A new study of pregnant Medicaid patients in Pennsylvania found that 12% filled prescriptions for opioids within 5 days of vaginal delivery, even though fewer than one-third of the women had pain-inducing conditions.

“Our study raises the question: Why is outpatient opioid use not rare after vaginal delivery?” lead author Marian Jarlenski, PhD, MPH, said in an interview. “Outpatient opioid prescriptions after a hospitalization may be one potential pathway to opioid use disorder. I hope the study will prompt some thought about why opioids are being prescribed for women after vaginal delivery and how to best manage postdelivery pain. This is especially important in areas of the country that have extraordinarily high rates of opioid use disorder.”

Liderina/Thinkstock

A new study of pregnant Medicaid patients in Pennsylvania found that 12% filled prescriptions for opioids within 5 days of vaginal delivery, even though fewer than one-third of the women had pain-inducing conditions.

“Our study raises the question: Why is outpatient opioid use not rare after vaginal delivery?” lead author Marian Jarlenski, PhD, MPH, said in an interview. “Outpatient opioid prescriptions after a hospitalization may be one potential pathway to opioid use disorder. I hope the study will prompt some thought about why opioids are being prescribed for women after vaginal delivery and how to best manage postdelivery pain. This is especially important in areas of the country that have extraordinarily high rates of opioid use disorder.”

Liderina/Thinkstock

A new study of pregnant Medicaid patients in Pennsylvania found that 12% filled prescriptions for opioids within 5 days of vaginal delivery, even though fewer than one-third of the women had pain-inducing conditions.

“Our study raises the question: Why is outpatient opioid use not rare after vaginal delivery?” lead author Marian Jarlenski, PhD, MPH, said in an interview. “Outpatient opioid prescriptions after a hospitalization may be one potential pathway to opioid use disorder. I hope the study will prompt some thought about why opioids are being prescribed for women after vaginal delivery and how to best manage postdelivery pain. This is especially important in areas of the country that have extraordinarily high rates of opioid use disorder.”

Liderina/Thinkstock

Combined tetanus, diphtheria, and pertussis (Tdap) vaccination during the second or third trimester of pregnancy does not appear to be associated with clinically significant harm to the fetus or neonate, according to findings from a systematic review of the literature.

However, the findings are limited by a dearth of randomized, placebo-controlled trials.

Piotr Marcinski/Thinkstock

[email protected]

Combined tetanus, diphtheria, and pertussis (Tdap) vaccination during the second or third trimester of pregnancy does not appear to be associated with clinically significant harm to the fetus or neonate, according to findings from a systematic review of the literature.

However, the findings are limited by a dearth of randomized, placebo-controlled trials.

Piotr Marcinski/Thinkstock

[email protected]

Combined tetanus, diphtheria, and pertussis (Tdap) vaccination during the second or third trimester of pregnancy does not appear to be associated with clinically significant harm to the fetus or neonate, according to findings from a systematic review of the literature.

However, the findings are limited by a dearth of randomized, placebo-controlled trials.

Piotr Marcinski/Thinkstock

[email protected]

Quick detection of nosocomial crusted scabies, followed by prompt implementation of infection prevention measures, may reduce the risk of such outbreaks, a small case series suggests.

What remains a matter of debate is how widely to use prophylaxis, according to authors of a study of two approaches published in Infection, Disease & Health.

The case series, coauthored by Dr. Nikki R. Adler and her colleagues at Alfred Hospital in Melbourne, compares and contrasts two approaches to a scabies outbreak in a tertiary care setting (Infect Dis Health. 2017. doi: 10.1016/j.idh.2017.01.001).

Michail_Petrov-96/Thinkstock.com

[email protected]

On Twitter @whitneymcknight

Quick detection of nosocomial crusted scabies, followed by prompt implementation of infection prevention measures, may reduce the risk of such outbreaks, a small case series suggests.

What remains a matter of debate is how widely to use prophylaxis, according to authors of a study of two approaches published in Infection, Disease & Health.

The case series, coauthored by Dr. Nikki R. Adler and her colleagues at Alfred Hospital in Melbourne, compares and contrasts two approaches to a scabies outbreak in a tertiary care setting (Infect Dis Health. 2017. doi: 10.1016/j.idh.2017.01.001).

Michail_Petrov-96/Thinkstock.com

[email protected]

On Twitter @whitneymcknight

Quick detection of nosocomial crusted scabies, followed by prompt implementation of infection prevention measures, may reduce the risk of such outbreaks, a small case series suggests.

What remains a matter of debate is how widely to use prophylaxis, according to authors of a study of two approaches published in Infection, Disease & Health.

The case series, coauthored by Dr. Nikki R. Adler and her colleagues at Alfred Hospital in Melbourne, compares and contrasts two approaches to a scabies outbreak in a tertiary care setting (Infect Dis Health. 2017. doi: 10.1016/j.idh.2017.01.001).

Michail_Petrov-96/Thinkstock.com

[email protected]

On Twitter @whitneymcknight

To the Editor:

Verrucous carcinoma is an uncommon type of squamous cell carcinoma (SCC) and was first described by Ackerman¹ in 1948. Rock and Fisher² called this condition oral florid papillomatosis. The distinctive features of this tumor are low-grade malignancy, slow growth, local invasiveness, and rarely intraoral and extraoral metastasis. Extraorally, it can occur in any part of the body,³ a common site being the anogenital region. Depending on the area of occurrence, the condition also is known as Buschke-Lowenstein tumor⁴ or giant condyloma acuminatum (anogenital region) and carcinoma cuniculatum⁵ (plantar region). The exact etiology of the condition is unknown, though it is associated with human papillomavirus infection, traumatic scars, chronic infection, tobacco, and chemical carcinogens.³ We report a rare case of verrucous carcinoma originating from the buccal mucosa that subsequently spread to involve the lip and cheek as a large cauliflowerlike growth, which is an unusual presentation.

A 65-year-old man presented to the dermatology department with a painless growth inside the left side of the oral cavity that had developed 5 years prior as a growth on the left buccal mucosa. The lesion gradually increased in size to involve the left oral commissure including the upper and lower lips and the skin of the left cheek; it extended beyond the nasolabial fold in a cauliflowerlike pattern. The lesion was insidious in onset and was not associated with pain, itching, or bleeding. The patient chewed tobacco for the last 40 years, with no similar lesions on any part of the body. On physical examination a warty papilliform lesion was seen on the left buccal mucosa with extension to 2 cm of the upper and lower lip on the left side including the left oral commissure and the skin of the left cheek beyond the nasolabial fold where it appeared as a cauliflowerlike growth measuring 4×5 cm in size (Figure 1). No notable lymphadenopathy was present.

Digital radiographs of the skull (posteroanterior oblique view)(Figure 2) and mandible (left oblique view) showed a lobulated soft-tissue density lesion overlying the left half of the mandible (near the mandibular angle) with involvement of both the upper and lower lips on the left side. However, no obvious underlying bony erosion was noted.

Computed tomography revealed a large soft-tissue mass (41.3×35.3 mm)(Figure 3A) involving the left buccal mucosa with extension into overlying muscle, subcutaneous tissue, and skin. Externally, the lesion was exophytic, irregular, and polypoidal with surface ulceration. Medially, the lesion involved the left oral commissure and parts of the adjoining upper and lower lips. No underlying bony erosion was seen. An enlarged lymph node measuring 20×15 mm was noted in the left upper deep cervical group in the submandibular region (Figure 3B).

Our clinical differential diagnosis included verrucous carcinoma and hypertrophic variety of lupus vulgaris. A 1×2-cm diagnostic incisional biopsy was performed from the cauliflowerlike growth and ultrasound-guided fine-needle aspiration was done from the lymph node. Histopathology revealed a hyperplastic stratified squamous epithelium with upward extension of verrucous projections, which was largely superficial to the adjacent epithelium (Figure 4A). In addition to the surface verrucous projections, there was lesion extension into the subepithelial zone in the form of round club-shaped protrusions (Figure 4B). There was no loss of polarity in these downward proliferations. No horn pearl formation was present. Fine-needle aspiration revealed reactive lymphadenitis.

The final diagnosis of verrucous carcinoma was made and the patient was referred to the oncosurgery department for further management.

Verrucous carcinoma is a rare, low-grade, well-differentiated SCC of the skin or mucosa presenting with a verrucoid or cauliflowerlike appearance. It shows locally aggressive behavior and has low metastatic potential,⁶ a low degree of dysplasia, and a good prognosis. Because it is a tumor with predominantly horizontal growth, it tends to erode more than infiltrate. It does not present with remote metastasis.⁷ It has been known by several different names, usually related to anatomic sites (eg, Ackerman tumor, oral florid papillomatosis, carcinoma cuniculatum).

In the oral cavity, verrucous carcinoma constitutes 2% to 4.5% of all forms of SCC seen mainly in men older than 50 years and also is associated with a high incidence (37.7%) of a second primary tumor mainly in the oral mucosa (eg, tongue, lips, palate, salivary gland).⁸ Indudharan et al⁹ reported a case of verrucous carcinoma of the maxillary antrum in a young male patient, which also was a rare entity. Verrucous carcinoma is thought to predominantly affect elderly men. Walvekar et al¹⁰ reported a male to female ratio of 3.6 to 1 in patients with verrucous carcinoma, with a mean age of 53.9 years. According to Varshney et al,¹¹ patients may range in age from the fourth to eighth decades of life, with a mean age of 60 years; 80% are male. The etiopathogenesis of verrucous carcinoma is related to the following carcinogens: biologic (eg, human papillomavirus), chemical (eg, smoking), and physical (eg, constant trauma).

Verrucous carcinoma should be considered in the differential diagnosis of slow-growing, locally spreading tumors. Oral tumors, especially in tobacco chewers, should raise suspicion of verrucous carcinoma, which will enable prompt management of the tumor.

To the Editor:

Verrucous carcinoma is an uncommon type of squamous cell carcinoma (SCC) and was first described by Ackerman¹ in 1948. Rock and Fisher² called this condition oral florid papillomatosis. The distinctive features of this tumor are low-grade malignancy, slow growth, local invasiveness, and rarely intraoral and extraoral metastasis. Extraorally, it can occur in any part of the body,³ a common site being the anogenital region. Depending on the area of occurrence, the condition also is known as Buschke-Lowenstein tumor⁴ or giant condyloma acuminatum (anogenital region) and carcinoma cuniculatum⁵ (plantar region). The exact etiology of the condition is unknown, though it is associated with human papillomavirus infection, traumatic scars, chronic infection, tobacco, and chemical carcinogens.³ We report a rare case of verrucous carcinoma originating from the buccal mucosa that subsequently spread to involve the lip and cheek as a large cauliflowerlike growth, which is an unusual presentation.

A 65-year-old man presented to the dermatology department with a painless growth inside the left side of the oral cavity that had developed 5 years prior as a growth on the left buccal mucosa. The lesion gradually increased in size to involve the left oral commissure including the upper and lower lips and the skin of the left cheek; it extended beyond the nasolabial fold in a cauliflowerlike pattern. The lesion was insidious in onset and was not associated with pain, itching, or bleeding. The patient chewed tobacco for the last 40 years, with no similar lesions on any part of the body. On physical examination a warty papilliform lesion was seen on the left buccal mucosa with extension to 2 cm of the upper and lower lip on the left side including the left oral commissure and the skin of the left cheek beyond the nasolabial fold where it appeared as a cauliflowerlike growth measuring 4×5 cm in size (Figure 1). No notable lymphadenopathy was present.

Digital radiographs of the skull (posteroanterior oblique view)(Figure 2) and mandible (left oblique view) showed a lobulated soft-tissue density lesion overlying the left half of the mandible (near the mandibular angle) with involvement of both the upper and lower lips on the left side. However, no obvious underlying bony erosion was noted.

Computed tomography revealed a large soft-tissue mass (41.3×35.3 mm)(Figure 3A) involving the left buccal mucosa with extension into overlying muscle, subcutaneous tissue, and skin. Externally, the lesion was exophytic, irregular, and polypoidal with surface ulceration. Medially, the lesion involved the left oral commissure and parts of the adjoining upper and lower lips. No underlying bony erosion was seen. An enlarged lymph node measuring 20×15 mm was noted in the left upper deep cervical group in the submandibular region (Figure 3B).

Our clinical differential diagnosis included verrucous carcinoma and hypertrophic variety of lupus vulgaris. A 1×2-cm diagnostic incisional biopsy was performed from the cauliflowerlike growth and ultrasound-guided fine-needle aspiration was done from the lymph node. Histopathology revealed a hyperplastic stratified squamous epithelium with upward extension of verrucous projections, which was largely superficial to the adjacent epithelium (Figure 4A). In addition to the surface verrucous projections, there was lesion extension into the subepithelial zone in the form of round club-shaped protrusions (Figure 4B). There was no loss of polarity in these downward proliferations. No horn pearl formation was present. Fine-needle aspiration revealed reactive lymphadenitis.

The final diagnosis of verrucous carcinoma was made and the patient was referred to the oncosurgery department for further management.

Verrucous carcinoma is a rare, low-grade, well-differentiated SCC of the skin or mucosa presenting with a verrucoid or cauliflowerlike appearance. It shows locally aggressive behavior and has low metastatic potential,⁶ a low degree of dysplasia, and a good prognosis. Because it is a tumor with predominantly horizontal growth, it tends to erode more than infiltrate. It does not present with remote metastasis.⁷ It has been known by several different names, usually related to anatomic sites (eg, Ackerman tumor, oral florid papillomatosis, carcinoma cuniculatum).

In the oral cavity, verrucous carcinoma constitutes 2% to 4.5% of all forms of SCC seen mainly in men older than 50 years and also is associated with a high incidence (37.7%) of a second primary tumor mainly in the oral mucosa (eg, tongue, lips, palate, salivary gland).⁸ Indudharan et al⁹ reported a case of verrucous carcinoma of the maxillary antrum in a young male patient, which also was a rare entity. Verrucous carcinoma is thought to predominantly affect elderly men. Walvekar et al¹⁰ reported a male to female ratio of 3.6 to 1 in patients with verrucous carcinoma, with a mean age of 53.9 years. According to Varshney et al,¹¹ patients may range in age from the fourth to eighth decades of life, with a mean age of 60 years; 80% are male. The etiopathogenesis of verrucous carcinoma is related to the following carcinogens: biologic (eg, human papillomavirus), chemical (eg, smoking), and physical (eg, constant trauma).

Verrucous carcinoma should be considered in the differential diagnosis of slow-growing, locally spreading tumors. Oral tumors, especially in tobacco chewers, should raise suspicion of verrucous carcinoma, which will enable prompt management of the tumor.

To the Editor:

Verrucous carcinoma is an uncommon type of squamous cell carcinoma (SCC) and was first described by Ackerman¹ in 1948. Rock and Fisher² called this condition oral florid papillomatosis. The distinctive features of this tumor are low-grade malignancy, slow growth, local invasiveness, and rarely intraoral and extraoral metastasis. Extraorally, it can occur in any part of the body,³ a common site being the anogenital region. Depending on the area of occurrence, the condition also is known as Buschke-Lowenstein tumor⁴ or giant condyloma acuminatum (anogenital region) and carcinoma cuniculatum⁵ (plantar region). The exact etiology of the condition is unknown, though it is associated with human papillomavirus infection, traumatic scars, chronic infection, tobacco, and chemical carcinogens.³ We report a rare case of verrucous carcinoma originating from the buccal mucosa that subsequently spread to involve the lip and cheek as a large cauliflowerlike growth, which is an unusual presentation.

A 65-year-old man presented to the dermatology department with a painless growth inside the left side of the oral cavity that had developed 5 years prior as a growth on the left buccal mucosa. The lesion gradually increased in size to involve the left oral commissure including the upper and lower lips and the skin of the left cheek; it extended beyond the nasolabial fold in a cauliflowerlike pattern. The lesion was insidious in onset and was not associated with pain, itching, or bleeding. The patient chewed tobacco for the last 40 years, with no similar lesions on any part of the body. On physical examination a warty papilliform lesion was seen on the left buccal mucosa with extension to 2 cm of the upper and lower lip on the left side including the left oral commissure and the skin of the left cheek beyond the nasolabial fold where it appeared as a cauliflowerlike growth measuring 4×5 cm in size (Figure 1). No notable lymphadenopathy was present.

Digital radiographs of the skull (posteroanterior oblique view)(Figure 2) and mandible (left oblique view) showed a lobulated soft-tissue density lesion overlying the left half of the mandible (near the mandibular angle) with involvement of both the upper and lower lips on the left side. However, no obvious underlying bony erosion was noted.

Computed tomography revealed a large soft-tissue mass (41.3×35.3 mm)(Figure 3A) involving the left buccal mucosa with extension into overlying muscle, subcutaneous tissue, and skin. Externally, the lesion was exophytic, irregular, and polypoidal with surface ulceration. Medially, the lesion involved the left oral commissure and parts of the adjoining upper and lower lips. No underlying bony erosion was seen. An enlarged lymph node measuring 20×15 mm was noted in the left upper deep cervical group in the submandibular region (Figure 3B).

Our clinical differential diagnosis included verrucous carcinoma and hypertrophic variety of lupus vulgaris. A 1×2-cm diagnostic incisional biopsy was performed from the cauliflowerlike growth and ultrasound-guided fine-needle aspiration was done from the lymph node. Histopathology revealed a hyperplastic stratified squamous epithelium with upward extension of verrucous projections, which was largely superficial to the adjacent epithelium (Figure 4A). In addition to the surface verrucous projections, there was lesion extension into the subepithelial zone in the form of round club-shaped protrusions (Figure 4B). There was no loss of polarity in these downward proliferations. No horn pearl formation was present. Fine-needle aspiration revealed reactive lymphadenitis.

The final diagnosis of verrucous carcinoma was made and the patient was referred to the oncosurgery department for further management.

Verrucous carcinoma is a rare, low-grade, well-differentiated SCC of the skin or mucosa presenting with a verrucoid or cauliflowerlike appearance. It shows locally aggressive behavior and has low metastatic potential,⁶ a low degree of dysplasia, and a good prognosis. Because it is a tumor with predominantly horizontal growth, it tends to erode more than infiltrate. It does not present with remote metastasis.⁷ It has been known by several different names, usually related to anatomic sites (eg, Ackerman tumor, oral florid papillomatosis, carcinoma cuniculatum).

In the oral cavity, verrucous carcinoma constitutes 2% to 4.5% of all forms of SCC seen mainly in men older than 50 years and also is associated with a high incidence (37.7%) of a second primary tumor mainly in the oral mucosa (eg, tongue, lips, palate, salivary gland).⁸ Indudharan et al⁹ reported a case of verrucous carcinoma of the maxillary antrum in a young male patient, which also was a rare entity. Verrucous carcinoma is thought to predominantly affect elderly men. Walvekar et al¹⁰ reported a male to female ratio of 3.6 to 1 in patients with verrucous carcinoma, with a mean age of 53.9 years. According to Varshney et al,¹¹ patients may range in age from the fourth to eighth decades of life, with a mean age of 60 years; 80% are male. The etiopathogenesis of verrucous carcinoma is related to the following carcinogens: biologic (eg, human papillomavirus), chemical (eg, smoking), and physical (eg, constant trauma).

Verrucous carcinoma should be considered in the differential diagnosis of slow-growing, locally spreading tumors. Oral tumors, especially in tobacco chewers, should raise suspicion of verrucous carcinoma, which will enable prompt management of the tumor.

Plasma levels of specific advanced glycation end products and oxidation products are associated with future severity of subclinical measures of atherosclerosis in patient with type 2 diabetes, results from a long-term analysis of VA patients suggest.

Advanced glycation end products (AGEs) and oxidation products (OxPs) “can damage vascular cells by different mechanisms,” wrote researchers led by corresponding authors Aramesh Saremi, MD, and Peter D. Reaven, MD, and colleagues. The report appeared online Feb. 1 in Diabetes Care.

“One frequently reported pathway is AGE binding to their purported (and relatively promiscuous) receptors on cells, such as macrophages, vascular endothelial cells, and vascular smooth muscle cells, although this has not been consistent for all AGEs. Other mechanisms include, among others, binding to and altering the function of intracellular proteins, the activation of vascular NADPH [nicotinamide adenine dinucleotide phosphate] oxidase, and the uncoupling of endothelial nitric oxide synthase.”

Noting that data in the current medical literature are lacking with respect to long-term longitudinal associations between plasma levels of AGEs and OxPs on the extent of subclinical atherosclerosis in T2D patients, the researchers set out to determine whether baseline plasma levels of AGEs and OxPs are associated with the extent of carotid intima-media thickness (CIMT), coronary artery calcification (CAC), and abdominal aortic artery calcification (AAC) over an average of 10 years of follow-up in the VA Diabetes Trial (VADT). They also examined whether this relationship was altered by intervening improved glucose control (Diabetes Care 2017 Feb. 1. doi: 10.2337/dc16-1875]).

At baseline of the VADT, 411 study participants underwent plasma measurements of methylglyoxal hydroimidazolone, N epsilon–carboxymethyl lysine (CML), N epsilon–carboxyethyl lysine (CEL), 3-deoxyglucosone hydroimidazolone and glyoxal hydroimidazolone (G-H1), 2-aminoadipic acid (2-AAA), and methionine sulfoxide. The mean age of the study subjects was 58 years, 64% were non-Hispanic white, 96% were male, 69% had a history of hypertension, and they had diabetes for a mean of 11 years.

After a mean follow-up of 10 years, the 411 patients underwent ultrasound assessment of CIMT, and computed tomography scanning of CAC and AAC.

In risk factor–adjusted multivariable regression models, G-H1was associated with the extent of CIMT as well as with the extent of CAC (P = .01 for both associations). In addition, 2-AAA was strongly associated with the extent of CAC (P = .03 for continuous variables and P less than .01 for dichotomous variables), and CEL was strongly associated with the extent of AAC (P less than .01).

“These findings suggest that the effect of hyperglycemia and subsequent increased levels of AGEs and OxPs in patients with long-standing T2D may have long-lasting adverse effects on the development of macrovascular complications,” the researchers concluded. They acknowledged certain limitations of the analysis, including the fact that it was conducted in an older, primarily male population. Therefore, “extrapolation of the study findings to other populations must be done with caution,” they wrote. “This study also does not allow us to make a definite claim of causation between AGEs and OxPs with the extent of atherosclerosis.”

The Veterans Affairs Cooperative Studies Program of the U.S. Department of Veterans Affairs Office of Research and Development funded the study. Additional support was received from National Institutes of Health, the American Diabetes Association, and the National Institute of Diabetes and Digestive and Kidney Diseases. Two study authors, Scott Howell, MS, and Paul J. Beisswenger, MD, disclosed that they are affiliated with PreventAGE Healthcare. The other researchers reported having no financial disclosures.

[email protected]
 

Plasma levels of specific advanced glycation end products and oxidation products are associated with future severity of subclinical measures of atherosclerosis in patient with type 2 diabetes, results from a long-term analysis of VA patients suggest.

Advanced glycation end products (AGEs) and oxidation products (OxPs) “can damage vascular cells by different mechanisms,” wrote researchers led by corresponding authors Aramesh Saremi, MD, and Peter D. Reaven, MD, and colleagues. The report appeared online Feb. 1 in Diabetes Care.

“One frequently reported pathway is AGE binding to their purported (and relatively promiscuous) receptors on cells, such as macrophages, vascular endothelial cells, and vascular smooth muscle cells, although this has not been consistent for all AGEs. Other mechanisms include, among others, binding to and altering the function of intracellular proteins, the activation of vascular NADPH [nicotinamide adenine dinucleotide phosphate] oxidase, and the uncoupling of endothelial nitric oxide synthase.”

Noting that data in the current medical literature are lacking with respect to long-term longitudinal associations between plasma levels of AGEs and OxPs on the extent of subclinical atherosclerosis in T2D patients, the researchers set out to determine whether baseline plasma levels of AGEs and OxPs are associated with the extent of carotid intima-media thickness (CIMT), coronary artery calcification (CAC), and abdominal aortic artery calcification (AAC) over an average of 10 years of follow-up in the VA Diabetes Trial (VADT). They also examined whether this relationship was altered by intervening improved glucose control (Diabetes Care 2017 Feb. 1. doi: 10.2337/dc16-1875]).

At baseline of the VADT, 411 study participants underwent plasma measurements of methylglyoxal hydroimidazolone, N epsilon–carboxymethyl lysine (CML), N epsilon–carboxyethyl lysine (CEL), 3-deoxyglucosone hydroimidazolone and glyoxal hydroimidazolone (G-H1), 2-aminoadipic acid (2-AAA), and methionine sulfoxide. The mean age of the study subjects was 58 years, 64% were non-Hispanic white, 96% were male, 69% had a history of hypertension, and they had diabetes for a mean of 11 years.

After a mean follow-up of 10 years, the 411 patients underwent ultrasound assessment of CIMT, and computed tomography scanning of CAC and AAC.

In risk factor–adjusted multivariable regression models, G-H1was associated with the extent of CIMT as well as with the extent of CAC (P = .01 for both associations). In addition, 2-AAA was strongly associated with the extent of CAC (P = .03 for continuous variables and P less than .01 for dichotomous variables), and CEL was strongly associated with the extent of AAC (P less than .01).

“These findings suggest that the effect of hyperglycemia and subsequent increased levels of AGEs and OxPs in patients with long-standing T2D may have long-lasting adverse effects on the development of macrovascular complications,” the researchers concluded. They acknowledged certain limitations of the analysis, including the fact that it was conducted in an older, primarily male population. Therefore, “extrapolation of the study findings to other populations must be done with caution,” they wrote. “This study also does not allow us to make a definite claim of causation between AGEs and OxPs with the extent of atherosclerosis.”

The Veterans Affairs Cooperative Studies Program of the U.S. Department of Veterans Affairs Office of Research and Development funded the study. Additional support was received from National Institutes of Health, the American Diabetes Association, and the National Institute of Diabetes and Digestive and Kidney Diseases. Two study authors, Scott Howell, MS, and Paul J. Beisswenger, MD, disclosed that they are affiliated with PreventAGE Healthcare. The other researchers reported having no financial disclosures.

[email protected]
 

Plasma levels of specific advanced glycation end products and oxidation products are associated with future severity of subclinical measures of atherosclerosis in patient with type 2 diabetes, results from a long-term analysis of VA patients suggest.

Advanced glycation end products (AGEs) and oxidation products (OxPs) “can damage vascular cells by different mechanisms,” wrote researchers led by corresponding authors Aramesh Saremi, MD, and Peter D. Reaven, MD, and colleagues. The report appeared online Feb. 1 in Diabetes Care.

“One frequently reported pathway is AGE binding to their purported (and relatively promiscuous) receptors on cells, such as macrophages, vascular endothelial cells, and vascular smooth muscle cells, although this has not been consistent for all AGEs. Other mechanisms include, among others, binding to and altering the function of intracellular proteins, the activation of vascular NADPH [nicotinamide adenine dinucleotide phosphate] oxidase, and the uncoupling of endothelial nitric oxide synthase.”

Noting that data in the current medical literature are lacking with respect to long-term longitudinal associations between plasma levels of AGEs and OxPs on the extent of subclinical atherosclerosis in T2D patients, the researchers set out to determine whether baseline plasma levels of AGEs and OxPs are associated with the extent of carotid intima-media thickness (CIMT), coronary artery calcification (CAC), and abdominal aortic artery calcification (AAC) over an average of 10 years of follow-up in the VA Diabetes Trial (VADT). They also examined whether this relationship was altered by intervening improved glucose control (Diabetes Care 2017 Feb. 1. doi: 10.2337/dc16-1875]).

At baseline of the VADT, 411 study participants underwent plasma measurements of methylglyoxal hydroimidazolone, N epsilon–carboxymethyl lysine (CML), N epsilon–carboxyethyl lysine (CEL), 3-deoxyglucosone hydroimidazolone and glyoxal hydroimidazolone (G-H1), 2-aminoadipic acid (2-AAA), and methionine sulfoxide. The mean age of the study subjects was 58 years, 64% were non-Hispanic white, 96% were male, 69% had a history of hypertension, and they had diabetes for a mean of 11 years.

After a mean follow-up of 10 years, the 411 patients underwent ultrasound assessment of CIMT, and computed tomography scanning of CAC and AAC.

In risk factor–adjusted multivariable regression models, G-H1was associated with the extent of CIMT as well as with the extent of CAC (P = .01 for both associations). In addition, 2-AAA was strongly associated with the extent of CAC (P = .03 for continuous variables and P less than .01 for dichotomous variables), and CEL was strongly associated with the extent of AAC (P less than .01).

“These findings suggest that the effect of hyperglycemia and subsequent increased levels of AGEs and OxPs in patients with long-standing T2D may have long-lasting adverse effects on the development of macrovascular complications,” the researchers concluded. They acknowledged certain limitations of the analysis, including the fact that it was conducted in an older, primarily male population. Therefore, “extrapolation of the study findings to other populations must be done with caution,” they wrote. “This study also does not allow us to make a definite claim of causation between AGEs and OxPs with the extent of atherosclerosis.”

The Veterans Affairs Cooperative Studies Program of the U.S. Department of Veterans Affairs Office of Research and Development funded the study. Additional support was received from National Institutes of Health, the American Diabetes Association, and the National Institute of Diabetes and Digestive and Kidney Diseases. Two study authors, Scott Howell, MS, and Paul J. Beisswenger, MD, disclosed that they are affiliated with PreventAGE Healthcare. The other researchers reported having no financial disclosures.

[email protected]
 

The use of advanced critical care in children and infants with liver failure is justified because orthotopic liver transplantation can be performed on the sickest children and achieve acceptable outcomes, results from a large analysis demonstrated.

“Hand in hand with improved care for critically ill children with liver failure, posttransplant critical care has made tremendous strides,” Abbas Rana, MD, wrote in a study published online in the Journal of the American College of Surgeons. “Our recipients have gotten sicker while our postoperative outcomes have improved. The question then becomes, have our operative skills and postoperative critical care management kept up with the abilities to keep sick children with liver failure alive? Just because transplantation is now possible in our sickest children, is it justified?”

To find out, Dr. Rana of the division of abdominal transplantation and hepatobiliary surgery at Baylor College of Medicine, Houston, and colleagues retrospectively analyzed United Network for Organ Sharing data from all orthotopic liver transplantation (OLT) recipients between Sept. 1, 1987, and June 30, 2015. The analysis paired the liver registry data with data collected by the Organ Procurement and Transplantation Network, and was limited to transplant recipients younger than age 18. The researchers followed a total of 13,723 recipients from date of transplant until either death or the date of last known follow-up (J Am Coll Surg. 2016 Dec 25. doi: 10.1016/j.jamcollsurg.2016.12.025).

In another part of the study, the researchers retrospectively reviewed the charts of 354 patients under 18 years of age who underwent OLT between March 1, 2002, and June 30, 2015, at Texas Children’s Hospital, including 65 who were admitted to the ICU at the time of transplantation.

In the analysis of national data, the researchers found that the rates of 1-year survival following OLT in children in the ICU improved from 60% in 1987 to 92% in 2013 (P less than .001). The rates of 1-year survival also improved for children on dialysis at the time of transplant (from 50% in 1995 to 95% in 2013; P less than .001) and for those dependent on a mechanical ventilator at the time of transplant (from 49% in 1994 to 94% in 2013; P less than .001). The significant risk factors were two previous transplants (hazard ratio, 4.2), one previous transplant (HR, 2.5), serum sodium greater than 150 mEq/L (HR, 2.0), dialysis or glomerular filtration rate less than 30 mL/min per 1.73 m² (HR, 2.0), mechanical ventilator dependence (HR, 1.8), body weight under 6 kg (HR, 1.8), encephalopathy (HR, 1.8), and annual center volume of fewer than five cases (HR, 1.7).

In the experience at Texas Children’s Hospital, the researchers observed “preserved and successful patient survival outcomes” in many markers of acuity. For example, the 10-year survival rates for patients dependent on mechanical ventilation and dialysis were 85% and 96%, respectively, and reached 100% for those requiring therapeutic plasma exchange, molescular adsorbent recirculating system (MARS) liver dialysis, and vasopressors.

“Our collective ability to keep sick children alive with liver failure has improved considerably over the years,” the researchers wrote. “Keeping pace, this analysis demonstrates that the posttransplant outcomes have also improved dramatically. The survival outcomes are comparable to the general population, justifying the use of scarce donors. Although we cannot declare in absolute that no child should be left behind, we can demonstrate acceptable outcomes to date and urge the continual revisiting of our concepts of futility.

“We have learned throughout our experience that almost every child with end-stage liver disease and acute liver failure should be offered liver replacement, as long as the vasoactive medication and mechanical support are not maximized prior to the initiation of the OLT procedure. Every effort should be made to transplant our sickest children.”

This study was supported by the Cade R. Alpard Foundation. The researchers reported having no relevant financial disclosures.

[email protected]

The use of advanced critical care in children and infants with liver failure is justified because orthotopic liver transplantation can be performed on the sickest children and achieve acceptable outcomes, results from a large analysis demonstrated.

“Hand in hand with improved care for critically ill children with liver failure, posttransplant critical care has made tremendous strides,” Abbas Rana, MD, wrote in a study published online in the Journal of the American College of Surgeons. “Our recipients have gotten sicker while our postoperative outcomes have improved. The question then becomes, have our operative skills and postoperative critical care management kept up with the abilities to keep sick children with liver failure alive? Just because transplantation is now possible in our sickest children, is it justified?”

To find out, Dr. Rana of the division of abdominal transplantation and hepatobiliary surgery at Baylor College of Medicine, Houston, and colleagues retrospectively analyzed United Network for Organ Sharing data from all orthotopic liver transplantation (OLT) recipients between Sept. 1, 1987, and June 30, 2015. The analysis paired the liver registry data with data collected by the Organ Procurement and Transplantation Network, and was limited to transplant recipients younger than age 18. The researchers followed a total of 13,723 recipients from date of transplant until either death or the date of last known follow-up (J Am Coll Surg. 2016 Dec 25. doi: 10.1016/j.jamcollsurg.2016.12.025).

In another part of the study, the researchers retrospectively reviewed the charts of 354 patients under 18 years of age who underwent OLT between March 1, 2002, and June 30, 2015, at Texas Children’s Hospital, including 65 who were admitted to the ICU at the time of transplantation.

In the analysis of national data, the researchers found that the rates of 1-year survival following OLT in children in the ICU improved from 60% in 1987 to 92% in 2013 (P less than .001). The rates of 1-year survival also improved for children on dialysis at the time of transplant (from 50% in 1995 to 95% in 2013; P less than .001) and for those dependent on a mechanical ventilator at the time of transplant (from 49% in 1994 to 94% in 2013; P less than .001). The significant risk factors were two previous transplants (hazard ratio, 4.2), one previous transplant (HR, 2.5), serum sodium greater than 150 mEq/L (HR, 2.0), dialysis or glomerular filtration rate less than 30 mL/min per 1.73 m² (HR, 2.0), mechanical ventilator dependence (HR, 1.8), body weight under 6 kg (HR, 1.8), encephalopathy (HR, 1.8), and annual center volume of fewer than five cases (HR, 1.7).

In the experience at Texas Children’s Hospital, the researchers observed “preserved and successful patient survival outcomes” in many markers of acuity. For example, the 10-year survival rates for patients dependent on mechanical ventilation and dialysis were 85% and 96%, respectively, and reached 100% for those requiring therapeutic plasma exchange, molescular adsorbent recirculating system (MARS) liver dialysis, and vasopressors.

“Our collective ability to keep sick children alive with liver failure has improved considerably over the years,” the researchers wrote. “Keeping pace, this analysis demonstrates that the posttransplant outcomes have also improved dramatically. The survival outcomes are comparable to the general population, justifying the use of scarce donors. Although we cannot declare in absolute that no child should be left behind, we can demonstrate acceptable outcomes to date and urge the continual revisiting of our concepts of futility.

“We have learned throughout our experience that almost every child with end-stage liver disease and acute liver failure should be offered liver replacement, as long as the vasoactive medication and mechanical support are not maximized prior to the initiation of the OLT procedure. Every effort should be made to transplant our sickest children.”

This study was supported by the Cade R. Alpard Foundation. The researchers reported having no relevant financial disclosures.

[email protected]

The use of advanced critical care in children and infants with liver failure is justified because orthotopic liver transplantation can be performed on the sickest children and achieve acceptable outcomes, results from a large analysis demonstrated.

“Hand in hand with improved care for critically ill children with liver failure, posttransplant critical care has made tremendous strides,” Abbas Rana, MD, wrote in a study published online in the Journal of the American College of Surgeons. “Our recipients have gotten sicker while our postoperative outcomes have improved. The question then becomes, have our operative skills and postoperative critical care management kept up with the abilities to keep sick children with liver failure alive? Just because transplantation is now possible in our sickest children, is it justified?”

To find out, Dr. Rana of the division of abdominal transplantation and hepatobiliary surgery at Baylor College of Medicine, Houston, and colleagues retrospectively analyzed United Network for Organ Sharing data from all orthotopic liver transplantation (OLT) recipients between Sept. 1, 1987, and June 30, 2015. The analysis paired the liver registry data with data collected by the Organ Procurement and Transplantation Network, and was limited to transplant recipients younger than age 18. The researchers followed a total of 13,723 recipients from date of transplant until either death or the date of last known follow-up (J Am Coll Surg. 2016 Dec 25. doi: 10.1016/j.jamcollsurg.2016.12.025).

In another part of the study, the researchers retrospectively reviewed the charts of 354 patients under 18 years of age who underwent OLT between March 1, 2002, and June 30, 2015, at Texas Children’s Hospital, including 65 who were admitted to the ICU at the time of transplantation.

In the analysis of national data, the researchers found that the rates of 1-year survival following OLT in children in the ICU improved from 60% in 1987 to 92% in 2013 (P less than .001). The rates of 1-year survival also improved for children on dialysis at the time of transplant (from 50% in 1995 to 95% in 2013; P less than .001) and for those dependent on a mechanical ventilator at the time of transplant (from 49% in 1994 to 94% in 2013; P less than .001). The significant risk factors were two previous transplants (hazard ratio, 4.2), one previous transplant (HR, 2.5), serum sodium greater than 150 mEq/L (HR, 2.0), dialysis or glomerular filtration rate less than 30 mL/min per 1.73 m² (HR, 2.0), mechanical ventilator dependence (HR, 1.8), body weight under 6 kg (HR, 1.8), encephalopathy (HR, 1.8), and annual center volume of fewer than five cases (HR, 1.7).

In the experience at Texas Children’s Hospital, the researchers observed “preserved and successful patient survival outcomes” in many markers of acuity. For example, the 10-year survival rates for patients dependent on mechanical ventilation and dialysis were 85% and 96%, respectively, and reached 100% for those requiring therapeutic plasma exchange, molescular adsorbent recirculating system (MARS) liver dialysis, and vasopressors.

“Our collective ability to keep sick children alive with liver failure has improved considerably over the years,” the researchers wrote. “Keeping pace, this analysis demonstrates that the posttransplant outcomes have also improved dramatically. The survival outcomes are comparable to the general population, justifying the use of scarce donors. Although we cannot declare in absolute that no child should be left behind, we can demonstrate acceptable outcomes to date and urge the continual revisiting of our concepts of futility.

“We have learned throughout our experience that almost every child with end-stage liver disease and acute liver failure should be offered liver replacement, as long as the vasoactive medication and mechanical support are not maximized prior to the initiation of the OLT procedure. Every effort should be made to transplant our sickest children.”

This study was supported by the Cade R. Alpard Foundation. The researchers reported having no relevant financial disclosures.

[email protected]

Rural health care and the VA seem to be on the front line in the battle over President Trump’s executive order halting travel to the U.S. for citizens of 7 Muslim-majority countries. The executive order, which has been temporarily suspended by a federal judge, could affect as many as 15,000 doctors and possibly even more pharmacists, nurses, and other health care providers. The ban also is expected to impact nearly 9,000 physicians from Iran and another 3,500 from Syria and 1,500 from Iraq.

The VA has long depended on foreign-born health care providers, and given the VA’s challenges in filling its more than 45,000 vacancies, this reliance was only expected to grow.. The Conrad 30 program allows J-1 medical doctors to apply for a waiver to the 2-year residence requirement upon completion of the J-1 exchange visitor program. Over the years, many international medical graduates (IMGs) earned permanent residence by agreeing to work 3 or 5 years in an underserved area or VA facility.

“The United States is facing a serious shortage of physicians. IMGs play an important role in U.S. health care, representing roughly 25% of the workforce,” AAMC (Association of American Medical Colleges) President and CEO Darrell G. Kirch, MD said in a statement. “In the last decade, Conrad 30 alone has directed nearly 10,000 physicians into rural and urban underserved communities. Impeding these U.S. immigration pathways jeopardizes critical access to high-quality physician care for our nation’s most vulnerable populations.”

Related: Medical Organizations Respond to Trump’s Immigration Order

According to an analysis of 2010 census data from the Migration Policy Institute (MPI), foreign-born workers make up 15% of the 1.1 million health care providers in the U.S., which includes a significant proportion of physicians and surgeons (27%) and a smaller, but still significant number of registered nurses (15%), technologists and technicians (12%), and therapists (10%). Among support personnel foreign-born workers range from 19% of health care support workers to 22% of nursing, psychiatric, and home health aides.

In a more recent analysis from the George Mason Institute for Immigration Research, 22% of nursing, psychiatric, and home health aides are foreign born.

Most of the foreign-born health care providers have acquired U.S. citizenship, according to MPI, “with naturalization rates ranging from 55% for those working as nursing, psychiatric, or home health aides to 78% for other health care practitioners and technical occupations. According to American Association of Family Practitioners (AAFP), 42% of office visits in rural America are with foreign-born physicians.

“Many family physicians are IMGs, who have completed all or part of their education and training in the U.S.,” AAFP President John Meigs, Jr, MD, FAAFP, wrote in a letter to President Trump. “They are professionals who dedicate their careers to the service of their patients in communities large and small, urban and rural. In fact, 20% of our membership and over 25% of family medicine residents [comprise] IMGs. The AAFP applauds and supports wholly the contributions of these individual family physicians to their patients and communities and we celebrate their diversity.”

Rural health care and the VA seem to be on the front line in the battle over President Trump’s executive order halting travel to the U.S. for citizens of 7 Muslim-majority countries. The executive order, which has been temporarily suspended by a federal judge, could affect as many as 15,000 doctors and possibly even more pharmacists, nurses, and other health care providers. The ban also is expected to impact nearly 9,000 physicians from Iran and another 3,500 from Syria and 1,500 from Iraq.

The VA has long depended on foreign-born health care providers, and given the VA’s challenges in filling its more than 45,000 vacancies, this reliance was only expected to grow.. The Conrad 30 program allows J-1 medical doctors to apply for a waiver to the 2-year residence requirement upon completion of the J-1 exchange visitor program. Over the years, many international medical graduates (IMGs) earned permanent residence by agreeing to work 3 or 5 years in an underserved area or VA facility.

“The United States is facing a serious shortage of physicians. IMGs play an important role in U.S. health care, representing roughly 25% of the workforce,” AAMC (Association of American Medical Colleges) President and CEO Darrell G. Kirch, MD said in a statement. “In the last decade, Conrad 30 alone has directed nearly 10,000 physicians into rural and urban underserved communities. Impeding these U.S. immigration pathways jeopardizes critical access to high-quality physician care for our nation’s most vulnerable populations.”

Related: Medical Organizations Respond to Trump’s Immigration Order

According to an analysis of 2010 census data from the Migration Policy Institute (MPI), foreign-born workers make up 15% of the 1.1 million health care providers in the U.S., which includes a significant proportion of physicians and surgeons (27%) and a smaller, but still significant number of registered nurses (15%), technologists and technicians (12%), and therapists (10%). Among support personnel foreign-born workers range from 19% of health care support workers to 22% of nursing, psychiatric, and home health aides.

In a more recent analysis from the George Mason Institute for Immigration Research, 22% of nursing, psychiatric, and home health aides are foreign born.

Most of the foreign-born health care providers have acquired U.S. citizenship, according to MPI, “with naturalization rates ranging from 55% for those working as nursing, psychiatric, or home health aides to 78% for other health care practitioners and technical occupations. According to American Association of Family Practitioners (AAFP), 42% of office visits in rural America are with foreign-born physicians.

“Many family physicians are IMGs, who have completed all or part of their education and training in the U.S.,” AAFP President John Meigs, Jr, MD, FAAFP, wrote in a letter to President Trump. “They are professionals who dedicate their careers to the service of their patients in communities large and small, urban and rural. In fact, 20% of our membership and over 25% of family medicine residents [comprise] IMGs. The AAFP applauds and supports wholly the contributions of these individual family physicians to their patients and communities and we celebrate their diversity.”

Rural health care and the VA seem to be on the front line in the battle over President Trump’s executive order halting travel to the U.S. for citizens of 7 Muslim-majority countries. The executive order, which has been temporarily suspended by a federal judge, could affect as many as 15,000 doctors and possibly even more pharmacists, nurses, and other health care providers. The ban also is expected to impact nearly 9,000 physicians from Iran and another 3,500 from Syria and 1,500 from Iraq.

The VA has long depended on foreign-born health care providers, and given the VA’s challenges in filling its more than 45,000 vacancies, this reliance was only expected to grow.. The Conrad 30 program allows J-1 medical doctors to apply for a waiver to the 2-year residence requirement upon completion of the J-1 exchange visitor program. Over the years, many international medical graduates (IMGs) earned permanent residence by agreeing to work 3 or 5 years in an underserved area or VA facility.

“The United States is facing a serious shortage of physicians. IMGs play an important role in U.S. health care, representing roughly 25% of the workforce,” AAMC (Association of American Medical Colleges) President and CEO Darrell G. Kirch, MD said in a statement. “In the last decade, Conrad 30 alone has directed nearly 10,000 physicians into rural and urban underserved communities. Impeding these U.S. immigration pathways jeopardizes critical access to high-quality physician care for our nation’s most vulnerable populations.”

Related: Medical Organizations Respond to Trump’s Immigration Order

According to an analysis of 2010 census data from the Migration Policy Institute (MPI), foreign-born workers make up 15% of the 1.1 million health care providers in the U.S., which includes a significant proportion of physicians and surgeons (27%) and a smaller, but still significant number of registered nurses (15%), technologists and technicians (12%), and therapists (10%). Among support personnel foreign-born workers range from 19% of health care support workers to 22% of nursing, psychiatric, and home health aides.

In a more recent analysis from the George Mason Institute for Immigration Research, 22% of nursing, psychiatric, and home health aides are foreign born.

Most of the foreign-born health care providers have acquired U.S. citizenship, according to MPI, “with naturalization rates ranging from 55% for those working as nursing, psychiatric, or home health aides to 78% for other health care practitioners and technical occupations. According to American Association of Family Practitioners (AAFP), 42% of office visits in rural America are with foreign-born physicians.

“Many family physicians are IMGs, who have completed all or part of their education and training in the U.S.,” AAFP President John Meigs, Jr, MD, FAAFP, wrote in a letter to President Trump. “They are professionals who dedicate their careers to the service of their patients in communities large and small, urban and rural. In fact, 20% of our membership and over 25% of family medicine residents [comprise] IMGs. The AAFP applauds and supports wholly the contributions of these individual family physicians to their patients and communities and we celebrate their diversity.”

To the Editor:

Dermatomyositis represents a rare idiopathic inflammatory process presenting with cutaneous lesions and muscular weakness. It often represents a paraneoplastic syndrome. We report the case of a 62-year-old man with a history of total-body poikiloderma and a recent diagnosis of chronic lymphocytic leukemia (CLL). Despite lacking typical features of the disease, a diagnosis of dermatomyositis was made. Our patient may represent a distinct poikilodermatous variant of dermatomyositis, sharing the generalized distribution of the erythrodermic subtype.

A 62-year-old man presented with pruritic poikiloderma involving the neck, arms, legs, abdomen, chest, and back of 2 years’ duration (Figure). He also experienced dysphagia and weakness of the legs. The rash was previously treated by other dermatologists with a combination of high-potency topical steroids and topical tacrolimus 0.1% without success. His history was notable for CLL, which had been diagnosed by a dermatologist 6 months prior to the current presentation. Prior to his visit to the dermatologist, the patient had received 6 chemotherapeutic sessions with a combination of rituximab and cyclophosphamide for the treatment of CLL. The rash did not improve with chemotherapy.

Repeat biopsies of affected regions only demonstrated features of mild interface dermatitis. Direct immunofluorescence studies showed scattered colloid body fluorescence for IgM. Because of bilateral weakness of the legs, a muscle biopsy was taken, which demonstrated severe atrophy and interstitial fibrosis, with neurogenic abnormalities detected in areas of lesser atrophy via abnormal muscle fiber–type grouping. Metabolic panel showed elevated muscle enzymes in the blood: creatine kinase, 243 U/L (reference range, 10–225 U/L); serum aldolase, 16 U/L (reference range, ≤8.1 U/L); lactate dehydrogenase, 314 U/L (reference range, 60–200 U/L). An autoimmune panel was negative for Jo-1, Scl-70, U1 ribonucleoprotein, DNA, desmoglein 1 and 3, and antiacetylcholine receptor antibodies. An elevated erythrocyte sedimentation rate was measured at 16 mm/h (reference range, 0–10 mm/h). Given these findings, the lesions were confirmed as a widespread poikilodermatous variant of dermatomyositis.

The patient was placed on a daily 50-mg dose of prednisone, which produced rapid improvement in scaling and erythema. Creatine kinase and serum aldolase levels normalized and motor strength increased. After 1 week the prednisone dosage was reduced to a daily 30-mg dose, and then 20 mg a week later. The skin lesions completely resolved within 4 to 5 months and the patient is currently on a prednisone dose of 5 mg, alternating with 2.5 mg of prednisone and rituximab infusion every 2 months.

Dermatomyositis is a rare entity with an incidence of approximately 0.5 to 1 per 100,000 individuals.¹ It presents with a characteristic rash composed of Gottron papules; pathognomonic flat violaceous papules on the dorsal interphalangeal joints, elbows, or knees; and a heliotrope rash, a violaceous erythema involving the eyelids. Poikiloderma frequently is reported to present in a shawl-like distribution, encompassing the shoulders, arms, and upper back.^1,2 Dermatomyositis of the poikilodermatous type can present in nonphotoexposed areas and photoexposed areas. The unusual feature is the total-body involvement, which is analogous to erythroderma.³

Our case may represent a distinct poikilodermatous manifestation sharing the distribution of the erythrodermic subtype. We believe that the skin lesions may have represented a paraneoplastic event presenting prior to diagnosis with CLL. Dermatomyositis has a strong association with cancer, with patients 3 times more likely to develop internal malignancy.⁴ Association is strongest for non-Hodgkin lymphoma, as well as ovarian, lung, colorectal, pancreatic, and gastric cancer. When associated with malignancy, symptoms of dermatomyositis or myositis typically precede the discovery of malignancy by an average of 1.9 years.⁵ Dermatomyositis has been previously reported to present as a paraneoplastic manifestation of CLL.⁶ One case has been reported of a patient with CLL who developed leukemia cutis presenting with poikiloderma in the characteristic dermatomyositis shawl-like distribution.⁷ The lack of dermal infiltration with leukemic cells in our patient, however, makes a paraneoplastic etiology much more likely.

Our patient’s rash did not initially improve with treatment of CLL, but dermatomyositis associated with hematological malignancy may precede, occur simultaneously, or follow the diagnosis of malignancy.⁸ Additionally, symptoms of dermatomyositis do not always parallel the course of hematological malignancy outcome. However, rituximab has been used as a treatment of dermatomyositis and may have contributed some synergistic effect in combination with prednisone in our patient.⁹

To the Editor:

Dermatomyositis represents a rare idiopathic inflammatory process presenting with cutaneous lesions and muscular weakness. It often represents a paraneoplastic syndrome. We report the case of a 62-year-old man with a history of total-body poikiloderma and a recent diagnosis of chronic lymphocytic leukemia (CLL). Despite lacking typical features of the disease, a diagnosis of dermatomyositis was made. Our patient may represent a distinct poikilodermatous variant of dermatomyositis, sharing the generalized distribution of the erythrodermic subtype.

A 62-year-old man presented with pruritic poikiloderma involving the neck, arms, legs, abdomen, chest, and back of 2 years’ duration (Figure). He also experienced dysphagia and weakness of the legs. The rash was previously treated by other dermatologists with a combination of high-potency topical steroids and topical tacrolimus 0.1% without success. His history was notable for CLL, which had been diagnosed by a dermatologist 6 months prior to the current presentation. Prior to his visit to the dermatologist, the patient had received 6 chemotherapeutic sessions with a combination of rituximab and cyclophosphamide for the treatment of CLL. The rash did not improve with chemotherapy.

Repeat biopsies of affected regions only demonstrated features of mild interface dermatitis. Direct immunofluorescence studies showed scattered colloid body fluorescence for IgM. Because of bilateral weakness of the legs, a muscle biopsy was taken, which demonstrated severe atrophy and interstitial fibrosis, with neurogenic abnormalities detected in areas of lesser atrophy via abnormal muscle fiber–type grouping. Metabolic panel showed elevated muscle enzymes in the blood: creatine kinase, 243 U/L (reference range, 10–225 U/L); serum aldolase, 16 U/L (reference range, ≤8.1 U/L); lactate dehydrogenase, 314 U/L (reference range, 60–200 U/L). An autoimmune panel was negative for Jo-1, Scl-70, U1 ribonucleoprotein, DNA, desmoglein 1 and 3, and antiacetylcholine receptor antibodies. An elevated erythrocyte sedimentation rate was measured at 16 mm/h (reference range, 0–10 mm/h). Given these findings, the lesions were confirmed as a widespread poikilodermatous variant of dermatomyositis.

The patient was placed on a daily 50-mg dose of prednisone, which produced rapid improvement in scaling and erythema. Creatine kinase and serum aldolase levels normalized and motor strength increased. After 1 week the prednisone dosage was reduced to a daily 30-mg dose, and then 20 mg a week later. The skin lesions completely resolved within 4 to 5 months and the patient is currently on a prednisone dose of 5 mg, alternating with 2.5 mg of prednisone and rituximab infusion every 2 months.

Dermatomyositis is a rare entity with an incidence of approximately 0.5 to 1 per 100,000 individuals.¹ It presents with a characteristic rash composed of Gottron papules; pathognomonic flat violaceous papules on the dorsal interphalangeal joints, elbows, or knees; and a heliotrope rash, a violaceous erythema involving the eyelids. Poikiloderma frequently is reported to present in a shawl-like distribution, encompassing the shoulders, arms, and upper back.^1,2 Dermatomyositis of the poikilodermatous type can present in nonphotoexposed areas and photoexposed areas. The unusual feature is the total-body involvement, which is analogous to erythroderma.³

Our case may represent a distinct poikilodermatous manifestation sharing the distribution of the erythrodermic subtype. We believe that the skin lesions may have represented a paraneoplastic event presenting prior to diagnosis with CLL. Dermatomyositis has a strong association with cancer, with patients 3 times more likely to develop internal malignancy.⁴ Association is strongest for non-Hodgkin lymphoma, as well as ovarian, lung, colorectal, pancreatic, and gastric cancer. When associated with malignancy, symptoms of dermatomyositis or myositis typically precede the discovery of malignancy by an average of 1.9 years.⁵ Dermatomyositis has been previously reported to present as a paraneoplastic manifestation of CLL.⁶ One case has been reported of a patient with CLL who developed leukemia cutis presenting with poikiloderma in the characteristic dermatomyositis shawl-like distribution.⁷ The lack of dermal infiltration with leukemic cells in our patient, however, makes a paraneoplastic etiology much more likely.

Our patient’s rash did not initially improve with treatment of CLL, but dermatomyositis associated with hematological malignancy may precede, occur simultaneously, or follow the diagnosis of malignancy.⁸ Additionally, symptoms of dermatomyositis do not always parallel the course of hematological malignancy outcome. However, rituximab has been used as a treatment of dermatomyositis and may have contributed some synergistic effect in combination with prednisone in our patient.⁹

To the Editor:

Dermatomyositis represents a rare idiopathic inflammatory process presenting with cutaneous lesions and muscular weakness. It often represents a paraneoplastic syndrome. We report the case of a 62-year-old man with a history of total-body poikiloderma and a recent diagnosis of chronic lymphocytic leukemia (CLL). Despite lacking typical features of the disease, a diagnosis of dermatomyositis was made. Our patient may represent a distinct poikilodermatous variant of dermatomyositis, sharing the generalized distribution of the erythrodermic subtype.

A 62-year-old man presented with pruritic poikiloderma involving the neck, arms, legs, abdomen, chest, and back of 2 years’ duration (Figure). He also experienced dysphagia and weakness of the legs. The rash was previously treated by other dermatologists with a combination of high-potency topical steroids and topical tacrolimus 0.1% without success. His history was notable for CLL, which had been diagnosed by a dermatologist 6 months prior to the current presentation. Prior to his visit to the dermatologist, the patient had received 6 chemotherapeutic sessions with a combination of rituximab and cyclophosphamide for the treatment of CLL. The rash did not improve with chemotherapy.

Repeat biopsies of affected regions only demonstrated features of mild interface dermatitis. Direct immunofluorescence studies showed scattered colloid body fluorescence for IgM. Because of bilateral weakness of the legs, a muscle biopsy was taken, which demonstrated severe atrophy and interstitial fibrosis, with neurogenic abnormalities detected in areas of lesser atrophy via abnormal muscle fiber–type grouping. Metabolic panel showed elevated muscle enzymes in the blood: creatine kinase, 243 U/L (reference range, 10–225 U/L); serum aldolase, 16 U/L (reference range, ≤8.1 U/L); lactate dehydrogenase, 314 U/L (reference range, 60–200 U/L). An autoimmune panel was negative for Jo-1, Scl-70, U1 ribonucleoprotein, DNA, desmoglein 1 and 3, and antiacetylcholine receptor antibodies. An elevated erythrocyte sedimentation rate was measured at 16 mm/h (reference range, 0–10 mm/h). Given these findings, the lesions were confirmed as a widespread poikilodermatous variant of dermatomyositis.

The patient was placed on a daily 50-mg dose of prednisone, which produced rapid improvement in scaling and erythema. Creatine kinase and serum aldolase levels normalized and motor strength increased. After 1 week the prednisone dosage was reduced to a daily 30-mg dose, and then 20 mg a week later. The skin lesions completely resolved within 4 to 5 months and the patient is currently on a prednisone dose of 5 mg, alternating with 2.5 mg of prednisone and rituximab infusion every 2 months.

Dermatomyositis is a rare entity with an incidence of approximately 0.5 to 1 per 100,000 individuals.¹ It presents with a characteristic rash composed of Gottron papules; pathognomonic flat violaceous papules on the dorsal interphalangeal joints, elbows, or knees; and a heliotrope rash, a violaceous erythema involving the eyelids. Poikiloderma frequently is reported to present in a shawl-like distribution, encompassing the shoulders, arms, and upper back.^1,2 Dermatomyositis of the poikilodermatous type can present in nonphotoexposed areas and photoexposed areas. The unusual feature is the total-body involvement, which is analogous to erythroderma.³

Our case may represent a distinct poikilodermatous manifestation sharing the distribution of the erythrodermic subtype. We believe that the skin lesions may have represented a paraneoplastic event presenting prior to diagnosis with CLL. Dermatomyositis has a strong association with cancer, with patients 3 times more likely to develop internal malignancy.⁴ Association is strongest for non-Hodgkin lymphoma, as well as ovarian, lung, colorectal, pancreatic, and gastric cancer. When associated with malignancy, symptoms of dermatomyositis or myositis typically precede the discovery of malignancy by an average of 1.9 years.⁵ Dermatomyositis has been previously reported to present as a paraneoplastic manifestation of CLL.⁶ One case has been reported of a patient with CLL who developed leukemia cutis presenting with poikiloderma in the characteristic dermatomyositis shawl-like distribution.⁷ The lack of dermal infiltration with leukemic cells in our patient, however, makes a paraneoplastic etiology much more likely.

Our patient’s rash did not initially improve with treatment of CLL, but dermatomyositis associated with hematological malignancy may precede, occur simultaneously, or follow the diagnosis of malignancy.⁸ Additionally, symptoms of dermatomyositis do not always parallel the course of hematological malignancy outcome. However, rituximab has been used as a treatment of dermatomyositis and may have contributed some synergistic effect in combination with prednisone in our patient.⁹

Japan has a universal health care system with low copays and short wait times for appointments, including those with specialists. Yet patient satisfaction scores are low compared with those of other countries. Researchers from Juntendo Urayasu Hospital, a university hospital in a Tokyo suburb, conducted a study of 214 patients with breast cancer to find out which aspects of radiation oncology care might affect patient satisfaction. The survey included questions about overall treatment, time from diagnosis to treatment start, wait times in the hospital, and length of consultations.

Related: Improving the Performance of the Chemotherapy Clinic at the North Florida/South Georgia Veterans Health System

In general, levels of satisfaction were high. However, wait time was significantly negatively associated with both overall satisfaction and satisfaction with the radiation oncologist. Wait time was just under an hour for an average 11-minute consultation. Although this was longer than the “notorious” Japanese situation of a “3 hours wait and 3 minutes consultation,” the researchers say, “We expect that an international audience will appreciate that even 11 minutes is an exceptionally short duration for a consultation visit with a specialist in radiation oncology.”

They note, though, a reasonable caveat. Anyone can walk into their hospital and, for an additional fee, see a specialist on the day they want, which can lead to extended wait times from sheer congestion. Their hospital’s chief breast cancer surgeon sees 60 to 70 patients a day; the radiation oncologist treats 500 to 600 patients a year without resident or trainee support. This situation is typical of Japanese university hospitals, the researchers add.

Related: Breast Cancer Treatment Among Rural and Urban Women at the Veterans Health Administration

Importantly, for Japanese patients, the researchers also included questions to measure patients’ opinions about sharing how they felt with their physicians. The level of sharing correlated with satisfaction, but the researchers point out that in Japan sharing feelings remains “challenging.” Their findings suggest, they say, that if this were improved, patients’ satisfaction might increase.

Japan has a universal health care system with low copays and short wait times for appointments, including those with specialists. Yet patient satisfaction scores are low compared with those of other countries. Researchers from Juntendo Urayasu Hospital, a university hospital in a Tokyo suburb, conducted a study of 214 patients with breast cancer to find out which aspects of radiation oncology care might affect patient satisfaction. The survey included questions about overall treatment, time from diagnosis to treatment start, wait times in the hospital, and length of consultations.

Related: Improving the Performance of the Chemotherapy Clinic at the North Florida/South Georgia Veterans Health System

In general, levels of satisfaction were high. However, wait time was significantly negatively associated with both overall satisfaction and satisfaction with the radiation oncologist. Wait time was just under an hour for an average 11-minute consultation. Although this was longer than the “notorious” Japanese situation of a “3 hours wait and 3 minutes consultation,” the researchers say, “We expect that an international audience will appreciate that even 11 minutes is an exceptionally short duration for a consultation visit with a specialist in radiation oncology.”

They note, though, a reasonable caveat. Anyone can walk into their hospital and, for an additional fee, see a specialist on the day they want, which can lead to extended wait times from sheer congestion. Their hospital’s chief breast cancer surgeon sees 60 to 70 patients a day; the radiation oncologist treats 500 to 600 patients a year without resident or trainee support. This situation is typical of Japanese university hospitals, the researchers add.

Related: Breast Cancer Treatment Among Rural and Urban Women at the Veterans Health Administration

Importantly, for Japanese patients, the researchers also included questions to measure patients’ opinions about sharing how they felt with their physicians. The level of sharing correlated with satisfaction, but the researchers point out that in Japan sharing feelings remains “challenging.” Their findings suggest, they say, that if this were improved, patients’ satisfaction might increase.

Japan has a universal health care system with low copays and short wait times for appointments, including those with specialists. Yet patient satisfaction scores are low compared with those of other countries. Researchers from Juntendo Urayasu Hospital, a university hospital in a Tokyo suburb, conducted a study of 214 patients with breast cancer to find out which aspects of radiation oncology care might affect patient satisfaction. The survey included questions about overall treatment, time from diagnosis to treatment start, wait times in the hospital, and length of consultations.

Related: Improving the Performance of the Chemotherapy Clinic at the North Florida/South Georgia Veterans Health System

In general, levels of satisfaction were high. However, wait time was significantly negatively associated with both overall satisfaction and satisfaction with the radiation oncologist. Wait time was just under an hour for an average 11-minute consultation. Although this was longer than the “notorious” Japanese situation of a “3 hours wait and 3 minutes consultation,” the researchers say, “We expect that an international audience will appreciate that even 11 minutes is an exceptionally short duration for a consultation visit with a specialist in radiation oncology.”

They note, though, a reasonable caveat. Anyone can walk into their hospital and, for an additional fee, see a specialist on the day they want, which can lead to extended wait times from sheer congestion. Their hospital’s chief breast cancer surgeon sees 60 to 70 patients a day; the radiation oncologist treats 500 to 600 patients a year without resident or trainee support. This situation is typical of Japanese university hospitals, the researchers add.

Related: Breast Cancer Treatment Among Rural and Urban Women at the Veterans Health Administration

Importantly, for Japanese patients, the researchers also included questions to measure patients’ opinions about sharing how they felt with their physicians. The level of sharing correlated with satisfaction, but the researchers point out that in Japan sharing feelings remains “challenging.” Their findings suggest, they say, that if this were improved, patients’ satisfaction might increase.

LAS VEGAS – Intrathecal hydromorphone, administered alone or with lidocaine, effectively controlled pain and decreased postoperative opioid use after colorectal surgery in a retrospective study.

The technique was so effective that 28% of patients required no postoperative opioids at all, Amit Merchea, MD, said at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress.

The intrathecal analgesic was part of an enhanced recovery pathway (ERP) for patients undergoing elective colorectal surgery at the Mayo Clinic, Jacksonville, Fla., where Dr. Merchea practices colorectal surgery.

©Dmitrii Kotin/Thinkstock.com

[email protected]

On Twitter @Alz_Gal

LAS VEGAS – Intrathecal hydromorphone, administered alone or with lidocaine, effectively controlled pain and decreased postoperative opioid use after colorectal surgery in a retrospective study.

The technique was so effective that 28% of patients required no postoperative opioids at all, Amit Merchea, MD, said at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress.

The intrathecal analgesic was part of an enhanced recovery pathway (ERP) for patients undergoing elective colorectal surgery at the Mayo Clinic, Jacksonville, Fla., where Dr. Merchea practices colorectal surgery.

©Dmitrii Kotin/Thinkstock.com

[email protected]

On Twitter @Alz_Gal

LAS VEGAS – Intrathecal hydromorphone, administered alone or with lidocaine, effectively controlled pain and decreased postoperative opioid use after colorectal surgery in a retrospective study.

The technique was so effective that 28% of patients required no postoperative opioids at all, Amit Merchea, MD, said at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress.

The intrathecal analgesic was part of an enhanced recovery pathway (ERP) for patients undergoing elective colorectal surgery at the Mayo Clinic, Jacksonville, Fla., where Dr. Merchea practices colorectal surgery.

©Dmitrii Kotin/Thinkstock.com

[email protected]

On Twitter @Alz_Gal