this target population,” wrote Dr. Shun Lu of Shanghai Lung Cancer Center, Shanghai Chest Hospital, Jiao Tong University, Shanghai, China, and colleagues.

Fruquintinib is a highly selective inhibitor of VEGFR-1, -2 and -3 kinases, and showed promising activity against solid tumors, including NSCLC, in a phase 1 trial. The current phase 2 trial evaluated the efficacy and safety of single-agent fruquintinib in 91 patients with advanced nonsquamous NSCLC. All patients had experienced disease progression after two lines of standard chemotherapy, and were randomly assigned to be treated with either fruquintinib (n = 61) or placebo (n = 30).

At data cutoff for PFS analysis, a total of 46 patients (75.4%) in the fruquintinib group and 25 (83.3%) in the placebo group had experienced a PFS event. The median follow-up for survival was 28.0 months for fruquintinib and 25.4 months for the placebo group.

Both the 3- and 6-month survival rates were numerically higher for patients receiving fruquintinib group versus placebo (90.2% vs. 73.3% for 3-month survival and 67.2% vs. 58.8% for 6-month survival).

The results for other secondary endpoints showed a more favorable overall response rate for fruquintinib vs placebo (13.1% vs 0%; P = .041), as was the disease control rate (60.7% vs 13.3%; P less than .001).

Subgroup analyses favored PFS with fruquintinib, as it was significantly longer vs. placebo for all patient subsets except for those with brain metastases. The median overall survival also was numerically greater with fruquintinib among patients positive for EGFR mutations (8.4 vs. 5.5 months; HR, 0.58; 95% CI, 0.30-1.141 P =.11).

Treatment emergent adverse events were higher in the fruquintinib arm (100% vs. 90%), but most of these were grade 1/2 in both groups. The most common grade 3 and higher events observed with fruquintinib were hypertension (8.2%), hand-foot syndrome (4.9%), and proteinuria (4.9%).

SOURCE: Lu S. et al. J Clin Oncol. 2018 Mar. 12 doi: 10.1200/JCO.2017.76.7145.

ORLANDO – Using videoconferencing to assess patients for a reported penicillin allergy saved more than 2 hours of physician time for every patient, and resulted in almost every patient having their allergy label removed, researchers reported.

In what the researchers said was the first study showing the utility of telemedicine in evaluating patient-reported penicillin allergies, allergy and immunology physicians did a secure telemedicine consultation with patients after they underwent penicillin skin testing with a physician assistant; an approach which, on average, took 123 minutes fewer each time than if the physician had done the consultation face-to-face. The teleconference can be done on a laptop or smartphone.

Thomas R. Collins/Frontline Medical Communications

“This is so overlabeled,” Dr. Ramsey said. “Ten percent of the population thinks they’re allergic to penicillin, and 90% of them are not.”

A stark difference was found in the types of medicines administered before and after the evaluations, with aminopenicillin therapy jumping from 0 days of use to 188 days, and vancomycin – a more potent, but more costly alternative – dropping from 130 days of use to 16 days (P less than .05 for both).

Dr. Ramsey noted that, in part because of the time-consuming nature of the penicillin skin tests, they often are simply not done, so the false allergy labels are not caught, leading to pointless costs and exposure to more potent and potentially harmful forms of antibiotic therapy.

“Some hospitals don’t have allergists who will come in to do testing,” she said. “Sometimes patients are on medications that may interfere. And then a lot of times it’s just underrecognized – the implications of a penicillin allergy label. That is a very hot topic in our field and also in infectious disease.”

She hopes the telemedicine approach catches on more widely, which would help minimize the multitude of problems linked to penicillin allergy labels.

“Patients that avoid penicillin, they’re on more costly second-line antibiotics that are, in general, less effective, depending on which infection you’re talking about,” Dr. Ramsey said. “The [second-line antibiotics] have more side effects. And there’s data to show that patients with [a] penicillin allergy label have longer hospital stays, more costly hospital stays, are at risk for more resistant infections. And it breeds antimicrobial resistance in the long-term.”

Dr. Ramsey had no relevant financial disclosures.

SOURCE: Ramsey AC et al. AAAAI/WAO Joint Congress, Abstract 104.

ORLANDO – Using videoconferencing to assess patients for a reported penicillin allergy saved more than 2 hours of physician time for every patient, and resulted in almost every patient having their allergy label removed, researchers reported.

In what the researchers said was the first study showing the utility of telemedicine in evaluating patient-reported penicillin allergies, allergy and immunology physicians did a secure telemedicine consultation with patients after they underwent penicillin skin testing with a physician assistant; an approach which, on average, took 123 minutes fewer each time than if the physician had done the consultation face-to-face. The teleconference can be done on a laptop or smartphone.

Thomas R. Collins/Frontline Medical Communications

“This is so overlabeled,” Dr. Ramsey said. “Ten percent of the population thinks they’re allergic to penicillin, and 90% of them are not.”

A stark difference was found in the types of medicines administered before and after the evaluations, with aminopenicillin therapy jumping from 0 days of use to 188 days, and vancomycin – a more potent, but more costly alternative – dropping from 130 days of use to 16 days (P less than .05 for both).

Dr. Ramsey noted that, in part because of the time-consuming nature of the penicillin skin tests, they often are simply not done, so the false allergy labels are not caught, leading to pointless costs and exposure to more potent and potentially harmful forms of antibiotic therapy.

“Some hospitals don’t have allergists who will come in to do testing,” she said. “Sometimes patients are on medications that may interfere. And then a lot of times it’s just underrecognized – the implications of a penicillin allergy label. That is a very hot topic in our field and also in infectious disease.”

She hopes the telemedicine approach catches on more widely, which would help minimize the multitude of problems linked to penicillin allergy labels.

“Patients that avoid penicillin, they’re on more costly second-line antibiotics that are, in general, less effective, depending on which infection you’re talking about,” Dr. Ramsey said. “The [second-line antibiotics] have more side effects. And there’s data to show that patients with [a] penicillin allergy label have longer hospital stays, more costly hospital stays, are at risk for more resistant infections. And it breeds antimicrobial resistance in the long-term.”

Dr. Ramsey had no relevant financial disclosures.

SOURCE: Ramsey AC et al. AAAAI/WAO Joint Congress, Abstract 104.

ORLANDO – Using videoconferencing to assess patients for a reported penicillin allergy saved more than 2 hours of physician time for every patient, and resulted in almost every patient having their allergy label removed, researchers reported.

In what the researchers said was the first study showing the utility of telemedicine in evaluating patient-reported penicillin allergies, allergy and immunology physicians did a secure telemedicine consultation with patients after they underwent penicillin skin testing with a physician assistant; an approach which, on average, took 123 minutes fewer each time than if the physician had done the consultation face-to-face. The teleconference can be done on a laptop or smartphone.

Thomas R. Collins/Frontline Medical Communications

“This is so overlabeled,” Dr. Ramsey said. “Ten percent of the population thinks they’re allergic to penicillin, and 90% of them are not.”

A stark difference was found in the types of medicines administered before and after the evaluations, with aminopenicillin therapy jumping from 0 days of use to 188 days, and vancomycin – a more potent, but more costly alternative – dropping from 130 days of use to 16 days (P less than .05 for both).

Dr. Ramsey noted that, in part because of the time-consuming nature of the penicillin skin tests, they often are simply not done, so the false allergy labels are not caught, leading to pointless costs and exposure to more potent and potentially harmful forms of antibiotic therapy.

“Some hospitals don’t have allergists who will come in to do testing,” she said. “Sometimes patients are on medications that may interfere. And then a lot of times it’s just underrecognized – the implications of a penicillin allergy label. That is a very hot topic in our field and also in infectious disease.”

She hopes the telemedicine approach catches on more widely, which would help minimize the multitude of problems linked to penicillin allergy labels.

“Patients that avoid penicillin, they’re on more costly second-line antibiotics that are, in general, less effective, depending on which infection you’re talking about,” Dr. Ramsey said. “The [second-line antibiotics] have more side effects. And there’s data to show that patients with [a] penicillin allergy label have longer hospital stays, more costly hospital stays, are at risk for more resistant infections. And it breeds antimicrobial resistance in the long-term.”

Dr. Ramsey had no relevant financial disclosures.

SOURCE: Ramsey AC et al. AAAAI/WAO Joint Congress, Abstract 104.

KAUAI, HAWAII – Gentler vacuum pressure seems to reduce the risk of paradoxical adipose hyperplasia after cryolipolysis, according to Suzanne Kilmer, MD, director of the Laser and Skin Surgery Center of Northern California, Sacramento.

She and her colleagues have noticed a reduction with the newer CoolAdvantage applicators from Zeltiq Aesthetics, the manufacturer of CoolSculpting equipment. CoolAdvantage runs colder and with less suction than earlier applicators. “It seems to work equally as well,” but with shorter treatment times, less bruising, and less discomfort. Although paradoxical adipose hyperplasia (PAH) “is incredibly rare, it is something we want to reduce, and we do see decreased incidence with these new applicators,” Dr. Kilmer said at the Hawaii Dermatology Seminar provided by Global Academy for Medical Education/Skin Disease Education Foundation.

M. Alexander Otto/Frontline Medical News

Another newer option from the manufacturer is the CoolMini applicator for submental fat. Dr. Kilmer generally does two overlapping applications with the CoolMini in the same session, in order to cover as much chin fat as possible. There will be what looks like a stick of butter under the chin when the applicators are removed; it goes away after a few minutes of massage. Patient satisfaction is high, but there can be unveiling of the platysmal bands, which is “something you want to talk to patients about ahead of time,” she said.

She sometimes uses the CoolMini first, followed by the other recently available option for submental fat, deoxycholic acid (Kybella). “We shrink down everything we can with CoolSculpting, and then come back with Kybella to clean up whatever’s left.” Using this approach, patients are injected with less deoxycholic acid, with less inflammation, she said.

“I think you get more fat loss out of a given CoolSculpting treatment than you do with Kybella,” said Dr. Kilmer, who noted that deoxycholic acid is also an option for PAH.

As for going off label with CoolSculpting for jowls, “we’ve done it, and I tell everybody there’s a chance of a 2-3 month palsy. All you are really doing is demyelinating the nerve, not injuring it. If you do liposuction, you actually have a little bit of risk of actually injuring it. You can use a nerve stimulator to map out the nerves beforehand,” she said.

Dr. Kilmer is a consultant for Zeltiq Aesthetics, and an investigator on many of the company’s development trials. She’s also a consultant for Allergan, manufacturer of Kybella, which recently acquired Zeltiq. SDEF/Global Academy for Medical Education and this news organization are owned by the same parent company.

[email protected]

KAUAI, HAWAII – Gentler vacuum pressure seems to reduce the risk of paradoxical adipose hyperplasia after cryolipolysis, according to Suzanne Kilmer, MD, director of the Laser and Skin Surgery Center of Northern California, Sacramento.

She and her colleagues have noticed a reduction with the newer CoolAdvantage applicators from Zeltiq Aesthetics, the manufacturer of CoolSculpting equipment. CoolAdvantage runs colder and with less suction than earlier applicators. “It seems to work equally as well,” but with shorter treatment times, less bruising, and less discomfort. Although paradoxical adipose hyperplasia (PAH) “is incredibly rare, it is something we want to reduce, and we do see decreased incidence with these new applicators,” Dr. Kilmer said at the Hawaii Dermatology Seminar provided by Global Academy for Medical Education/Skin Disease Education Foundation.

M. Alexander Otto/Frontline Medical News

Another newer option from the manufacturer is the CoolMini applicator for submental fat. Dr. Kilmer generally does two overlapping applications with the CoolMini in the same session, in order to cover as much chin fat as possible. There will be what looks like a stick of butter under the chin when the applicators are removed; it goes away after a few minutes of massage. Patient satisfaction is high, but there can be unveiling of the platysmal bands, which is “something you want to talk to patients about ahead of time,” she said.

She sometimes uses the CoolMini first, followed by the other recently available option for submental fat, deoxycholic acid (Kybella). “We shrink down everything we can with CoolSculpting, and then come back with Kybella to clean up whatever’s left.” Using this approach, patients are injected with less deoxycholic acid, with less inflammation, she said.

“I think you get more fat loss out of a given CoolSculpting treatment than you do with Kybella,” said Dr. Kilmer, who noted that deoxycholic acid is also an option for PAH.

As for going off label with CoolSculpting for jowls, “we’ve done it, and I tell everybody there’s a chance of a 2-3 month palsy. All you are really doing is demyelinating the nerve, not injuring it. If you do liposuction, you actually have a little bit of risk of actually injuring it. You can use a nerve stimulator to map out the nerves beforehand,” she said.

Dr. Kilmer is a consultant for Zeltiq Aesthetics, and an investigator on many of the company’s development trials. She’s also a consultant for Allergan, manufacturer of Kybella, which recently acquired Zeltiq. SDEF/Global Academy for Medical Education and this news organization are owned by the same parent company.

[email protected]

KAUAI, HAWAII – Gentler vacuum pressure seems to reduce the risk of paradoxical adipose hyperplasia after cryolipolysis, according to Suzanne Kilmer, MD, director of the Laser and Skin Surgery Center of Northern California, Sacramento.

She and her colleagues have noticed a reduction with the newer CoolAdvantage applicators from Zeltiq Aesthetics, the manufacturer of CoolSculpting equipment. CoolAdvantage runs colder and with less suction than earlier applicators. “It seems to work equally as well,” but with shorter treatment times, less bruising, and less discomfort. Although paradoxical adipose hyperplasia (PAH) “is incredibly rare, it is something we want to reduce, and we do see decreased incidence with these new applicators,” Dr. Kilmer said at the Hawaii Dermatology Seminar provided by Global Academy for Medical Education/Skin Disease Education Foundation.

M. Alexander Otto/Frontline Medical News

Another newer option from the manufacturer is the CoolMini applicator for submental fat. Dr. Kilmer generally does two overlapping applications with the CoolMini in the same session, in order to cover as much chin fat as possible. There will be what looks like a stick of butter under the chin when the applicators are removed; it goes away after a few minutes of massage. Patient satisfaction is high, but there can be unveiling of the platysmal bands, which is “something you want to talk to patients about ahead of time,” she said.

She sometimes uses the CoolMini first, followed by the other recently available option for submental fat, deoxycholic acid (Kybella). “We shrink down everything we can with CoolSculpting, and then come back with Kybella to clean up whatever’s left.” Using this approach, patients are injected with less deoxycholic acid, with less inflammation, she said.

“I think you get more fat loss out of a given CoolSculpting treatment than you do with Kybella,” said Dr. Kilmer, who noted that deoxycholic acid is also an option for PAH.

As for going off label with CoolSculpting for jowls, “we’ve done it, and I tell everybody there’s a chance of a 2-3 month palsy. All you are really doing is demyelinating the nerve, not injuring it. If you do liposuction, you actually have a little bit of risk of actually injuring it. You can use a nerve stimulator to map out the nerves beforehand,” she said.

Dr. Kilmer is a consultant for Zeltiq Aesthetics, and an investigator on many of the company’s development trials. She’s also a consultant for Allergan, manufacturer of Kybella, which recently acquired Zeltiq. SDEF/Global Academy for Medical Education and this news organization are owned by the same parent company.

[email protected]

SAN DIEGO – Pediatric hematologists should consider testing for vitamin D deficiency to optimize bone health in children who will be receiving chronic anticoagulation. That’s a key message from a single-center retrospective review presented during a poster session at the biennial summit of the Thrombosis & Hemostasis Societies of North America.

“More research is needed to determine which children should be targeted for screening for low [bone mineral density], though our research suggests that children with prolonged treatment with steroids may be at the highest risk,” Kavita N. Patel, MD, one of the study’s authors, said in an interview.

The study population was a retrospective cohort of children aged 10-21 years who received anticoagulation for more than 1 year at Children’s Healthcare of Atlanta between Jan. 2, 2012, and Oct. 15, 2017. The researchers evaluated a number of factors, including demographic variables, anticoagulants used, vitamin D status, previously reported comorbid conditions and medications associated with changes in BMD. They defined vitamin D deficiency as less than 20 ng/mL and insufficiency as 20-29 ng/mL.

Dr. Patel reported results from 27 males and 23 females. Of these, 15 (30%) underwent bone density testing with dual-energy X-ray absorptiometry; 5 (10%) did not undergo dual-energy X-ray absorptiometry testing because there is no age-specific standardization below the age of 5 years. Nearly half of the patients (42%) were Caucasian, 34% were African American, 16% were Hispanic, and the rest were from other ethnicities. The top four common indications for extended anticoagulation were recurrent venous thromboembolism (26%), extended treatment for deep vein thrombosis (18%), antiphospholipid syndrome (14%), and thrombophilia plus a single venous thromboembolism (14%).

The anticoagulants most often utilized were enoxaparin (59%), warfarin (29%), and rivaroxaban (7%). The most frequent risk factor for low BMD was long-term use of steroids (16%; defined as greater than 6 months of continuous use in the year prior to BMD testing).

Vitamin D deficiency was identified in 52% of subjects who were tested, while another 24% had insufficient levels of vitamin D. Overall, the median lumbar spine z score was –1.4. Five (30%) subjects who completed BMD testing had low BMD, with median z score of –2.5. None met fracture criteria for pediatric osteoporosis. On linear regression, the only factor found to be significantly associated with a BMD lumbar spine z score in chronically anticoagulated children was the long-term use of steroids (P = .04).

Dr. Patel acknowledged certain limitations of the study, including its single-center design and the fact that not all of the children receiving chronic anticoagulation could be tested.

She reported having no financial disclosures.

[email protected]

SOURCE: Patel KN et al. THSNA 2018, Poster 65.

SAN DIEGO – Pediatric hematologists should consider testing for vitamin D deficiency to optimize bone health in children who will be receiving chronic anticoagulation. That’s a key message from a single-center retrospective review presented during a poster session at the biennial summit of the Thrombosis & Hemostasis Societies of North America.

“More research is needed to determine which children should be targeted for screening for low [bone mineral density], though our research suggests that children with prolonged treatment with steroids may be at the highest risk,” Kavita N. Patel, MD, one of the study’s authors, said in an interview.

The study population was a retrospective cohort of children aged 10-21 years who received anticoagulation for more than 1 year at Children’s Healthcare of Atlanta between Jan. 2, 2012, and Oct. 15, 2017. The researchers evaluated a number of factors, including demographic variables, anticoagulants used, vitamin D status, previously reported comorbid conditions and medications associated with changes in BMD. They defined vitamin D deficiency as less than 20 ng/mL and insufficiency as 20-29 ng/mL.

Dr. Patel reported results from 27 males and 23 females. Of these, 15 (30%) underwent bone density testing with dual-energy X-ray absorptiometry; 5 (10%) did not undergo dual-energy X-ray absorptiometry testing because there is no age-specific standardization below the age of 5 years. Nearly half of the patients (42%) were Caucasian, 34% were African American, 16% were Hispanic, and the rest were from other ethnicities. The top four common indications for extended anticoagulation were recurrent venous thromboembolism (26%), extended treatment for deep vein thrombosis (18%), antiphospholipid syndrome (14%), and thrombophilia plus a single venous thromboembolism (14%).

The anticoagulants most often utilized were enoxaparin (59%), warfarin (29%), and rivaroxaban (7%). The most frequent risk factor for low BMD was long-term use of steroids (16%; defined as greater than 6 months of continuous use in the year prior to BMD testing).

Vitamin D deficiency was identified in 52% of subjects who were tested, while another 24% had insufficient levels of vitamin D. Overall, the median lumbar spine z score was –1.4. Five (30%) subjects who completed BMD testing had low BMD, with median z score of –2.5. None met fracture criteria for pediatric osteoporosis. On linear regression, the only factor found to be significantly associated with a BMD lumbar spine z score in chronically anticoagulated children was the long-term use of steroids (P = .04).

Dr. Patel acknowledged certain limitations of the study, including its single-center design and the fact that not all of the children receiving chronic anticoagulation could be tested.

She reported having no financial disclosures.

[email protected]

SOURCE: Patel KN et al. THSNA 2018, Poster 65.

SAN DIEGO – Pediatric hematologists should consider testing for vitamin D deficiency to optimize bone health in children who will be receiving chronic anticoagulation. That’s a key message from a single-center retrospective review presented during a poster session at the biennial summit of the Thrombosis & Hemostasis Societies of North America.

“More research is needed to determine which children should be targeted for screening for low [bone mineral density], though our research suggests that children with prolonged treatment with steroids may be at the highest risk,” Kavita N. Patel, MD, one of the study’s authors, said in an interview.

The study population was a retrospective cohort of children aged 10-21 years who received anticoagulation for more than 1 year at Children’s Healthcare of Atlanta between Jan. 2, 2012, and Oct. 15, 2017. The researchers evaluated a number of factors, including demographic variables, anticoagulants used, vitamin D status, previously reported comorbid conditions and medications associated with changes in BMD. They defined vitamin D deficiency as less than 20 ng/mL and insufficiency as 20-29 ng/mL.

Dr. Patel reported results from 27 males and 23 females. Of these, 15 (30%) underwent bone density testing with dual-energy X-ray absorptiometry; 5 (10%) did not undergo dual-energy X-ray absorptiometry testing because there is no age-specific standardization below the age of 5 years. Nearly half of the patients (42%) were Caucasian, 34% were African American, 16% were Hispanic, and the rest were from other ethnicities. The top four common indications for extended anticoagulation were recurrent venous thromboembolism (26%), extended treatment for deep vein thrombosis (18%), antiphospholipid syndrome (14%), and thrombophilia plus a single venous thromboembolism (14%).

The anticoagulants most often utilized were enoxaparin (59%), warfarin (29%), and rivaroxaban (7%). The most frequent risk factor for low BMD was long-term use of steroids (16%; defined as greater than 6 months of continuous use in the year prior to BMD testing).

Vitamin D deficiency was identified in 52% of subjects who were tested, while another 24% had insufficient levels of vitamin D. Overall, the median lumbar spine z score was –1.4. Five (30%) subjects who completed BMD testing had low BMD, with median z score of –2.5. None met fracture criteria for pediatric osteoporosis. On linear regression, the only factor found to be significantly associated with a BMD lumbar spine z score in chronically anticoagulated children was the long-term use of steroids (P = .04).

Dr. Patel acknowledged certain limitations of the study, including its single-center design and the fact that not all of the children receiving chronic anticoagulation could be tested.

She reported having no financial disclosures.

[email protected]

SOURCE: Patel KN et al. THSNA 2018, Poster 65.

Stratification of colorectal cancer (CRC) risk was enhanced by joint consideration of the independent family history and genetic risk score predictors, according to an ongoing population-based, case-control study of patients recruited during 2003-2010.

Courtesy Wikimedia Commons/Nephron/Creative Commons License

The research was conducted using data from DACHS (Colorectal Cancer: Chances for Prevention Through Screening), an ongoing population-based, case-control study in Germany, reported Korbinian Weigl, PhD, and his colleagues in the journal Clinical Epidemiology (doi: 10.2147/CLEP.S145636). They included 2,363 eligible CRC patients who were identified by 22 participating hospitals and frequency matched with respect to sex, age, and residential location to 2,198 randomly selected controls that had genome-wide association studies data. The population consisted of 40% women, and the median ages for cases and controls were 69 and 70 years, respectively.

Genetic risk score was calculated by genotyping 53 single-nucleotide polymorphisms reported in published literature to be associated with higher CRC risk for individuals of European descent. Seven genetic risk score groups – very low, low, low-medium, medium, medium-high, high, and very high – were established according to categories generated on the basis of weighted risk allele distribution among controls. Family history referred to CRC in first-degree and second-degree relatives. Selected potential confounders included age, sex, body mass index, education, hormone replacement therapy in women, smoking, and colonoscopy history. Odds ratios with 95% confidence intervals were estimated by multiple logistic regression models that included adjustment for potential confounders. Statistical calculations examined individual and joint family history and genetic risk score associations with risk for CRC and the effect of potential confounding factors.

At least one colonoscopy was performed on over half the individuals in the control group, while a significantly lower number (P less than .0001) were performed on case individuals (22.1%). Family history of CRC in first-degree relatives was reported by 316 case participants (13.4%) and 214 controls (9.7%; P less than .0001). The calculated genetic risk score ranged from 20 to 48, with a substantially higher proportion of cases in the higher deciles.

Investigators compared the risk for CRC in the top decile with that in the lowest and found an increased risk of 2.9-fold (OR, 2.94) based on genetic risk analysis adjusted for sex and age and an increased risk of 3.0-fold (OR, 3.0) when all other covariates except family history were included. Comparing results against analysis with the 27 single-nucleotide polymorphisms that had been used in previous studies indicated a sizable improvement in genetic risk stratification as a result of increasing the number of single-nucleotide polymorphisms (P value for increase in c statistic = .003) included in the analysis.

Risk associated with having a family history of CRC in a first-degree relative was 1.5-fold (OR, 1.47) higher in an age- and sex-adjusted analysis. Risk prediction increased to an OR of 1.86 when calculations were adjusted with covariates, especially with previous colonoscopies. Using genetic risk scoring as a calculation adjustment only slightly changed the result (OR, 1.83). A similar trend, but with lower-magnitude associations, was observed with family history of CRC in second-degree relatives.

A dose-response association between the number of risk alleles and CRC risk determined by a logistic regression model revealed a curvilinear relationship between genetic risk score and CRC risk. At higher genetic risk score levels, the increase in CRC risk was particularly strong. The dose-response association indicated an independent relationship between family history and CRC such that individuals with first-degree relatives with CRC will reach the same risk level with a lower genetic risk score as those with a higher genetic risk score but no first-degree relatives with CRC.

SOURCE: Weigl K et al. Clin Epidemiol. 2018;10:143-52.
 

Stratification of colorectal cancer (CRC) risk was enhanced by joint consideration of the independent family history and genetic risk score predictors, according to an ongoing population-based, case-control study of patients recruited during 2003-2010.

Courtesy Wikimedia Commons/Nephron/Creative Commons License

The research was conducted using data from DACHS (Colorectal Cancer: Chances for Prevention Through Screening), an ongoing population-based, case-control study in Germany, reported Korbinian Weigl, PhD, and his colleagues in the journal Clinical Epidemiology (doi: 10.2147/CLEP.S145636). They included 2,363 eligible CRC patients who were identified by 22 participating hospitals and frequency matched with respect to sex, age, and residential location to 2,198 randomly selected controls that had genome-wide association studies data. The population consisted of 40% women, and the median ages for cases and controls were 69 and 70 years, respectively.

Genetic risk score was calculated by genotyping 53 single-nucleotide polymorphisms reported in published literature to be associated with higher CRC risk for individuals of European descent. Seven genetic risk score groups – very low, low, low-medium, medium, medium-high, high, and very high – were established according to categories generated on the basis of weighted risk allele distribution among controls. Family history referred to CRC in first-degree and second-degree relatives. Selected potential confounders included age, sex, body mass index, education, hormone replacement therapy in women, smoking, and colonoscopy history. Odds ratios with 95% confidence intervals were estimated by multiple logistic regression models that included adjustment for potential confounders. Statistical calculations examined individual and joint family history and genetic risk score associations with risk for CRC and the effect of potential confounding factors.

At least one colonoscopy was performed on over half the individuals in the control group, while a significantly lower number (P less than .0001) were performed on case individuals (22.1%). Family history of CRC in first-degree relatives was reported by 316 case participants (13.4%) and 214 controls (9.7%; P less than .0001). The calculated genetic risk score ranged from 20 to 48, with a substantially higher proportion of cases in the higher deciles.

Investigators compared the risk for CRC in the top decile with that in the lowest and found an increased risk of 2.9-fold (OR, 2.94) based on genetic risk analysis adjusted for sex and age and an increased risk of 3.0-fold (OR, 3.0) when all other covariates except family history were included. Comparing results against analysis with the 27 single-nucleotide polymorphisms that had been used in previous studies indicated a sizable improvement in genetic risk stratification as a result of increasing the number of single-nucleotide polymorphisms (P value for increase in c statistic = .003) included in the analysis.

Risk associated with having a family history of CRC in a first-degree relative was 1.5-fold (OR, 1.47) higher in an age- and sex-adjusted analysis. Risk prediction increased to an OR of 1.86 when calculations were adjusted with covariates, especially with previous colonoscopies. Using genetic risk scoring as a calculation adjustment only slightly changed the result (OR, 1.83). A similar trend, but with lower-magnitude associations, was observed with family history of CRC in second-degree relatives.

A dose-response association between the number of risk alleles and CRC risk determined by a logistic regression model revealed a curvilinear relationship between genetic risk score and CRC risk. At higher genetic risk score levels, the increase in CRC risk was particularly strong. The dose-response association indicated an independent relationship between family history and CRC such that individuals with first-degree relatives with CRC will reach the same risk level with a lower genetic risk score as those with a higher genetic risk score but no first-degree relatives with CRC.

SOURCE: Weigl K et al. Clin Epidemiol. 2018;10:143-52.
 

Stratification of colorectal cancer (CRC) risk was enhanced by joint consideration of the independent family history and genetic risk score predictors, according to an ongoing population-based, case-control study of patients recruited during 2003-2010.

Courtesy Wikimedia Commons/Nephron/Creative Commons License

The research was conducted using data from DACHS (Colorectal Cancer: Chances for Prevention Through Screening), an ongoing population-based, case-control study in Germany, reported Korbinian Weigl, PhD, and his colleagues in the journal Clinical Epidemiology (doi: 10.2147/CLEP.S145636). They included 2,363 eligible CRC patients who were identified by 22 participating hospitals and frequency matched with respect to sex, age, and residential location to 2,198 randomly selected controls that had genome-wide association studies data. The population consisted of 40% women, and the median ages for cases and controls were 69 and 70 years, respectively.

Genetic risk score was calculated by genotyping 53 single-nucleotide polymorphisms reported in published literature to be associated with higher CRC risk for individuals of European descent. Seven genetic risk score groups – very low, low, low-medium, medium, medium-high, high, and very high – were established according to categories generated on the basis of weighted risk allele distribution among controls. Family history referred to CRC in first-degree and second-degree relatives. Selected potential confounders included age, sex, body mass index, education, hormone replacement therapy in women, smoking, and colonoscopy history. Odds ratios with 95% confidence intervals were estimated by multiple logistic regression models that included adjustment for potential confounders. Statistical calculations examined individual and joint family history and genetic risk score associations with risk for CRC and the effect of potential confounding factors.

At least one colonoscopy was performed on over half the individuals in the control group, while a significantly lower number (P less than .0001) were performed on case individuals (22.1%). Family history of CRC in first-degree relatives was reported by 316 case participants (13.4%) and 214 controls (9.7%; P less than .0001). The calculated genetic risk score ranged from 20 to 48, with a substantially higher proportion of cases in the higher deciles.

Investigators compared the risk for CRC in the top decile with that in the lowest and found an increased risk of 2.9-fold (OR, 2.94) based on genetic risk analysis adjusted for sex and age and an increased risk of 3.0-fold (OR, 3.0) when all other covariates except family history were included. Comparing results against analysis with the 27 single-nucleotide polymorphisms that had been used in previous studies indicated a sizable improvement in genetic risk stratification as a result of increasing the number of single-nucleotide polymorphisms (P value for increase in c statistic = .003) included in the analysis.

Risk associated with having a family history of CRC in a first-degree relative was 1.5-fold (OR, 1.47) higher in an age- and sex-adjusted analysis. Risk prediction increased to an OR of 1.86 when calculations were adjusted with covariates, especially with previous colonoscopies. Using genetic risk scoring as a calculation adjustment only slightly changed the result (OR, 1.83). A similar trend, but with lower-magnitude associations, was observed with family history of CRC in second-degree relatives.

A dose-response association between the number of risk alleles and CRC risk determined by a logistic regression model revealed a curvilinear relationship between genetic risk score and CRC risk. At higher genetic risk score levels, the increase in CRC risk was particularly strong. The dose-response association indicated an independent relationship between family history and CRC such that individuals with first-degree relatives with CRC will reach the same risk level with a lower genetic risk score as those with a higher genetic risk score but no first-degree relatives with CRC.

SOURCE: Weigl K et al. Clin Epidemiol. 2018;10:143-52.
 

Elderly individuals who have excessive daytime sleepiness might be more susceptible to accumulation of an Alzheimer’s disease (AD) biomarker, results of a prospective, longitudinal cohort study suggest.

In the study, excessive daytime sleepiness (EDS) was associated with increased accumulation of beta-amyloid, an important biomarker of AD that manifests in early preclinical stages, wrote first author Diego Z. Carvalho, MD, and his colleagues at the Mayo Clinic, Rochester, Minn. The report was published online March 12 in JAMA Neurology.

Jupiterimages/Thinkstock

The prospective, longitudinal cohort analysis from Dr. Carvalho and his colleagues included 283 participants age 70 or older without a diagnosis of dementia who filled out a sleepiness assessment survey and underwent baseline and follow-up imaging studies as part of the Mayo Clinic Study of Aging.

All participants included in the analysis underwent at least two consecutive carbon 11–labeled Pittsburgh compound B PET (PiB-PET) scans. EDS, defined as a score of at least 10 on the Epworth Sleepiness Scale, was seen in 63 participants (22.3%), the researchers found.

At baseline, EDS was significantly associated with increased beta-amyloid accumulation in the anterior cingulate (P = .04), posterior cingulate-precuneus (P = .02), and parietal (P = .04) regions. The association between EDS and longitudinal beta-amyloid accumulation was most pronounced in participants who had global PiB positivity at baseline in anterior cingulate and cingulate-precuneus regions (P = .02 for both), they reported.

Findings of the study are consistent with a previous investigation of middle-aged participants without dementia, Dr. Carvalho and coauthors said in a discussion of the results. In that study, increased daytime somnolence was associated with increased beta-amyloid burden in regions including the precuneus and anterior cingulate. Daytime sleepiness in that study was measured using a different measure, the Sleep Scale, which was originally developed as part of the Medical Outcomes Study.

Further investigation of the link between EDS and beta-amyloid accumulation is needed. In particular, the researchers suggested that future studies might evaluate whether amyloid accumulation can be avoided through early recognition of EDS and subsequent treatment of the underlying sleep disorder.

The study was funded by grants from the National Institutes of Health and several foundations. Dr. Carvalho reported no disclosures related to the study. Many of his coauthors reported relationships with a variety of pharmaceutical companies developing therapies for Alzheimer’s.

SOURCE: Carvalho D et al., JAMA Neurol. 2018 Mar 12. doi: 10.1001/jamaneurol.2018.0049

Elderly individuals who have excessive daytime sleepiness might be more susceptible to accumulation of an Alzheimer’s disease (AD) biomarker, results of a prospective, longitudinal cohort study suggest.

In the study, excessive daytime sleepiness (EDS) was associated with increased accumulation of beta-amyloid, an important biomarker of AD that manifests in early preclinical stages, wrote first author Diego Z. Carvalho, MD, and his colleagues at the Mayo Clinic, Rochester, Minn. The report was published online March 12 in JAMA Neurology.

Jupiterimages/Thinkstock

The prospective, longitudinal cohort analysis from Dr. Carvalho and his colleagues included 283 participants age 70 or older without a diagnosis of dementia who filled out a sleepiness assessment survey and underwent baseline and follow-up imaging studies as part of the Mayo Clinic Study of Aging.

All participants included in the analysis underwent at least two consecutive carbon 11–labeled Pittsburgh compound B PET (PiB-PET) scans. EDS, defined as a score of at least 10 on the Epworth Sleepiness Scale, was seen in 63 participants (22.3%), the researchers found.

At baseline, EDS was significantly associated with increased beta-amyloid accumulation in the anterior cingulate (P = .04), posterior cingulate-precuneus (P = .02), and parietal (P = .04) regions. The association between EDS and longitudinal beta-amyloid accumulation was most pronounced in participants who had global PiB positivity at baseline in anterior cingulate and cingulate-precuneus regions (P = .02 for both), they reported.

Findings of the study are consistent with a previous investigation of middle-aged participants without dementia, Dr. Carvalho and coauthors said in a discussion of the results. In that study, increased daytime somnolence was associated with increased beta-amyloid burden in regions including the precuneus and anterior cingulate. Daytime sleepiness in that study was measured using a different measure, the Sleep Scale, which was originally developed as part of the Medical Outcomes Study.

Further investigation of the link between EDS and beta-amyloid accumulation is needed. In particular, the researchers suggested that future studies might evaluate whether amyloid accumulation can be avoided through early recognition of EDS and subsequent treatment of the underlying sleep disorder.

The study was funded by grants from the National Institutes of Health and several foundations. Dr. Carvalho reported no disclosures related to the study. Many of his coauthors reported relationships with a variety of pharmaceutical companies developing therapies for Alzheimer’s.

SOURCE: Carvalho D et al., JAMA Neurol. 2018 Mar 12. doi: 10.1001/jamaneurol.2018.0049

Elderly individuals who have excessive daytime sleepiness might be more susceptible to accumulation of an Alzheimer’s disease (AD) biomarker, results of a prospective, longitudinal cohort study suggest.

In the study, excessive daytime sleepiness (EDS) was associated with increased accumulation of beta-amyloid, an important biomarker of AD that manifests in early preclinical stages, wrote first author Diego Z. Carvalho, MD, and his colleagues at the Mayo Clinic, Rochester, Minn. The report was published online March 12 in JAMA Neurology.

Jupiterimages/Thinkstock

The prospective, longitudinal cohort analysis from Dr. Carvalho and his colleagues included 283 participants age 70 or older without a diagnosis of dementia who filled out a sleepiness assessment survey and underwent baseline and follow-up imaging studies as part of the Mayo Clinic Study of Aging.

All participants included in the analysis underwent at least two consecutive carbon 11–labeled Pittsburgh compound B PET (PiB-PET) scans. EDS, defined as a score of at least 10 on the Epworth Sleepiness Scale, was seen in 63 participants (22.3%), the researchers found.

At baseline, EDS was significantly associated with increased beta-amyloid accumulation in the anterior cingulate (P = .04), posterior cingulate-precuneus (P = .02), and parietal (P = .04) regions. The association between EDS and longitudinal beta-amyloid accumulation was most pronounced in participants who had global PiB positivity at baseline in anterior cingulate and cingulate-precuneus regions (P = .02 for both), they reported.

Findings of the study are consistent with a previous investigation of middle-aged participants without dementia, Dr. Carvalho and coauthors said in a discussion of the results. In that study, increased daytime somnolence was associated with increased beta-amyloid burden in regions including the precuneus and anterior cingulate. Daytime sleepiness in that study was measured using a different measure, the Sleep Scale, which was originally developed as part of the Medical Outcomes Study.

Further investigation of the link between EDS and beta-amyloid accumulation is needed. In particular, the researchers suggested that future studies might evaluate whether amyloid accumulation can be avoided through early recognition of EDS and subsequent treatment of the underlying sleep disorder.

The study was funded by grants from the National Institutes of Health and several foundations. Dr. Carvalho reported no disclosures related to the study. Many of his coauthors reported relationships with a variety of pharmaceutical companies developing therapies for Alzheimer’s.

SOURCE: Carvalho D et al., JAMA Neurol. 2018 Mar 12. doi: 10.1001/jamaneurol.2018.0049

The fastest growing segment of the American population is the elderly. Moreover, they are also the fastest growing segment of the population with new-onset epilepsy and recurrent seizures. Many medical conditions that are common among the elderly population—including stroke, intracranial hemorrhage, brain tumor, and dementia—have a higher risk for resultant epilepsy, hence the higher incidence of epilepsy in this age group. This special subgroup of epilepsy patients presents unique challenges, including diagnosis, management, risk factors, and medication choice. Many of these challenges are interrelated.

The first and possibly the most difficult challenge is diagnosis. Seizures can begin at any age, not necessarily childhood. There does not have to be a genetic family history of epilepsy. Seizures in the elderly can present in a subtle fashion and are often not recognized as such. In addition, these symptoms are often attributed to other common medical conditions or lumped together with other generic symptoms that are frequently seen in the elderly.

For example, seizures can present with one or more of the following: slow speech, pauses in speech, confusion, memory loss, loss of track of time, trembling of the extremities, blinking, staring, slow responsiveness, chewing movements, and grabbing movements. As such, seizures may be misidentified as dementia, tremor, a movement disorder, delirium, overall slowness, or “aging.”

The potential implication has a compounding effect. Individuals with these symptoms can be diagnosed with a condition that they do not have, prescribed medication that they do not need, and be subject to the side effects of this incorrect medication. In addition, the patient could have unnecessary diagnostic testing, which can be a hardship in this population.

The correct diagnosis, in this case seizures/epilepsy, may be delayed, which could lead to potential consequences such as recurrent seizures, falls, injury, memory loss, and possible sudden death. This contributes to a decreased quality of life.

What are the central issues that lead to the delayed diagnosis? First, as mentioned above, the presentation can be quite subtle. Unlike what is most often portrayed in the media, not all seizures involve a loss of consciousness, body stiffening, and/or body shaking. Second, the patient is not necessarily aware that the above symptoms have occurred. It is often a friend or family member that reports them, and the patient may deny the occurrence. Third, even after the diagnosis is confirmed the patient may still be skeptical because he/she is still “functioning.” Often the question becomes how long have these signs/symptoms actually been present?

Epilepsy in the elderly is real and increasing. Unfortunately, it is frequently this subgroup of the population that has the least education about the disease. Increasing awareness of epilepsy is an ongoing goal by epilepsy advocacy organizations. Along with these organizations, physicians and other health care provides need to play an active role in increasing awareness for this special subpopulation with epilepsy.

The fastest growing segment of the American population is the elderly. Moreover, they are also the fastest growing segment of the population with new-onset epilepsy and recurrent seizures. Many medical conditions that are common among the elderly population—including stroke, intracranial hemorrhage, brain tumor, and dementia—have a higher risk for resultant epilepsy, hence the higher incidence of epilepsy in this age group. This special subgroup of epilepsy patients presents unique challenges, including diagnosis, management, risk factors, and medication choice. Many of these challenges are interrelated.

The first and possibly the most difficult challenge is diagnosis. Seizures can begin at any age, not necessarily childhood. There does not have to be a genetic family history of epilepsy. Seizures in the elderly can present in a subtle fashion and are often not recognized as such. In addition, these symptoms are often attributed to other common medical conditions or lumped together with other generic symptoms that are frequently seen in the elderly.

For example, seizures can present with one or more of the following: slow speech, pauses in speech, confusion, memory loss, loss of track of time, trembling of the extremities, blinking, staring, slow responsiveness, chewing movements, and grabbing movements. As such, seizures may be misidentified as dementia, tremor, a movement disorder, delirium, overall slowness, or “aging.”

The potential implication has a compounding effect. Individuals with these symptoms can be diagnosed with a condition that they do not have, prescribed medication that they do not need, and be subject to the side effects of this incorrect medication. In addition, the patient could have unnecessary diagnostic testing, which can be a hardship in this population.

The correct diagnosis, in this case seizures/epilepsy, may be delayed, which could lead to potential consequences such as recurrent seizures, falls, injury, memory loss, and possible sudden death. This contributes to a decreased quality of life.

What are the central issues that lead to the delayed diagnosis? First, as mentioned above, the presentation can be quite subtle. Unlike what is most often portrayed in the media, not all seizures involve a loss of consciousness, body stiffening, and/or body shaking. Second, the patient is not necessarily aware that the above symptoms have occurred. It is often a friend or family member that reports them, and the patient may deny the occurrence. Third, even after the diagnosis is confirmed the patient may still be skeptical because he/she is still “functioning.” Often the question becomes how long have these signs/symptoms actually been present?

Epilepsy in the elderly is real and increasing. Unfortunately, it is frequently this subgroup of the population that has the least education about the disease. Increasing awareness of epilepsy is an ongoing goal by epilepsy advocacy organizations. Along with these organizations, physicians and other health care provides need to play an active role in increasing awareness for this special subpopulation with epilepsy.

The fastest growing segment of the American population is the elderly. Moreover, they are also the fastest growing segment of the population with new-onset epilepsy and recurrent seizures. Many medical conditions that are common among the elderly population—including stroke, intracranial hemorrhage, brain tumor, and dementia—have a higher risk for resultant epilepsy, hence the higher incidence of epilepsy in this age group. This special subgroup of epilepsy patients presents unique challenges, including diagnosis, management, risk factors, and medication choice. Many of these challenges are interrelated.

The first and possibly the most difficult challenge is diagnosis. Seizures can begin at any age, not necessarily childhood. There does not have to be a genetic family history of epilepsy. Seizures in the elderly can present in a subtle fashion and are often not recognized as such. In addition, these symptoms are often attributed to other common medical conditions or lumped together with other generic symptoms that are frequently seen in the elderly.

For example, seizures can present with one or more of the following: slow speech, pauses in speech, confusion, memory loss, loss of track of time, trembling of the extremities, blinking, staring, slow responsiveness, chewing movements, and grabbing movements. As such, seizures may be misidentified as dementia, tremor, a movement disorder, delirium, overall slowness, or “aging.”

The potential implication has a compounding effect. Individuals with these symptoms can be diagnosed with a condition that they do not have, prescribed medication that they do not need, and be subject to the side effects of this incorrect medication. In addition, the patient could have unnecessary diagnostic testing, which can be a hardship in this population.

The correct diagnosis, in this case seizures/epilepsy, may be delayed, which could lead to potential consequences such as recurrent seizures, falls, injury, memory loss, and possible sudden death. This contributes to a decreased quality of life.

What are the central issues that lead to the delayed diagnosis? First, as mentioned above, the presentation can be quite subtle. Unlike what is most often portrayed in the media, not all seizures involve a loss of consciousness, body stiffening, and/or body shaking. Second, the patient is not necessarily aware that the above symptoms have occurred. It is often a friend or family member that reports them, and the patient may deny the occurrence. Third, even after the diagnosis is confirmed the patient may still be skeptical because he/she is still “functioning.” Often the question becomes how long have these signs/symptoms actually been present?

Epilepsy in the elderly is real and increasing. Unfortunately, it is frequently this subgroup of the population that has the least education about the disease. Increasing awareness of epilepsy is an ongoing goal by epilepsy advocacy organizations. Along with these organizations, physicians and other health care provides need to play an active role in increasing awareness for this special subpopulation with epilepsy.

Gut bacteria found in the small intestines could play a role in triggering an autoimmune response in genetically predisposed individuals, such as those with lupus, a research report suggests.

Recent studies have shown that gut commensals can reside within gastrointestinal-associated lymph tissues of healthy hosts, but it has been unclear whether pathobiont translocation was involved in systemic autoimmunity. Silvio Manfredo Vieira, PhD, and his colleagues at Yale University, New Haven, Conn., addressed this knowledge gap by studying the Gram-positive gut commensal Enterococcus gallinarum, which was identified in mesenteric lymph nodes, liver, and spleen cultures from genetically susceptible mouse models.

“Pathobiont-specific treatment can abrogate host autoimmune processes without needing to suppress the immune system, which can lead to systemic adverse events in current clinical practice,” they wrote.

The researchers then tested for E. gallinarum translocation to human livers in patients with systemic lupus erythematosus (SLE) and autoimmune hepatitis (AIH) with serologic features of lupus, including antinuclear antibodies and anti-dsDNA immunoglobulin G antibodies.

Liver biopsies from three SLE patients were positive for E. gallinarum, whereas samples from four of six healthy liver transplant donors with normal liver histology tested positive for the presence of other Enterococcus species but not E. gallinarum.

“Consistent with enhanced adaptive immune responses to E. gallinarum, the majority of SLE and AIH patients also showed increased serum antibody titers against E. gallinarum and particularly its RNA,” they said.

The authors said their findings showed that E. gallinarum translocates into systemic organs as a result of the breakdown of the gut barrier in autoimmune-prone hosts to drive autoimmune pathogenesis. They suggested that the translocating bacteria skewed T helper cell differentiation but also acted directly on colonized tissues such as the liver to induce autoantigens, endogenous retrovirus proteins, cytokines, and other autoimmune-promoting factors.

“If the complexity of host-tissue microbiota interactions is considered in chronic autoimmunity, it may offer new therapeutic avenues for these debilitating and potentially lethal diseases,” they concluded.

The study was supported by grants from various institutes and initiatives within the National Institutes of Health as well as from the Arthritis National Research Foundation, the Arthritis Foundation, and the Lupus Research Institute. Dr. Vieira and the senior author, Martin A. Kriegel, MD, PhD, are inventors on a patent application filed by Yale University related to the use of antibiotics and commensal vaccination to treat autoimmunity.

SOURCE: Vieira S et al. Science. 2018;359(6380):1156-61.

Gut bacteria found in the small intestines could play a role in triggering an autoimmune response in genetically predisposed individuals, such as those with lupus, a research report suggests.

Recent studies have shown that gut commensals can reside within gastrointestinal-associated lymph tissues of healthy hosts, but it has been unclear whether pathobiont translocation was involved in systemic autoimmunity. Silvio Manfredo Vieira, PhD, and his colleagues at Yale University, New Haven, Conn., addressed this knowledge gap by studying the Gram-positive gut commensal Enterococcus gallinarum, which was identified in mesenteric lymph nodes, liver, and spleen cultures from genetically susceptible mouse models.

“Pathobiont-specific treatment can abrogate host autoimmune processes without needing to suppress the immune system, which can lead to systemic adverse events in current clinical practice,” they wrote.

The researchers then tested for E. gallinarum translocation to human livers in patients with systemic lupus erythematosus (SLE) and autoimmune hepatitis (AIH) with serologic features of lupus, including antinuclear antibodies and anti-dsDNA immunoglobulin G antibodies.

Liver biopsies from three SLE patients were positive for E. gallinarum, whereas samples from four of six healthy liver transplant donors with normal liver histology tested positive for the presence of other Enterococcus species but not E. gallinarum.

“Consistent with enhanced adaptive immune responses to E. gallinarum, the majority of SLE and AIH patients also showed increased serum antibody titers against E. gallinarum and particularly its RNA,” they said.

The authors said their findings showed that E. gallinarum translocates into systemic organs as a result of the breakdown of the gut barrier in autoimmune-prone hosts to drive autoimmune pathogenesis. They suggested that the translocating bacteria skewed T helper cell differentiation but also acted directly on colonized tissues such as the liver to induce autoantigens, endogenous retrovirus proteins, cytokines, and other autoimmune-promoting factors.

“If the complexity of host-tissue microbiota interactions is considered in chronic autoimmunity, it may offer new therapeutic avenues for these debilitating and potentially lethal diseases,” they concluded.

The study was supported by grants from various institutes and initiatives within the National Institutes of Health as well as from the Arthritis National Research Foundation, the Arthritis Foundation, and the Lupus Research Institute. Dr. Vieira and the senior author, Martin A. Kriegel, MD, PhD, are inventors on a patent application filed by Yale University related to the use of antibiotics and commensal vaccination to treat autoimmunity.

SOURCE: Vieira S et al. Science. 2018;359(6380):1156-61.

Gut bacteria found in the small intestines could play a role in triggering an autoimmune response in genetically predisposed individuals, such as those with lupus, a research report suggests.

Recent studies have shown that gut commensals can reside within gastrointestinal-associated lymph tissues of healthy hosts, but it has been unclear whether pathobiont translocation was involved in systemic autoimmunity. Silvio Manfredo Vieira, PhD, and his colleagues at Yale University, New Haven, Conn., addressed this knowledge gap by studying the Gram-positive gut commensal Enterococcus gallinarum, which was identified in mesenteric lymph nodes, liver, and spleen cultures from genetically susceptible mouse models.

“Pathobiont-specific treatment can abrogate host autoimmune processes without needing to suppress the immune system, which can lead to systemic adverse events in current clinical practice,” they wrote.

The researchers then tested for E. gallinarum translocation to human livers in patients with systemic lupus erythematosus (SLE) and autoimmune hepatitis (AIH) with serologic features of lupus, including antinuclear antibodies and anti-dsDNA immunoglobulin G antibodies.

Liver biopsies from three SLE patients were positive for E. gallinarum, whereas samples from four of six healthy liver transplant donors with normal liver histology tested positive for the presence of other Enterococcus species but not E. gallinarum.

“Consistent with enhanced adaptive immune responses to E. gallinarum, the majority of SLE and AIH patients also showed increased serum antibody titers against E. gallinarum and particularly its RNA,” they said.

The authors said their findings showed that E. gallinarum translocates into systemic organs as a result of the breakdown of the gut barrier in autoimmune-prone hosts to drive autoimmune pathogenesis. They suggested that the translocating bacteria skewed T helper cell differentiation but also acted directly on colonized tissues such as the liver to induce autoantigens, endogenous retrovirus proteins, cytokines, and other autoimmune-promoting factors.

“If the complexity of host-tissue microbiota interactions is considered in chronic autoimmunity, it may offer new therapeutic avenues for these debilitating and potentially lethal diseases,” they concluded.

The study was supported by grants from various institutes and initiatives within the National Institutes of Health as well as from the Arthritis National Research Foundation, the Arthritis Foundation, and the Lupus Research Institute. Dr. Vieira and the senior author, Martin A. Kriegel, MD, PhD, are inventors on a patent application filed by Yale University related to the use of antibiotics and commensal vaccination to treat autoimmunity.

SOURCE: Vieira S et al. Science. 2018;359(6380):1156-61.

Attendees at the upcoming Endocrine Society annual meeting in Chicago can expect many of the scheduled sessions to be practice changing, according to Ann Danoff, MD, clinical chair of this year’s meeting program.

“It’s going to be an absolutely fabulous program. I always encourage clinicians to attend the plenaries to see where the field is going. And we are going big.”

Endocrine Society President Lynnette K. Nieman, MD, will lead off the plenary sessions on March 17, by presenting awards to six visionary investigators. Noteworthy among these will be the work of Diana Lynn Blithe, PhD, National Institutes of Health, for her research on male contraception. Dr. Blithe will speak about what’s in the clinical pipeline and what direction future research will take.

The second plenary session has an intriguing title – Rhythm and Blues. This session will cover circadian rhythmicity, which is, coincidentally, the research area of the three joint winners of the 2017 Nobel Prize in Physiology or Medicine.

In a plenary sessions scheduled for March 17, at 3:00 p.m., the topic under discussion will be the issue of circadian rhythm and metabolic health. Dysregulation of light and dark exposure puts people at risk for a variety of metabolic disease, said Dr. Danoff, who is chief of the medical service at the Philadelphia Veterans Affairs Medical Center. Specifically, two of the presentations – one on Circadian Rhythms, Blue Light, and Setting Your Internal Clock and the other on Improving Health by Time-Restricted Eating – are likely to be enlightening.

The Endocrine Society has revamped this year’s approach to sessions on guidelines to take the format of a discussion of how the guidelines affect patients on case-by-case basis. The moderator of each session will not be a member of the guideline-writing committee, but the panelists will be committee members.

New guidelines to be discussed are those dealing with gender incongruence and testosterone therapy. The session on transgender issues in endocrinology will take place on March 19, and is entitled Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline. The session on testosterone therapy is entitled: Testosterone Therapy in Men with Hypogonadism: An Endocrine Society Clinical Practice Guideline, also on March 19.

Another change to the approach taken to guidelines are sessions that go beyond the guidelines to discuss patients who fall between the cracks. Topics of these sessions are osteoporosis, indeterminate thyroid nodules, and challenging hyperprolactinemia and prolactinoma cases The panels involved in these discussions may include a surgeon, and two-thirds of them will include a fellow. “I am committed to the bringing along of young trainees,” said Dr. Danoff.

And what is an annual meeting without a few debates? On March 18, there will be a debate on Debate: This House Believes that Adrenal Vein Sampling Has a Major Role to Play in the Management of Patients with Primary Aldosteronism. Speaking in favor will be William F. Young Jr., MD, of the Mayo Clinic in Rochester, Minn., and against will be Paul Michael Stewart, MD, of the University of Leeds (England). Another debate topic, scheduled for March 17, will be The LDL Limbo: How Low Should You Go? Taking up the side that Benefits of LDL Reduction Are Continuous and Extend to Extremely Low Levels will be Steven Nissen, MD, of the Cleveland Clinic. There to discuss Lower LDL Is Better but What About Very-Low LDL? will be Henry N. Ginsberg, MD, Columbia University College of Physicians and Surgeons, New York.

Attendees at the upcoming Endocrine Society annual meeting in Chicago can expect many of the scheduled sessions to be practice changing, according to Ann Danoff, MD, clinical chair of this year’s meeting program.

“It’s going to be an absolutely fabulous program. I always encourage clinicians to attend the plenaries to see where the field is going. And we are going big.”

Endocrine Society President Lynnette K. Nieman, MD, will lead off the plenary sessions on March 17, by presenting awards to six visionary investigators. Noteworthy among these will be the work of Diana Lynn Blithe, PhD, National Institutes of Health, for her research on male contraception. Dr. Blithe will speak about what’s in the clinical pipeline and what direction future research will take.

The second plenary session has an intriguing title – Rhythm and Blues. This session will cover circadian rhythmicity, which is, coincidentally, the research area of the three joint winners of the 2017 Nobel Prize in Physiology or Medicine.

In a plenary sessions scheduled for March 17, at 3:00 p.m., the topic under discussion will be the issue of circadian rhythm and metabolic health. Dysregulation of light and dark exposure puts people at risk for a variety of metabolic disease, said Dr. Danoff, who is chief of the medical service at the Philadelphia Veterans Affairs Medical Center. Specifically, two of the presentations – one on Circadian Rhythms, Blue Light, and Setting Your Internal Clock and the other on Improving Health by Time-Restricted Eating – are likely to be enlightening.

The Endocrine Society has revamped this year’s approach to sessions on guidelines to take the format of a discussion of how the guidelines affect patients on case-by-case basis. The moderator of each session will not be a member of the guideline-writing committee, but the panelists will be committee members.

New guidelines to be discussed are those dealing with gender incongruence and testosterone therapy. The session on transgender issues in endocrinology will take place on March 19, and is entitled Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline. The session on testosterone therapy is entitled: Testosterone Therapy in Men with Hypogonadism: An Endocrine Society Clinical Practice Guideline, also on March 19.

Another change to the approach taken to guidelines are sessions that go beyond the guidelines to discuss patients who fall between the cracks. Topics of these sessions are osteoporosis, indeterminate thyroid nodules, and challenging hyperprolactinemia and prolactinoma cases The panels involved in these discussions may include a surgeon, and two-thirds of them will include a fellow. “I am committed to the bringing along of young trainees,” said Dr. Danoff.

And what is an annual meeting without a few debates? On March 18, there will be a debate on Debate: This House Believes that Adrenal Vein Sampling Has a Major Role to Play in the Management of Patients with Primary Aldosteronism. Speaking in favor will be William F. Young Jr., MD, of the Mayo Clinic in Rochester, Minn., and against will be Paul Michael Stewart, MD, of the University of Leeds (England). Another debate topic, scheduled for March 17, will be The LDL Limbo: How Low Should You Go? Taking up the side that Benefits of LDL Reduction Are Continuous and Extend to Extremely Low Levels will be Steven Nissen, MD, of the Cleveland Clinic. There to discuss Lower LDL Is Better but What About Very-Low LDL? will be Henry N. Ginsberg, MD, Columbia University College of Physicians and Surgeons, New York.

Attendees at the upcoming Endocrine Society annual meeting in Chicago can expect many of the scheduled sessions to be practice changing, according to Ann Danoff, MD, clinical chair of this year’s meeting program.

“It’s going to be an absolutely fabulous program. I always encourage clinicians to attend the plenaries to see where the field is going. And we are going big.”

Endocrine Society President Lynnette K. Nieman, MD, will lead off the plenary sessions on March 17, by presenting awards to six visionary investigators. Noteworthy among these will be the work of Diana Lynn Blithe, PhD, National Institutes of Health, for her research on male contraception. Dr. Blithe will speak about what’s in the clinical pipeline and what direction future research will take.

The second plenary session has an intriguing title – Rhythm and Blues. This session will cover circadian rhythmicity, which is, coincidentally, the research area of the three joint winners of the 2017 Nobel Prize in Physiology or Medicine.

In a plenary sessions scheduled for March 17, at 3:00 p.m., the topic under discussion will be the issue of circadian rhythm and metabolic health. Dysregulation of light and dark exposure puts people at risk for a variety of metabolic disease, said Dr. Danoff, who is chief of the medical service at the Philadelphia Veterans Affairs Medical Center. Specifically, two of the presentations – one on Circadian Rhythms, Blue Light, and Setting Your Internal Clock and the other on Improving Health by Time-Restricted Eating – are likely to be enlightening.

The Endocrine Society has revamped this year’s approach to sessions on guidelines to take the format of a discussion of how the guidelines affect patients on case-by-case basis. The moderator of each session will not be a member of the guideline-writing committee, but the panelists will be committee members.

New guidelines to be discussed are those dealing with gender incongruence and testosterone therapy. The session on transgender issues in endocrinology will take place on March 19, and is entitled Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline. The session on testosterone therapy is entitled: Testosterone Therapy in Men with Hypogonadism: An Endocrine Society Clinical Practice Guideline, also on March 19.

Another change to the approach taken to guidelines are sessions that go beyond the guidelines to discuss patients who fall between the cracks. Topics of these sessions are osteoporosis, indeterminate thyroid nodules, and challenging hyperprolactinemia and prolactinoma cases The panels involved in these discussions may include a surgeon, and two-thirds of them will include a fellow. “I am committed to the bringing along of young trainees,” said Dr. Danoff.

And what is an annual meeting without a few debates? On March 18, there will be a debate on Debate: This House Believes that Adrenal Vein Sampling Has a Major Role to Play in the Management of Patients with Primary Aldosteronism. Speaking in favor will be William F. Young Jr., MD, of the Mayo Clinic in Rochester, Minn., and against will be Paul Michael Stewart, MD, of the University of Leeds (England). Another debate topic, scheduled for March 17, will be The LDL Limbo: How Low Should You Go? Taking up the side that Benefits of LDL Reduction Are Continuous and Extend to Extremely Low Levels will be Steven Nissen, MD, of the Cleveland Clinic. There to discuss Lower LDL Is Better but What About Very-Low LDL? will be Henry N. Ginsberg, MD, Columbia University College of Physicians and Surgeons, New York.